Author Forensic Question: Evidence of Pregnancy on Autopsy



Aray Asks
:

Can an autopsy show evidence of a three week old fetus? I’m researching for a novel I’m writing and I need your help, considering that the information has to be accurate.
My MC’s mother’s body is severely mutilated ( carved into).  She was three weeks pregnant at the time this gruesome murder took place. Police officials accuse her husband of doing the deed.  Having no leads, they arrest him. The husband’s on trial for capital murder.  The medical examiner takes the witness stand. The lawyer asks him a series of questions, one being the autopsy report.
Amryn Says:
A 3 week old fetus would not be visible during an autopsy. At that point in development, the fetus is a ball of cells but without any physical characteristics that one would recognize as human. If the medical examiner needs to detect that the victim was pregnant, the best way would be to perform an HCG test on the victim’s blood.
HCG is the hormone that is responsible for making a pregnancy test appear positive. It usually takes 3-4 weeks for this hormone to be at a high enough level to trigger a positive test, however a quantitative test might be enough to suggest that the victim’s hormone levels were slightly above normal. I wouldn’t think it would be enough for a medical examiner to definitively say the victim was pregnant, but it might be enough for he/she to say it’s possible. Any time after 4 weeks, the HCG levels will begin to rise almost exponentially and therefore would be more easily detected.  

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Amryn Cross is a full-time forensic scientist and author of romantic suspense and mystery novels. Her first novel, Learning to Die, is available on Amazon. The first book in her latest series, loosely based on an updated Sherlock Holmes, is available for pre-order on Amazon. Look for Warzone in January 2015. You can connect with Amryn via her websiteTwitter and Facebook.

Ectopic Pregnancies: Dr. Tanya Goodwin

Today I’m going to talk about ectopic pregnancy. An ectopic pregnancy really means any pregnancy not in the uterus. Mostly this refers to pregnancy in the fallopian tube or tubal pregnancy.


The uterus has a fallopian tube attached to each side. At the end of each fallopian tube are delicate fingerlike projections called fimbriae. These fimbriae function to catch ova (eggs) released from the ovary and help transport the egg(s) down the tube and into the uterus. Sperm actually meet the ovum (egg) in the tube. The resulting early embryo is then wafted down to the uterus where implantation normally occurs. Tiny little hair-like structures inside the fallopian tube called cilia beat rhythmically, also moving the embryo along the tube. If the embryo gets stuck along the way then an ectopic/tubal pregnancy occurs. The embryo grows in the narrow tube until the tube can no longer accommodate it. The tube then ruptures, causing bleeding into the abdomen.

An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. Wikipedia
Symptoms of tubal pregnancy include missed period (which may be a short irregular one), spotting, and pelvic/abdominal pain. The pregnancy test will be positive. OB/GYN’s specifically look at the blood (serum) pregnancy test result called a beta HCG. This result is typically abnormally low compared to a healthy pregnancy in the uterus. Normally this value, early in pregnancy, should double every 48 hours. If these values do not double appropriately, then a tubal pregnancy is suspected.

If a woman presents with a positive pregnancy test, a tender distended belly, low blood pressure, and rapid pulse, then she must be taken for emergency surgery as blood from the ruptured tube is spilling into the abdomen resulting in shock.

Most of the time, this scenario is not that dramatic. There may be blood leaking from the end of the tube, or the tube may not have ruptured. If caught early enough by pelvic ultrasound, and if the tube hasn’t ruptured, then the tubal pregnancy can be treated medically with Methotrexate. This is an anti-neoplastic medicine (meaning killing growing cells) that is injected into a muscle (ie usually buttock/hip). This hopefully should kill (dissolve) the ectopic pregnancy. Given the appropriate conditions, Methotrexate works well. The pregnancy hormone levels must be watched carefully until they decline to zero. Occasionally a second dose is needed. Sometimes Methotrexate fails and surgery to remove the tubal pregnancy is necessary.

Surgery for tubal pregnancy can involve removing the part of the tube affected if it is ruptured (salpingectomy). If the rupture is slight or not at all, then the tube may be surgically slit open, the ectopic pregnancy scooped out, and the tube heals over time (salpingostomy). These surgeries are usually done laparascopically.

Any woman having a tubal pregnancy is at risk to have another tubal pregnancy in the future. We tell these women to be checked out early the minute they know they are pregnant.

