CT SCAN: A COMPLIMENTARY APPROACH TO MATERNAL AUTOPSY?

Dr Mohamad Helmee Bin Mohamad Noor General and Forensic Radiologist MD (USM), MMed Radiology(UKM), Fellowship in Forensic Radiology, (University of Maryland, Baltimore,USA) Hospital Kuala Lumpur & National Institute of Forensic Medicine,HKL

CT Scan: A complimentary approach to maternal autopsy

Introduction

Anatomy of uterus

Radiology imaging of uterus in normal CECT

Uterus in PMCT

Maternal Death in Malaysia - The abnormality findings of maternal complication on CECT

Forensic Radiology

The Challenges in PMCT

PMCT Maternal death cases @IPFN HKL

Conclusion

Introduction

Maternal mortality is defined by WHO as the death of a woman while pregnant or within 42 days of the termination of pregnancy.

Worldwide ~ women died of complication of pregnancy and childbirth is estimated about ~ every minute there is death

There is no comprehensive study done on postmortem ct on maternal death worldwide. ~ there is not enough case for such study in

developed countries.!

The Millennium Development Goal (MDG) by United Nations with 2 objectives; -To reduce the maternal mortality ratio by 3/4 between 1990 and 2015. -Achieving universal access to reproductive health 2015

In Malaysia demonstrates significant reduction of MMR:

In 1950 ~ 540/100,000 LB

In 1970 ~ 139/100,000 LB

In 1991 ~ 44/100,000 LB

In 2000 ~ 28.1/100,000 LB

11/100,000 LB by 2015

In Radiology – extra care

In obstetrics radiology – studies are done for years before we able appreciating images

Years to makes images are prefect & able to appreciate by medical personal initially then follow by a common people

Similar with MRI

Effect of Ionizing imaging In Radiology

Ionizing Imaging in Radiology – x pregnant mother ~ preventive action

???

Ghosting artifact from CR image

Anatomy of uterus

Relations

anteriorly - bladder; uterovesical

pouch

posteriorly - rectum; pouch of Douglas

laterally - broad ligament; uterine vessels

uterine tubes open into its upper part

inferiorly - uterine cavity communicates with that of the vagina

Radiology imaging of uterus in normal CECT

Non pregnant uterus in Radiology ~ in CECT

In the adult, it measures about 7.5 cm in length, 5 cm wide at its upper part, and nearly 2.5 cm in thickness

Non pregnant uterus in non contrasted filled urinary bladder

Early pregnancy uterus in CECT

20-year-old woman at 7 weeks of gestation with right lower quadrant abdominal pain.

Axial contrast-enhanced CT image shows gestational sac as fluid-filled cystlike structure (white arrow) in uterus, and placenta (black arrow) is visible as eccentric, briskly enhancing, curvilinear structure at periphery of gestational sac.

Gravid uterus in PMCT -In standard PMCT no contrast given

Maternal Deaths Malaysia – The

abnormality findings of maternal complication on CECT

PPH is leading cause of maternal death (25%) due to retained placenta dan uterine atony.

HDP next common cause which most deaths occurring postpartum ~ associate with eclampsia, pulmonary complication and cerebral haemmorrhge, severe preeclampsia and DIVC

Thromboembolism

Maternal Deaths Malaysia -The

abnormality finding of maternal complication on CECT

Associated medical conditions eg. Rheumatic heart disease esp mitral stenosis.

Obstetric trauma include uterine rupture, vaginal and uterine tears.

Others includes anterpartum heemorrhage,sepsis, ectopic associated with anaesthsia ,trauma, unknown

Post Partum Hemorrhage

Represent about 25%.

Cause by uterine atony & retained or adherent placenta.

Risk factors >40 yrs,multiparity.

Home delivery -19-37% of death

Risk of dying from PPH for mothers delivering at home is 3-5x > than hospital delivery.

CECT of PPH

Hypertensive disorders of pregnancy

1/3 primigravida

The immediate association with death were eclampsia, cardiopulmonary complication, cerebral hemorrhage, DIVC and severe PE.

Obstetric embolism

Amniotic fluid & blood clot embolism.

Only 11/91 had pm confirmation (from 97’-2000).

AFE was previously high mortality rate of 16-30% but with better intensive care and earlier recognition

Obstetric trauma

Most frequent causes- uterine rupture, pelvic hematoma, cervical laceration etc

Preeclampsia

Severity ranges from Mild disorder (transient hypertension in later part of

pregnancy to - A life threatening disorder ~ with sx and symptom of

seizures, HELLP syndrome, fetal hypoxia and growth retardation.

> severe disease 0.56 per 1000 deliveries Predisposed women to other serious

complication Placenta abruption Cerebral hemorrhage Disseminated intravascular coagulation

Preeclampsia ~ CECT fatty/liver infarct

Fatty liver Liver Infarct

Posterior reversible encephalopathy

seizure

A CT shows high density in the left transverse sinus and hemorrhagic venous infarction in the left temporal lobe

Infection

Presented in advance stage of disease ~ were from the lower socio economic and lower education status

In HIV/AIDS – oral thrush & respiratory sym were primary presentation.

12 death from 97-2000

Lung infection.

Forensic Radiology

Forensic medicine – application of medical knowledge and technologies in the collection of evidence to be used in a court of law.

