MATERNAL DEATH AUTOPSY

DR.JANANI MATHIALAGAN1st year PG - Pathology

OVERVIEW• Definition• Classification• Direct causes• Indirect causes• Summary

DEFINITION• Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by pregnancy or its management but not accidental or incidental causes.

MATERNAL MORTALITY RATIO = No. of maternal death x 100,000 No. of live births

INDIA: 2007-2009 = 212/100,000 live births2011-2013 = 167/100,000 live births

CLASSIFICATION OF MATERNAL DEATH• DIRECT • INDIRECT• COINCIDENTAL

Direct Indirect Coincidental

Definition Conditions directly related to pregnancy &/or deliveryOnly happens through pregnancy

Diseases not directly related to pregnancy or delivery but are exacerbated by it.

Diseased or events unrelated to pregnancy and not influenced by pregnancy.

Examples

• Pre-eclampsia• Amniotic fluid

embolism• Genital tract

trauma• Post partum

hemorrhage• Genital tract sepsis

• Aortic dissection

• Congenital heart disease

• Venous thromboembolism

• HIV/AIDS

• Homicide• Road collision• Illicit drug

toxicity• Most cancers• Some suicides

DIRECT CAUSES• Amniotic fluid embolism syndrome• Hypertensive disease of pregnancy• Peripartum hemorrhage• Peripartum dilated cardiomyopathy• Sepsis• Air embolism

AMNIOTIC FLUID EMBOLISM SYNDROME• Clinical triad

Hypotension/ cardiac arrestPulmonary vasospasmCoagulopathy with severe bleeding

During or just after labor or caesarean section

Entry of amniotic fluid, fetal hair, amniotic & fetal squamous cells into maternal circulation

Embolise in the small vessels of the lungs

Triggers acute anaphylactic response

Cardiopulmonary shutdown, clotting cascade, consumptive coagulopathy.

Important autopsy pathology is in the lungs.

Stains used: H & E Alcian blue (amniotic acid mucin) LP 34 (high molecular wt keratin) Endothelial CD31 (diff b/w embolic squames & sloughed endothelial cells)

• Renal glomeruli:fibrin thrombi is usually found in capillary

lumens (indicating DIC as a part of AFES)

• Uterus:mucosal bleeding sitesAmniotic fluid material in mural veins

MEDICO LEGAL ASPECT:• AFE is inevitably fatal.• So can be used as a defence against claims of clinical negligence where there has been fatal peri- or postpartum hemorrhage.

HYPERTENSIVE DISEASES OF PREGNANCYPre-eclampsia: raised blood pressure,

oedema,proteinuria.

Predisposing factorsessential hypertension,renal disease,obesity

Asssociated with HELLP syndrome (hemolysis, elevated liver enzymes, low platelet

count)

• Eclampsia:clonic tonic seizures occurring in a patient with

pre-eclampsia.

It has high mortality rate.

Eclampsia induced endothelial cell damage

Vasogenic oedema

Encephalopathy

HELLP syndrome

Liver failure and capsular rupture

Intra-abdominal hemorrhage

Eclampsia

Intracerebral

hemorrhage

death

AUTOPSY PATHOLOGY:• BRAIN: deep intracerebral hemorrhage

diffuse cortical petechial hemorrhage – occipital lobe

diffuse cerebral oedema

• KIDNEY: Glomerular endotheliosis endothelial cells are swollen and appears

bloodlessglomerulus herniates into proximal tubuleendothelial cells vacuolated with lipid

Special stain: Silver – basement membrane thickening and remodeling resulting in string of beads appearance

• UTERUS AND PLACENTA:reduced arterial blood supply on the villi, with

foci of infarction.decidua shows atherosis and fibrinoid necrosis

of the spiral arterioles.

• LIVER:focal and confluent hemorrhagic necrosisMicroscopically – Periportal fibrin deposition,

hemorrhage,hepatocyte necrosis

PERI & POSTPARTUM HEMORRHAGECAUSES:• uterine atony, placenta praevia, retained placenta

• placental abruption• creta syndromes• genital tract trauma• uterine rupture• abortion

UTERINE ATONY, PLACENTA PRAEVIA, RETAINED PLACENTA

PLACENTAL ABRUPTIONDEFINITION:

Premature separation of placenta from the walls of the uterus during pregnancy.

Leaves a clot b/w maternal placental surface and uterus

CRETA SYNDROMESAdherent placenta

It can be accretaincretapercreta

Previous c- section

Fibrotic scar

Decidua becomes sub-

optimalPlacental villi

attaches directly to uterine muscle

Adherent placenta

GENITAL TRACT TRAUMABy large babies or clumsly assisted delivery.

