Infant deaths fmt powerpoint presentation.

Infant death is one of the important topics in forensic medicine and toxicology.
Infant death refers to death of a child before 1 year of age.

1. Infant deaths

2. definitions INFANTICIDE : is unlawful destruction of a child under the age of one year by anyone. It does not include death of fetus during labor, or when it is destroyed by craniotomy or decapitation. FILLICIDE : is killing of a child older than 24 hrs by its own parents. FETICIDE : is killing of fetus at anytime prior to birth. NEONATICIDE : is killing of an infant within 24 hrs of birth.

3. Stillbirth A stillborn child is one which is born after 28th week of pregnancy and which did not breathe or show any other signs of life at any time after being completely born [WHO]. Salient features: (1) The child was alive in utero but dies during the process of birth. (2) Causes – ( i ) Anoxia (ii) Birth trauma [especially intracranial hemorrhage due to excessive moulding ] (iii) Congenital defects (iv) Erythroblastosis fetalis (v) Placental abnormalities (vi) Prematurity (vii) Toxemia of pregnancy.

4. Dead birth Dead born child is one, which has died in utero, and shows one of the following signs after it is completely born, (1) maceration (2) rigor mortis (3) putrefaction (4) adipocere (5) mummification

5. Maceration is degenerative change occurring in a fetus retained in utero after death. It occurs due to the softening effect of soaking on solid tissues (pulpy fetus). Salient features: (1) 12 hours : Skin slippage [earliest sign]. The epidermis can be easily separated from the dermis by applying oblique pressure. (2) 24 hours : Skin blebs [Fluid-filled bullae are formed between dermis and epidermis].

6. (3) 48 hours : ( i ) Sweetish, disagreeable odor (ii) internal fetal organs and connective tissue show increasing purple discoloration due to hemolysis and breakdown of red cells. (iii) Dark, red-stained fluid accumulates in the serous cavities. This should be distinguished from serous effusions acquired antemortem. (iv) Proteolytic digestion by kallikrein contributes to – vascular permeability. (v) Similar color changes are observed in the amniotic fluid, which has a deep dark red appearance (“tobacco juice”), or in the event of passage of meconium, a thick brown appearance. (vi) The volume of the amniotic fluid decreases following fetal death, and the level of α-fetoprotein in it increased because of concentration effect. (vii) Autolysis of connective tissue causes laxity of joints (viii) Bones become flexible and joints become abnormally mobile. (ix) Abdominal organs may show green discoloration due to leakage of bile pigments from the gallbladder

7. (4) 3 to 4 days ( i ) Fetal epidermis loses integrity. (ii) Umbilical cord is red, soft and smooth. (5) 5th day : S/c edema up to 5 mm. (6) >1 week ( i ) Meconium released into the abdominal cavity. Dystrophic calcification may develop in the autolyzed liver tissue. (ii) Fluid accumulation may mimic hydrops fetalis. (iii) distortion of skull occurs during vaginal delivery. (7) Several weeks – ( i ) a fading of color to yellow–gray occurs. (ii) Progressive loss of fluid from the fetus eventually results in the formation of “fetus papyraceous.” (iii) Dehydration results in shrinkage and compaction of tissues and organs.

8. Rigor Mortis, Putrefaction, Adipocere and Mummification : Rigor mortis - is a usual change after death. Putrefaction - occurs if air enters the liquor amnii after death. Adipocere - would occur if sufficient liquor amnii is there. Mummification - would occur if all liquor amnii has drained out. Radiological Signs of IU Deaths : 1.Robert’s sign Earliest sign to appear. 12 hours after death. Air in aorta, pulmonary vessels or abdomen. 2. Spalding’s sign Appears 2 days after death. Overlapping of fetal skull bones seen on x-ray (or ultrasound) examination. 3. Deuel’s halo sign Appears 3 days after death. Separation of the subcutaneous fat of the fetal scalp from the cranial bones.

