Pregnancy-associated deaths: a 15-year retrospective study and overall review of maternal pathophysiology

Pregnancy-related death is defined by the International Classification of Diseases, Tenth Revision (ICD-10) as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death. In the year 2000, a collaborative effort involving World Health Organization (WHO), UNICEF, and UNFPA estimated 660 maternal deaths in the United States. This averages 11 maternal deaths per 100,000 live births reported. Many pregnancy-associated deaths are not easily identified as such since the presence of a recent or current pregnancy may not be listed on the death certificate. Thus, the WHO estimates that in the United States, the maternal mortality is approximately 17/100,000 pregnancies. This is significantly higher than the goal set by the US Department of Health and Human Services in Healthy People 2010, which sets the target for maternal mortality at less than 3.3/100,000 live births. The most common causes of maternal death vary somewhat from region to region in the United States. They include pulmonary thromboembolism, amniotic fluid embolism, primary postpartum uterine hemorrhage, infection, and complications of hypertension including preeclampsia and eclampsia. Pulmonary disease, complications of anesthesia, and cardiomyopathy also are significant contributors to maternal mortality in some populations. The death of a pregnant or recently pregnant individual poses a wide scope of challenges to the forensic pathologist and investigator. The pathologist must have a broad knowledge of the physiologic and biochemical changes that occur during pregnancy, as well as the clinical and pathological manifestation of these changes. Conditions that may be "benign" in the nonpregnant individual may be lethal in the puerperal period. In addition, it should be kept in mind that deaths during pregnancy may be due to unnatural causes. Accident, homicide, and suicide must be ruled out in each case. The authors reviewed all forensic cases referred for autopsy to the Forensic Section of the Medical University of South Carolina from January 1989 through December 2003. All decedents listed as pregnant or postpartum were analyzed as to maternal age, race, past medical history, previous pregnancies and outcome, prenatal care, gestational age, fetal or neonatal outcome, location of delivery, placental findings, maternal autopsy findings, toxicology, cause of death, manner of death, and fetal or neonatal autopsy findings. The authors present this retrospective study to better determine the factors leading to maternal demise and discuss the autopsy/ancillary techniques useful in determining the cause of death in this challenging area.     

32例妊娠期死亡法医病理学研究

目的　探讨妊娠死亡的特点。　方法　对 1990～ 2 0 0 0年间华西医科大学法医学院所做 3 2例妊娠死亡尸检病例进行分析。　结果　妊娠产妇死亡年龄以 2 5～ 3 0岁为多见 ,职业以农民常见 ,且绝大多数无产前检查记录 ,死亡多发生于分娩过程中 ,区、乡一级卫生院多发。前四位的死因依次为 :胎盘残留、输卵管妊娠破裂、产后感染和子宫血管结扎出血 ,绝大多数妊娠产妇死亡前产下活婴。　结论　有必要加强基层与农村医疗保健工作和制订有关的预防措施 ,以降低妊娠产妇的死亡率。     

Maternal mortality in Slovenia: Case report and the method of identifying pregnancy-associated deaths

We report on the case of fatal intracerebral haemorrhage that followed the development of severe preeclampsia/eclampsia with haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in a 22-year-old primipara. Peculiarities of the reported case are abrupt onset of preeclampsia/eclampsia during the delivery, fulminant course of the disease, minimal changes in kidneys and signs of pre-existing accelerated arteriosclerosis. Since very few forensic pathologists have sufficient experience with such cases and the differential diagnosis may be difficult, we consider it necessary that in all maternal deaths the post-mortem examination is performed by a team of two forensic pathologists and the case further analysed in collaboration with expert obstetrician.Maternal deaths are rare in developed countries but extremely important, because they represent the “tip of the iceberg” of severe maternal and neonatal morbidity and because they reflect accessibility and quality of prenatal and obstetric care as well as the health status of reproductive-aged women. Unfortunately, they are often misclassified in death certificates which may lead to insufficient engagement in solving underlying problems. In Slovenia, the method of active search for pregnancy-associated deaths is used in order to enable accurate monitoring of maternal mortality and minimise underreporting. The method is based on the manual revision of death certificates and the computer-based linkage of Mortality Database with birth register and foetal deaths register and has proved to be highly efficient.     

