Postmortem Hemorrhage

Bleeding occurs after death if blood vessels, engorged by blood postmortem, rupture. Contributory factors include increased pressure caused by body position, early decomposition, and trauma. Rupture of capillaries is manifest as petechiae (Tardieu spots). The development of petechiae is a harbinger of decomposition, but they can be seen as early as 2 to 4 h after death, if the body has been suspended (6). Rupture of larger vessels (venules) causes purpura or larger ecchymoses. The distribution of postmortem cutaneous hemorrhage is in areas of livor and is not seen in areas uninvolved by lividity (Fig. 15).

• Significance

° Postmortem hemorrhage (petechiae, purpura/ecchymoses or "pseudobruises," external bleeding) mimics true injuries occurring antemortem (see Chapter 8, Subheading 3.1.; see also Fig. 16).

° Open antemortem wounds in dependent body sites can continue to ooze blood after death. Open postmortem injuries (e.g. abrasions, lacerations) can redden and "bleed" mimicking a vital reaction (35,36).

° A significant amount of bleeding can occur from major vessels in a dependent part of the body (e.g., aorta, ranging from 100 to 1300 mL [average 450 mL] into the pleural cavity [37]). The presence of a hemothorax from a traumatically ruptured aorta in the context of an instantaneously fatal brainstem injury implies that bleeding likely occurred postmortem (37).

° Microscopic examination cannot distinguish between the extravasation of blood seen in an early antemortem contusion and postmortem hemorrhage.

° Loose supporting connective tissue (e.g., face, neck) in a dependent body site can promote the development of external and internal postmortem hemorrhage (see Chapter 5, Fig. 5).

Fig. 15. Found prone. Lividity on chest associated with numerous petechiae, which did not involve the nonlivid abdomen.

Nosebleeds can occur (3). "Pseudobruises" tend to be small; however, pronounced facial bruising has been described in an individual who was in a head-down position and sustained postmortem scalp injuries (38). Periorbital hematomas ("black eyes") can be caused by direct trauma, tracking of blood from a scalp wound, and hemorrhagic extravasation from an orbital plate fracture (39). Black eyes can occur around the time of infliction of a rapidly fatal injury (39). They can also be observed postmortem (see Heading 11.). Removal of eyes for corneal transplantation can cause periorbital hemorrhage (Fig. 17; ref. 39). Postmortem head trauma can result in periorbital hematoma and is enhanced by lividity (39). A small hematoma of a single eyelid, compared with extensive hemorrhage in both eyelids, in the absence of direct trauma is not necessarily an antemortem event (39). The presence of postmortem petechiae and larger confluent hemorrhages in the conjunctiva and sclera raises the suspicion of asphyxia from neck compression (Figs. 18 and 19, and refs. 40-42). Information from investigators about the circumstances of the death and the exclusion of internal neck trauma by careful neck dissection help rule out foul play.

A head-dependent position is associated with temporalis muscle and galeal hemorrhages simulating blunt trauma (see Chapter 3, Fig. 2; see also ref. 40). The

Forensic Pathology
Fig. 16. Suicide by hanging. Victim had also bound his flexed legs with electrical cord (see Chapter 3, Fig. 11). Intense lividity of lower extremities and petechiae noted on posterior legs. Perianal "hemorrhage." No evidence of anal trauma (inset). Congested mucosal veins were seen.
Fig. 17. "Black" eyes. Eyes removed postmortem for the purpose of donation. Sudden death owing to cardiomyopathy in an obese individual. (Courtesy of Dr. D. King, Regional Forensic Pathology Unit, Hamilton, Ontario, Canada.)

Fig. 18. Postmortem orbital petechiae, resulting from the prone head-down position. (A) Lividity of face with sparing of left side which was pressed against the floor. Note petechiae below right eyelid (arrowhead). (B) Right lower eyelid retracted to show conjunctival petechiae. (C) Left eye showed no petechiae.

Fig. 18. Postmortem orbital petechiae, resulting from the prone head-down position. (A) Lividity of face with sparing of left side which was pressed against the floor. Note petechiae below right eyelid (arrowhead). (B) Right lower eyelid retracted to show conjunctival petechiae. (C) Left eye showed no petechiae.

Eye Petechial Hemorrhages
Fig. 19. Postmortem orbital hemorrhage. (A) Found prone in tub. (B) Confluent ocular hemorrhage owing to pronounced facial lividity.

head-down position has been recognized as a predisposing factor for the development of soft-tissue neck hemorrhage in fatal drownings (6). These hemorrhages can be extensive (Fig. 20 and ref. 43). Focal hemorrhages are found in the anterior, middle, and posterior compartments of the neck and are, at least, partly attributable to hypostasis (see Chapter 5, Subheading 10.6. [43]). The finding of neck hemorrhage is not exclusive to drowning and is found in any situation in which lividity occurs in a body that is prone or head-down (see Chapter 3, Subheading 1.4.; Chapter 5, Heading 12.). The effect of the prone or head-down position is enhanced if the buttocks are elevated.

Fig. 20. Extensive soft-tissue hemorrhage in anterior neck in individual found prone. No fractures of the hyoid-larynx were observed.
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Responses

  • AATIFA
    Can petechial haemorrhaging in the soft tissue of the eyes occur postmortem?
    7 years ago
  • Bryan Johnson
    Can petechial hemmorrage occur after death?
    7 years ago

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