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She certainly looked pregnant

Posted Jul 04 2009 9:14pm
But, she was not pregnant. Not one bit.

The woman presented to L&D with c/o contractions. She looked to be about 34-38 weeks pregnant, with a gravid abdomen. She had the waddle going on.

Once she was taken into a triage room, the nurse tried to find fetal heart tones. Nothing. Not even placental swooshing sounds. The nurse called the MD to do an ultrasound. The nurse figured that it was a fetal demise, with the absence of fetal heart tones.

It was, in fact, a case of pseudocyesis - "false pregnancy".

Upon ultrasound, it was determined that not only was she not pregnant with an approximate 8 month gestation, there was nothing - nada - zilch - in her uterus.

The woman calmly said, "ok, thank you". She got dressed and left the unit. No surprise. No shock. No "where's my baby???" She simply left the unit.

She wasn't my patient, but I was left with a big "WTF??" Why didn't the doc order a psych consult, or even just try and talk to the woman? (Unit was probably too busy to deal with something that wasn't of any great concern at that moment.)

Having worked on L&D, I can tell you that this is not uncommon. It happens more often that I could imagine. Women who insist they are pregnant, or in advanced stages of pregnancy, when they are not pregnant at all. Young women, middle aged women, peri-menopausal women. Women with mental illness. Women without mental illness. It crosses all races and religions.

Pseudocyesis has multiple potential causations. The woman could have an intense emotional desire to be pregnant or have a baby. This intense desire causes changes in her endocrine system that produce symptoms of pregnancy. She could have a history of having children, or a history of miscarriage/stillbirth, or infertility. She could have a mental illness where she has an extreme focus on pregnancy or being pregnant. There is also a theory that depression can cause such changes in the body (especially in the nervous system) that it mimics the physical symptoms of pregnancy. Or, she could have a history of childhood sexual abuse.

The incidence of pseudocyesis, from what I can gather, is about 1 to 6 in 22,000 women. I actually believe that there are more cases than that. How are the individual cases reported? How is the data gathered and calculated? I see gaping holes in the statistics of pseudocyesis and the reporting of incidences.

Here is an obvious case of mental illness as the cause of a false pregnancy.

From Psychology Today
Mar/Apr2007, Vol. 40 Issue 2, p28-28:

A 30-YEAR-OLD woman waddles into a family clinic with a large belly and tender breasts. She says she can feel her baby moving inside of her. A doctor performs a pelvic exam and discovers that not only is there no baby, there's no uterus. Her medical records show she'd had a hysterectomy two years earlier.

This case presented itself to Paul Paulman, a professor and family practitioner at the University of Nebraska. It was his first encounter with a rare condition called pseudocyesis, or false pregnancy. "I showed the woman a scan of her abdomen and explained the facts," Paulman says, "and then I never saw her again. I don't know if she ever accepted the truth."

In pseudocyesis, the mind tricks the body, and vice versa. Doctors think it develops when a woman obsesses over pregnancy out of desire or fear. (Queen "Bloody" Mary I of England famously suffered false pregnancy under pressure to continue the royal line.) A woman may stop menstruating, or her stomach may become distended due to stress or constipation. But her brain interprets the signs as pregnancy, which triggers the pituitary gland to secrete hormones like prolactin to prepare the body to carry a child. She gains more weight around the midsection, and her breasts swell and might even lactate. Many false pregnancies end when the woman goes into labor and delivers nothing.

Pseudocyesis occurs in only 1 to 6 of every 22,000 pregnancies, and it can also happen to children, the elderly, and men. "I think the men are a little more emotionally ill," Paulman says. Doctors confront the patient with medical evidence and offer counseling. If that doesn't work, the patient could have an underlying psychotic illness.

Pseudocyesis has a sibling syndrome: "couvade," or sympathetic pregnancy, where men experience many of the symptoms of their wives' or daughters' pregnancies--weight gain, nausea, headache, irritability, backaches, abdominal pain. A study of 81 expectant fathers found that almost half of them gained weight in the third trimester. Sympathy abdominal pains during birth are even more common, Paulman says. "I guess we all want to be in touch with our feminine side."


Here is another case from Journal of Obstetrics & Gynaecology, 01443615, Nov96, Vol. 15, Issue 6:

A 20 year old single woman presented to the casualty department claiming that she was 8 months pregnant, had fallen that day and was experiencing regular contractions and vaginal bleeding. A distended abdomen, marked fetal movements and a fetal heart rate of 120 beats per minute--maternal heart rate being 100--were noted on examination. Ultrasonography showed a small non-pregnant uterus. The consultant obstetrician was of the opinion that she had never been pregnant and she was referred to the psychiatric service.

She reported that she had tried to conceive for 6 months, followed by 8 months amenorrhoea and two positive home pregnancy tests. She described morning sickness, breast enlargement and tenderness, abdominal distension and stomach cramps and claimed that she had fetal movements from 6 months at which time she had also experienced minor vaginal bleeding. Her reported attendance for regular antenatal care could not be substantiated.

She described her partner as becoming particularly caring of her during the 'pregnancy'. She found fulfilment in her pregnancy role, partly compensating for her recent unemployment.

She did not express any psychotic symptoms or major mood disorder and neuroleptics were not prescribed. Although distressed at discovering that she was not pregnant, with supportive psychotherapy she became less convinced, surmising that she had 'miscarried' and that her antenatal file was 'missing'. Her boyfriend ended his relationship with her soon afterwards and she returned to live with her parents.


Another one from Journal of Obstetrics and Gynaecology, April 2007; 27(3): 322 – 335:

We present a case report of a 16-year-old female with pseudocyesis.
Her pseudo pregnancy occurred after using Depo-Provera and then
Microgynon for contraception. We consider whether the sideeffects
of long-acting, progestin-only contraceptive contributed to
her belief of pregnancy.

Case report
A 16-year-old female self-referred, with vaginal bleeding and mild
abdominal pain, having been amenorrehoeic for 4 months, and in
supposed second trimester of pregnancy. She had been using
Depo-Provera for contraception until her last injection in March
2005. In June 2005, she started using the combined oral contraceptive
pill –Microgynon. Her last menstrual period was early July.

She was confident that there was no break in contraception cover
while changing methods. She reported having done two home
pregnancy tests – one positive and one negative, and had attended a
Family Planning Clinic on several occasions prior to her admission.
She stated that a midwife had confirmed a pregnancy of 20 – 24
weeks’ gestation, having identified fetal heart using a Doppler and
fetal movement on examination. In addition, the patient had
experienced breast tenderness, fullness and milk discharge.
Uterine fundus was not palpable abdominally and bimanual
examination confirmed a normal size uterus. On speculum
examination, the cervix appeared normal. Urinary pregnancy test
was negative, this was confirmed by serum Beta-HCG. Follicular
stimulating hormone and luteinising hormone levels were checked
to rule out other causes of amenorrhoea, e.g. polycystic ovary
syndrome. Prolactin levels did not substantiate the patient’s claim
of milk discharge.

These findings were presented to the patient, who remained
convinced that she was pregnant. She was, therefore, referred for
ultrasound scan, which showed no evidence of pregnancy. Uterus
outline was normal with an endometrial thickness of 7.8 mm and
no adnexal masses or free fluid were seen. The patient and her
family initially showed disbelief at these findings but with
discussion, eventually appeared to accept them.

This woman was followed up at the gynaecology clinic, by which
time she had fully accepted that she was not pregnant and had
started menstruating.

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