6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

LucasAnnex 9.1. Pathological overview of cardiacdeaths including sudden adult/arrhythmic deathsyndrome (SADS)S Lucas (on behalf of the Centre for Maternal and Child Enquiries)St Thomas’ Hospital, London, UKCorrespondence: Dr Sebastian Lucas, St Thomas’ Hospital, 2nd Floor, North Wing, London SE1 7EH, UK. Email: sebastian.lucas@kcl.ac.ukCardiac deaths: pathology goodpractice points• Do the heart examination well, with full dissection ofthe coronary arteries, accurate weight of the heart,measurement of the ventricle thicknesses and carefulevaluation of the valves.• Correlate these data with the woman’s body weightand body mass index (BMI).• Do histology on a standard mid-horizontal slice ofheart muscle, to examine the right and left ventricles.• Look at the lung histopathology for clues (e.g. pulmonaryhypertension).• Retain a blood sample in case cocaine and otherstimulant drug analysis is necessary.• Consider consulting a cardiac pathologist to gainadvice and support for the diagnosis.• If the diagnosis is going to be SADS, make sure allother reasonable cardiac diagnoses, as well as pregnancy-relateddiagnoses (such as amniotic fluidembolism), are excluded.• If SADS or a standard cardiomyopathy seems to bethe diagnosis, retain a sample of frozen spleen forpossible later genetic evaluation; the coroner will notbe expected to resource such investigations, but theNHS cardiac genetic clinics will.The main trends in cardiovascular pathology for this trienniumare the reduction in deaths associated with congenitalheart disease and the apparent rise in incidence ofSADS. This is better described as sudden arrhythmic deathsyndrome where unexpected and unpredicted cardiac arrestoccurs and it is discussed later.Cardiac pathology is what pathologists should do well, asit is the commonest scenario of death they encounter inroutine practice in the UK. Broadly, for coronary ischaemicheart disease, infective endocarditis, pulmonary hypertensionand congenital heart disease and for dissection ofaorta and other vessels, this was true in the maternal deathsreviewed this triennium. But it was not the case for difficult,non-obvious cases where acute cardiac failure was thescenario.Ischaemic heart diseaseIn the deaths examined, the usual patterns were seen ofcoronary artery atheroma, with or without acute thrombosis,and cardiac muscle damage, as either acute infarctionor chronic fibrotic ischaemic damage.Two women had different specific causes of coronaryartery occlusion. One had postpartum dissection of the leftanterior coronary artery causing myocardial infarction. It isremarkable that pregnancy is the major risk factor for suchdissection, albeit uncommon. It is presumed that thehormonal effect on arterial muscle tone interacts on anin-built medial damage to cause it. From the practical perspective,pathologists should note that, without very closegross inspection, a dissection of a coronary artery can lookvery like an acute thrombosis; histology is useful here toconfirm the process.The other woman was an adolescent who presented severalmonths after pregnancy with myocardial infarction.The aetiology was a rare autoimmune disease (Kawasakidisease) with vasculitis of the coronary arteries and secondarystenosis and occlusion.Dissection of the aortaThe seven women who died from dissection of the aorta hadautopsies. Not surprisingly, most were well done, althoughthree reports had no height or weight (therefore no autopsyBMI was calculable). Although the gross pathology is selfevident,it is arguable whether histopathology is required to116 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203