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

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15 Pathology
An obese multigravid woman with a long history of substance abuse including heroin, cocaine
and amphetamines had pre-eclampsia controlled by labetalol. A few weeks after delivery her
blood pressure was recorded as 130/90 mm/Hg but the following day she had a fi t. Cerebral and
subarachnoid haemorrhage was diagnosed on CT scan and she died shortly afterwards. Despite
the known connection between cocaine and cerebral haemorrhage, no autopsy was authorised
by the coroner.
All six autopsies were conducted to a very high standard. In half of the cases there were antecedent
causes such as hypertension, primary erythrocytosis and haemorrhage into a vascular malformation. One
death occurred some days after delivery in a woman with a two day history of worsening headaches. The
pathologist carefully searched for and excluded features of pre-eclampsia and reviewed the literature
around pregnancy-associated cerebral haemorrhage and stroke in the absence of pre-eclampsia 19, 20 .
Another unique case had a family history of death from cerebral haemorrhage in pregnancy:
A fi rst time mother booked saying that two close female family relatives had died from a brain
haemorrhage in the latter half of their pregnancies. A thrombophilia screen of unknown detail
had been negative. This history seems to have been ignored and she was not referred for
assessment until she was admitted in the third trimester with vomiting, weakness and loss of
balance. It was thought she had a neurological problem and she was transferred to a medical
ward in another hospital where a CT scan showed brain swelling. She was then transferred to the
local neurological centre where the cause of the swelling remained obscure even after a brain
biopsy. A cerebral haemorrhage was thought to be the most likely diagnosis and despite intensive
treatment she rapidly deteriorated and died.
At autopsy a cerebral vein thrombosis (CVT) deep in the thalamostriate vein was the cause of death.
The superfi cial venous sinuses were patent confi rming the imaging fi ndings when she was alive. The
pathologist was able to review material from one of the relatives’ autopsy and concluded that a deep
cerebral CVT, not cerebral haemorrhage was the cause of her death. It was not possible to examine
material from the other relative though her death was confi rmed as ‘cerebral haemorrhage’ in pregnancy.
Even if this family has an undetected inherited thrombophilia, the occurrence of a deep CVT arising in late
in pregnancy in two, and probably three family members and without any other clinical manifestations of a
thrombotic tendency is striking. It also demonstrates that the modern imaging techniques used to diagnose
cerebral haemorrhage do not provide all the answers and a good autopsy can still add diagnostic value.
Epilepsy
Ten of the women who died from epilepsy in this triennium had a postmortem; only one was poor in
its macroscopic description but this and two others lacked postmortem toxicology and therefore are
considered defi cient. Seven deaths were classifi ed as due to sudden unexpected death in epilepsy
(SUDEP). In this condition death is usually not witnessed and may or may not occur during a seizure but is
not due to a complication of the seizure such as aspiration. It is not clear whether pregnancy is a direct risk
factor for SUDEP. One reason for this is that there is only limited information on drug compliance during
pregnancy. Clinically antiepileptic therapy was discontinued or only intermittently taken in at least two
cases but only confi rmed by postmortem toxicology in one of these.
In three cases there was no postmortem toxicology and the results were not detailed for a fourth. As both
the SUDEP study and the College Guidelines 1 state, toxicology is indicated in these deaths. There was no
underlying morphological abnormality in the brain in ten cases but detailed neuropathological examination
was only performed in two.