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

Box 15.6
Pathology learning points: neurology
Cerebral haemorrhage
Cerebral haemorrhage is a fi nal common pathway with several different causes: a well conducted
postmortem can add value to even the most detailed clinical investigation.
Epilepsy
Deaths from epilepsy should have toxicological analysis of a postmortem blood sample.
Infection
Three deaths from tuberculosis, all in women from the Asian subcontinent, three other deaths from
meningitis and four from pneumonia were reviewed for this Chapter. None of the women who died from
tuberculosis had a postmortem. Two of the three deaths from meningitis were due to the pneumococcus
and the organism was not ascertained in the third death. None had an autopsy.
Two of the deaths from pneumonia were due to the pneumococcus. One woman had positive blood
cultures and classical lobar pneumonia after a two week history of a ‘fl u-like’ illness. The other autopsy was
poor in attributing the lobar pneumonia and her acute mitral and aortic endocarditis to meningitis. Histology
was taken but no report was included and attempts by the regional assessor to obtain the histology report
and slides failed. One death was due to a staphylococcal pneumonia complicated by invasive aspergillosis
following an infl uenza B infection and the other an atypical pneumonia.
Endocrine and immunological causes
Apart from the diabetic women who died from ischaemic heart disease there were three other diabetic
deaths. In one, a woman whose chaotic life style was associated with multiple episodes of ketoacidosis
was found dead in bed a few days after discharge from hospital when her blood glucose had been
16mmol/L. Her baby had been stillborn. The poor autopsy excluded unnatural causes and the cause of
death was given as unascertained but glucose and ketone sampling was not undertaken.
SLE/Antiphospholipid syndrome.
There were four deaths in this category. There was no autopsy for one and good autopsies addressed the
clinical issues in two of the other deaths. The fi nal case was a woman with a mid trimester stillbirth who
was admitted with diffi culty in breathing and chest pain. Clinical investigations suggested a diagnosis of
SLE but the postmortem simply gave the cause of death as ARDS. As the local assessors comment: ‘It is
obvious that the question needing an answer is whether the death was directly due to systemic lupus……
the pathology report, albeit on a severely limited autopsy is substandard and does not give any evidence of
attempting to elucidate the true nature of the underlying disease leading to death.’
Miscellaneous Indirect deaths
Included in this category are deaths from a number of other causes as shown in Chapter 10, Indirect
deaths. Of particular note were two deaths from liver rupture and bowel infarction related to Ehlers Danlos
Syndrome (EDS). The chief features of EDS IV are thin lax skin, joint hypermobility, bleeding, blood vessel
rupture particularly aortic dissection, intestinal rupture and preterm labour. If suspected then tissue from
skin or aorta can be analysed for decreased type III collagen or skin for the mutation in the COL3A1 gene
that is found in Ehlers Danlos type IV.
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