9. Viability of fetus Viability is the ability of a fetus to survive outside the uterus. Indian Law - Age of viability has not been defined in Indian law. English law - Age of viability is 28 weeks Physiology - at age of viability pulmonary surfactant appears in the alveoli of lungs, which causes decreased surface tension of alveoli, alveoli become able to inflate. When the pulmonary surfactant is deficient, it causes Infant respiratory distress syndrome [IRDS, neonatal respiratory distress syndrome]

10. Live birth Legally - “live-birth” means the complete expulsion of fetus from its mother, irrespective of the duration of pregnancy, and who after such expulsion breathes or shows any other evidence of life. Signs of live birth includes : Shape of the chest Position of diaphragm Changes in Lungs Changes in stomach and intestines Changes in middle ear Other signs

11. Signs of live birth : 1. Shape of chest : (1) Before respiration – Chest is flat. Circumference 1-2 cm less than that of abdomen at the level of umbilicus (2) After respiration – Chest expands. Drum shaped. 2 . Position of diaphragm: (1) Before respiration – at the level of 4th or 5th rib. (2) After respiration – at the level of 6th or 7th rib. 3. Lung :

12. S no. Feature Before respiration After respiration 1. Color Uniformly reddish brown or deep violet Mosaic or mottled 2. Volume Small, do not cover heart Large, covers heart 3. Surface Smooth Uneven 4. Margins Sharp Rounded 5. Lowest margin At level of 4-5th ribs At level of 6-7 th ribs 6. Consistency Liver like, dense and firm Crepitant, elastic and soft 7. Blood within lungs less more 8. Weight of both lungs 35g 70g 9. Weight of both lungs in relation to body weight 1/70 1/35

13. S no. Feature Before respiration After respiration 10. Specific gravity 1.04-1.05 0.94 11. Hydrostatic test -ve, sinks in water +ve, floats in water 12. Thoracic cavity Not fully occupied by lungs Fully occupied by lungs Pleura Loose, wrinkled Stretched Cut section 1. Oozing of blood Little, froth less blood Abundant, frothy blood 2. Bronchi and bronchioles Empty Contains blood stained froth 3. Alveoli Not inflated Inflated 4. MLI Indicated stillborn or deadborn Indicates liveborn

14. Weight of lungs: i . Fodéré’s test [syn, Static test] (1) Procedure - Lungs are ligated across their hila, separated and weighed. (2) Wt of both lungs combined - ( i ) before respiration - 35 g (ii) after respiration - 70 g (3) The increasing weight is due to increased flow of blood. ii. Ploucquet’s test (1) Wt of lungs is calculated as a ratio of infant’s total weight to even out differences due to wt of infants (2) Wt of both lungs combined - ( i ) before respiration – 1/70th of body wt (ii) after respiration – 1/35th of body wt.

15. iii. Hydrostatic test ( Raygat’s test) Principle - Upon breathing, both wt and vol of lungs are increased. Hydrostatic test is performed in following four stages: Stage1 – Whole thoracic pluck consisting of both lungs and heart are placed in a bucket of water. If the pluck floats indicates air in lungs, indicates that the infant may have born alive. If the pluck sinks, move to second stage. A piece of liver is also sunk in water as control. It must sink in normal conditions. If it floats, it may indicate putrefaction. Stage 2 – Each bronchus is tied, and lungs severed above the ligature. Each lung is then placed separately in water. If either lung floats, it indicates that the infant may have born alive. If either lung sinks, move to third stage.

16. (iii) Stage 3 – Cut each lung in 12-20 pieces Roll a piece of lung gently between a finger and thumb near the ear and see if there is a crackling crepitant noise. Dip each piece under water and squeeze between thumb and finger and see if any bubbles are escaping (c) observe if they float independently. For moving to the next stage same criteria applies as above (iv) Stage 4 – Each piece is now taken out of water, wrapped in a piece of cloth and squeezed by putting a weight. Residual air still remains within the alveoli, which can not be taken out by any means. This residual air is responsible for keeping the lungs afloat in infants who have been born alive and respired. If the lungs were floating in earlier stages due to artifacts, the pieces of lungs would not continue to float till the last stage.

