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Chapter 10: Other Indirect deathscal questions of alternative diagnoses to epilepsy, which isimportant in the case of SUDEP, and included ancillaryblood tests to identify anticonvulsant and other drugs. Thebasic mechanism of SUDEP is thought to be an arrhythmiaoccurring during an epileptic seizure, stopping the heartbeat.Cerebral thrombosisAutopsies were performed in the minority of women withischaemic stroke because imaging pre-mortem usuallyidentifies the pathology. Thrombophilia was a factoralready known in one woman. The pathologist cannotidentify an inherited thrombophilic state post-mortembecause functional blood clotting tests cannot beperformed on autopsy blood. Genetic studies of DNA forknown prothrombotic conditions have not been validatedon autopsy material.Not all of the cases of stroke were aetiologically resolved.In one woman, who died of a thrombotic stroke in thepuerperium and did not have an autopsy, the diagnosiscould have been arterial occlusion, possibly from paradoxicalthromboembolism, sagittal sinus or cerebral veinthrombosis, or tuberculous meningitis. Obviously, knowingwhich was the case, would have informed clinical audit, aswell as categorising the case better as a Direct, Indirect orCoincidental death.Cerebral haemorrhageSubarachnoid haemorrhageOf the six women who died with a subarachnoid haemorrhage,only one had an autopsy. The others were diagnosedat CT scan and/or craniotomy, with the aneurysm identifiedalong with the subarachnoid and intracerebral haemorrhage.With a confident clinical cause of death there wasno requirement for a medico-legal autopsy. The singleautopsy exemplifies some of the problems in specifying thecause of death when women present as ‘death in the community’:An obese woman collapsed in a car park toward the end ofpregnancy and was dead on arrival at the EmergencyDepartment. Her booking blood pressure was 110/80 mmHg. The neuropathological autopsy found a rupturedberry aneurysm and subarachnoid haemorrhage; but theheart weighed 411 g, definitely enlarged with left ventricularhypertrophy. The kidney was not scrutinised for glomerularendotheliosis (the histological marker for pre-eclampsia), sothe questions regarding the underlying predisposition foraneurysm rupture remain open: was this essential hypertensiondespite the booking blood pressure, acute pre-eclampsiawith rise in blood pressure, obesity cardiomyopathy andcoincidental ruptured aneurysm or idiopathic left ventricularhypertrophy with ruptured aneurysm?InfectionThe women with apparently primary bacterial pneumoniaswere not well evaluated at autopsy apart from a womenwho died in her second trimester from staphylococcalpneumonia complicating type B influenza. For the otherwomen, no attempt at lung microbiology was made,which is disappointing given the importance of the epidemiologyof community-acquired pneumonia in this agegroup. In neither of the two HIV-positive women was acoronial autopsy necessary, but in one woman it was performed.However, the pathologist showed little insightinto the complex pathologies encountered in late-stageHIV disease, and the report would have helped neitherthe HIV doctors nor the obstetricians in their clinicalaudit.DiabetesAll the women who died of diabetic hypoglycaemia hadautopsies, which were not all well done. In two of thethree women the characteristic red neurone change inthe brain was not documented histologically and nor werethe glucose and insulin levels measured in blood andvitreous fluids.The associated dead-in-bed syndrome is worth mentioningas a relatively new entity. The basic mechanism of SU-DEP is thought to be an arrhythmia occurring during anepileptic seizure, stopping the heart beat. Similarly withunexplained deaths in diabetes, the so-called diabetic‘dead-in-bed syndrome’. This was documented twice in thistriennium in women who had been insulin-dependent diabeticsfor more than 10 years. For example:A woman with longstanding type 1 diabetes for many yearsand who had had many hypoglycaemic episodes, was founddead in bed in mid-pregnancy. The post-mortem biochemistryfor glucose and insulin was ambiguous, as is often thecase but the brain histopathology showed hypoglycaemictypeneuronal necrosis. The diabetologist consulted on thecase proposed the sudden nocturnal death in diabetes scenario,which comprises a diabetic autonomic neuropathy,and a long QT interval—leading to fatal arrhythmia. 9 Significantlythis is not just hypoglycaemia causing death; hypoglycaemiais critically associated with cardiac electricalinstability.Liver diseaseTwo women died as a result of bleeding from cirrhoticportal hypertension. The deaths of two other womenhighlight how complicated medicine can be, because whatactually happened was not finally resolved despite goodautopsies. In a woman who had liver abscesses and peritonitis,the route of infection was not ascertained, despiteª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 129