DOI: 10.1111/tog.
12554 2019;21:127–34
The Obstetrician & Gynaecologist
http://onlinetog.org
Autopsy in the event of maternal death –
a UK perspective
Sebastian Lucas FRCP FRCPath
Emeritus Professor of Pathology, St Thomas’ Hospital, London SE1 7EH, UK
Correspondence: Sebastian Lucas. Email: sebastian.lucas@kcl.ac.uk
Accepted on 1 December 2018. Published online 18 March 2019.
Key content
• The UK has one of the lowest maternal mortality rates in the world
and the highest autopsy rate of maternal deaths.
• Autopsy data contribute to the national confidential enquiries into
maternal deaths and help to identify remediable factors to reduce
future mortality.
Learning objectives
 To understand the law and practices surrounding maternal
autopsies, which are mostly medico-legal.
Please cite this paper as: Lucas S. Autopsy in the event of maternal death – a UK perspective. The Obstetrician & Gynaecologist. 2019;21:127–34. https://doi.org/10.
1111/tog.12554
Introduction
The UK has one of the lowest maternal mortality rates
(MMRs) among high-income countries and the highest
autopsy rate after such deaths. A confidential enquiry
published in 2017,1 covering deaths in 2013–2015, found
the MMR from direct and indirect maternal deaths to be
8.76 per 100 000 maternities. Currently, there are an average
of 60–70 such deaths per annum. Of these, 84% have an
autopsy. The autopsy report is scrutinised for the enquiry, as
well as clinical information. Two-thirds of coincidental
maternal deaths are autopsied. The glossary provides
definitions of the types of maternal death.
The MBRRACE (Mothers and Babies: Reducing Risk
through Audits and Confidential Enquiries across the UK)1
review process of notified maternal deaths starts with a
review of the autopsy report by expert pathologists to
confirm the declared cause of death, or otherwise suggest a
more accurate pathology. Thereafter, clinical review
panels evaluate the clinical care and consider remedial
factors to reduce, if possible, the likelihood of deaths in
the future.
This review summarises the processes of the maternal
autopsy in the UK, its relation to the law and what happens
after the autopsy. It also considers the more important and
interesting clinical pathologies involving pregnancy, delivery
and the postpartum period. There are also suggestions for
ª 2019 Royal College of Obstetricians and Gynaecologists
Review
 To understand the variety of clinical pathologies that cause
maternal death.
 To better understand what takes place before, during and after a
maternal autopsy and learn how obstetricians can assist
the investigation.
Keywords: autopsy / pregnancy / maternal death / SADS
obstetricians and midwives that may help them to better deal
with a maternal fatality under their care.
Why so many maternal autopsies?
There are two non-contingent reasons as to why the UK
investigates these deaths assiduously. First, there is the legal
requirement for a medical certificate of cause of death
(MCCD) to be written and recorded centrally through the
Registrars of Births and Deaths. This certificate is written by
the attending doctor if they are able to state the cause ‘to the
best of their knowledge and belief ’.2 If not possible, a coroner
(or procurator fiscal in Scotland) investigates the case,
usually by way of an autopsy, and writes the MCCD. This
requirement is why, in the UK, one in six of all deaths
(men, women and children) results in a medico-legal
(coronial) autopsy.3
Secondly, since 1952, UK obstetricians have regularly
reviewed all deaths to seek their causes and ways of reducing
them, through confidential enquiries, published reports and
recommendations. At the time of writing, the centre for these
activities is MBRRACE-UK in Oxford. Because these
enquiries have been so useful and have changed practice
over the years, the belief has grown that most or all deaths in
pregnancy and delivery should be investigated with autopsy;
thus most maternal deaths are reported to a coroner. The
high maternal autopsy rate almost entirely comprises
127
 Maternal autopsy in the UK
medico-legal autopsies, with few consented instances in
which clinicians, although they know the cause of death, wish
to determine the clinical pathology with greater accuracy
than they could in life. A related factor is a belief among the
relatives of a dead mother that, since maternal deaths are
genuinely uncommon, something must have gone wrong and
that medical error may have played a role in the death; this
reinforces the reporting of such cases to a coroner.
The law in the UK
The primary role of a coroner is to investigate known or
suspected unnatural deaths. Under the current legislation for
England and Wales,4 deaths within the coroner’s jurisdiction
area are reported to them if it is suspected that:
1. the deceased died a violent or unnatural death
2. the cause of death is unknown
3. the deceased died while in custody or otherwise in state
detention (including psychiatric hospitals).