Vagina, cevix, lower uterus can be torn

Entitre genital tract en block dissection is done (from vagina to uterine fundus)FixedSerially horizontally sliced and sampled to depict tear dimention and vesses rupture.

UTERINE RUPTURE• Causes: big baby

small pelvisprolonged labourdrugs – misoprotol and oxytocics

On examination of uterus, typically lateral rupture is seen.

ABORTION• Expulsion of products of conception before completion of 28 weeks of gestation.

• Causes of maternal death is due toascending genital tract sepsisuterine hemorrhage

SEPSIS• Sepsis is commonly due to bacteraemic septic shock

multi-organ failureDIC

SEPSIS CLASSIFICATION

SEPSIS CLASSIFICATIONS.No

Category Case definition Agent Pathology

1. Unsafe abortion Illegal termination of pregnancy

Clostridium spp.

Mulit organ failure

2. Ruptured membranes GT infections during the time of membrane rupture

E.coli Infected and inflamed placenta, cord, membrane, GT sepsis, MOF

3. Postdelivery Delivery followed by 1-2 days of wellness followed by GT infection

Group A streptococcus pyogenes (GAS)

GT sepsis, MOF,

4. Community acquired sepsis

Membranes intact, not in labour

GAS, Pneumococcus

TSS,MOF

5. Postpartal sepsis related to birth process, but GT not involved

C-section wound infection, infected spinal anaesthesia

Gram negative & gram positive organisms

Localised sepsis leading to MOF

• Autopsy pathology:placenta (with microbiology culture)pre-evisceration maternal blood culture (taken

aseptically)any pre-death cultures if done

• SEMELWEIS SYNDROME:

INDIRECT CAUSES• Venous thromboembolism• Cardiac causes• Systemic hypertension• Idiopathic arterial pulmonary hypertension• Pre-existing thrombophilia states (anti-PLA syndrome)• Thrombotic thrombocytopaenic purpura• Stroke• Psychiatric causes• SUDEP (sudden unexplained death in epilepsy)

VENOUS THROMBOEMBOLISM• It occurs following C-section in the form of massive pulmonary embolism.

• Pregnant women are 10 times more prone for VTE

• Autopsy pathology:examine the entire length of the pulmonary

artery tree to show massive thromboembolism

CARDIO VASCULAR DISEASEPATHOGENESIS:

inherent predisposition +

progesterone associated weakening of the tunica media

(Elastic degenerationMucin depositsAttenuated muscle)

Weakening of the wall of aorta,

medium and large arteries

Aneurysm

Dissection

Rupture

CARDIAC DISEASESIt includes• congenital heart lesion with pulmonary hypertension

• inheritable cardiomyopathy• acquired cardiac muscle disease• SADS (sudden unexpected arrhythmic cardiac death synd)

• valvular disease (IV drug users, rheumatic mitral stenosis)

• Predisposing factors:lifestyleobesityincreasing age of pregnant women

In inheritable cardiac conditions (long QT syndrome), autopsy will be negative and heart morphologically normal. Retaining a piece of frozen spleen tissue is done for later DNA analysis.

PERIPARTUM CARDIOMYOPATHY:

• Heart failure during the last month of pregnancy and upto 5 months post-delivery with all other causes excluded.

Aetiology: oxidative pro-apoptotic stress on myocytes,

related to prolactin.

THROMBOTIC THROMBOCYTOPAENIC PURPURA

Abnormalities of von Willebrand factor

Platelet clustering and adhesion to endothelium

Platele thrombi blocking small vessels to brain,

kidney, heart

Laboratory data: low plateletsnormal clotting factors and fibrin

C/P:microangiopathic anaemiarenal failureblockage of arterioles and venules in

myocardium resulting in hemorrhagic infarction and acute heart failure

PREGNANCY ASSOCIATED INFECTIONS• Pregnancy is a relative immunodepressed state • So

listeriosis, tuberculosis, viral infections are more aggressive

EPIDEMIC INFLUENZA• Type A/ H1N1 influenza• Mainly affects third trimester• Results in

influenza pneumonitis,acute lung injury,secondary bacterial pneumonia.

HIV• More prevalent in low-income countries with high HIV prevalence

• 10 fold increase in maternal mortality

• Death is mostly due to TB or other opportunistic infections or sepsis.

SUMMARY• Before evisceration, sterile blood cultures is to be sampled

• Close attention to pulmonary artery, heart and genital tract

• Systemic sampling of all organs for histopathology• If autopsy is negative, retain a piece of spleen for DNA analysis

• Clinical negligence claim

References:• Recent advances in histopathology 23 ( chapter 2 )

• WHO website ( maternal mortality )

Thankyou