The epidemiology of sudden infant death syndrome in Finland in 1969-1980

SIDS cases were defined by examining all death certificates, in which sudden deaths were expected to be found from the years 1969-80 from the Central Statistical Office of Finland. The age limits were 28-364 days. If the death certificate did not give enough information as to whether the cause of death was explained or unexplained, autopsy records and microscopic specimens were examined. If the death was sudden, but no autopsy was done, no microscopic specimens were taken, or there were some slight findings which could have partly explained the death were classified as borderline cases. The mean annual incidence of SIDS in Finland was 0.41/1000 livebirths in 1969-80. In 1969-74 and 1975-80 the incidences were 0.31 and 0.51, respectively. The increasing tendency of SIDS was partly due to more borderline cases in the first period and partly due to more twins, and infants with small birth weight, dying of SIDS in the second period. Deaths at weekends and sleeping with parents in the second period were more common than in the first study period. In the SIDs group the young maternal age, low social class, family type unmarried couple or single mother, maternal anemia during pregnancy were more common than in the control group. Mothers of SIDS infants had more previous children and fewer visits and later first visit to prenatal clinics than control mothers. The duration of gestation was shorter and the mean birth weight and length were smaller in the SIDS case than in the control group. Twins were more common among SIDS infants than in the common population. The most important risk factor of SIDS was maternal smoking during pregnancy. The epidemiological results conform with the hypoxia hypotheses.     

Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy‐Associated Autopsies

Abstract: Pregnancy‐associated death is defined as the death of a woman from any cause during pregnancy or in the year after delivery. This review concentrates on cardiac conditions that may result in pregnancy‐associated death including, but not limited to, acute myocardial infarction, endocarditis, peripartum cardiomyopathy, and prolonged QT syndrome. Lethal vascular conditions may also occur involving arterial dissection and thromboembolism, on occasion exacerbated by hypercoagulability, and altered hormonal and physiologic states. The autopsy evaluation of these patients includes a careful assessment of the medical history particularly for prior pregnancy‐related conditions, fetal loss, and episodes of unexplained collapse. A family history of sudden death at an early age may be significant. At autopsy, evaluation for underlying syndromes such as Marfan, or evidence of intravenous narcotism should be undertaken. Autopsy examination involves careful dissection of the heart and vessels with consideration of conduction tract studies and possible genetic evaluation for prolonged QT syndrome.     

孕产妇死亡医疗纠纷案法医病理研究

目的探讨孕产妇死亡医疗纠纷案的特点、主要死因及其防范对策。方法采用回顾性研究的方法,对我室1985年至2003年12月的法医尸体解剖案例资料进行统计,并对其中存在医疗纠纷的孕产妇死亡案例进行分析。结果31例存在医疗纠纷的死亡孕产妇法医尸检案例中:(1)围产期死亡26例(83.9%),妊娠早期人工流产后死亡5例(16.1%);(2)产科出血引起的失血性休克死亡22例(71.0%),羊水栓塞死亡5例(16.1%),其它原因死亡4例(12.9%);(3)乡镇医疗机构17例(54.8%),地县级医院占7例(23.6%),市级医院占4例(12.9%),其他占3例(9.7%);(4)纠纷产生的原因中疑为误治14例(45.2%),误诊的9例(29.0%),抢救不及时的7例(22.6%),其他1例(3.2%)。结论孕产妇死亡医疗纠纷案主要发生在围产期,其次是妊娠早期;产科出血是导致孕产妇死亡的最主要因素之一;乡镇及县级医疗机构易引起纠纷;引起纠纷的主要原因是误诊、误治和抢救不及时。     

Use of "therapeutic complication" as a manner of death

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.     

上海地区非法行医致孕妇死亡案例回顾性研究

目的研究上海地区非法行医致孕妇死亡案例并分析其特点,探究其形成原因及预防机制。方法收集本研究所2001～2005年接受上海市公安机关委托非法行医致孕妇死亡案例11例,按照孕妇情况、死亡原因及非法行医者的诊疗措施等进行分类整理分析。结果非法行医致孕妇死亡的原因多为产后大出血、羊水栓塞,多伴软产道裂伤。孕妇多未进行正规产前检查,到缺乏必要医疗条件的个体非法行医者处或者家中分娩,非法行医者往往存在不正当应用催产素,强行分娩,未采取及时有效抢救措施。     

Spontaneous rupture of unscarred gravid uterus

Rupture of gravid uterus during pregnancy is a rare entity. Overall incidence of rupture of uterus during pregnancy is 0.07%. The maternal and fetal prognoses are bad especially when the rupture occurs in an unscarred uterus. Fortunately, the sole major risk factor of spontaneous rupture of unscarred uterus is preventable, which is "multiparity." In this article, we report the death of a pregnant woman and her unborn child because of spontaneous rupture of unscarred uterus.     

