Paper 1: Fatal ruptured ectopic (tubal) pregnancy masquerading as homicide -Examined under Sec. 176 Cr. P. C: A case report by Mukhopadhyay and Karmakar: Anil Aggrawal's Internet Journal of Forensic Medicine: Vol. 11, No. 2 (July - December 2010)
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Received: July 5, 2009
Received in revised form: August 25, 2009
Accepted: September 17, 2009
Ref: Mukhopadhyay, P.P., Karmakar, R.N.  Fatal ruptured ectopic (tubal) pregnancy masquerading as homicide -Examined under Sec. 176 Cr. P. C: A case report.  Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology [serial online], 2010; Vol. 11, No. 2 (July - December 2010): [about 6 p]. Available from: . Published : July 1, 2010, (Accessed: 

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P.P. Mukhopadhyay R N Karmakar
P.P. Mukhopadhyay
R N Karmakar

Fatal ruptured ectopic (tubal) pregnancy masquerading as homicide -Examined under Sec. 176 Cr. P. C: A case report

by Partha Pratim Mukhopadhyay, MBBS MD PhD*, R N Karmakar, MBBS DFM MD**
*Associate Professor
**Professor and Head
Dept. of Forensic And State Medicine
Burdwan Medical College, Burdwan,
West Bengal, India


Abstract

Ruptured ectopic pregnancy is one of the causes of sudden and suspicious death in women revealed at autopsy .This paper reports and discusses a fatal case of ruptured ectopic (tubal) pregnancy in a young female masquerading as homicide. The case was investigated under magisterial inquest. The medico-legal autopsy established the truth.

Keywords

Fatal rupture, ectopic pregnancy, sudden death, married female, homicide investigation, autopsy.

Introduction

In India any unnatural death of a woman within seven years of her marriage is investigated by a magistrate according to the provisions of section 176 of Code of Criminal Procedure, (Cr P C). Deaths due to ruptured ectopic gestation can present in sudden and suspicious condition in an otherwise healthy normal female. Incidence of ectopic gestation is common, leading to a number of deaths in obstetric emergency. Though amenable to treatment by surgical intervention, early diagnosis of ectopic pregnancy is of utmost importance. This is a case report of a sudden and suspicious death of a newly married female masquerading as homicide.

Case Report

History

Figure 1. Ruptured ectopic( Tubal) pregnancy  : White arrow showing site
Figure 1. Ruptured ectopic( Tubal) pregnancy : White arrow showing site. [Click all pictures to enlarge]

A 24 years old female dead body was brought by the police to the Dept. of Forensic and State Medicine, Burdwan Medical College for medico-legal autopsy to ascertain the cause of death. The inquest report revealed that she belonged to a middle class family and was married three months back. The husband had given history of abdominal pain with gradual weakness and collapse followed by death .The man was alone at the time and was suspected of obscuring something, not making an attempt to consult a doctor and giving unconvincing reply to some pertinent questions. Coupled with this was the history of early discord following marriage. On the basis of the complaint lodged by the parents of the deceased a case was registered with charges of murder (section 302 Indian Penal Code). Police records revealed that body was found lying on her bed with clothes and hair unkempt. The subject’s face appeared bluish black and eyes sunken.

Autopsy findings

Figure 2. Product of conception :  the villous structure shown by the arrow
Figure 2. Product of conception : the villous structure shown by the arrow [Click all pictures to enlarge]