Forensic radiology – is the application of the science of diagnostic imaging to questions of law.

Forensic CT – modality …….virtual autopsy (Ct virtopsy) / PMCT/Imaging autopsy…

Evolution of forensic science fields

Microscope

Finger Print

DNA

Ct virtopsy/ Post Mortem CT ( PMCT)

Evolution of forensic science fields

Physician Rudolf Virchow – has introduced microscopic examination to classic pathology about midway through the 19th century that helped to establish modern pathology

Radiology vs forensic

In 1895, Wilhelm Roentgen discovered X-rays and just a few months later, a bullet lodged in the leg of a gunshot victim

It was shown in an X-ray and the evidence was used in court to successfully prosecute the accused for attempted murder.

The Driven Factors for PMCT Scan Modality in Malaysia

Religious factors ( esp for Muslim).

To Facilitate forensic pathologists..ie for planning pre autopsy esp. at the place difficult or unusual for dissection.

To make it Easier for the non medical persons(esp judges/lawyers) to understand about the forensic medicine.

For data Storage and easy retrieval (esp with the

advance technology).

Institut Perubatan Forensik Negara (IPFN) HKL

New PMCT building @ IPFN- early June 2010

Institut Perubatan forensik Negara (IPFN) HKL~ 64-Slices PMCT

Wide bore

PMCT Protocol

The Challenges in PMCT

Positioning & Rigor Mortis

Postmortem changes: Artifacts from Livor Mortis

Artifacts from Decomposed Body

Ct Positioning in Living Person

Positioning in CT forensic

1st scan Repositioning for 2nd scan

Positioning in ct forensic ~bone Artifact

Custom in Malaysia ~upper limbs anterior onto abdomen

? Fatty liver/? Infarct

PMCT Artifacts due Livor Mortis

Due to post mortem changes which causes pmct artifacts ~ should be considered normal & not mistaken for a pathologic process or injury.

This finding is easily noted in large caliber arteries and veins as well in cardiac camber

PMCT artifacts due to livor mortis~ Hemostasis in cardiac camber & Collapsed of the ivc/aorta

Hemostasis in Great Vessels/cardiac cambers

Collapsed of the IVC/Aorta

PMCT Artifacts due to livor mortis

In these structures blood separates into serum and erythrocytic components due to the effect of gravity~ produces a fluid level on CT.

This noticeable in the aorta and in the posterior dural sinuses of the cranial fossa.

PMCT artifacts due to livor

mortis~cerebral

PMCT Artifact True Subdural bleed

PMCT Artifacts due to livor mortis

Visceral livor mortis is most commonly identified in the lung parenchyma on PMCT –this is because of inherent attenuation differences between aerated lung and pulmonary vasculature.

There is increasing attenuation (HU) from non dependent to dependent portion of lung

parenchyma with increase degree of livor mortis.

PMCT artifacts due to livor mortis~lungs

Pulmonary edema

Not lung infection but PMCT artifacts due to livor mortis~ postmortem pulmonary oedema

Coronal View – Post Mortem Pulmonary

Oedema

Decomposition artifacts in PMCT

Occur immediately upon death.

Spectrum of decomposition changes on PMCT, classify as Early, Moderate and Advanced

Influenced by : Temperature Place External trauma Sepsis Organs

Decomposition artifacts in PMCT

Putrefactive gas should not be mistaken as pathologic gas collection that contributed or causes of death such as air embolism, pneumothorax, penumoperitoneum or gas forming infection.

putrefaction changes ~ kidneys (not air embolism)

Decomposition artifacts in PMCT~ Cerebral

Cerebral autolysis ~among the earliest sx of decomposition.

Studies done show that some evidence of cerebral autolysis in majority of bodies been scanned even though the body has been stored in cooling mortuary chambers

Decomposition artifacts in PMCT ~ Cerebral

Early changes Moderate-Advanced Decomposition

~Shrunken brain

Decomposition artifacts in PMCT

The intestinal wall and mesenteric and portal venous systems are generally the 1st sites of putrefactive gas on PMCT in addition to small and large intestine which may be distended with gas from proliferation of intestinal bacteria.

Not air embolism but due to Decomposition artifacts in PMCT~ putrefaction changes in the liver

Early Moderate

Decomposition artifacts in PMCT~ the liver

Advanced stage

Another PMCT Mother death ~ Indonesian

PMCT Angiography

What PMCTA is good at…

Artifacts due to postmortem and decomposition changes ~ Postmortem CT Angiography in determining antemortem or postmortem thrombus

Postmortem CTA artifact- antemortem /postmortem thrombus clot.

Not for PMCTA

In future ~ Hope further researches and studies on maternal

death we able to support MMR by using pmct and pmcta

PPH – -placenta abruptio

Conclusion

PMCt is adjunct and complimentary procedure to conventional autopsy providing cross-sectional imaging an anatomic overview of the body prior to dissection.

Total of 2,601 PMCt cases had been done from since 1st June 2010 until August 2014 with 9 cases postmortem CT on maternal death at IPFN HKL.

Integrating cross sectional imaging into a forensic environment has positive implications for both forensic pathology and radiology fields. ~ PMCt is potential to be part of complimentary post

mortem tool and procedure of maternal death / MMR in the future.

Thank you