Pseudocyesis Vera in a Health Institution, North Western Nigeria.

Pseudocyesis was first reported in 19th Century and several others have been subsequently reported. The classes of the illness include Pseudocyesis vera, Delusional Pseudocyesis, Stimulated Pseudocyesis and Erroneous Pseudocyesis. This case report typifies Pseudocyesis vera called true pseudocyesis. It is said to be commoner in rural communities, where people don't have access to maternity services and where found they were not being used. It is authors' believe that such illness can be prevented with more enlightenment on advantages of use of available antenatal services.

Introduction

It is the joy of most consenting married couples to have children. One or two years after marriage without a child, people particularly family members begin to show concern. This concern and pressure on the couple become worse many years after without any child. In Africa, most people attribute childlessness to the fault of women. Ukpong and Orji reported that Nigeria women who have difficulty in conceiving are subjected to mental abuse, isolated from social functions, neglected and despised.[1] Some have been reported to developed frank psychotic disorder while others developed anxiety, depression and pseudocyesis. Pseudocyesis is defined as development of classical symptoms of pregnancy and labor pains accompanied by symptoms such as complete cessation of menstruation, nausea, enlargement and pigmentation of the breasts, abdominal distention and simulated labor pain.[2] The Diagnostic and Statistical Manual of Mental Disorders[3] also defined pseudocyesis as false belief of being pregnant that is associated with objective signs and reported signs of pregnancy which may include abdominal enlargement, reduced menstrual flow, amenorrhea, subject sensation of fetal movement, nausea, breast engorgement and secretion and labor pains at the expected date of delivery. Classes of pseudocyesis include Pseudocyesis Vera referred to as true pseudocyesis, Delusional Pseudocyesis secondary to a delusional idea, Stimulated Pseudocyesis in which the individual is deceptive knowing well she’s not pregnant and Erroneous Pseudocyesis which involves misinterpretation of symptoms of amenorrhea, galactorhea and or abdominal enlargement. After being reported by Jenkin, Revita and Tousignt in 19th Century,[4] several others have also been reported. The western medical literature describes pseudocyesis as an uncommon condition, with a prevalence in gynecological practice of 1-6 cases per 22,000 births,[5] whereas in Africa, there is a higher prevalence, with estimates of about 1 out of 160 patients presenting for infertility treatment.[6]

In Nigeria, pseudocyesis was initially thought to be rare.[7] Coker and colleagues,[8] in 2009, however, reported 5 cases of delusion of pregnancy over a period of 6 months in Yaba Neuro Psychiatric hospital Lagos, Nigeria. Yaba reported cases are secondary to delusions and therefore classified as delusional pseudocyesis. This case report typified the Pseudocyesis Vera (True Pseudocyesis).

Case Report

A 25-year-old housewife of Islamic faith presented at labor room of federal Medical Center, Gusau on the 16/8/2013 at about 4.30 a.m as case of expectant mother. She was unbooked G4P1+2,Ao non-alive patient. She presented with bleeding per Vaginal, abdominal distention, abdominal pain of 8 hours duration prior to admission. There was no drainage of liquor and last menstrual period could not be ascertained. Physical examination revealed a fully conscious young lady with Blood Pressure of 130/90 mmHg and moderately distended and tensed abdomen. No palpable fetal part and no obvious vaginal bleeding. The internal orifice of the uterus was closed and initial abdominal ultrasound conducted at labor ward revealed no fetal part. Attention of the Psychiatric Unit was drawn to the patient and further history revealed there was no visit to any hospital throughout presumed pregnancy. She had her first delivery, which was uneventful March 2010 at home. The baby however died 6 months after delivery.

She had 2 and 3 months miscarriages in 2012. She’s the 3rd wife of the husband, said to a trader. Other wives had children from her husband. No history of substance use. She’s premorbidly described as gentle, friendly and religious person.

Mental state examination revealed a calm and cooperative woman. Her speech was spontaneous, coherent and relevant. She had euthymic mood and no perceptual disorder. Cognitive function was normal and insightful. An assessment of pseudocyesis was made and repeat abdominopelvic scan and pregnancy test were conducted. She was transferred into post-natal ward for further observation. Repeat investigations revealed normal results and family counseling was carried out explaining to them the results of the investigation. They were thereafter reassured and discharged home after 48 hours of observation. She came for follow-up 2 weeks after discharged and remained clinically stable. She was referred back to O/G team for further assessment on her recurrent abortion.

Discussion

Pseudocyesis affects all ethnic, racial and socio economic group. The presented case is that of a 25-year-old patient, which is consistent with finding that majority of cases of pseudocyesis are observed among women aged 20-44 years, with no age exemption.[9] One or multiple episodes of pseudocyesis have been described and 80% of the affected persons are usually married.[10] Patient presented is married and also experienced her first episode. This is a case of true pseudocyesis classified as Pseudocyesis vera. It is said to be commoner in areas where people don’t have access to health facilities and where antenatal care were not possible. It is also said to occur more in rural and undeveloped community where women are not usually examined by a physician or midwife until they are in labor. Patient revealed that she had no antenatal care. The emotional burden undergone by the family will have been avoided if she had presented for antenatal care at the nearest health facility. The family residential abode is about 30 km to Bungudu General Hospital and about 60 km to FMC Gusau, both in Zamfara state of Nigeria. One couldn’t understand reasons for their nonvisit to the hospitals for her antenatal care. However, being uneducated, desired to have children like her mates, previous miscarriages and loss of her only surviving child might have contributed to her state of pseudocyesis. Urine (pregnancy) test, which cost at most N200 (1$) per test, will have reduced the financial burden undergone by the family. Provision of mother and child care services at the nearest health facility and psycho education emphasizing the usefulness of such facilities, the importance of God gift of children whether male or female will go in a long way in preventing similar occurrences. The need to encourage and support expectant women should be further sensitized. Religious and community leaders’ role in educating the masses will also reduced stigmatization of the barren women.

Conclusions

This report highlight that Pseudocyesis vera occurs in our community and more awareness of usefulness of mother/child facilities especially in our local and rural communities should be enhanced in preventing this illness and also reducing emotional and financial burden associated with the illness.