Risk factors for tubal pregnancy are previous tubal pregnancy, scarred tubes from tubal infections, endometriosis (also can scar tubes), smoking (causes the cilia to not beat properly, and previous tubal ligation (sterilization by tying tubes, burning them, or placing special clips/rings on tubes). Tubes can re-cannulize or grow back together. Also assisted reproduction such as in vitro fertilization (IVF) can increase the risk that the embryo can migrate up into the tube.

More rare and extremely dangerous ectopic pregnancies include cornual ectopics (getting stuck in the junction where the tube inserts into the uterus), cervical ectopics (in cervix), and pregnancies inside the abdomen. These pregnancies can get very large and when rupture occurs it can cause extensive blood loss.
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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

A Minor Detail: Heidi Creston

Handling the medical treatment of a minor can be tricky. Heidi Creston is back to discuss some of these special circumstances.

Welcome back, Heidi!

I work in L&D, and by far, dealing with family issues is more demanding of my time and energy than anything else. There is one issue that continually pops up and more and more I am finding it in the books I’ve been reading as well. I’m not an expert but I’d like to toss my two cents in for whatever it’s worth.

There are three primary condition that will emancipate a minor WITHOUT a court order:

1. Marriage
2. Joining the Armed Forces
3. Reaching the age of 18

Marriage or enlistment in military service by a minor brings about a new relationship of obligation and responsibility between the child and someone other than the parents. The severing of the child-parent relationship in this manner constitutes as an implied emancipation.

Substantiated reports of desertion, abandonment, non-support and other conduct of the parent may constitute reasonable circumstances for implied emancipation of a minor depending on the age and maturity level of the minor.

Pregnancy, in most states, does not constitute for implied emancipation. The pregnant minor is MEDICALLY emancipated, meaning they can make medical decisions for themselves and their baby only. The best option is to research the emancipation laws in the state that your are writing about because regulations vary from state to state.

Some states are pretty liberal with their emancipation procedures and a judge can sign off on it without a hearing if all parties involved are in agreement. So if you are planning some animosity within your story with those teenagers, take a quick peek at the laws first.

Marriage is another minor detail as well. Some states, like Wyoming, the legal age of marital consent is 19, not 18. So there is good reason said boy had to talk to girl’s dad first.

Jordyn here: I did a series as well on HIPAA issues that you might find interesting. Several aspects of this law are violated by authors frequently. Check these links for further information.

1. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-13.html
2. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-part-23.html
3. http://jordynredwood.blogspot.com/2011/12/author-beware-law-hipaa-33.html

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Are Home Deliveries Safe?

I’m pleased to host Tanya Cunningham today as she discusses the safety of home deliveries. I think this is another one of those instances where some important information is not as prominent as what is portrayed by celebrities and others.

What do you think? Welcome, Tanya!

The birth of a new baby is a life changing, exciting event in the lives of the expecting mother and father to be. The number of decisions to be made are numerous and often overwhelming. One question many expecting parents ask is whether to give birth in a hospital setting or at home with the aid of a certified nurse midwife (CNM).

