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
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