Massive hemoperitoneum due to ruptured ectopic gestation: Postmortem CT findings in a deeply frozen deceased person

A deceased 23 year old female was repatriated from a 3rd world country in a deeply frozen state as no conventional mortuary refrigeration was available. Prior to her death the deceased had complained of abdominal pain, nausea and vomiting followed by collapse. She was unable to be resuscitated. Postmortem CT scanning on arrival at our mortuary (105 h after death) revealed a large volume hemoperitoneum in two distinct forms. In the pelvis, uniform hyperdense material with a mean Hounsfield unit (HU) density of 74, encircled the uterus and Fallopian tubes. In the upper abdomen there was a highly unusual appearance of multiple, thin, parallel and intersecting linear structures having a mean HU density of −10 to 10 within more dense, dependent material (mean HU density of 50) around the spleen and liver. CT also revealed a sac in the uterine cavity and a complex cystic mass of 4 × 2.5 cm in diameter in the right adnexum. No other cause for bleeding was detected. Findings were interpreted by the forensic radiologist as a ruptured right adnexal ectopic gestation with frozen clotted blood in the pelvis (so-called “sentinel clot”) and crystallization of serum in frozen liquid blood filling the upper abdominal cavity. Urgent postmortem serum ßhCG was elevated (7714 International Units/L), consistent with early pregnancy. Once time had elapsed to allow the body to fully thaw, an autopsy limited to the abdomen confirmed all CT findings albeit without the icicles. This case exemplifies the value of the clinical CT “sentinel clot” sign in localizing the source of abdominal hemorrhage on postmortem imaging and highlights the value of postmortem CT scanning in determining cause of death even in a deeply frozen individual.