Bath-related sudden death in pregnancy associated with post-hemorrhagic epilepsy: An autopsy case report

Sudden unexpected death is a rare but clinically important event in pregnant women with epilepsy. This case report describes a fatal bathtub drowning in a pregnant woman with epilepsy secondary to pregnancy-related intracerebral hemorrhage. A 31-year-old woman at 6 months' gestation was found submerged in a bathtub filled with 41 °C water, and resuscitation attempts were unsuccessful. At age 29 years, she experienced intracerebral hemorrhage requiring hematoma evacuation during delivery of her first child and subsequently developed poststroke epilepsy. She had three nocturnal generalized tonic-clonic seizures before death. Autopsy revealed increased lung weight and frothy fluid in the airways, consistent with drowning. Neuropathological examination revealed a previous right frontal white matter hemorrhage involving the cortical surface, considered a potential epileptogenic focus. Microscopic examination revealed significant hemosiderin deposition and associated chronic inflammatory changes in the affected area, which may be linked to epileptogenesis. Despite treatment with the maximum dose of levetiracetam (3,000 mg/day), the postmortem blood concentration was near the lower limit of the therapeutic range. This case highlights the structural basis of epilepsy following pregnancy-related intracerebral hemorrhage, the difficulty in preventing fatal seizure-related events in pregnant women, and the potential role of hyperthermia during bathing as a seizure trigger.