In the realm of maternal deaths, the first criterion includes
the deaths of mothers in road traffic collisions, accidents,
homicide, suicide and drug overdoses. While suicide is now
considered a direct maternal death, the others are
coincidental. The possibility of a medical, surgical or
pharmacological mishap is another aspect of this criterion
that involves the coroner (i.e. was this an unnatural and
preventable death?).
The second criterion is the reason why most maternal
autopsies are authorised by a coroner. If the death occurred
in hospital, the doctors involved often do not know what
happened, particularly if the death happened around the time
of delivery; if it occurred in the community (e.g. at home),
then the coroner must investigate because its medical cause
will rarely be evident (or it may be traumatic, coming under
criterion 1). The very occasional deaths following home births
will always be investigated, as will deaths following abortion.
Maternal deaths not resulting in an autopsy, in which a treating
doctor can write an accurate MCCD, occur particularly in cases of
known fatal cancers – hence the lower autopsy rate for these
coincidental deaths. In the MBRRACE system, expert
pathologists also review these cases to provide their opinion on
whether or not the death should have had an autopsy
investigation. In most cases, the answer is ‘not necessary’.
Autopsy: when, where and by whom?
An advantage of the UK coronial system is that when a
coroner determines, from the information presented by
doctors, relatives and other informed parties, that an autopsy
is required to determine the cause of death, then it is virtually
impossible to prevent the autopsy from taking place through
a legal challenge. Therefore, autopsies can follow as soon
as this decision is made. Ideally, autopsies should take place
128
the next day, since post-mortem decomposition and
deterioration of the fine structure of internal organs is
inevitable, no matter how well refrigerated the body was in a
mortuary. Certainly in cases of sepsis, autopsy should take
place sooner rather than later so that samples from the body
can be cultured for bacterial infection with as little
contamination from the normal body/gut flora as possible.
Usually, maternal autopsies take place within the working
week following death.
Autopsies in the UK take place in both hospital mortuaries and
in local authority public mortuaries (free-standing buildings, not
associated with the National Health Service). The critical issues
are whether the mortuary is sufficiently equipped to undertake
maternal autopsies (specifically, having microbiology culture
sample bottles available, as well as access to histopathology
laboratories for subsequent microscopic examination of the
tissues) and whether the pathologist is sufficiently skilled to
perform the autopsy dissection and undertake any further
investigations such as histology. In addition, the quality of
assistance from the mortuary’s anatomical pathology
technologists can be critical – they help with dissection as well
as reconstructing the body afterwards.
As noted in the confidential enquiry reports, in previous
decades, the standard of maternal autopsies and their reports
varied from ‘excellent’ to ‘appalling’.5 The latter lack of
quality followed after autopsies and reports were carried out
by forensic pathologists who, generally, have no interest in
maternal death, but were presented with the cases by
coroners. This message has passed to the UK pathology
community, such that many pathologists (including forensic
pathologists) now decline to perform maternal autopsies
because of having insufficient experience. It should be noted
that, because of their rarity, many pathologists will never
encounter a case during their career. Learning on the job in
their first, often difficult, case is not good practice.
Consequently, coroners – and their officers who are active in
organising coronial autopsies – increasingly seek out experienced
pathologists to perform maternal autopsies. Such experts may
work outside the geographical area of the coroner’s jurisdiction.
Coroners realise that in difficult and contentious cases, it is worth
a delay and additional expense to have the case transferred to a
distant mortuary because they can then be more confident in the
results of an autopsy that is carried out by an experienced
pathologist. Eventually, we should arrive at an arrangement
whereby a small number of regional mortuaries, staffed by at least
two pathologists with an interest in maternal death, perform all
maternal autopsies. See Suggestion 1.
The autopsy process and timing of results
In most cases, the actual autopsy dissection involves a
complete autopsy: the head and brain might be omitted if the
cause of death is obviously below the neck, but otherwise all
ª 2019 Royal College of Obstetricians and Gynaecologists

internal organs are removed. The dissection is generally
straightforward; in cases of peripartum haemorrhage,
complete removal of the entire genital tract is a non-
standard procedure. In most instances, organ samples will be
retained for histology, and sometimes a whole organ is fixed
in formalin before it is cut and blocked for histology. Blood,
urine, cerebrospinal fluid (CSF) and any septic focus may be
sampled for microbiology culture. Blood, urine and vitreous
samples may be needed for toxicological analysis: these are
mandatory in cases of suspected drug overdose and frequent
in cases of sudden and unexpected maternal death in
the community.
It is always helpful to examine the placenta in cases of
maternal death, but many deaths occur after a normal or
otherwise unremarkable delivery and placentas are routinely
discarded. If there has been a hysterectomy following
peripartum haemorrhage, it is essential to examine the
uterus specimen. See Suggestion 2.
