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

association with obesity as eight of the deaths were in women with a Body Mass Index (BMI) over 30. Review
of the reports suggested that there was increased diffi culty in diagnosing severe infections in such women.
The most common organisms were eight cases of streptococci and six cases of coliforms, often admixed
with enterococci. There were also three exotic infections by citrobacter koseri and listeria monocytogenes
as well as aeromonas subrea in an HIV positive patient. Two women had predisposing immunodefi ciency
states, one of whom was known to be HIV positive. The other had incontinentia pigmenti, a condition
associated with the NEMO gene, abnormalities of which not only give rise to incontinentia pigmenti but can
also be associated with immunodefi ciency states 9 .
Of the eight maternal deaths associated with streptococcal infection, one was due to ascending genital
tract infection by strep pneumoniae but the other cases were all from Group A. Though not directly
comparable with this review, the HPA’s fi gure for streptococcal puerperal sepsis (3%) suggests that
maternal death is a relatively rare complication of the infection. Coliform infections were usually associated
with premature rupture of membranes or the insertion of cervical sutures.
The reports of 20 women who allegedly died from infection have been reviewed although not all of them
are counted in Chapter 7 - Sepsis. In two cases no autopsy was conducted, one of whom died from
necrotising fasciitis. Of the eighteen autopsy reports, nine were good or excellent and three adequate but
six were poor or appalling.
All of the good or excellent reports had undertaken careful clinicopathological correlation and investigations
relevant to the clinical circumstances. In most this involved appropriate microbiology and more specifi cally
a search for the portal of entry. This search was inconclusive in several instances but in two cases there
was clear histological evidence of infl ammation centred on the genital tract and with a chorio-amniitis and
funisitis in the placenta and cord. One other had not only demonstrated chorioamnitis due to enterococci
and coliforms but had excluded streptococcal infection by polymerase chain reaction.
A frequent feature in the poor postmortem reports was inconsistency within the report itself. For instance,
in one report the heart weighed 161 gm but was described as showing left ventricular hypertrophy. The
most common defi ciency however was a failure to address the clinical problems. In one death from
streptococcal puerperal sepsis the woman had a preceding history of a sore throat and her lungs were
described as consolidated but there was no histology taken to exclude either respiratory or genital tract
infection. Furthermore, a laparotomy had revealed a dusky bowel and infarcted ovary but these features
were not identifi ed at the autopsy nor was there comment on the discrepancy. In another of the six poor
postmortems there is serious doubt whether death was truly due to sepsis:
A woman with congenital heart block had routine antenatal care by her midwife and General Practitioner
(GP) until late in pregnancy when pernicious anaemia was diagnosed. Only then was she referred to a
cardiologist. Labour was induced but a caesarean section was performed for fetal distress. She called
her GP a day or so after discharge because of vomiting and was readmitted and received intravenous
antibiotics. A few days after discharge, she suddenly collapsed with dyspnoea and quickly died.
At the autopsy, performed some days after her death, there was a duodenal ulcer and the incision into
the uterus was gaping although the sutures were intact. There was no description of local infl ammation
or peritonitis. A suggestion of retained placental tissue within the uterus and of lung basal consolidation
was not confi rmed by histology and no defi nite focus of infection was identifi ed either macroscopically or
histologically. No microbiological samples were taken. Her heart was mildly enlarged but there was no
detailed examination and there was no detailed histology. Although there was a history of puerperal sepsis
this had clinically responded well to antibiotics and there was no evidence of continuing infection after her
fi nal discharge from hospital. There was no defi nite evidence of sepsis at the autopsy and the mode of
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