NAME: SHARVIENRAAJ A/L VELUKUMARAN

MATRIC NO: BM18110030

DATE: 27/05/2022

ASSIGNMENT FOR LOGBOOK 2

Case scenario
A young pregnant woman became dyspneic and hypotensive during delivery. She
soon became unresponsive and died despite aggressive resuscitation efforts.
Amniotic fluid embolism was suspected.

You are the forensic pathologist conducted autopsy. Please write the procedure of
autopsy you have done for this individual case (with expected findings) and how to
detect amniotic fluid embolism at autopsy (including any-procedure prior autopsy can
help to diagnose the air embolism).

ANSWER:

Brief Clinical History:

The patient was 28 years old female primigravida, came to emergency department
for delivery at 38 weeks of gestation on 24/5/2022 at 3pm. During delivery, patient
developed dyspnea and tachypnea with the respiratory rate of 22 breaths per
minute. The patient also developed hypotension which the blood pressure was 83/72
mm Hg. Her temperature was 35.4 °C and oxygen saturation is 90% at room
temperature. Patient became unresponsive. She had jitters and rolling up of eyes.
Aggressive resuscitation efforts were done. Intubation was done for the patient and
she was on life support ventilator. Fluid resuscitation and blood transfusion was also
done. Though much efforts made the patient was still unresponsive and she was
declared dead on 27/05/2022. There was no history of uneventful pregnancy.
External examination:

General Examination:
A female, with height 170 cm and weight of 63 kg, and medium built. There is no
significant scar or any tattoos. The dentition is natural and complete and no denture.
Her hair was long at shoulder level and it was in black colour. She is having
conjunctival pallor and her oral mucosa s pale. There is no extremity peripheral
edema. The examination of external genitalia and the anus was normal. It was a
normal female genitalia.

Post mortem changes:

There are signs such as rigor mortis, hypostasis stain at the back. There were no
decomposition findings.

External injuries/marks of violence:

There are no marks of violence or any signs of external injuries.

Internal Examination:

Mouth, throat, and neck structures:

There is no notable findings in mouth, epiglottis, tongue and the pharyngeal
muscles. There is no findings on the neck specifically the hyoid bone, thyroid
cartilage and the larynx.

Head:
There is no significant findings on the meninges nor the scalp and skull. The brain
weight is 1310 g which is normal. Cross section of the brain showed no significant
findings. Carotid arteries, jugular vein and vagus nerve are normal. The cervical
vertebra and spinal cord have no significant findings. There is no significant findings
on thyroid gland.

Thorax:
There is no congestion in lungs indicating pulmonary oedema. The added weight of
the both lungs is 1010g. Serous fluid was in the pleural cavity. There was diffuse
damage to the alveolar area. In the pulmonary blood vessels, there are squamous
cell of the fetus. This was confirmed with immunohistochemical stain. Mucinous
material found in multiple sites of small pulmonary blood vessels, positive with
mucicarmine stain. Lanugo hair was found in small pulmonary vessels. In heart there
are multiple sites of hemorrhage indicates disseminated intravascular coagulopathy
(DIC). The weight of heart is 240 g.

Otherwise there are no significant findings for esophagus, chest wall, trachea,
bronchi, pericardium and coronary arteries.

Abdomen:
No unusual liquid in the peritoneum. Stomach content is food sources, rotten, and
mucosa not excessively thick. Little and digestive organ has no ulceration, and no
hemorrhage. Liver weight is 1320 g, on the cut segment there is no nutmeg liver and
indications of malignancy. Spleen is typical size with weight of 138g. On the cut
segment of spleen there is no clog and malignancy changes. Pancreas has no
unusual discoveries. Adrenal glands are great and on cut segment no clog. Left
kidney is 100g and right kidney is 119g, on the cut area showed petechial
hemorrhage of the kidneys. There are draining in the stomach depression around
1015ml. In any case, no critical discoveries in uterus, bladders, ovaries, pelvic bone,
and vertebrae.

Placental examination:
The placenta is completely intact and 495g in weight. There is no significant
abnormalities.

Laboratory investigations:
Lab investigation to be done is immunohistochemical stain to affirm the squamous
cell and mucinous material. Histopathology examination of heart, lungs, kidneys,
digestive tract, liver, and spleen.

Summary:
Patient died unfortunately during delivery. On external examination, she has no
significant findings. On internal examination, there was pulmonary edema and
congestion, diffuse alveolar damage, pleural cavity containing serous fluid, and
finding of fetal squamous cells, lanugo hair in the small pulmonary vessels in
thoracic cavity examination and the heart has multiple sites of hemorrhage. There is
excessive bleeding in abdominal cavity and petechial hemorrhage of both kidneys, it
was see in abdominal examination.

Cause of death:
Cause of death is respiratory failure due to pulmonary edema due to amniotic fluid
embolism.

For amniotic embolism, the classical findings at autopsy including the presence of
fetal squamous cells, lanugo hair, fat from vernix mucosa, and mucin got from fetal.
Different findings are checked pulmonary edema, diffuse alveolar harm, and proof of
DIC which is presence of fibrin thrombi which are the effect of amniotic fluids enter
the maternal circulation. Meconium, cells from chorion and amnion and other cellular
detritus additionally can enter the maternal circulation. Solid elements impacted in
lungs capillaries however rarely tracked down in systemic circulation.