Pseudocyesis

When a woman believes herself to be pregnant and develops symptoms and signs of pregnancy, this is called pseudocyesis. Bivin and Klinger (2) wrote their classic monograph in 1937 having collecting 444 cases from the literature. Most sufferers were parous, including women with as many as 10 children. As many as six multiple episodes of pseudocyesis have been described.

The differential diagnosis includes delusions of pregnancy, in which there are no somatic signs of pregnancy. This is a common delusion and can also occur in men, with or without the somatic phenomena of pseudocyesis. Pregnancy may also be simulated for social, mercenary, or legal purposes (e.g. to escape the death penalty).

The clinical features include the following:

• a firm belief in the pregnancy, usually lasting until the onset of a false labour at 9 months, after which the disorder usually resolves

• amenorrhoea

• morning sickness and pica

• enlargement of the breasts and nipples, and even a discharge of colostrum

• abdominal enlargement, caused by muscular contraction, tympanites, fat, or pathological lesions, but without effacement of the navel

• an illusion of fetal movements

• enlargement of the uterus to the size of a 6-week pregnancy.

The correct diagnosis should be made on ultrasound examination, revealing that the uterus is too small for pregnancy. Where radiology or ultrasound are unavailable, an examination under anaesthetic is recommended; a family member should be present to avoid accusations of having aborted the patient. Modern diagnostic tests have greatly reduced the frequency of pseudocyesis.

The psychological basis is usually an intense desire for children, especially in older childless women. In some cases, however, a guilty fear of pregnancy has been the background cause; this has occasionally led to dangerous attempts at abortion by women who are not pregnant.(3)

Pseudocyesis is a demonstration of the influence of psyche over soma, mediated by hormonal secretion. It occurs in dogs, cattle, and rodents owing to the persistence of the corpus luteum. This explains the breast changes, moderate uterine enlargement, and secretory endometrium. In humans, however, persistence of the corpus luteum is not the only explanation. Hormonal measurements have been made in at least 30 patients, and have shown chronic anovulatory states, hyperprolactinaemia, and androgen excess to be alternative explanations.

These women require psychotherapy. Simply revealing the diagnosis is unsatisfactory because the patient may go to another doctor with the same symptoms, or develop a recurrence. The underlying conflicts must be explored, helping the patient to face the fact that she is not pregnant. Some require antidepressant medication.

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