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ORIGINAL ARTICLE
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 22-25

Maternal deaths: A medicolegal autopsy study in a tertiary care hospital


Department of Forensic Medicine and Toxicology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission09-Dec-2021
Date of Decision14-Dec-2021
Date of Acceptance22-Dec-2021
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Supriya Keisham
Department of Forensic Medicine and Toxicology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_141_21

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  Abstract 

Background: Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy. This can be due to direct causes or indirect unrelated causes. It is an important indicator of health-care services. Autopsy, which is an important tool of investigation, provides valuable input regarding the sequence of events leading to maternal death.
Objectives: The objective of this study is to determine factors causing maternal deaths and to discuss the utility of medicolegal knowledge in ascertaining the causes of maternal deaths.
Materials and Methods: This was a retrospective study where individual records of all maternal deaths brought for autopsy in the hospital mortuary during the past 10 years from January 2011 to December 2020 were studied. The cause of death and the factors which led to death in each individual case were analyzed.
Results: A total of 15 maternal deaths were brought during the study period. Most maternal deaths (40%) occurred in the age group of 31-40 years. Maximum of the cases 11 of 15 were able to reach a health-care center before delivery. Direct causes accounted for 86.67% of maternal deaths. Hemorrhage and shock (38.46%) were the major direct cause of maternal deaths. The majority of the deaths occurred during the postnatal period (53.33%). Regarding the pregnancy outcome, 8 (53.33%) mothers were able to deliver live-born babies, of which 5 (62.5%) were delivered by lower segment cesarean sections and 3 (37.5%) by normal vaginal deliveries.
Conclusion: There is scope for improvement as a large proportion of the observed deaths are preventable. Improving the rural health centers, upgrading the referral centers with round-the-clock functioning blood banks is the need of the hour.

Keywords: Direct causes, hemorrhage, maternal deaths, medicolegal autopsy


How to cite this article:
Singh KP, Keisham S, Chetri D, Wanio Sungoh JD, Zohlupuii LB, Meera TD. Maternal deaths: A medicolegal autopsy study in a tertiary care hospital. J Med Soc 2022;36:22-5

How to cite this URL:
Singh KP, Keisham S, Chetri D, Wanio Sungoh JD, Zohlupuii LB, Meera TD. Maternal deaths: A medicolegal autopsy study in a tertiary care hospital. J Med Soc [serial online] 2022 [cited 2022 Sep 30];36:22-5. Available from: https://www.jmedsoc.org/text.asp?2022/36/1/22/355576




  Introduction Top


Pregnancy and childbirth are universally celebrated event, yet pregnancy involves a vulnerability that put women at risk of dying. If a pregnancy results in death, it leads to extreme strain over the family dynamics, and questions about the death have to be addressed by the health-care providers. If this anger that is part of the grieving process is not adequately resolved, healing cannot occur. It is then that the family may pursue the legal process to help obtain answers about what happened and, more importantly, why it happened to their loved one.

Maternal death or maternal mortality as defined by the World Health Organization (WHO) is “the death of a woman while pregnant or within 42 days of termination of pregnancy and 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.”[1] These maternal deaths are divided into two categories: (1) direct maternal deaths resulting from obstetric complications of the pregnant state, i.e., pregnancy, labor, and puerperium from interventions, omissions, incorrect treatment, or a chain of events resulting from any of the above and (2) indirect maternal deaths resulting from previously existing diseases or diseases developing during pregnancy and not due to direct obstetrical causes, but which may have been aggravated by the physiological effects of pregnancy. India is one of many countries which records a high amount of pregnancy-related deaths each year, although the data showed a declining trend in recent years. As per the Sample Registration System (SRS) report by Registrar General of India for the past 3 years, the maternal mortality ratio of India has reduced from 130 per 100,000 live births in SRS 2014-16-122 in SRS 2015–17 and to 113 per 100,000 live births in SRS 2016–18.

Maternal death is an important indicator of health-care services and is regarded as one of the composite measures to assess the country's progress. Despite the improved methodology, specific central targeted program on maternal health care, maternal mortality remains a cause of concern. The present study was undertaken with a view to determine factors causing maternal deaths and to discuss the utility of medicolegal knowledge in ascertaining the causes of maternal deaths. Hence, forensic autopsies play an important role in identifying these cases with appropriate cause of death.


  Materials and Methods Top


A retrospective study was conducted during the period of 10 years from January 2011 to December 2020 on all the cases of maternal death brought for medicolegal autopsy in the Department of Forensic Medicine and Toxicology, Regional Institute of Medical Sciences, Imphal, Manipur. The study was carried out after obtaining approval of the concerned institutional ethics committee. Relevant information and history from the relatives of deceased and all the available clinical records were collected before the autopsy.

The findings on autopsy including the external features, postmortem changes, injuries, i.e., surgical and nonsurgical, needle puncture marks, were noted and recorded. All the cavities and organs were inspected and dissected minutely. The abdominal and pelvic cavities were given extra emphasis to allow clear demonstration of anatomy and injuries if any to the pelvic vessel and its surrounding structures. The placenta if present and left attached to the uterine wall was inspected. Retained products of conception or fetus if present were noted and recorded. Histology of all organs, chemical examination of viscera, blood, urine, and swab from infected lesions (if present) were sent for microbiological examination.

The collected data were statistically analyzed as regards to the age, phase of pregnancy, causes of death, place of death, pregnancy outcome, and mode of delivery if delivered.


