Pseudocyesis

Journal of Family Practice, May, 1990 by Paul M. Paulman, Abdul Sadat

Pseudocyesis has been known since antiquity. Hippocrates wrote of 12 women who "believed they were pregnant" in 300 BC.[sup.]1 Mary Tudor, Queen of England in the 16th century, thought herself to be pregnant. When she found out she was not, she embarked on the persecutions that made her reign infamous.[sup.]2

Several names have been given to this condition including spurious pregnancy, feigned pregnancy, imaginary pregnancy, hysterical pregnancy, wind in the bowels, and grosses nerveuse. John Mason Good coined the term pseudocyesis from the Greek words pseudes (false) and kyesis (pregnancy) in 1923.[sup.]3 Flanders Dunbar defined pseudocyesis in 1938 as "a condition in which a woman firmly believes herself to be pregnant and develops objective pregnancy signs in the absence of pregnancy."[sup.]1 Although pseudocyesis is occasionally reported in men as well as in women, this definition holds true today. ILLUSTRATIVE CASE A 30-year-old single woman came to the University of Nebraska Family Practice Clinic for a prenatal evaluation. The patient stated that she was 13.5 weeks pregnant, had abdominal distension, and had felt fetal movements. The patient's mental status examination was felt to be within normal limits. Physical examination revealed a 12-cm well-healed vertical midline lower abdominal scar. The patient's abdomen was slightly distended. Pelvic examination revealed the cervix and uterus to be absent. A urine test for human chorionic gonadotrophin was negative, and ultrasound of the pelvis revealed absence of the uterus. Past surgical and obstetric records (obtained later) showed the patient had two spontaneous abortions at 3 and 4 weeks' gestation, respectively, and no full-term pregnancies. Two years before the clinic visit, the patient had undergone an abdominal hysterectomy. The patient had been informed of the examination, laboratory, and ultrasound findings and appeared to accept them. A follow-up visit had been scheduled but the patient was lost to follow-up despite numerous telephone calls and letters. BRIEF LITERATURE REVIEW Etiology There are several theories regarding the cause of pseudocyesis, the following of which are the most widely accepted:

1. Conflict theory. A desire for or fear of pregnancy creates an internal conflict and causes endocrine changes to explain the signs, symptoms, and laboratory findings in pseudocyesis.

2. Wish-fulfillment theory. Minor body changes initiate the false belief in pregnancy in susceptible individuals.

3. Depression theory. Pseudocyesis may be initiated by the neuroendocrine changes associated with a major depressive disorder. There is evidence in the literature to support afl of these theories, and one or more may be simultaneously appropriate for patients with pseudocyesis. Pseudocyesis is considered a heterogeneous disorder without a unifying cause. Research to discover the underlying cause of pseudocyesis has been hampered by the relatively low numbers of patients with the illness. Epidemiology Pseudocyesis occurs at a frequency of 1 to 6 cases per 22,000 births.[sup.]4 The peak incidence of case reporting was between 1890 and 1910, when 156 cases were reported in the English literature; in contrast, only 42 cases were reported between 1959 and 1979. The age range of patients with pseudocyesis is 6 1/2 to 79 years (with an average age of 33 years). Eighty percent of women with pseydocyesis are married, 14.6% are unmarried, and 2.3% are

TABLE 1. SIGNS AND SYMPTOMS OF PSEUDOCYESIS
   Signs or Symptoms                      Percentage of Patients
   Abdominal enlargement                             63
   Menstrual irregularities                          56
   Sensation of fetal movements                      48
   Gastrointestinal symptoms                         41
   Breast changes or secretions                      40
   Labor pains                                       28
   Uterine enlargement                                9
   Cervical softening                                 6
   From small.[sup.]5

widowed. Pseudocyesis is more common in women during their second marriage than during their first marriage. Thirty-seven percent of women with pseudocyesis have been pregnant at least once. Symptoms usually last 9 months but can last for a few months or up to several years. There have been over 500 cases of pseudocyesis reported in women and at least three cases reported in men. Signs and Symptoms Almost every symptom and sign of pregnancy except for true fetal heart tones, fetal parts seen by imaging techniques, and delivery of the fetus, have been documented in patients with pseudocyesis (Table 1).[sup.]5

The most common sign of pseudocyesis, abdominal distension, is thought to be due to excess fat, gaseous distension, fecal and urinary retention, and an exaggerated lumbar lordosis causing forward displacement of the abdominal viscera. The abdominal distension often resolves under general anesthesia. Laboratory Findings Laboratory findings in patients with pseudocyesis show variable results. Estrogen and progesterone values can be high, low, or normal; prolactin tends to be elevated, and follicle stimulating hormone (FSH) tends to be low. There has been a documented case of a persistent corpus luteum in pseudocyesis.[sup.]6