Commode Cardia—Death by Valsalva Maneuver: A Case Series

The Valsalva maneuver is used in clinical medicine for the diagnosis and/or treatment of various cardiovascular conditions. It can also be used in activities of daily living, such as defecation. Due to the cardiovascular effects produced during the Valsalva maneuver, it may be contraindicated in certain medical conditions and could be a trigger of sudden cardiac death. The incidence and prevalence of death following Valsalva maneuver in the presence of underlying cardiovascular disease, or “commode cardia,” has not been examined. In 2012, the Wayne County Medical Examiner's Office (Detroit, MI) investigated 21 deaths that occurred on the toilet, fourteen of which were due to cardiovascular disease. In another 31 deaths in the bathroom due to cardiovascular disease, the possibility that the decedent defecated immediately prior to death could not be excluded. Hence, the incidence of commode cardia in this population ranges from 2.3 to 7.4% of all cardiovascular‐related deaths.     

A Case of Toxic Shock due to Clandestine Abortion by Misoprostol self‐administration

Maternal mortality and morbidity are the leading causes of death and illness, respectively, among women of reproductive age in many countries throughout the world. Of all maternal deaths, those related to unsafe abortions are the most widely underestimated, but they are also the most largely preventable. Medical abortion is a safe and reliable method for termination of a pregnancy in early gestation, although it is important to be aware of signs and symptoms of severe infection and toxic shock syndrome after the medical termination of pregnancy; case studies in literature are rarely fatal events. We report the first case of septic shock syndrome following a clandestine pregnancy termination with a misoprostol‐only regimen (12 tablets 200 μg each). Autopsy findings and histopathological examination proved that the woman died from septic shock. This case suggests to improve the forensic investigations in case of unsafe, often clandestine, abortion is suspected.     

Comparative histologic studies of the origin of petechial thymus hemorrhage

Systematic histological investigations were carried out on the thymus with regard to the incidence and genesis of petechial thymus hemorrhages in 145 cases of death (fetuses from pregnancy terminations and stillbirth, mature and immature neonates, SIDS cases, other baby deaths, deaths during infancy and childhood). Petechial thymus hemorrhages were most frequently found in SIDS cases (87%). Even though distinguishable, a distribution pattern similar to that of thymus hemorrhages in SIDS cases (including hemorrhages mainly in the cortical zone of the lobes) could be detected in the group of fetuses from pregnancy terminations and stillbirth, as well as in mature and immature neonates. Histologically, deaths in babies and infants without extrinsic suffocation showed a different histological bleeding pattern (irregular hemorrhages of varying size in the cortex and medulla of the lobes). In violent extrinsic suffocation of babies and infants, thymus hemorrhages were much rarer and less pronounced in quantitative terms. Acute and subacute or chronic forms of asphyxia, the cause of death and the duration of the death struggle are discussed as pathogenetic factors to explain the different patterns of the findings.     

Cocaine and fetal death

Toxicologic screening for cocaine and its metabolites was performed on 103 cases of fetal death autopsied in the Office of Chief Medical Examiner, City of New York. In 64 cases cocaine or its metabolites were found in the blood or in the brain. Some malformations were also found. The study indicates that maternal use of cocaine may lead to abruptio placentae, abortion and fetal death. The importance of toxicologic examination in these deaths is emphasized.     

Evaluation of certifier practices regarding alcohol-related deaths: Fulton County Medical Examiner's Center, Atlanta, Georgia, 2004

CONTEXT: Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation. OBJECTIVE: To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004. MAIN OUTCOME MEASURES: Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death. RESULTS: Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case. CONCLUSIONS: The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.     

U.S. Navy and Marine Corps recruit training deaths in San Diego, California, 1973-1985; a review of 31 cases.

The deaths of military recruits associated with training activities nearly always fall under close scrutiny from relatives of the deceased recruit and the media. The literature contains isolated case reports of recruit deaths but no comprehensive reviews of all deaths at a single training facility. The purpose of this study is to describe the circumstances and causes of all recruit deaths occurring at the Naval Training Command and the Marine Corps Recruit Depot in San Diego, California, from 1973 through 1985. Thirty-one male recruits died in training during this period; eight died from medical conditions not detected by preenlistment questioning or examination. In five of these cases, the conditions were probably known to the recruit but were not listed on a medical history form. Seven recruits died in incidents related to training, and there were six cases of "sudden cardiac death," as well as eight deaths caused by infectious diseases.     

