Neonatal fatal haemorrhage after a ritual circumcision: forensic and ethical considerations

Neonatal circumcision is a common procedure worldwide, which may be performed for medical reasons and for cultural and religious motivations. Regarding ritual circumcision, there has been a wide-ranging debate in medical society about the level of acceptability of this practice. Even from a bioethical and legal point of view, the problem is approached differently in different contexts worldwide, especially given that, even if rare, complications can occur both during and after the procedure, and may result in infections, bleedings, hemorrhages and even death. Bleeding occurs most frequently after the fourth week of life and is related to the presence of an abundant venous vascularization of the penile shaft. Unlike adults, the blood loss rates suggestive for hemorrhagic shock are not defined in neonatal populations. Therefore, the diagnosis of the cause of death can be challenging for the forensic pathologist, especially if circumstantial information is missing. We report the case of a full-term infant boy born after a terminally complicated pregnancy. He underwent a "domestic" circumcision on 22nd day of life. The same day he was admitted to the emergency room in cardiac arrest and died despite resuscitation procedures. The autopsy findings revealed the presence of a large amount of blood in the diaper and a circumferential laceration of the penile shaft, consistent with a recent circumcision. Diffuse organ pallor was macroscopically and microscopically demonstrated, consistently with a hemorrhagic shock. To conclude, the diagnosis of hemorrhagic shock can be difficult in the newborn and requires the estimation of lost blood volume. Moreover, due to the possibility of rare fatal complications, neonatal circumcision should be performed only in a controlled, medical environment.