Autopsy revealed an average built moderately nourished body of a fair complexioned female subject. Rigor mortis was well developed and present all over the body. Lips and fingertips appeared bluish (cyanosis). Post mortem staining was present over the back except in the areas of contact pallor. No external injury could be detected even on careful examination .On opening the abdomen there was intraperitoneal hemorrhage with 1.2L of blood (fluid and clot). The uterus measured 8.5cm x 4.0cm x 2.5cm in size. There was evidence of full-thickness rupture of ampullary region of the right fallopian tube. A reddish brown swelling with finger like tissue attached to the wall of the tube (Figure-1). There was bleeding from the site of rupture clots around it and the ovary .The rupture in the roof (superior aspect) of the tube measured .5cm x.5cm x full thickness of wall. The product of conception was inside the lumen and adherent to the wall of the ampullary region (Figure-2). The structure on the other side was normal. The uterus was observed for sign of intrauterine conception keeping in mind the chance of heterotopic pregnancy. All the organs were pale. The lungs were congested with diffuse edema. Kidneys showed bilateral congestion and scattered cortical pinpoint hemorrhage Tissue was preserved from site of rupture and the product of conception to confirm by histopathology.

Discussion

Medical literature is replete with reports of hemorrhagic shock and fatal outcome of ectopic gestation.1 , 2 , 3 Ruptured ectopic pregnancy is widely reported and the risk factors are identified.4 It is an important medical emergency contributing to maternal mortality. With new techniques of assisted reproduction the number has increased manifold. In the U.K reported incidence of ectopic pregnancy is 11.0 per 1000 pregnancy with a mortality rate of 0.4 per 1000 ectopic pregnancies. Bilateral and heterotpoic pregnancies are also not uncommon now days. 5 The presentation of ruptured tubal pregnancy may be varied. I t is the degree of clinical suspicion and early diagnosis that is helpful in saving the life of the mother. Common presentations are like that of appendicitis, obstructed inguinal hernia and other acute abdomen. Even cases with negative urine pregnancy tests are reported 6
What is already known on this topic

 Incidence of ectopic gestation is common, leading to a number of deaths in obstetric emergency. Though amenable to treatment by surgical intervention, early diagnosis of ectopic is of utmost importance.

 With new techniques of assisted reproduction the number has increased manifold.

 Common presentations are like that of appendicitis, obstructed inguinal hernia and other acute abdomen. Even cases with negative urine pregnancy tests are reported.

What This study adds

 The present case reported is important as it presented as a sudden suspicious and unnatural death of otherwise healthy normal young woman within three months of her marriage.

 The objective findings of a thorough autopsy ascertained the cause of death as ruptured tubal pregnancy

 In the present case the hemorrhage was intraperitoneal but there was no extrusion of the conceptus from the tube.

 Regarding the duration of pregnancy our case appears to be quite early as ampullary ruptures are commonly reported at about 8-12 weeks

 The death due to ruptured tubal pregnancy presented in a rare manner masquerading as homicide.

Suggestions for further development

 Against the backdrop of patriarchal society, where cases of dowry related deaths (even blatant and heinous homicides) are not uncommon, every unnatural death (of married woman) must be investigated thoroughly to identify and establish the cause and nature of death.

The present case reported is important as it presented as a sudden suspicious and unnatural death of otherwise healthy normal young woman within three months of her marriage. The deceased was found and reported dead by the husband in such a setting that there was seemingly a case of foul play. The police was suspecting death due to smothering. Given the socio economic reality of our country marital discords are more often than not due to dowry related matters. Even homicides due to dowry are on the rise. 7 The objective findings of a thorough autopsy ascertained the cause of death as ruptured tubal pregnancy. The mechanism of death was intra peritoneal hemorrhage and shock No history of pregnancy was noted in the inquest by the police. It was important to ascertain the nature of death as well.

Ruptured ectopic pregnancy is usually spontaneous and thus death as a result of it is natural. However it may be precipitated by blunt force, trauma associated with coitus and even bi-manual examination. 8 Ruptured ectopic pregnancy are associated with domestic violence where physical force is resorted to by the intimate partner In the present case the hemorrhage was intraperitoneal but there was no extrusion of the conceptus from the tube. Regarding the duration of pregnancy our case appears to be quite early as ampullary ruptures are commonly reported at about 8-12 weeks. 9 10

Against the backdrop of patriarchal society, where cases of dowry related deaths (even blatant and heinous homicides) are not uncommon, every unnatural death must be investigated thoroughly to identify and establish the cause and nature of death. It is important to establish beyond reasonable doubt the cases where the death is natural or accidental in nature. Suspicion is important but objective scientific investigations often can prevent the miscarriage of justice. This important fact is exemplified by the present case, death due to ruptured tubal pregnancy presenting in a rare manner masquerading as homicide.