Depending on the cause of death, the time taken for the
final autopsy result varies: if no histology or toxicological
studies are needed, i.e. if the diagnosis is made on naked-eye
appearances only, then a week is reasonable. However, most
cases involve histological analysis, and if the clinical
pathology is complex and consultation with colleagues is
required, then it may take up to 3 months for the final report
and diagnosis to emerge. For this reason, those undertaking
serious untoward incident inquiries, which regularly follow
hospital-based maternal deaths, must be made aware of these
unavoidable delays and be careful about reaching conclusions
about past and future practice before the autopsy diagnosis is
declared. See Suggestion 3.
Inquests and after
Formal inquests are inquiries held in the coroner’s court.
They feature witnesses and are open to the public. In England
and Wales, inquests follow 44% of all deaths that have an
autopsy.3 In the remaining autopsy cases, the coroner takes
the pathologists’ cause of death and completes the MCCD so
that the relatives can present this to the Registrar of Birth and
Deaths. There are no fixed rules on whether a particular
maternal death should have an inquest, only that all evidently
unnatural deaths do result in an inquest. An inquest is likely
if the cause of death is particularly complicated, if there are
concerns over the mother’s care, or if the relatives are making
complaints against a hospital or particular doctors. These
usually take place months after the death, but in complex
cases can sometimes (regrettably) take place years later.
Outside expert witnesses may be called to give evidence, both
in written reports and at the inquest.
Hospitals are always represented by lawyers; often,
individual healthcare staff have attending lawyers, and the
family may also be so represented. The role of lawyers is to ask
ª 2019 Royal College of Obstetricians and Gynaecologists
Lucas
questions of the witnesses and thereby assist the coroner in
coming to a conclusion. The outcome will be the cause of
death and often a narrative commentary on how the death
came about. It is important to realise that the coroner’s
inquiry does not apportion any blame for a death – such
considerations take place elsewhere – but any subsequent civil
or criminal litigation will usually take a transcript of the
inquest as evidence.
In a maternal autopsy, the pathologist will usually meet the
family when there is an inquest. Ideally, by the end of the
inquiry, all of the issues will have been explored, but further
questions can be addressed. This in turn raises the question:
should the pathologist communicate with the family whenever
a maternal autopsy occurs? Arguably, if the family do not
understand what has happened, despite having the autopsy
report, they should be given the opportunity for further
clarification through talking to the pathologist.
In all cases of maternal death in a UK hospital, there
should be – at least – an internal inquiry into the death.
Autopsy reports contribute significantly to these
considerations. If there is unusual pathology, or the death
demonstrates an important lesson for future practice, a
hospital grand round or departmental clinico-pathological
conference (attended by the pathologist) is most instructive.
If the autopsy report and its conclusions seem incorrect
according to the clinical story known to the attending
doctors, then the report should be queried as soon as
possible. Most pathologists have little experience in this area
and can produce wrong diagnoses. See Suggestion 4.
The clinical pathology of maternal death
The reasons why mothers die depend almost entirely on
where they live and their access to medical and obstetric care.
In low-income countries, where the MMR may be 10–100 times
that seen in the UK, the major causes of death are: haemorrhage,
sepsis, unsafe abortion, complications of delivery and
hypertensive diseases of pregnancy. However, these causes
of death are estimated based on clinical opinion and
retrospective verbal autopsy:6 autopsy morbid anatomical
information is rarely available. The picture in the UK is
completely different; for example, out of more than 700 000
maternities, there is now fewer than one death a year from
eclampsia,1 and unsafe (criminal) abortion is extremely rare
thanks to 1960s legislation. In contrast with poorer countries,
where most maternal deaths are of direct obstetric cause,
indirect deaths predominate in the UK (56% versus 44%).
This indication of the overall high quality of obstetric care is
further boosted if venous thromboembolism is removed
from the direct category; clinico-pathologically, it should be
included in the indirect group.
Since 2014, reviews of the pathology of maternal death,
made by expert pathologists, have been presented in annual
129
 Maternal autopsy in the UK

MBRRACE reports, either alongside clinical category reviews better medical care during the last trimester and delivery.
or in separate sections of the report. Here, I focus on specific Often, these conditions are only diagnosed at autopsy (see
clinical pathologies and discuss how the autopsy contributes Autopsy Case 1). The mysterious peripartum cardiomyopathy
to their diagnosis and knowledge of their pathogenesis. (PPCM) continues to cause progressive heart failure in the
Table 1 indicates the causes of sudden death around the third trimester and after delivery.
