STRESS MEDICINE, VOL. 6: 43-45 (1990)

STRESS AND ILLNESS

PREMONITION OF FOETAL DEATH KENNETH CHAPMAN FRCOG, FRACOG, MMSA* AND ROKHSAREH CHAPMAN MD, FRCOG, FRACOG*

Department of Obstetrics and G-vnaecology, Tokoroa Hospital, Tokoroa, New Zealand

Five patients who had a presentiment that their unborn child would die are described and their treatment and foetal outcome are discussed.

K E Y WORDS-Foetal death, premonition, stillbirth, Caesarian Section, depression

‘She remained extremely nervous, anxious about the outcome and was difficult t o reassure . . . The baby subsequently died.’

The above quotation, taken from an Obstetric Registrar’s discharge letter, illustrates a woeful insensitivity and lack of comprehension of the pregnant woman. It has prompted this short Paper which consists, essentially, of five case reports.

CASE REPORTS

Case 1

A 34 year old multipara who had had two previous normal deliveries and one stillbirth sought termi- nation of her pregnancy at Northwick Park Hospi- tal, London, because she was convinced that her foetus would die in labour. Her request was refused. Pregnancy continued normally but the patient’s morale deteriorated. A visiting psychia- trist was unable to change her melancholy out- look. At term her blood pressure was minimally elevated so labour was induced surgically and augmented with synthetic oxytocin. Despite con- tinuous monitoring in labour the foetal heart suddenly disappeared and it was only sub- sequently discovered that the uterus and bladder had ruptured. Caesarean hysterectomy and repair of the bladder were performed. There was no disproportion and the reason for the uterine rup- ture remained obscure. No abnormality of the stillborn foetus was detected.

~

*Present address: 144 Harley Street, London, WIN IAH

Case 2 A primigravida aged 25 years had an uneventful pregnancy until the 34th week when foetal move- ments ceased. She was referred to Tokoroa Hos- pital, New Zealand, where she subsequently delivered a macerated foetus. No cause was found for the stillbirth. Throughout the pregnancy she had suffered from an unexplained horror that the foetus would die.

Within a year the patient was pregnant again. This pregnancy was monitored throughout and she spent much of her time in hospital for she suffered from the same fears and needed much encouragement. From the 30th week onwards there was evidence of foetal growth retardation. Her membranes ruptured spontaneously at the 38th week, foetal distress developed and Caesar- ean Section was performed. The infant, who weighed 2,420 g, survived.

Case 3 A 25 year old patient, who had had two normal confinements followed by four abortions, was referred to Tokoroa Hospital, New Zealand, for sterilization. She confided that she would have liked to have a further child, Soon afterwards she became pregnant. In addition she had recurrent nightmares in which the child died during its birth. She was referred to a psychiatrist but refused to see him again. She was admitted to hospital for supportive therapy and recovered sufficiently to be allowed home. By the 30th week her reactive depression again necessitated her admission to hospital. Despite heavy sedation her condition

Received ! I July 1989 0748-8386/ 90jO 10043-03$05.00 0 1990 by John Wiley & Sons, Ltd.

44 KENNETH CHAPMANAND ROKHSAREH CHAPMAN

deteriorated so much that it was feared she might attempt to take her own life. A promise was therefore given that a healthy baby would be obtained for her by Caesarean Section at the 38th week and that sterilization would be performed at the same time. She gladly accepted the offer. Although her nightmares continued, she began to cope with life again, so much so that sedation had been completely discontinued by the time that Caesarean Section had produced the promised healthy child which weighed 3,620 g. Her fears disappeared immediately and she cared wonder- fully for her baby. When seen several weeks later she was radiant with happiness.

Case 4 A 29 year old multipara gave a history of four normal confinements and one ectopic pregnancy. Early in the sixth pregnancy recurrent left iliac fossa pain necessitated laparotomy. Omental adhesions were found and divided. During her convalescence she became disturbed and requested termination of pregnancy because, although the child was wanted, she was convinced that it would ‘get stuck’ during labour and die. These fears recurred continually. Psychiatric help failed to give relief. Eventually she cheered up when pro- mised that, in the event of labour being difficult, Caesarean Section would be undertaken. Bouts of severe depression recurred from time to time, especially in the third trimester. This necessitated her admission to Tokoroa Hospital, New Zealand, on several occasions for supportive therapy. She went into labour spontaneously at the 39th week but her terror become almost unsupportable. We had no hesitation, therefore, in carrying out immediate Caesarean Section and sterilization. A healthy child weighing 3,670 g was obtained. The patient’s fears immediately disappeared and all who saw her remarked on the dramatic change which had occurred.

Case 5 A Maltese gravida 5 para 2 aged 34 years, with no past psychiatric history, had an uneventful preg- nancy until the 36th week when she started to have recurrent dreams in which her unborn child died. She demanded immediate Caesarean Section. Tests for foetal well-being, which included cardiotocography, were normal and the patient was reassured. The unpleasant dreams continued.

At the 38th week the patient made her way to Blacktown Hospital, Sydney, with ruptured mem- branes. The cervix was tightly closed but she was draining grade 3 meconium. We performed an immediate Caesarean Section. A living female infant with Apgar scores of 8 and 9 at one and 5 minutes respectively, and weighing 2,750 g, was delivered. No cause was found for the foetal distress. She subsequently developed postpartum depression and required psychiatric treatment.

DISCUSSION

In the secular world in which we live now anything which smacks of precognition is viewed with dis- belief. This is unfortunate because we are apt to fail our patients in their hour of greatest need. Psychiatric aid may be sought, but, if the patient has already formed a rapport with her obste- trician, she may well resent this. This was certainly our experience in cases 3 and 4 where the patients refused to co-operate with their psychiatrists.

A very close bond exists between the pregnant woman and her unborn child. It is certain that many women experience ‘life’ within their body months before quickening occurs. This being S O it is reasonable to assume that some women will appreciate that all is not well with their unborn child long before the obstetrician. In Case 2 it is possible that growth retardation had occurred before the death of the first child. Certainly it was detected clinically several weeks before her second child was delivered. Case 1, medically speaking, is inexplicable. Careful monitoring of the pregnancy and labour gave no cause for alarm. Death occurred suddenly at the time of uterine rupture. Both cases 3 and 4 had psychiatric histories. It is possible, therefore, that their respective pregnancies reactivated their depressive tendencies. Whether this is so or not one thing is sure: that is that the offer of Caesarean Section provided a way out of the impasse. In both cases the outcome was more than for which we could have hoped. The babies born to them became their most prized possessions. Their fears vanished and they rewarded their Obstertricians by becoming their most grateful patients.

Case 5 is a cautionary ending to the tale. Had we been more in tune with the patient she would have been in hospital at the time that her membranes ruptured so that Caesarean Section would have been performed even more expeditiously. In addi- tion, we should like to think that, perhaps, she

FOETAL DEATH 45

however, this occupies most of their waking and sleeping hours it is pathological. Unfortunately, all too often, the patients’ worst fears are realised.

Besides careful monitoring of pregnancy and labour, it is suggested that, in certain circum- stances, promise of elective Caesarean Section on psychiatric grounds can resolve what otherwise might become an intolerable situation.

might have been spared the puerperal depression from which she subsequently suffered.

CONCLUSION

The majority of women at some stage of their pregnancy worry about their unborn child. When,