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

Obesity was present in 55% of these cases and morbid obesity was present a quarter of women who
died of ischaemic heart disease/myocardial infarction. A similar picture was seen for deaths from sudden
adult death syndrome (SADS). Abdominal obesity is the form of obesity most strongly associated with
the metabolic syndrome with its associated increased risk of cardiovascular disease. Clinically there
is increased waist circumference with raised triglycerides, total cholesterol and low concentrations of
high-density lipoprotein cholesterol in the peripheral blood. Non-esterifi ed fatty acids are also frequently
raised. Raised levels of non-esterifi ed fatty acids have also been associated with sudden death from
cardiovascular disease 13 . Measurement of non-esterifi ed fatty acids at postmortem is unreliable but a
good proxy is measurement of abdominal circumference particularly in ratio to the hip circumference 14 . For
women an abdominal girth greater than 88 centimetres would be a criterion helping to defi ne the metabolic
syndrome 15 .
Ischaemic and unascertained
Three of the 12 women who died from ischaemic heart disease and whose cases were assessed had no
postmortem. Three autopsies were poor but the other six were good or better. All these women had clinical
risk factors such as smoking, obesity or diabetes. The clinical history was often suggestive in the cases
of women who died from sudden adult death syndrome (SADS). One woman, who had been investigated
some years earlier for episodes of collapse that had been attributed to vasovagal faints, collapsed and
died whilst talking to someone. Two other cases may have been due to SADS but cannot be adequately
categorised; the coroner failed to release the autopsy report in one case whilst in the other the autopsy
was so bad that an attributable cause may have been missed. Of the other cases of SADS where autopsy
reports were available, one was adequate and another poor but the majority were very good and had
clearly excluded other potential causes. For example:
A young girl was found dead a few months after delivery and a thorough, detailed, autopsy failed
to demonstrate a cause of death. Cardiomyopathy was suspected but excluded after referral to a
cardiac pathologist and so a diagnosis of SADS was made. Subsequently cardiac tissue that had
been submitted for genetic studies showed a mutation which was not in the European Society of
Cardiology database.
The pathogenicity in this particular case is not known and can obviously only be determined when more
cases are identifi ed. This would require more detailed investigation of cardiomyopathies and SADS. It
is, however, vital that there is further screening of the family members when a young woman under the
age of 40 years has an unascertainable cause of death. In one study there were cardiac abnormalities
in 40% of the families associated with such deaths. The causes included electrical conduction problems,
cardiomyopathies of all types and hypercholesterolaemia 16 .
Arterial dissections
There were 17 deaths from arterial dissection subject to pathological review. Of these eight were in the
aorta, four in the splenic artery, three in the coronary arteries and one each in the external iliac and the
basilar arteries.
All of the postmortems on the aortic dissections were performed to a high standard. Two women were
morbidly obese, two had Marfanoid features, the father of another had died of aortic dissection and one
had three separate aortic dissections with only the third rupturing. One further woman died of pulmonary
embolus: the dissection had re-entered to create a double barreled aorta. In all but one case histology
revealed features such as organisation of the blood within the aortic wall indicating that the dissection
had started some days prior to fi nal rupture though the duration of the clinical symptoms had rarely been
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