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

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15 Pathology
death was much more indicative of a sudden cardiac arrhythmia rather than sepsis.
Box 15.3
Pathology learning point: sepsis
Where possible the nature and portal of entry of the infection should be identifi ed.
Other causes of Direct death
The cases reviewed in this category include nine deaths from ectopic pregnancy, two following miscarriage,
two terminations of pregnancy, four anaesthetic deaths, three deaths from choriocarcinoma and a small
number of individually rare causes. Autopsy confi rmed the deaths from ectopic pregnancy and miscarriage,
and one probable illegal abortion was identifi ed. In this case a perforation was found in the lateral fornix in
a woman who died of septicaemia from an unusual organism.
Autopsies for the anaesthetic deaths confi rmed the absence of other causes of death and in one case
demonstrated haemothorax from subclavian vein perforation during central venous line insertion. One
death from choriocarcinoma deserves particular mention:
Following an intrauterine death at term, an externally normal infant was delivered. A detailed
perinatal autopsy demonstrated a massive haemoperitoneum with a tumour on the liver which
was shown to be choriocarcinoma. No primary site was identifi ed in the placenta but eight weeks
after delivery the mother was admitted to hospital with a brain haemorrhage. A brain biopsy
demonstrated metastatic choriocarcinoma and, despite treatment, she died.
The results of the perinatal autopsy report had not been sent to the family or any of her health professional
carers. Indeed they were not known to them until the mother had been admitted with her fatal brain
haemorrhage. Given that choriocarcinoma is curable if treated in time, this long delay represents
substandard care. Sadly this may be a critical refl ection on the paucity of paediatric pathologists that has
now developed in the United Kingdom. Failure to demonstrate a primary site for choriocarcinoma is a rare,
but well documented, event 10, 11 .
Other miscellaneous Direct deaths include one death in a woman diagnosed as having fatty liver, but who
probably had Ehlers-Danlos syndrome. There was no autopsy in another Indirect case of Ehlers-Danlos
but the diagnosis was made on the bowel following resection for mesenteric vein thrombosis. 12
Indirect deaths
The leading overall, and Indirect cause of maternal death, is cardiac disease. The second most common
death from Indirect causes is suicide. This is a reversal from the last Report.
Cardiac disease
Obesity
Forty-eight women died from heart disease during pregnancy or within six weeks of delivery in this triennium
and a further thirty four Late deaths occurring some months after childbirth were also considered by the
Enquiry. Sixty-one of these deaths have been reviewed by the pathology assessor together with six cases of
non-aortic dissections. Fifty four cases had available autopsy reports of which 29 were good or excellent, 11
adequate, 11 poor and three were appalling. As discussed later, they have been broadly subclassifi ed into
ischaemic heart disease and unascertained, arterial dissections, cardiomyopathies and miscellaneous.