the maternal death autopsy
TRANSCRIPT
Recent Advances in Histopathology - 23Sebastian Lucas
MMR: 11.4/1,00,000 (UK), 120 death a year
India : 178 per 1,00,000
Possible cause of death is very wide Evaluation of causation is complex Medical, social and legal consequences are
profound, prolonged and expensive
Death at anytime during pregnancy, delivery and up to 42 days postdelivery
Deaths after 42days from delivery are included only if they result from a problem that arose before that caesura
PPCM
Prolonged survival in intensive care
Direct Pre-eclampsia, AFE, genital tract trauma and
sepsis, PPH
Indirect Sudden cardiac death, DOA, CHD, VTE, AIDS,
SLE, SUDEP, APLA, Tumors
Coincidental Homicide, road collision, drug toxicity, Cancers
Cause of death
Standard protocol
Information and samples
Placenta
Classic form – sudden cardioresp collapse
Clinical triad
Hypotension / cardiac arrest
Pulmonary vasospam
Coagulopathy with severe bleeding
High mortality ; treatment is supportive
Amniotic fluid, amniotic and fetal squamouscells and hair embolise to small vessels of the lungs
H and E AB HMWCK CD31
Renal glomeruli – fibrin thrombi in capillary lumen – DIC
Uterus – mucosal bleed – entry of AF into uterine veins – via CS incision or mucosal split
Pathogenesis – debated
Acute anaphylactic response with cardiopulmshutdown + triggering the clotting cascade and consumptive coagulopathy
? Eg of SIRS – inappropriate release of endogenous inflammatory mediators, an abnormal maternal response to fetal Ag
Used as defence against claims of clinical negligence – Fatal peri or PPH
AFE : inevitably fatal
Pre-eclampsia and eclampsia – 3rd trimester
Increased BP, oedema and proteinuria
Predisp : essential HT, renal disease & obesity
Clonic-tonic seizures in pre-eclampsia
HELLP Syndrome
Etiopathogenesis – poorly understood Generalised vasculopathy
Mode of acute death HT type intracerebral Hm
Encephalopathy caused by vasogenic edema ( severe generalized version of PRES – due to endothelial damage)
Fatal cardiac arrhythmia
HELLP : intra abdominal Hm
Brain
Intracerebral Hm without pre-exisiting berry aneurysm or predisposing factor (60%)
Diffuse cortical petechial Hm – occipital lobes
Swelling and diffuse cerebral oedema
Kidney
Glomerular endotheliosis (unique)
Endothelial cells are swollen ; glomerular capillaries appear bloodless
Glomerulus may also herniate into proximal tubules
Endothelial cells maybe vacuolated with lipid
Silver staining : string of beads appearance
Uterus and placenta Effects of reduced arterial blood supply on villi + foci
of infarction
Decidua – atherosis, fibrinoid necrosis of spiral arterioles
Liver Gross : blotchy focal or confluent Hm necrosis
Histo : periportal fibrin deposition, Hm and hepatocyte necrosis ( unique )
General autopsy findings of hypovolemicshock
Pallor
Pituitary infarction
Hypoxic – ischaemic neuronal necrosis in brain
Uterine atony – commonest cause Placenta praevia Retained placenta Placental abruption – severe coagulopathy Creta syndromes
Accreta (villi attach direct to uterine muscle)
Increta (invade further into myometrium)
Percreta ( through myometrium)
Genital tract trauma – large babies / iatrogenic ENBLOC removal of genital tract
Uterine rupture – big baby/ small pelvis/ prolonged labour/ drugs
Abortion Spont ( <24 weeks) : septic or aseptic : genital tract
sepsis/ uterine Hm/ molar preg Legal termination of preg Criminal : infection/Hm
Several syndromes with diff pathogensis
Severe cases – end results : bacteraemicseptic sock and multiorgan failure with DIC
Placental examination – critical + microbiological culture + HPE
Maternal blood cultures : aseptic – neck veins or heart
CATEGORY TYPICAL INFECTIONAGENT
PATHOLOGY
1. Unsafe abortion Clostridium spp Genital tract necrotising sepsis ; septic shock; MOF
2. Ruptured membranes E coli Infected and inflamed placenta, cord and membranes, genital tract sepsis; MOF
3. Post delivery Group A Streptococcuspyogenes (GAS)
Genital tract sepsis, sometimes necrotisingwith high bact load; MOF
CATEGORY TYPICAL INFECTIONAGENT
PATHOLOGY
4. Community acquired sepsis
GAS, pneumococcus TSS ; MOF
5. Post partum sepsis related to birth process but genital tract not involved
Gram negative and positive organisms
Localised sepsis, leading to MOF
Collapse and die suddenly Critical to examine the entire length of pulm
artery
Pregnancy is a procoagulant state
Prevents severe Hm when placenta detaches from decidua
10X relative risk of VTE (through out preg to week after delivery)
Common category
Aneurysm, dissection and rupture – 3rd trimester
Etiology :multihit Inherent predisposition + progestrone-associated
weakening of the media
Histo : elastic degeneration, mucin deposits and attenuated muscle
Outcome : collapse from shock
Congenital heart lesion with pulmonary HT Inheritable cardiomyopathy – HOCM, ARVCM Acquired cardiac muscle disease – IHD,
endocardial fibroelastosis, myocarditis SADS – sudden unexpected arrhythmic
cardiac syndrome – negative autopsy – long QT syndrome
Obesity and sudden cardiac death Valvular disease
Heart failure during last month of pregnancy and upto 5 months post delivery
Dilated cardiomyopathy
Nonsp histology
Oxidative proapoptotic stress on myocytes, related to prolactin
Pregnancy increases risk of TTP
Abnormalities of vWF physiology – platelet clustering and adhesion to endothelia of the microvasculature – brain, kidney, heart
Postpartum confusion, MAHA and renal failure
Lab : low platelet but normal CF and fibrin
Preg – relative immunodep state [CMI ]
Viral infection ( HS , hepatitis , influenza ) Listeriosis Tb
2009-10 pandemic – type A/H1N1
3rd trimester preg – influenze pneumonitisand A/c lung injury
Acquired secondary bacterial pneumonia
Preg was the pre-eminent risk factor for death with H1N1 infection
Maternal mortality raises by 10 fold
Late presentation at around time of delivery
Death – Tb or opportunistic infections, sepsis or complications of abortion
Obtain as much as clinical information and lab data as possible before starting the autopsy
Take sterile blood culture; later, retain a femoral venous blood sample
Pay close attention to pulm artery , heart and genital tract
‘Negative’ autopsy : retain a piece of spleen in freezer
To establish cause of death – discuss the case openly with obstetricians, physicians, anaesthestists and intensivists