time of term delivery; it includes the most difficult challenges A major change in the UK (and this probably applies to other
that pathologists face in determining the cause of death. The high-income countries, although it has not yet been formally
scenarios listed derive from personal experience as well as documented) is the increased incidence of diagnosed ‘sudden
the literature. arrhythmic cardiac death syndrome with a morphologically
normal heart’ (SADS/MNH). This occurs in someone who
Cardiac deaths suffers acute cardiac arrhythmia and dies, usually in the
In the UK, deaths from cardiovascular disease are the single community. It is a diagnosis of exclusion, made when all other
most common group of disorders causing maternal death.1 possible causes of death (including toxicological and
Ischaemic coronary heart disease is associated with increasing anaphylactic) are excluded. Many cases are suspected to
maternal age; valvular heart disease is a particular issue in result from inherited abnormalities of the heart rhythm
people who had rheumatic fever in their youth; structural (channelopathies), although this has been confirmed in only
cardiomyopathies, splenic artery aneurysm rupture and a few cases.7 SADS/MNH has always occurred, but the reasons it
dissection of the aorta continue to present as rapid collapse is now reported more frequently are that pathologists had been
and death; congenital heart disease is more frequently seen in reluctant to make the diagnosis and/or there had been no
pregnant women, but, thanks to improved surgical pathological examination, and/or any pathological
management, the fatality rate appears to be declining with examination had not been robust enough to exclude other
possible diagnoses. See Autopsy Case 2.
It is important that apparent cardiac deaths in young,
Table 1. Causes of sudden maternal death around the time of delivery pregnant women are properly examined, because there is
Organs and inevitable discrepancy between the imaging and
systems Clinical pathologies physiological information in life and what is actually
found at autopsy.
Lung Thromboembolism
Amniotic fluid embolism*
Venous thromboembolism to the lungs
Fat embolism
Air embolism** Pregnancy enhances the risk of venous thromboembolism
Acute asthma (VTE) in women by a factor of about 10; hence, pulmonary
Sickle cell crisis embolism is a major cause of maternal death. It occurs from
Pulmonary hypertension
the second trimester through to several weeks after delivery.
Pneumothorax
Polyvinyl alcohol (PVA) particle embolisation Obesity and caesarean section are well-known risk factors,
following uterine artery embolisation*** and the most common site of embolus origin is the left iliac
Heart Structural disease vein. Antithrombotic prophylaxis reduces the risk of
Diastolic dysfunction syndrome and post-delivery embolism and death but does not eliminate the risk.
fluid overload When a death does occur and the diagnosis is made – as it
Sudden arrhythmic cardiac death syndrome with a
morphologically normal heart usually is – at autopsy, questions may be asked as to whether
Pre-eclampsia-related cardiac arrest prophylaxis could have prevented the death. Here, the critical
Brain Acute haemorrhage (eclampsia or other issues can be addressed at autopsy: when did the deep vein
pathogenesis) thrombosis start (months, weeks, days or immediately before
Venous sinus thrombosis the fatal embolism)? Was the fatal embolism the first and last
Epileptic seizure
occasion, or were there previous episodes? Histological
Systemic Severe sepsis examination of the likely sites of the deep vein thrombosis
Thrombotic thrombocytopenic purpura (TTP)
Acute anaphylaxis and of the thrombus in the lung arteries can inform on
Drug toxicity (e.g. cocaine) chronology. Histology of the lung tissue may also reveal
Anaesthesia Spinal – high spinal block previous subclinical emboli. If no histology is done, then it is
General – respiratory failure usually impossible to narrow down the chronology of VTE.8
Haemorrhage Genital tract haemorrhage
Artery rupture Anaesthetic deaths
*See Autopsy case 2; **See Autopsy case 3; ***See Autopsy case 4 These deaths are complications of both spinal and
general anaesthesia.

130 ª 2019 Royal College of Obstetricians and Gynaecologists


Spinal anaesthesia
Infection of the spinal cord and meninges is a rare
complication. Postdural puncture headache is common
and, with severe CSF leakage, can lead to subdural
haemorrhage and even death. Obviously an autopsy is
critical for evaluating these scenarios.
The uncommon cardiopulmonary complications of high-
spinal block from spinal anaesthesia are more difficult to
diagnose.9 These will be diagnoses of exclusion (i.e. there is
no other pathologically evident cause of death) made after a
critical review of the medical records done in conjunction
with anaesthetist colleagues.
General anaesthesia
Deaths caused by general anaesthesia are very difficult for
pathologists to determine because there is no residual morbid
anatomical evidence, and measuring levels of anaesthetic
agents in body fluids is unhelpful. Cardiac arrhythmia from
anaesthetic drugs is not diagnosable from autopsy. The most
common scenario of post-delivery death following general
anaesthesia is respiratory failure after removal of an
endotracheal tube because of premature removal and/or
blockage of the tube. However, an autopsy cannot provide
positive proof.
On a practical note, while levels of anaesthetic drugs in the
blood are not informative, it is always worth measuring
blood mast cell tryptase levels after anaesthetic death. High
mast cell tryptase levels indicate an acute anaphylaxis
reaction, often to drugs.
Amniotic fluid embolism syndrome
Amniotic fluid embolism (AFE) syndrome (AFES) occurs as
a clinically diagnosed event in about 2 per 100 000 deliveries
in the UK.10 In about 20% of cases, death results from
cardiopulmonary collapse followed by a coagulopathy with
haemorrhage from the uterus and other sites.
The clinical story is critical for diagnosing this syndrome,
in conjunction with autopsy pathology. Amniotic and fetal
skin squamous cells should be found in the lungs, along with
amniotic mucin forming a plug of the distal pulmonary
arterioles and capillaries. If the patient has survived long
enough, coagulopathy with local haemorrhage is present,
particularly from the genital tract, but there is no
disseminated intravascular coagulation (DIC) in the kidney
glomeruli. The squames and mucin may also be visible in the
uterine and cervical veins.
Diagnostic problems with autopsy are two-fold: there are
cases with a typical clinical story, with or without a
coagulopathy, where no AFE material is seen in the lungs;
and those with an atypical or ambiguous clinical story that
still have AFE material in the lungs. In the latter scenario,
note that vigorous cardiopulmonary resuscitation can readily
force AFE material into the pulmonary circulation as an
ª 2019 Royal College of Obstetricians and Gynaecologists
Lucas
artefact and, in this instance, does not indicate AFES
(see Autopsy Case 2). In the former scenario, my view is
that a negative autopsy does not negate a positive clinical history
when all other clinicopathological possibilities are excluded.
Sepsis
Reviews of sepsis in pregnancy and delivery have tended to
group all the scenarios into a single category, with emphasis on
infection acquired during delivery – the ‘Semmelweis
syndrome’. However, different patterns of severe and fatal
infection have completely different pathogeneses and,
implicitly, different approaches to reduce their occurrence.11
There are six separate categories to consider, and the autopsy is
critical for determining the appropriate one.
1. Sepsis following unsafe termination of pregnancy: non-
aseptic techniques can introduce numerous virulent
infections. This scenario is rare in high-income countries
but is a major cause of maternal death in poor countries,
particularly in those where safe termination is illegal.
2. Ascending genital tract infection associated with miscarriage,
usually in the second trimester: the most common infection
agent is Escherichia coli; however, it is not usually possible to
determine from an autopsy whether it is the cause of the
miscarriage and rupture of membranes, or infects the tract
following rupture of membranes. The bacteria come from the
mother’s perineum, pass up into the uterus and initiate
endometritis. Then, in susceptible mothers, systemic sepsis
syndrome occurs. Pathologically, it is striking that nearly all
deaths in this scenario occur rapidly once the mother feels ill
and show DIC in capillaries of the kidney. It is likely that the
triggering of DIC, which probably has a genetic predisposition,
is the critical factor in determining the outcome.
3. Genital tract infection and subsequent systemic sepsis:
occurring within hours or days of delivery, whether the
delivery was vaginal (assisted or not), by caesarean section,
or a medical or surgical termination at any gestation.
Semmelweis syndrome, in which midwives and doctors
introduce bacteria such as Group A Streptococcus pyogenes
(GAS) into the mother’s genital tract, is now very
uncommon in high-income countries. However, mothers
are still able to spread nasal bacteria from their own nose,
or their children’s noses, to their lower genital tract.
Perinatally acquired herpes simplex infection can
disseminate to cause devastating abdominal and systemic
infection, exacerbated by the lowered cell mediated
immunity typical of late trimester pregnancy.
4. Systemic sepsis: typically arising from GAS infection,
usually a fulminant infection in mothers who are not in
labour and whose membranes have not ruptured. This
scenario is probably unrelated to pregnancy per se; rather,
it may reflect the community load of GAS and the host
woman’s immune status.
131
 Maternal autopsy in the UK
5. Severe infection related to pregnancy and delivery, but
outside the genital tract: include infected spinal
anaesthesia sites, infected caesarean section suture lines
and perforation of a viscus during obstetric surgery.
6. Other infections such as HIV, bacterial meningitis,
tuberculosis, pneumonia and influenza: during the
recent H1N1 influenza pandemic, pregnancy was the
most significant risk factor for severe respiratory illness
and death.12 It is notable that in the UK, where virtually all
mothers are tested for HIV and can be treated with anti-
retrovirals, HIV/AIDS is rarely a contributory cause of
maternal death.
A final note on sepsis in pregnancy: pregnant women with
sickle cell diseases (both HbSS and HbSC genotypes) are
particularly liable to severe infection (commonly
Streptococcus pneumoniae) because their disease renders
them relatively immunocompromised.
Pre-eclamptic toxaemia/eclampsia
Death from severe hypertensive disease in pregnancy can
occur in the second and third trimesters and also after
delivery (postnatal eclampsia). If there was any doubt before
the death, autopsy pathology is critical for identifying these
deaths. Most fatal cases of eclampsia involve intracerebral
haemorrhage (through arterial hypertension); in HELLP
(haemolysis, elevated liver enzymes and low platelet count)
syndrome, liver failure through periportal necrosis and
haemorrhage is important. Pathologically, it is likely that
pre-eclamptic toxaemia (PET) can also cause death via
cardiac arrest, as a cerebral–vagal–cardiac arrhythmia,
although this scenario is not yet generally accepted.
Positive autopsy histology evidence for PET/eclampsia
includes: abnormal spiral arteries (atherosis) in the uterine
decidua, abnormal placental histology and glomerular
endotheliosis in the kidney; and liver periportal
haemorrhage in HELLP.
Peripartum haemorrhage
The major causes of peripartum haemorrhage include atonic
uterus, retained placenta, traumatic tears to the genital tract,
rupture of the uterus, placenta praevia and accreta and AFES.
The autopsy is essential to evaluate these possible
pathologies, and consideration is given as to whether the
whole genital tract should be removed en bloc, fixed and
examined in detail. Histology is useful in all of these possible
scenarios, except that an atonic uterus generally has no
specific features that are visible under the microscope. Where
there has been a hysterectomy, it is vital to examine the
removed organ alongside the rest of the body. If still
available, the placenta must also be examined. See Suggestion
2 and Autopsy Case 4.
132
Special cases
Mothers who are Jehovah’s Witnesses and have sickle cell
anaemia may present particular problems if and when blood
loss occurs, since they do not accept blood products. In such
cases, deaths will usually have a coronial autopsy in which the
relevant morbidities in addition to anaemia must be carefully
evaluated so that the refusal to accept blood products can be
placed in context regarding the cause of death.
Other special cases include the very uncommon deaths
around the time of delivery where, despite autopsy
investigations and available clinical physiology data, a
definite cause of death is not found (i.e. the pathologies
listed in Table 1, with the exception of SADS/MNH, are
excluded). Families, coroners, hospitals and litigation lawyers
do not like this and neither do pathologists. Whether such
deaths, which occur in full view of many experienced clinical
staff, are labelled as ‘unascertained’ or ‘SADS/MNH’ varies.
The quality of the autopsy is critical to making the distinction
and detailed clinical and anaesthetic input is essential (see
Autopsy Case 3).
Conclusion
Unlike many countries, the UK has accurate information about
the causes of death through regular peer review and the high
autopsy rate following maternal deaths. A key factor is the
availability of pathological expertise in this area. Results
monitor the changes in the epidemiology of maternal mortality
and enable realistic recommendations for reducing mortality.
Inevitably, a very small number of deaths that occur during
delivery and sudden deaths in the community will never be
resolved through autopsy pathology, but review systems
should be in place to ensure that these are kept to a minimum.
Glossary
 Maternal death: the universal definition of maternal death
is death occurring in women from conception through to
delivery and up to 6 weeks postpartum. In the UK, all
deaths up to 1 year postpartum are notified, though not all
will be centrally reviewed. The deaths are categorised as
direct, indirect or coincidental.
 Direct maternal death: caused by a disease process specific
to pregnancy and delivery; e.g. pregnancy-related
infection, hypertensive diseases of pregnancy, peripartum
haemorrhage, death from anaesthesia, amniotic fluid
embolism, deaths in early pregnancy, peripartum
cardiomyopathy (PPCM), gestational trophoblastic
diseases and postpartum psychotic suicide. For historical
reasons, deaths resulting from VTE are also counted as
direct causes. However, since these also occur in non-
ª 2019 Royal College of Obstetricians and Gynaecologists

pregnant people, it would be better to classify them
as indirect.
 Indirect maternal death: caused by diseases that also occur in
women who are not pregnant, but which are exacerbated by
pregnancy, critically affect the pregnancy, or where the
treatment is complicated by pregnancy; e.g. cardiac diseases
other than PPCM; indirect sepsis (e.g. influenza); neurological
diseases other than VTE; immunological disorders;
gastrointestinal, renal, endocrine and pulmonary diseases;
liver disease (other than acute fatty liver of pregnancy and
HELLP syndrome); primary pulmonary hypertension; and
diseases involving bone marrow or solid organ
transplantation. None of the standard non-trophoblastic
cancers are really affected by pregnancy, apart from the
undoubted fact that treatment options for the mother are
compromised by the presence of the fetus in utero.
 Coincidental maternal death: death resulting from diseases
unrelated to pregnancy; e.g. accidents, homicide, drug
overdose and alcoholism.
 HELLP: hepatic elevated enzymes and low platelets; a
variant of PET/eclampsia.
Suggestions for obstetricians who deal
with a maternal death
1. When communicating with the coroner (or fiscal) about a
mother’s death that requires investigation, discuss whether
a specialist pathologist can perform the autopsy, even if it
means having the body transferred out of district.
2. In cases of maternal death, it is helpful to be able to present
the placenta to the pathologist. If there are problems during
delivery, ensure that the placenta is retained and fixed in
formalin. If there has been a hysterectomy before death, it is
essential that the pathologist performing the autopsy can
examine the removed organ.
3. When a post-death inquiry is initiated, be aware that the
final cause of death may not be available for weeks to
months afterwards. Do not make final conclusions until
this information is presented.
4. If an autopsy report appears wrong according to your view
of the clinical problems and their management, or omits
consideration of important factors, approach the coroner
and request a review.
Autopsy cases: how the autopsy can alter
the apparent diagnosis
Case 1
A 35-year-old woman had a caesarean section at 36 weeks of
gestation for slow fetal growth. Medically, she appeared well.
Once discharged, she collapsed at home on the third day post-
delivery and could not be resuscitated by the ambulance crew.
ª 2019 Royal College of Obstetricians and Gynaecologists
Lucas
At autopsy, the expected pathology was a massive
pulmonary thromboembolism, which is associated with risk
factors of pregnancy, caesarean section and obesity. However,
there was no pulmonary thromboembolism and the iliac
veins were clear. Instead, acute staphylococcal infective
endocarditis was found, affecting the aortic valve and the
anterior cusp of the mitral valve. One aortic valve cusp had
perforated, causing acute heart failure. Underlying the
endocarditis, the aortic valve was bicuspid. Congenital
bicuspid aortic valves have a 10–30% lifetime risk of
developing endocarditis. The causative organism is most
commonly Staphylococcus aureus.
Case 2
A 27-year-old primip reached 39 weeks of gestation with no
antenatal medical problems. She had not started labour and
her membranes were not ruptured. She was witnessed to
collapse, stop breathing and become pulseless. A bystander
commenced CPR and this was continued by members of the
ambulance staff. They found no pulse, and the ECG trace
showed the woman was in ventricular fibrillation. A
defibrillator was used to deliver one shock, but this did not
restore the heart rhythm and she was asystolic thereafter. The
woman was declared dead after more than 1 hour of intensive
resuscitation and a perimortem caesarean section.
Lung histology taken at autopsy found that the only
morphological abnormality was massive quantities of
amniotic fluid material in the pulmonary arteries.
In this scenario, there was clear evidence of acute cardiac
arrhythmia; absence of labour, rupture of membranes or
interference with the uterus prior to her collapse; and no
evident prodromal symptoms indicative of AFES. Therefore,
it was decided that the death was caused not by AFES but
sudden cardiac death. Previous reports have documented the
presence of AFE material forced into the maternal circulation
by resuscitation efforts.
Case 3
A woman had a caesarean section under spinal anaesthesia at
38 weeks of gestation. While the uterus was being closed, she
became breathless, with a respiratory arrest, followed by
cardiac arrest. She survived for some days with hypoxic-
ischaemic encephalopathy before eventually dying. Apart
from brain damage, the autopsy was entirely negative.
The diagnoses listed in Table 1 were considered in a
multidisciplinary consultation, and all but air embolism and
fluid overload syndrome were discarded. Further
examination of fluid balance and drug charts indicated no
fluid overload. Although no air embolism was seen at
autopsy – and would not be expected, given that any air
would have been absorbed during the 3-day delay between
collapse and death – the final diagnosis, on balance of
probabilities, was air embolism.
133
 Maternal autopsy in the UK
Case 4
A 40-year-old woman with two previous caesarean section
deliveries had a third such delivery at 40 weeks of gestation. As
placenta accreta had already been diagnosed, she had uterine
artery embolisation (UAE) with polyvinyl alcohol (PVA)
particles at delivery to reduce the placental blood flow. Two
weeks later there was still blood flow through the placenta, so
UAE was repeated. Soon after, she deteriorated with
hypotension. Internal bleeding was suspected but a
laparotomy found none, and a subtotal hysterectomy was
performed. She died shortly afterwards.
At autopsy, all of the pulmonary arterioles were found
blocked by chains of PVA particles, with proximal thrombosis
causing acute cor pulmonale. The uteroplacental resection
contained similar particles, with partial infarction of the
placenta (which was percreta rather than accreta).
Somehow, the UAE procedure pushed the PVA particles
through the uterus circulation into the iliac veins and then into
the lung circulation, to cause pulmonary artery obstruction.
This has not been described before in pregnancy. Histology of
the uterus found no obvious arteriovenous fistula channel.
Disclosure of interests
SL is the lead Pathology Assessor for MBRRACE-UK and
contributes to their annual reports.
Acknowledgements
The MBRRACE-UK epidemiologist, Kathryn Bunch,
provided the autopsy rate data. Professor Marian Knight
(MBRRACE-UK) provided helpful suggestions.
References
1 Knight M, Tuffnell D, Shakespeare J, Kenyon S, Kurinczuk J (Eds) on behalf
of MBRRACE-UK. Saving lives, improving mothers’ care. Lessons learned to
inform maternity care from the UK and Ireland Confidential Enquiries into
Maternal Deaths and Morbidity 2013–2015. Oxford: National Perinatal
Epidemiology Unit, University of Oxford; 2017 [https://www.npeu.ox.ac.
134
uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Re
port%202017%20-%20Web.pdf].
2 National Archives. Birth and Deaths Registration Act, 1953. London: UK
Government; 1953 [http://www.legislation.gov.uk/ukpga/Eliz2/1-2/20].
3 UK Ministry of Justice. Coroners statistics 2017. London: UK
Government; 2017 [https://www.gov.uk/government/statistics/coroners-
statistics-2017].
4 National Archives. Coroners and Justice Act, 2009. London: UK Government;
2009 [https://www.legislation.gov.uk/ukpga/2009/25/contents].
5 Millward-Sadler H. Chapter 15: Pathology. In: Lewis G, Clutton-Brock T,
Cooper G, Drife J, Edwards G, Harper A, et al. Saving Mothers’ Lives:
reviewing maternal deaths to make motherhood safer – 2003–2005.
London: Confidential Enquiry into Maternal and Child Health; 2007 [http://
www.publichealth.hscni.net/sites/default/files/Saving%20Mothers%27%
20Lives%202003-05%20.pdf].
6 World Health Organization (WHO). Maternal mortality. Geneva: WHO;
2018 [http://www.who.int/news-room/fact-sheets/detail/maternal-morta
lity].
7 Lucas SB, Chapter 3.5.4: SADS/MNH. In: Knight M, Nair M, Tuffnell D,
Kenyon S, Shakespeare J, Brocklehurst P, et al (Eds.). Saving Lives, Improving
Mothers’ Care. Surveillance of maternal deaths in the UK 2012–14 and
lessons learned to inform maternity care from the UK and Ireland
Confidential Enquiries into Maternal Deaths and Morbidity 2009–14.
Oxford: MBRRACE; 2016 [https://www.npeu.ox.ac.uk/downloads/files/mb
rrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202016%20-%
20website.pdf].
8 Lucas SB. Appendix A1: Venous thromboembolism – pathological aspects.
In: Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ
(Eds.). Saving Lives, Improving Mothers’ Care. Surveillance of maternal
deaths in the UK 2011–13 and lessons learned to inform maternity care
from the UK and Ireland Confidential Enquiries into Maternal Deaths and
Morbidity 2009–13. Oxford: MBRRACE; 2015 [https://www.npeu.ox.ac.
uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Re
port%202015.pdf].
9 Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-
related mortality in the United States: 1979–2012. Obstet Gynecol
2011;117:69–74.
10 Knight M, Tuffnell D, Brocklehurst P, Spark P, Kurinczuk JJ, UK Obstetric
Surveillance System. Incidence and risk factors for amniotic fluid embolism.
Obstet Gynecol 2010;115:910–7.
11 Lucas SB. Annex 7.1. Maternal sepsis, a possible future approach to case
definitions. In: Lewis G, Cantwell R, Clutton-Brock T, Cooper G, Dawson A,
Drife J, et al. Saving Mothers’ Lives: reviewing maternal deaths to make
motherhood safer – 2006–08. Centre for Maternal and Child Enquiries,
BJOG, March 2011, vol 118 (Suppl 1): pp97–101.
12 Lucas SB. Predictive clinicopathological features derived from
systematic autopsy examination of patients who died with A/H1N1
influenza infection in the UK 2009-10 pandemic. Health Technol Assess
2010;14:83–114.
ª 2019 Royal College of Obstetricians and Gynaecologists