Although there are benefits to both hospital and home births, the American College of Obstetricians and Gynecologists does not recommend home births due to a concern for safety and a need for much more research according to Dr. Joseph R. Wax of Maine Medical Center in Portland.
The benefits of home births that appeal to expectant mothers include a more relaxed or therapeutic setting, decreased risk of tearing and episiotomies, decreased risk of hemorrhage, decreased risk of infections, and a sense of autonomy concerning her birth plan.
In a systematic review of literature by Laurie Barclay, MD and Hien T. Nghiem, MD, they found that planned home births have a worrisome neonatal mortality rate triple that of hospital births, despite similar perinatal mortality rates. So while an actual delivery may go as planned, triple the number of newborns die in the first month of life after a planned home birth.  Barclay and Nghiem also found the 9% of parous (repeat mothers) and 37% of nulliparous (first time mothers) had to be transported to the hospital during planned home labor.
Other safety concerns I personally cannot ignore is the “what if” factor. Hopefully everything does go as planned whether delivering at home or at a hospital, but what if the new mother does hemorrhage in the postpartum period? The amount of blood loss in minutes can be catastrophic, and if it’s me, I want to be in a hospital setting where quick and timely interventions such as an emergent blood transfusion can save my life.
Another example is fetal distress. If severe or prolonged enough, an emergent or “crash” c-section may be a necessity. Again, if it’s me in the delivery room, I take comfort knowing an OR is seconds away if needed.
I love the idea of the home delivery, but I don’t love the realities. The reality is, even in the most straightforward, low risk pregnancies, unforeseen and even emergent complications can occur during labor and delivery. I do feel the OB hospital setting and staff have been vilified a bit, as time driven, heartless wardens chaining the laboring woman to a hospital bed with fetal monitoring against her will.
As a postpartum RN, I can assure you our first interest is the health of the mother and baby. As long as their well being isn’t compromised, mothers are encouraged to labor as they wish. At the hospital where I work, women are free to roam the halls and utilize birthing balls and birthing tubs. There are many women who deliver naturally, and their birth plans are respected and followed.
If you’ve had a negative experience in a hospital setting delivering a baby, feeling rushed by medical interventions or that a c-section might have been premature, remember, that may be more of an issue with your health care provider or the staff working at the time. I’d encourage you to research doctors who are more flexible and work with expectant/laboring mothers to follow their birth plans as closely as possible.
We who are in the business of delivering and caring for new mothers and babies seek to be as therapeutic as possible, but there are times when medical interventions are necessary to protect the health and well being of either the mother or baby. While delivering a baby at home might be more desirable to an expectant mother as far preserving her autonomy, the truth is hospital deliveries are safer. If you’re expecting or planning to have a child in the future, be sure you make an informed decision when considering where to deliver your precious little one.
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Tanya Cunningham is a mother/baby RN and lives in Missouri with her husband and two small children. She has been caring for mothers and their newborns for almost four years, before which she was a RN in the USAF. During that time, Tanya worked on a multipurpose inpatient unit for two and a half years (taking care of ortho, neuro, medical, general surgical, and tele) and a family practice residency clinic for a year and a half. Tanya earned her BSN at Oral Roberts University.
Tanya has been writing children’s stories for almost 2 years now and is working towards being published. She enjoys raising her children, cooking, and reading medical suspense/mysteries, especially those in Christian Fiction. You can find out more about Tanya by visiting her website.

Medical Question: Flu and Pregnancy

Bonnie asks:

My question has to do with one of my characters who gets a deadly form of influenza (swine and avian flu combined) early in her pregnancy. She winds up in the ICU. She survives but then discovers she’s pregnant. She worried about the baby.

What are the possible dangers to the baby?
Heidi says:
The flu is actually more dangerous to the pregnant woman herself than to the fetus. Most women and healthcare providers delay preventative and treatment of the flu because they fear possible effects on the baby. More women in their third trimester of pregnancy die of the flu, than anything else including accidents and domestic violence.
Untreated flu symptoms that can and usually do send pregnant woman to the ICU include such things as high fevers, dehydration, and viral infections. The effects on the fetus include an increase in still births, brain damage, premature birth, and spontaneous abortion. Woman early in pregnancy are at greatest risk for spontaneous abortion. This would be the case for your patient. Treatment of the flu (antiviral’s), is the best thing for this patient, the benefits greatly outweigh the risks.
I encourage all pregnant patients to get the flu shot and to call their health care provider immediately for flu like symptoms. Tamiflu and Relenza work best when given within the first 48 hours of flu symptoms. Always your best defense is a good offense, get your flu shot.
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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 

Nurse Assisted Deliveries: Heidi Creston

Babies come when they want to, not necessarily when we want them to. Every labor and delivery nurse and OB provider are well aware of this fact. Nurse assisted deliveries happen daily.

The primary reasons for nurse assisted deliveries are:

  1. Physicians are over extended.  They have more than one patient delivering at one time or are  covering OR and/or ER as well as OB.
  2. They are not on site due to office hours.
  3. Precipitous Deliveries (baby comes quickly).
Labor and delivery nurses are specially trained to monitor and keep close observation on a patient’s status in order to notify the OB provider in a timely manner. Most patients are kept on continual electronic fetal monitoring. The pattern on the fetal strip provides information concerning both fetal and maternal status to include how soon delivery may be.
Sterile vaginal exams or cervical examinations to monitor dilation is another skill that L&D nurses are trained to perform. Nurses also educate their patients to report any signs of increased pressure.
It is always preferable for the OB provider to be present for the delivery, due to the increased risk to the patient (possible birth complications such shoulder dystocia), but in the event the provider does not make it, labor nurses are trained to deliver.
The L&D staff will make every effort to contact the provider, they will stop any measures taken to induce labor (turn off pitocin, instruct patient how to breathe thru contractions), provide support, and set up for delivery.
If the delivery is imminent, the nurse will guide the patient in her delivery, guiding the head, checking for nuchal cord. A nuchal cord is when the  umbilical cord is around the neck.  In some cases the cord can be untangled by hand.  Tight cords need to be reduced, clamped and cut.
Nurses also must be careful of other body parts being entangled by the cord as well. Delivery of the body is usually rapid once the head and shoulders are out.
If there are no complications with the infant, nurses will usually leave the baby on the mother’s chest with an uncut cord for 3-5 minutes. Nurses do not attempt to deliver the placenta, but if the placenta delivers spontaneously they place it in a container for the provider.
After delivery, if the provider remains unavailable, the nurse will clean the perineum and assess for tears and bleeding. Given the situation (excessive bleeding) the nurse may restart the pitocin, give a dose of methergine or hemabate, provide continuous fundal massage, and or perform a vaginal sweep. Upon arrival of the provider, the nurse will give them a full report.
Although most deliveries are uneventful, there are many things that could go fatally wrong with the delivery itself or during the post partum period. These include but are not limited to: malpresentation (ie: breech, compound limbs), cord prolapse/cord accidents/nuchal cords/body cords, placental abruption, and post partum hemorrhage.

