司法解剖確認之羊水栓塞案例分析

The Analysis of Amniotic Fluid Embolism Cases Confirmed by the Forensic Autopsy

10.6134/tjfm.2013.0501.02

鄒忠宗(Chung-Tsung Tsou)；潘至信(Chih-Hsin Pan)；孫家棟(Chia-Tung Shun)

羊水栓塞 ； 司法解剖 ； 法醫 ； 醫療糾紛 ； 孕產婦死亡 ； Amniotic fluid embolism ； Forensic autopsy ； Forensic pathologist ； Medical dispute ； Pregnancy-related maternal death

台灣法醫學誌

5卷1期（2013 / 06 / 01）

14 - 27

繁體中文

前言：羊水栓塞是發生率極低但致死率極高的產科併發症。司法解剖是能夠確定診斷羊水栓塞的最佳方法，而鑑定報告也是法庭作為醫療糾紛判定的最佳證據。研究對象及方法：法務部法醫研究所的資料庫中，從民國88年1月1日起到民國96年12月31日止，鑑定報告死因含有羊水栓塞的案例有47件。加上筆者臨床遇到的一個案例。將個案死者之基本資料、生產狀況、解剖發現、顯微鏡發現、鑑定結果等全都加以歸納與分析。結果：有10例在解剖時有其他同時存有的特殊發現：如子宮頸撕裂傷、肝臟撕裂傷、腦疝、肺栓塞、內出血、植入性胎盤、心肌炎等。有一例僅抽取右心室血液做檢驗而未接受解剖。有一例在解剖及顯微鏡下均未發現羊水栓塞之證據。討論：以臨床醫師的觀點來看，有四分之一的典型羊水栓塞案例無法在患者的肺部血管中發現證據。但是某些法醫病理醫師則認為只有在肺部檢體中發現胎兒細胞或羊水中的物質才能做出診斷。結論：模擬兩可的鑑定結果將造成無窮盡的爭論！本文並不做法醫鑑定好壞的評定，卻希望藉由本文的討論，期待未來臨床診斷標準的確立，進而促使相關的法醫鑑定標準建立。

Foreword: Although the amniotic fluid embolism (AFE) has extremely low probability, it is actually an item of obstetric complication which often causes inevitable death. The forensic autopsy seems the best method to confirm the diagnosis of AFE. The report of forensic autopsy is also the best evidence which the judge determines the medical malpractice or not.Materials and methods: Forty seven cases were collected from the database of Institute of Forensic Medicine, Ministry of Justice from Jan 1, 1999 to Dec 31, 2007. All cases were AFE as cause of death and confirmed by the forensic autopsy. An addition case was met by the author in 2009. We analyze and discuss the general characteristics and obstetric records of the cases. The gross and microscopic findings of autopsies and the differential diagnosis of death were also included.Results: There are 10 cases having associated autopsied findings in addition to AFE: cervical laceration, hepatic laceration, brain herniation, pulmonary embolism, internal bleeding, placenta accreta, and myocarditis. One case has only blood examination due to family unwilling to receive autopsy. There is just one case which has no evidence of AFE in gross finding and the microscopic review.Discussion: From clinician's viewpoint, about one fourth such cases won't have the evidence of fetal or amniotic materials in maternal lungs. But some pathologists insist that the AFE diagnosis must have evidences in histopathological examination of lung sections.Conclusion: Equivocal conclusion will lead to the inexhaustible argument! This article does not give any comment about the quality of investigation report by forensic pathologist. We just hope the standard criteria or procedure to confirm AFE will be established soon after this discussion, regardless in clinic or forensic medicine.

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