Investigation of elderly deaths in nursing homes by the medical examiner over a year

Despite death being one of the most common reasons for discharge from a nursing home, fewer than 1% of nursing home resident deaths are autopsied. To evaluate our role as medical examiner in nursing home deaths, we conducted a retrospective review of all decedents in Jefferson County, Alabama, for the year 2001. Death certificate data indicate that 995 deaths occurred in nursing homes in Jefferson County in 2001. Of those 995 deaths, 119 (12%) were reported to the Jefferson County Coroner/Medical Examiner Office. Jurisdiction was accepted in 5 cases in which the circumstances already made clear that the death was a nonnatural event. In the remaining 96% of nursing home deaths reported to the medical examiner, the statements of the reporting person were taken to be true concerning the expected nature of the death. An independent scene evaluation was provided by a police officer or paramedic in 82% of the cases reported to the medical examiner's office. Elderly individuals, as a group, are expected to die, but the death of a particular elder may or may not be expected. In our jurisdiction, only 12% of all nursing home deaths are reported to our office, and only 4% of reported deaths are actively investigated. Actively investigating each nursing home death would overwhelm the resources currently available to our office. We advocate the study and development of criteria to aid in determining whether the death of an individual elder is sudden and unexpected.     

Pulmonary embolization by chorionic villi causing maternal death after a car crash

Throughout the last century, there has been a marked decline in obstetric maternal deaths, resulting in an increase in the proportion of nonobstetric deaths among pregnant women. Trauma, in particular, has become a leading cause of maternal death. We report the case of a 20-year-old primigravid woman who was involved in a motor vehicle crash at 36 weeks gestation. The woman developed abruptio placentae, followed by disseminated intravascular coagulation, adult respiratory distress syndrome, and shock, and died the day after the crash. Widespread pulmonary embolization by chorionic villi was identified at autopsy. This report discusses traumatic maternal deaths, with emphasis on the differences in injury pattern observed in pregnant trauma victims in comparison with other adults. It is important that the pathologist be aware of these problems so that an accurate cause of death can be identified in cases of maternal death after trauma. Also discussed is the relationship between trauma and placental abruption and the mechanism of death in the patient. To the authors' knowledge, this is the first reported case of extensive embolism of chorionic villi to the lungs after trauma.     

Cocaine babies: the scourge of the '90s

Six cases of cocaine-related deaths of infants have covered the spectrum of potentially devastating effects. They include an intrauterine death of a 35-week-old fetus following acute maternal cocaine abuse; anoxic encephalopathy at birth with 3 months' vegetative survival from a similar episode; traumatic compression asphyxia in a 4-month-old; infectious cardiomyopathy with heart failure in a twin at age 21 months following maternal cocaine abuse at birth; malnutrition and dehydration in a 7-week-old during continuing cocaine abuse by the parents; and a teenage sibling's cocaine lacing of a baby milk bottle ingested by his 6-week-old brother. All the cases had positive toxicological screening for cocaine or metabolites or both in the mother at delivery or in the infant at birth, or both. There were no instances of sudden infant death syndrome (SIDS, or "crib death"). Pathologic and toxicologic, as well as birth, developmental, and social data are presented. An integrated medical, public health, law enforcement, and educational policy to prevent or at least ameliorate these tragic cases, now approaching epidemic proportions, has yet to be developed. A careful obstetrical history and examination of the mother, indication on the birth certificate of maternal drug abuse, and notification of health authorities (by birth certificate checking, among other ways) may send an early warning message to providers for intercession. Active ingestion/injection and passive inhalation by older children and teenagers require more intensive monitoring and aggressive interaction by pediatricians, social workers, school authorities, and employers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Death due to thrombotic thrombocytopenic purpura in pregnancy: case report with review of thrombotic microangiopathies of pregnancy.

Maternal death during pregnancy, although uncommon, may result from a broad range of conditions. In this paper, a case of thrombotic thrombocytopenic purpura diagnosed by postmortem examination is presented. Thrombotic thrombocytopenic purpura is one of a subset of diseases that result in the formation of microthrombi within the vasculature, either as a primary or secondary manifestation. Other conditions included in the differential diagnosis during pregnancy are hemolytic uremic syndrome, systemic lupus erythematosus, preeclampsia-eclampsia and the HELLP syndrome, acute fatty liver of pregnancy, antiphospholipid antibody syndrome, and disseminated intravascular coagulation. The histologic manifestations of these diseases can be similar and in most cases do not provide adequate information to accurately differentiate these diseases in the postmortem period. This paper addresses the need for clinical history (i.e., symptomatology, trimester of onset) and antemortem laboratory testing in addition to a thorough autopsy to accurately differentiate among the conditions named previously. In the absence of an adequate clinical history and antemortem laboratory testing, the more general diagnosis of "thrombotic microangiopathy of pregnancy" is acceptable.