  Results Top


In this study, of the total of 15 cases brought for medicolegal autopsy, 3 cases (20%) were below the age of 20 years, 5 cases (33.33%) were between 21 and 30 years, 6 cases (40%) were between 31 and 40 years, which is maximum and 1 case (6.67%) was above 40 years of age [Table 1].
Table 1: Age-wise distribution of maternal deaths

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The majority of maternal death, 8 cases (53.33%) occurred during the postnatal period, 6 cases (40%) occurred during the antenatal period, while 1 case (6.67%) succumbed during the intranatal period [Table 2].
Table 2: Distribution of maternal deaths based on the phase of pregnancy

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The most common cause of maternal death is direct cause which is observed in 13 cases (86.67%) while indirect unrelated cause is observed in 2 cases (13.33%) following postpartum depression [Table 3]. Of the 13 cases of direct cause of maternal death, the most common direct cause encountered in our study was hemorrhage and shock in 5 cases (46.15%) followed by amniotic fluid embolism and disseminated intravascular coagulation, 2 (15.39%) cases each. Ruptured ectopic pregnancy, pregnancy-induced hypertension, and septicemia accounted for 1 (7.69%) case each [Table 4].
Table 3: Causes of maternal deaths

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Table 4: Causes of direct maternal deaths

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In our study, maximum of the cases 11 of 15 were able to reach a health-care center before delivery. Even though 11 cases could reach health-care center, they could not be saved. Of the 11 cases, 9 cases succumbed within 24 h of admission, while 2 cases succumbed on the 4th and 5th day, respectively. However, 2 cases died on the way to the hospital, while 2 cases of indirect maternal deaths were due to suicide at their residence [Table 5].
Table 5: Place of death

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Regarding the pregnancy outcome and place of delivery, of the 15 cases, 8 (53.33%) mothers were able to deliver a live baby before they succumbed, while 6 (40%) of the mothers succumbed before giving birth and 1 (6.67%) succumbed after undergoing an abortion. From the data collected, it was also observed that all the 8 live births were institutional deliveries, of which 5 (62.5%) were delivered by lower segment cesarean sections and 3 (37.5%) by normal vaginal deliveries [Table 6].
Table 6: Pregnancy outcome and mode of delivery

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  Discussion Top


The purpose of this study is to determine factors causing maternal deaths and to discuss the importance of medicolegal knowledge in ascertaining the cause of maternal deaths.

In our study, the maternal death is more in the age group of 31–40 years which is 40% which is in the higher age group in comparison to the study done by Thomas Z which showed the age group 25–29 years as the most common age group for maternal death.[2]

In this study, 86.67% of maternal deaths were due to direct causes. Hemorrhage 38.46% was the major direct cause of maternal deaths followed by amniotic fluid embolism 15.39%. Our findings were consistent with studies conducted by Thomas,[2] Bhadra et al.,[3] and Sridevi and Shanmugavadivu.[4] In a systematic review by the WHO, hemorrhage was the leading cause of maternal death in Africa and Asia at 33.9% and 30.8%, respectively.

Regarding the mode of delivery, in our study, 62.5% of maternal death occurred following cesarean section and 37.5% following a normal vaginal delivery. This finding is consistent with the study done by Sridevi and Shanmugavadivu which showed 62% and 38% maternal mortality following cesarean and normal vaginal delivery, respectively.[4]

It was observed that with reference to the time interval between admission into hospital and death, maximum 81.81% of deaths occurred within the first 24 h of reaching the hospital, followed by 9.09% on the 4th and 5th day, respectively. Similar findings were observed in the study conducted by Yadav et al.,[5] Purandare et al.,[6] and Kavitkar et al.,[7] where the number of maternal deaths occurred within the first 24 h after admission into hospital. This can be attributed to the delay in reporting to a health-care center or due to late/delayed referrals to a higher center. Further, unavailability or inaccessibility to blood and blood products are other factors which may contribute to the number of maternal mortalities, especially in postpartum phases which are about 53.33% as observed in our study.




  Conclusion Top


Maternal deaths are tragic situations and carry significant short-and long-term impacts for family members. The purpose of this article is to emphasize the importance of conducting a detailed autopsy to find the causes of maternal deaths. Maternal deaths can be prevented by improving the health-care facilities where pregnant women can have access to good quality antenatal, intranatal, and postnatal care and ensuring round-the-clock availability of functioning blood banks from where blood and blood products can be obtained. Medicolegal autopsy of such cases helps in contributing to a wider surveillance and research processes that can, in turn, contribute to changes in clinical practice, policymaking, and subsequently changes in maternal mortality rates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: https://apps.who.int/iris/bitstream/handle/10665/70929/9789241548458_eng.pdf. [Last accessed on 2021 Oct 23].  Back to cited text no. 1
    
2.
Thomas Z. Direct causes of maternal death an autopsy study. Int J Adv Res 2017;5:2278-85.  Back to cited text no. 2
    
3.
Bhadra B, Choudhury RR, Sarkar D, Sarkar S. An epidemiological study of mortality among mothers admitted in a rural tertiary hospital of West Bengal. J Family Med Prim Care 2017;6:270-3.  Back to cited text no. 3
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4.
Sridevi G, Shanmugavadivu L. Analysis of maternal mortality at a government teaching hospital GMKMCH, Salem, Tamil Nadu, India: A retrospective study. Int J Reprod Contracept Obstet Gynecol 2018;7:5093-6.  Back to cited text no. 4
    
5.
Yadav K, Namdeo A, Bhargava M. A retrospective and prospective study of maternal mortality in a rural tertiary care hospital of central India. Indian J Community Health 2013;25:16-21.  Back to cited text no. 5
    
6.
Purandare N, Chandock AS, Upadhya S, Sanjanwala SM, Saraogi RM. Maternal mortality at a referral centre: A five year study. J Obstet Gynecol India 2007;57:248-50.  Back to cited text no. 6
    
7.
Kavitkar AN, Sahasrabudha NS, Jadhav MV, Deshmukh SD. Autopsy study of maternal deaths. Int J Gynaecol Obstet 2003;81:1-8.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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