Time was when every obstetrics text included a description and discussion of pseudocyesis, otherwise known as false, imaginary, phantom, hysterical, or spurious pregnancy. Textbook authors typically explained that even experienced physicians could make a mistaken diagnosis when there was not an actual pregnancy, because the outward signs and symptoms of this condition can be so convincing. Many 19th century authors pointed out that the woman having a false pregnancy generally would be newly married or near menopause and, in most cases, eager to be pregnant. Most 20th century textbook authors have considered pseudocyesis to be a psychiatric condition—an idea that I found too narrow when I encountered my first case during my second year of midwifery practice. My friend had plenty of the presumptive symptoms of pregnancy, but when I palpated her uterus, I found nothing in it. When I showed her a reference to false pregnancy in a medical book, she readily accepted my diagnosis, and her “pregnancy” symptoms quickly subsided. A year or so later, she had the first of her three real pregnancies. She was not neurotic, let alone psychotic.
According to textbooks, the usual scenario in a false pregnancy would be that a woman would come to the doctor (or midwife) with a distended abdomen, swollen breasts, darkened areolae, reporting that her menstrual period had stopped. Often, she would report morning sickness and fetal kicking. Textbook authors typically pointed out that such signs and symptoms should be regarded as presumptive, rather than definite, as it is possible for the mind to affect the body sufficiently to mimic the pregnant condition even when no pregnancy exists. During the 19th and early 20th centuries, authors cautioned doctors-in-training about the necessity of getting it right; Dr Lusk wrote in his 1881 textbook: “Mistakes as to the diagnosis of the pregnant state can never be covered up. They therefore inevitably subject the author of them to criticism and ridicule” (1, pp 92-93). In the 1926 edition of his textbook, Joseph DeLee’s cautionary remarks were similar:
Sometimes the diagnosis may be made very quickly, but the accoucheur is warned to guard his statements, because the people believe the fact of pregnancy should be very patent and will discredit the physician if the event prove him wrong, and, further, much depends on his decision. (2, p 265)
Lusk put it this way:
If [some women] once suspect pregnancy, they are apt to simulate other corroborative signs; or, on the other hand, they may proceed far in gestation without the slightest misgivings of their true condition. In such instances the physician, unless he bases his opinion on purely objective symptoms, is at times drawn into error, which places both himself and his patient in a ludicrous position. (1, p 93)
Because of the popular reality television program, “I Didn’t Know That I Was Pregnant,” the United States public has been made aware that even a woman who has been pregnant before can miss the fact that she is pregnant until she is actually giving birth. Women and couples who had this experience are interviewed on the program about how they missed the usual signs. Their stories provide people with real examples of the variety of ways in which pregnancy can be experienced (or missed). In these episodes, generally the only way a doctor is involved is by being in the emergency room or being the person who had earlier told the woman that it would be impossible for her to conceive. Because the end of the story is the birth of a healthy baby (whether in a hospital or a front yard), the outcome is surprise and a grateful happiness, and people seem glad to share their stories with others.
For the woman with pseudocyesis, however, the situation is different and often extremely humiliating, because most people, never having heard of the phenomenon, regard the woman who thought herself pregnant as delusional. Those who judge women in this condition have not experienced for themselves how convincing the symptoms can sometimes be.
The higher the woman’s social status, the higher are the stakes for the doctor. In the 16th century, Queen Mary of England provided a famous, most visible case of pseudocyesis, given that her “pregnancy” was to result in an heir to the English throne. Her doctor’s career effectively came to an end when her expected baby failed to be born after months upon months of waiting, and she began a series of persecutions that made her reign infamous. “The physician cannot always accept the statements of a patient as true because she may even delude herself into believing she is pregnant,” cautioned J. P. Greenhill in 1965 (3, P 246). Experienced doctors who had encountered cases of pseudocyesis emphasized that the only sure signs of pregnancy were a fetal heartbeat that could be distinguished from that of the mother and a manual examination that revealed fetal parts, given that molar pregnancies and certain tumors can be mistaken for pregnancy. Even manual examinations could be inconclusive in some cases, according to several authors, because the rigidity of the woman’s abdominal muscles or perineum could prevent the examiner from making a conclusive diagnosis. Remembering that first case of pseudocyesis I encountered (I had provided care for fewer than 30 women at the time), I can imagine how much more difficult it could be in some cases for a male physician to massage a woman’s abdominal muscles long enough to relax them sufficiently to palpate the uterus.
Some 19th century doctors who suspected that they might be dealing with a case of pseudocyesis were advised to anesthetize the woman to make a definitive diagnosis. This recommendation was made in those cases when the woman’s abdomina] and pelvic muscles were too rigidly held (whether unconsciously or consciously) for a manual examination to identify the uterus. Once under anesthesia that same woman’s abdominal muscles would relax enough to permit diagnosis. One early textbook features a drawing of a “pregnant” woman in her white lace bonnet with a shawl around her shoulders as she sits upright in her bed with her distended belly visible. A second drawing shows her, slumped to one side, completely unconscious, with a noticeably deflated belly (4, p 106).