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Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

 
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished.

Assisted Reporduction is not for Whimps

Today, I’m pleased to host Bette Lamb who discusses her research into infertility clinics. I was certainly surprised by what she found. Are you?

Welcome, Bette!

“You and I know that without babies we are nothing.
A hiss of surprise escaped Petra’s lips. “Dr. Vesey–“
“Oh, I say what’s expected to my patients. But you’re not my patient anymore, are you? We’re just two barren women facing a meaningless future.”
This interchange comes from our new novel, Sisters in Silence, where a fertility counselor takes on a ”noble mission” to save her barren sisters from suffering —  by killing them.
That’s probably not what actually happens when you go to a fertility clinic for Assisted Reproductive Technology (ART). I mean you don’t end up dead, but you do end up with a murdered bank account and a pummeled ego hovering around zero.
Consider this: For women over thirty-five who want a baby, the news is not good. That’s no matter what they do — with technology or without it. To me, that alone was a surprising piece of information. BTW, every time I blink, the age that determines whether your eggs are too old keeps getting younger. The last figure I heard, off the record, was 27 years old.
When I started researching our medical thriller (the novel is co-written with J. J. Lamb), the media buzz was all about women pursuing their careers and waiting to have babies later – sometimes well into their fifties. And women buy it – I mean, against all reason, they believe it.
 I’ve talked to intelligent, savvy women in their mid-forties who say, “I’m just beginning to think about having a baby.” And many might as well keep right on thinking about it. Because no matter how young you look or how much you’re into Pilates, or how many vitamins you take, or whether the forties are the new thirties, you’re in for a surprise when you take that first trip to a fertility specialist who you’ll probably have to end up seeing. You’ll be floored.
When I started delving into this specialty for our book, the statistics for success knocked me over. My day job, for most of my career, was as an RN in Ob/Gyn. I thought I knew exactly the kind of information I would find. After all, these clinics are everywhere. They have to deliver the goods to keep the doors open. Right?  Wrong.
Most women seeking professional help DO NOT SUCCEED. That means they do not walk away with a baby that they carry to term and deliver. In fact, the odds of success are pretty grim: From about 4% for women older than 42, to a high of 37% for women under 35. (After a woman reaches her mid thirties, success rates start to tank dramatically.).
Put yourself in the skin of a 42-year-old woman who has a successful career, a stable relationship, and some money put away. Watch her after starting down the ART runway. In the first steps, she looks like a million – she’s confident, she knows she’ll be in that winning percentage of women coming home with a baby.
And I’ll bet she doesn’t even want to hear about surrogacy (using some other people’s eggs) or adoption. Babies are not that available and who wants some older kid? After several cycles of hormones that make her feel like she’s losing her mind, a love life that is based on her cyclic ticking clock, a significant other who’s now having ED because of the scheduled sexual demands that have nothing to do with lust, life becomes hell in a toaster.
This is the world of our fictional fertility counselor. A world of disappointments, lost love, and unfulfilled expectations day after day. That might drive you off your rocker, too.
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Bette Golden Lamb is unmistakably from the Bronx – probably why she likes to write thrillers. When she isn’t writing crime novels, you can find her in her studio playing with clay.  Her artistic creations appear in juried regional, national, and international exhibitions. She sells through galleries, associations, and stores. She’s also an RN, which explains, Bone Dry, a medical thriller, and Heir Today, an adventure/thriller which also has a medical aspect to it. And just released at Amazon .com, Sister in Silence, a medical thriller about barren women — available as an ebook or trade paperback. Both books were co-authored with husband J.J. Lamb. You can learn more about Bette here: