Autopsy in Maternal Death

Presenter- Dr Asha Meena

Moderator- Dr Jayanti Mala
Definition
• Death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its management but
not from accidental or incidental causes.
Classification of maternal death

• Direct 
• Indirect
• Coincidental
                         Direct Maternal Death
• Those resulting from obstetric complication of pregnant state (i.e.
pregnancy, labor and puerperium) from interventions, omissions,
incorrect treatment, or from a chain of events resulting from any of the
above.
•  Peri and postpartum hemorrhage
•  Preeclampsia
•  Amniotic fluid embolism
•  Genital tract sepsis.
• Air embolism
• Acute fatty liver of pregnancy
                          Indirect maternal death
• Those resulting from previous existing disease or disease that
developed during pregnancy, and which were not due to a direct
obstetric cause, but were aggravated by the physiologic effect of
pregnancy.
• Venous thromboembolism
• Cardiovascular disease
• Thrombotic thrombocytopenic purpura
•   Pregnancy associated infection
                    Coincidental maternal death

• Death from unrelated causes that happen to occur in pregnancy or

the puerperium.
• Homicide
•  Illicit drug toxicity
•  Most cancers.
Objective of Autopsy

1. To find out cause of death.

2. To find out manner of death.
3. To find out time since death.
4. To collect physical evidence in order to identify object causing
death.
5. In case of death due to injury or poisoning, the period of survival
after sustaining injuries/poisoning.
6. Whether injury which has caused death is expected to cause death
in normal course of disease.
 Role of Autopsy

• Most maternal deaths are not preventable or predictable, are usually

multifactorial in causation
• In a proportion of cases there will be a fetus or neonate and a
placenta to examine
• It is also wise in every case to take samples of heart blood, gastric and
intestinal content and urine at the start of an autopsy.
Placental Examination

• Particular emphasis being laid on lesions which may be related to the

cause of death These include:
(i) morbidly adherent placenta
(ii) amniotic fluid embolism
(iii) retroplacental haemorrhage
(iv) uteroplacental ischaemia
(v) embryonic or fetal death prior to delivery
(vi) retained products of conception
(vii) infection and criminal abortion
Peri and postpartum hemorrhage
Causes
• Uterine atony
• Placenta previa
• Abruption of the placenta
• Placenta accreta, increta, percreta
• Genital tract trauma
• Rupture of uterus
• Abortion
Uterine atony
• Most common cause of PPH, but leaves no definable pathology.

Placenta previa
• Diagnosed in life
• If the placenta is still in situ the uterus and vagina should be removed as a
single block and the uterus subsequently opened from the fundus, this
allowing for the clear demonstration of placenta covering the lower uterine
segment 
 Abruptio placentae
• If patient died of abruptio placentae it is necessary to confirm the
retroplacental bleeding.
• If the placenta has been delivered it should be examined for adherent
thrombus or a depressed empty crater on the maternal surface.
• If the placenta is still within the uterus the blood may have tracked from
the retroplacental area to extend widely into the myometrium (Couvelaire
uterus) 
 Retained placenta
• Retained placental material is rarely fatal, cause hemorrhagic death
following birth at home.
A. Lacerations of the separated placenta B. Abruptio placenta
on maternal surface suggest retained
placenta
Placenta accreta, increta and percreta 
•  Villi are directly implanted into the myometrium without an
intervening layer of deciduas, resulting in adherence of the placenta to
the uterus, leading to a risk of postpartum bleeding, fever and uterine
rupture.
• Placenta accreta- partial or complete absence of decidua with
adherence of placenta directly to the superficial myometrium 
• Placenta increta- villi invade into but not through the myometrium.
• Placenta percreta-villi invade through the full thickness of
myometrium to the serosa; may cause uterine rupture.
Placenta accreta
Placenta increta
Placenta percreta
Genital tract trauma:
• Vagina, cervix and lower uterus can be torn due to large babies,
poorly assisted delivery
• Arteries and veins in the submucosa are ruptured – severe
hemorrhage
Uterine rupture:
• Traumatic
• Spontaneous 
• Scar associated (30-60%): previous CS, myomectomy, cornual resection,
following reimplantation of fallopian tubes into the uterus, previous
invasive mole, surgical treatment of Asherman’s syndrome
• Consequence of macrosomia, small pelvis and prolonged labor
• Drugs that enhance uterine contraction (misoprostol and oxytocics) 
Pre-eclampsia

• Preeclampsia is defined as high blood pressure, edema, proteinuria.

• Eclampsia is defined as clonic-tonic seizures occurring in a patient
with pre-eclampsia 
• High mortality
• HELLP syndrome - high mortality
Haemolysis
Elevated liver enzyme
Low platelets
Pre-eclampsia
Brain 
• Deep intracerebral hemorrhage.
• Diffuse cortical petechial hemorrhages in the cerebral cortex and
cerebellum.

Liver 
• Grossly focal and confluent hemorrhagic necrosis.
• Microscopically periportal fibrin deposition, hemorrhage and
hepatocyte necrosis.
 TYPICAL HYPERTENSIVE LATERAL GANGLIONIC HEMORRHAGE
Kidney 
• Glomerulus shows bloodless
capillaries, endothelial cell swelling,
and herniate into the proximal tubule.

Uterus and placenta

• Placenta shows effect of reduced
arterial blood supply on the villi, with
foci of infarction.
• Decidua shows atherosis and
fibrinoid necrosis of spiral arterioles
with presence of large number of
lipophages.
 Amniotic fluid embolism syndrome
Lungs
•  In the lungs amniotic fluid, fetal squamous cells and fetal
hair embolise to the small vessels of lungs.
• Alcian blue to show amniotic mucin, and IHC stain against LP34
highlighting the squames.
• An endothelial CD31 is used to distinguish between embolic sqames
from sloughed endothelial cells.

Kidney
• In the renal glomeruli, fibrin thrombi is usually found
in the capillary lumens.
Uterus 
• Mucosal bleeding.
• Amniotic fluid material in the mural veins.
• It may be possible to demonstrate the location of entry of Amniotic fluid
into the uterine veins e.g. via caesarean incision or mucosal split.

Placenta 
• Placenta may reveal squames  and other debris dissecting between
amnion and chorion.
Amniotic fluid embolism syndrome

• Mucin within a small arteriole

in the lung
•Lung with intravascular squames (arrow) and mucin
(arrowhead)
A. Thrombotic microangiopathy B. Immunohistochemical stain
in glomerulus against LP34 highlighting the
sqames.
Sepsis

Autopsy finding
• Septic endometritis
• Myometrial abscesses
• Purulent salpingitis
• Pelvic peritonitis
• Septicemia
Air embolism

• Pregnant uterus is particular vulnerable to air embolism due to large

venous sinuses that are exposed at placental separation.
• 500-600 ml of air – fatal 
• Dark, frothy, bubble studded blood in the
right side of heart
Inferior vena cava 
Uterine veins
Acute fatty liver of pregnancy

• Can present with abdominal pain and recurrent vomiting without

prior warning or jaundice.
• The salient features are the presence of fat in small vacuoles in
centrilobular hepatocytes, while a ring of normal hepatocytes remains
around portal systems.
• There is commonly associated renal failure with tubular necrosis
Hepatocytes show a clear cytoplasm (arrow) or many minute
vacuoles (arrowhead) 
Indirect cause

• Venous thromboembolism
• Cardiovascular disease
• Thrombotic thrombocytopenic purpura
• Pregnancy associated infection
Venous thromboembolism

• It occurs following C-section in the form of massive pulmonary

embolism

• Autopsy pathology- examine the entire length of the pulmonary

artery tree to show massive thromboembolism'
Cardiovascular disease
• Weakening of wall of aorta and some medium or large arteries result
in aneurysm, dissection and rupture.
• Histologically, there is elastic degeneration, deposits of mucin and
attenuated muscle.
• Patient dies due to sudden unexpected collapse from shock.
 Thrombotic thrombocytopenic purpura

• Pregnancy increases the risk of TTP 

• Abnormalities of von Willebrand factor physiology that promote platelet
clustering and adhesion to the endothelia of the microvasculature.
• Platelet thrombi block small vessels in the brain, kidney, heart and
elsewhere.
• Clinical presentation is usually postpartum.
• Confusion, microangiopathic anemia and renal failure.
• Death is due to blockage of arterioles and venules in the myocardium,
with hemorrhagic microinfarction and acute heart failure. 
Pregnancy associated infections

Epidemic influenza
• Type A/H1N1 influenza affects mainly third trimester pregnant
women, who becomes severely ill from influenza pneumonitis and
acute lung injury.
• Pregnancy is the pre-eminent risk factor for death with H1N1
infection.
HIV/AIDS

• In high HIV prevalence countries, it is the major contributor in

maternal mortality.
• Diagnosed late with advanced HIV disease at around the time of
delivery.
• Death is mostly due to tuberculosis and other opportunistic infections
or from sepsis. 
Thank You