Conclusions

1. Ruptured ectopic pregnancy is one of the causes of sudden and suspicious death in women revealed at autopsy.

2. Rupture is usually spontaneous but it can be precipitated by trauma. This must be borne in mind by the forensic pathologist during autopsy.

3. It can masquerade as homicide especially when the victim is newly married and dowry related problems are alleged. This is important in India where dowry related deaths are alarmingly common.

4. The role of the autopsy surgeon is vital. Extensive and proper scientific investigations can prevent the miscarriage of justice.

References

(1) Stabile I, GruDzniskas JG. Ectopic pregnancy :a review of incidence, etiology, and diagnostic aspects. Obstetrical and Gynaecological Survey,1990,45(6);335-47 [Pubmed - www.pubmed.gov] (Back to [citationin text)
(2) Lewis G,Drife J., editors. Why mothers die 2000-2002. The sixth report of confidential enquiries into maternal deaths in the United Kingdom. London RCOG Press 2004.  (Back to [citation] in text)

(3) Kansaria J.Chauhan Amayadeo N .An unusual case of bilateral tubal ectopic pregnancy Bombay Hospital Journal 2002, 44(1)  (Back to [citationin text)

(4) Rizk B, Morcos S, Avery S, Elder K, Brinsden P, Mason B, Edwards R. Rare ectopic pregnancies after in-vitro fertilization: one unilateral twin and four bilateral tubal pregnancies. Hum Reprod. 1990 Nov;5(8):1025-8.  [Pubmed - www.pubmed.gov] (Back to [citationin text)

(5) Al-Mosawi A, Ayyash E, Hayat S, Asfar S. Ruptured extrauterine gestation in heterotopic pregnancy. Ann Saudi Med. 2005 Sep-Oct;25(5):413-4. [Pubmed - www.pubmed.gov] (Back to [citationin text)

(6) Kaliniski M A ,Guss D A .Haemorrhagic shock from ruptured pregnancy in patient with negative urine pregnancy test. Annals of Emergency Medicine 2002;40(1):102-5. [Pubmed - www.pubmed.gov] (Back to [citationin text)

(7) Crime in India 2005 National Crime Record Bureau , Ministry Of Home Affairs Govt .Of India New Delhi 2005.  (Back to [citationin text)

(8) Vorhies RW, Waswick WA, Delmore JE, Dort JM, Shaw JW. Blunt abdominal trauma with ruptured 16-week cornual ectopic pregnancy. Am Surg. 2004 Jun;70(6):559-60. [Pubmed - www.pubmed.gov] (Back to [citationin text)

(9) Tse K Y , Leung W C ,Lau N T , Lau C T . Haemoperitoneum due to tubal abortion in a patient with negative pregnancy test – a case report. Hong Kong J Gynaecology Obs Midwifery 2006;6:45-8.  (Back to [citationin text)

(10) Al-Quraan GA, Al-Taani MI, Nusair BM, El-Masri A, Arafat MR, Khateeb MM. Spontaneous ruptured and intact bilateral tubal ectopic pregnancy. East Mediterr Health J. 2007 Jul-Aug;13(4):972-4.  [Pubmed - www.pubmed.gov] (Back to [citationin text)


*Corresponding author and requests for clarifications and further details:
Dr Partha Pratim Mukhopadhyay, MBBS MD PhD
Associate Professor
Dept. of Forensic And State Medicine
Burdwan Medical College, Burdwan, WB
India
E-mail: drpartha99md@gmail.com
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