Q: My sister-in-law had a miscarriage a week before her delivery date. The baby died before she delivered. When she went for a check up last week the doctor said that everything was normal. When she went for check up this week the doctor said that there was no heart beat of the baby and after scanning they confirmed that the baby died inside. Its so heart breaking for our entire family. We all were expecting the baby within a week but everything went wrong and the baby was a boy. We are not able to come out of the shock. Please doctor tell us what might be the reasons for this and what should be done in future to avoid such things. The same type of incidents occurred for my cousin sister just before 7 or 10 days of delivery. Will she be able to conceive normally once again? She was in Singapore and for the delivery she came to India at the end of 7th month. What steps should be taken to avoid this incident once again and what might be the reasons for that? She is so mentally upset and what she should to come out of this shock?

A:I am sorry to hear about the tragedy. I understand the grief that the whole family is going through and the questions that must be going through your minds. Unfortunately you will not find answers even if you get all possible tests done. It is not clear from your letter but I assume that you did not get a post mortem done for the dead fetus. In the absence of a thorough post mortem examination I am afraid we will never know what went wrong. Invariably when we get a case like this the patient and her family ask what went wrong since until the previous day / week the baby was alright. Unfortunately it is always like this. When we say the baby is alright in the clinic it only means that the baby's heart is beating alright at that moment and there is no way to say that it will remain ok for even the next few moments leave alone next week or month. Barring a few instances like a very high blood pressure and uncontrolled diabetes or severe maternal infections which can be diagnosed, in very few cases the cause of a sudden still birth is ever found. These are called unexplained still birth. This is probably what happened to your sister in laws case. These cases are nearly impossible to diagnose and are thus called because the cause cannot be explained by the existing medical knowledge. We tend to somehow forget that a fetus in nine months inside the womb can get all the diseases (like cough/cold/diarrhoea/vomiting pneumonia and infections) that we get outside the womb in the next 60/70 or 80 years that we live in this world. Unfortunately these cannot generally be diagnosed before birth and since the immunity of the baby and other protective mechanisms are poor, any of these relatively mild problems in the adult, can kill a fetus inside the uterus. The fetus also may be suffering form one of the major diseases like endocrinal disorders or liver, lungs or kidney disorders. Besides these intrauterine diseases the baby may also be abnormal. Contrary to the popular perception only a fraction of these abnormalities can be found by ultrasound and other tests that are done in a normal pregnancy. In other words since the pregnancy was low risk there was no need to do hundreds of tests and in my opinion I can assure you that I do not believe anything that should have been done was missed. And as happens in most such cases of unexplained still birth no cause is ever found. Of course the doctors will do some basic tests to try and find out the cause. Test should include exclusion of possible intrauterine infections, anti phospholipid syndrome, basic blood counts, urine examination and kidney functions tests and test to rule out diabetes. In all probability these tests will all be normal. And we will have to say that this a was one off accident of nature. In fact a lot of these unexplained still births are because of heart rhythm disorders (cardiac arrhythmia) which are likely to be due to a cardiac abnormality but can also happen in a perfectly normal heart under severe stress like a metabolic disturbance. All these could lead to a kind of a prenatal heart attack, which is the final event in most cases. It has also been seen that these foetuses who have a demise so close to term cannot take the stress of a transformation from the intrauterine environment to the independent existence. In effect all these are speculations and the honest answer to your question as to what happened is that we do not know. Modern medicine with its current knowledge cannot explain what went wrong and in all probability we will never know no matter how many tests we do. What we do know is that these still births occur (as you know form the experience of your cousin earlier) and not much can be done to prevent these. They happen with equal probability in countries which provide the best medical care and in countries which provide only the most basic care. Of course she will conceive normally and there is nothing to suspect that she will have problems in conceiving. But ideally the pregnancy should be managed rationally. The couple and the family would required repeated assurances and counseling. In most cases a tragedy like this is followed by a completely normal pregnancy. If a cause which affects repeated pregnancies is found it should be treated but in case no such thing is found, the next pregnancy should be treated as a normal pregnancy. There is no need for precautions and irrational treatments. Of course one should take all measures to avoid complications like diabetes and blood pressure and anaemia, in absence of these the pregnancy should be allowed to progress normally. In the meantime if the lady who lost her baby is in severe shock you should consider taking professional help as post-natal depression is a common and serious complication.