The maternal death autopsy
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Transcript of The maternal death autopsy
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Recent Advances in Histopathology - 23Sebastian Lucas
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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
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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
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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
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Cause of death
Standard protocol
Information and samples
Placenta
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Classic form – sudden cardioresp collapse
Clinical triad
Hypotension / cardiac arrest
Pulmonary vasospam
Coagulopathy with severe bleeding
High mortality ; treatment is supportive
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Amniotic fluid, amniotic and fetal squamouscells and hair embolise to small vessels of the lungs
H and E AB HMWCK CD31
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Renal glomeruli – fibrin thrombi in capillary lumen – DIC
Uterus – mucosal bleed – entry of AF into uterine veins – via CS incision or mucosal split
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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
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Used as defence against claims of clinical negligence – Fatal peri or PPH
AFE : inevitably fatal
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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
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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
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Brain
Intracerebral Hm without pre-exisiting berry aneurysm or predisposing factor (60%)
Diffuse cortical petechial Hm – occipital lobes
Swelling and diffuse cerebral oedema
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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
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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 )
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General autopsy findings of hypovolemicshock
Pallor
Pituitary infarction
Hypoxic – ischaemic neuronal necrosis in brain
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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)
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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Preg – relative immunodep state [CMI ]
Viral infection ( HS , hepatitis , influenza ) Listeriosis Tb
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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
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Maternal mortality raises by 10 fold
Late presentation at around time of delivery
Death – Tb or opportunistic infections, sepsis or complications of abortion
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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
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To establish cause of death – discuss the case openly with obstetricians, physicians, anaesthestists and intensivists
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