Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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15 Pathology
Pulmonary embolus
Death from pulmonary embolus was given as the cause in twenty-three autopsy reports, of which eight
were excellent or good, nine were adequate but six were poor or appalling. Again there was a common
failing not to search for evidence of previous episodes of pulmonary embolus:
A woman who had a termination of pregnancy presented to the Emergency Department (ED) with
chest pain few weeks later. She had tachycardia and was apyrexial but, despite this, she was
diagnosed as having pelvic infl ammatory disease. She died one week later.
Her autopsy report was less than one side of a sheet of A4. It identifi ed impacted emboli in the pulmonary
arteries of both lungs and stated there was no evidence of embolism (sic) in the pelvic veins. There was no
histology or attempt, even macroscopically, to demonstrate previous pulmonary emboli. There was also no
attempt to confi rm or refute the clinical diagnosis of pelvic infl ammatory disease. Pregnancy was not stated in
the cause of death although in the opinion of the assessors it was a contributing factor of major signifi cance.
This case contrasts dramatically with those who had excellent reports: in one, thrombi in the internal iliac
vein and tributaries were histologically confi rmed as recent in some veins and organising in others. Many
small pulmonary vessels were undergoing extensive recanalisation but the major pulmonary emboli were
confi rmed as fresh thrombi with no organisation.
Box 15.1
Pathology learning points: pulmonary embolism
At autopsy:
Predisposing causes for thromboembolism should be identifi ed.
The source of the emboli should be stated.
Evidence for episodes of thromboembolism preceding death should be sought.
Pre-eclampsia/ eclampsia
The case reports of 16 of the 18 women who died from pre-eclampsia or eclampsia were reviewed. Eleven
were associated with cerebral haemorrhage or infarction, three with the HELLP syndrome and one was
an anaesthetic death. The remaining woman had pre-eclampsia but her immediate cause of death was
necrotising fasciitis involving the cervix and uterus. Three women who died from cerebral haemorrhage
did not have an autopsy although they were referred to the coroner. Nine of the remaining 13 reports were
good or excellent and there was only one poor autopsy:
A non-English-speaking woman was admitted for induction of labour. On admission her blood
pressure was 136/83 mm/Hg and the diastolic remained at this level through most of her labour,
which lasted around ten hours. Her raised blood pressure was not treated. During the second stage
of labour she had a convulsion, at which point her blood pressure had risen and she had marked
proteinuria. A CT scan revealed a cerebral haemorrhage and she died in intensive care. The
postmortem report identifi ed cerebral haemorrhage but there was no clinical resume, the macroscopic
description of all organs was exceedingly brief and there was no attempt to perform any histology.
In four other cases there was a very rapid rise in blood pressure during labour, leading directly to death.
The rapid escalation and/or onset of fulminating hypertension in pre-eclampsia has been noted in previous
Reports. No deaths from fulminating pre-eclampsia arising between antenatal reviews occurred in this
triennium, but this is a possibility that may present as a sudden community death to be investigated by a
pathologist. In such instances histology may be the only evidence for the sequence of events.