17. Fallacies of hydrostatic test: Two major fallacies of this test : Child respired after birth yet lungs sink. Causes are : Absorption of air Atelectasis Alveolar duct membrane Diseases like cong. Syphilis, acute edema, pneumonia Feeble respiration Child did not respired after birth yet lungs float. Causes are : Artificial respiration Putrefaction Respiration within womb Respiration within vagina

18. Changes in stomach and intestine: Air in stomach and intestines Breslau’s second life test; stomach bowel test - Stomach and intestines are removed after tying double ligatures at each end, and put in water. They float if respiration had taken place; otherwise they sink Principle - Air is swallowed into the stomach and intestines during respiration, making them buoyant False + ve causes – ( i ) Resuscitation attempts (ii) Bacterial gas formation [putrefaction] Drawbacks and Fallacies – ( i ) Useless in putrefaction (ii) Air may be swallowed by the child in attempting to free the air passages of fluid obstructions in cases of stillbirth.

19. Changes in middle ear Wreden’s test – Procedure – Skull cap is removed and base of skull submerged in water. Petrous part of temporal bone [which forms roof of the middle ear] is opened. If a bubble of air escapes from middle ear, the child was born alive.

20. OTHER SIGNS OF LIVEBIRTH : a. Blood (1) Nucleated RBC disappear in 24 h (2) Fetal Hb [synthesized mainly in liver]"( i ) Before birth"80-90% (ii) 3 rd month - 7-8% (iii) 6 months - disappears completely. b. Meconium (1) Characteristics: ( i ) It is a green viscid substance consisting of thickened bile and mucus (ii) Stains are brownish green (iii) Stiffen the cloth (iv) Reaction is acidic (2) Expulsion - Completely excreted from the large intestine in 24-48 h after normal birth

21. c . Caput succedaneum Caput succedaneum [CS] is an area of soft swelling that forms in the scalp over the presenting part of the head in vertex presentations. Causes – Juxtaposition of scalp to the opening of the dilated cervix during labor, vacuum extraction. Mechanism – Rigid cervical ring presses on presenting part, decreases venous return causing localized area of congestion and edema. Fate – Starts diminishing soon after birth, completely disappears in a week. d/d – cephalohematoma

22. S no. Feature Caput succedaneum Cephalohematoma 1. Cause edematous swelling between skin and galea due to pressure of presenting part Localized accumulation of blood between periosteum and skull due to periosteal capillary rupture 2. Contents Serosanguinous fluid Blood 3. occurrence Common Rare 4. Suture line Extends across them Doesn't extend across them 5. Size larger Smaller 6. Situation Bilateral Unilateral 7. Color No discoloration Discoloration present 8. Impulse on crying No impulse No impulse 9. Development Immediately after birth Develops after 24 -48 hrs 10. Complications None Jaundice , calcification 11. Disappearance Fully in one week 6-8 weeks 12. MLI Sign of live birth Regression helps in timing survival period

23. d. Skin (1) Initially - ( i ) Skin is bright red. (ii) Vernix caseosa covers skin mostly in axilla, inguinal region, folds of neck, buttocks. (iii) Rarely absent. It may also have been washed away (2) 2 days – darker, brick red. (3) 3rd day – ( i ) Yellow due to physiological jaundice [due to relative insufficiency of enzymes required for conjugation and excretion of bilirubin]. (ii) Skin of abdomen exfoliates during first 3 days after birth (4) 7 days – color is normal.

24. e. Umbilical cord i . Changes in umbilical cord proper (1) 2h – Blood clots in the cut end (2) 12-24h - Cord attached to the child shrinks and dries in relation with live birth; seen in deadborn and stillborn also]. (3) 36-48h – An inflammatory ring forms at the base of stump. (4) 2-3 d – Cord mummifies [No relation to live birth; seen in dead born and stillborn also]. (5) 5-6 d – Cord falls off, leaving an ulcer (6) 10-12 d – Ulcer heals, leaving a scar. ii. Vascular changes (1) 10h–3d – UA closes (2) 3-5 d – Left UV closes iii. Signs of human interference (1) Whether ligature has been applied or not [generally indicates live birth]. (2) Whether cut by scissors [sharp edges] or torn [ragged edges]. Latter indicates self delivery or unskilled delivery. (3) Note length of remaining cord.

25. S no. Structure Closure period 1. Umbilical arteries 10 hrs - 3 days 2. Left umbilical vein 3 -5 days 3. Ductus venosus 3 -5 days 4. Ductus arteriosus 7 – 10 days 5. Foramen ovale 2 -3 months f. Placenta If placenta found with the body, it must be examined g. Circulation