The 20th century brought visual technologies such as x-ray and ultrasonography. At last, a way to peer into the uterus! Iffy and Kaminetzy wrote in 1981: “Ultrasound pregnancy detection and follow-up continues to improve and permits immediate determination of growth and viability.” At the same time, they cautioned, “Regardless of this sophistication, errors still occur, and awareness of the variability of the testing procedures, their inherent peculiarities, and the range of specificity of each method is the responsibility of the clinician” (5, p 715). Such cautionary words, however, were missing from the most widely read obstetrics textbook of the late 20th century—the venerable Williams Obstetrics. The 16th, 17th, 18th, and 19th editions, which appeared in 1980, 1984, 1989, and 1993, respectively, included a three-paragraph description of pseudocyesis that contained no reference to the difficulty in making the diagnosis that many other previous texts mentioned. Instead, the material on false pregnancy was summed up in this way:
Careful examination of such women usually leads to a correct diagnosis without great difficulty since the small uterus can be palpated on bimanual examination. The greatest difficulty encountered in the care of such women may be that of convincing her of the correct diagnosis. Psychotic women may persist for years in the delusion that they are pregnant. (6, pp 270-271)
By the 21st edition of Williams Obstetrics , which appeared in 1997, the editors seem to have concluded that only a passing reference to “spurious or imaginary pregnancy” was necessary, which was only in reference to how breast changes in these cases mimic the breast changes in real pregnancies. The 22nd and 23rd editions that have been published since contain no reference at all to pseudocyesis, despite the fact that cases continue to occur in women. Apparently, the editors thought this age-old phenomenon was no longer important enough to even mention (7).
A new but now widely read obstetrics textbook, Obstetrics: Normal and Problem Pregnancies , made its first appearance in 1986, followed by a second edition in 1991. A 30-page chapter on the endocrinology and diagnosis of pregnancy contained no hint that pregnancy could ever be misdiagnosed. By the fifth edition, published in 2007, however, the editors had decided to correct the absence of information about pseudocyesis with two paragraphs defining and describing the phenomenon. “Gentle and supportive provision of information to challenge the belief of pregnancy with referral for psychotherapy is an appropriate intervention strategy,” the editors concluded (8, pp 1278-1279).
All of this history would be a meaningless academic exercise if it were not for ignorance of the real consequences of pseudocyesis for women who have it and (sometimes) for the physicians or residents who diagnose a pregnancy that does not exist. I became aware of this possibility when I read an online news artide about a North Carolina woman who first got the news that she was not pregnant after being cut open to extract her “baby” who was supposed to have died, because no heartbeat could
be detected by means of ultrasound. It is possible that the mother who underwent this surgery in 2008 might have wondered if there could have been a less troublesome way to discover her pregnancy status.
I would have dismissed this medical mistake as unfortunate but unlikely to be an indication of a trend until I had my first opportunity after learning about it to repeat this story to a group of doctors and nurses. The occasion was a meal with the head of obstetrics of a large urban hospital, attended by several of her colleagues. Her reaction to my telling that story surprised me: she was rather embarrassed to admit that she had almost performed surgery on a nonpregnant woman very recently, and that only her manual examination, performed just before the scheduled surgery had corrected the mistaken diagnosis that her residents had made. That incident piqued my curiosity about how her residents could have made the mistaken diagnosis of pregnancy in this case. Surely, I thought, if they had read their obstetrics textbook, they would have become aware of the possibility of false pregnancy—the same way I had. The next big surprise for me was the discovery just after my lecture that the latest edition of Williams Obstetrics had dispensed with pseudocyesis as a phenomenon worth knowing about. No wonder they didn’t know!
I have spoken at only one other hospital since, but interestingly, this latest visit turned up yet another story of a false pregnancy revealed only by surgery. This time the “mother-to-be” was a teenager, and the residents were so sure that she was pregnant and in labor that they dispensed with doing an ultrasound or a manual examination.
I therefore recommend that all editors of obstetrics textbooks put pseudocyesis back into future editions. It would not be a bad idea to put it on page one of the textbook, because that would command students’ interest and enlarge their knowledge in a memorable way. I also recommend that residents be taught Leopold’s maneuvers. Any physician who is unable to distinguish a pregnant uterus from a full bowel needs additional education.
- Lusk WT. The Science and Art of Midwifery, 4th ed. New York: D. Appleton and Co., 1896.
- DeLee JB. The Principles and Practice of Obstetrics , 5th ed. Philadelphia & London: W.B. Saunders Co., 1928.
- Greenhill JP. Obstetrics, 13th ed. Philadelphia & London: W.E. Saunders Co., 1965.
- Garrigues HJ. A Text-Book of the Science and Art of Obstetrics. Philadelphia & London: J.B. Lippincott Co., 1902.
- Iffy L, Kaminetzy HA, eds. Principles and Practice of Obstetrics & Perinatology, Vol. l. New York: John Wiley & Sons, 1981.
- Pritchard JA, MacDonald Pc. Williams Obstetrics , 16th ed. New York: Appleton-Century-Croft, 1980.
- Cunningham F, Leveno K, Bloom S, Hauth J. Williams Obstetrics , 23th ed. New York: McGraw-Hill Professional, 2009.
- Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies , 5th ed. New York: Churchill Livingstone, 2007.
Ina May Gaskin, CPM, MA, PhD (Hon)
Birth 39:1 March 2012