Pseudo- pregnancy (Pseudocyesis)

Pregnancy can be an exciting time for the expectant parents-to-be. Sometimes, though, pregnancy doesn't end as anticipated - with a baby. In rare cases, a woman (or even a man) believes she is pregnant, only to find out that her symptoms were caused not by pregnancy, but by something else entirely.

Pseudocyesis is a rare psychiatric syndrome. In literature it is also called false pregnancy, pseudopregnancy, hysterical pregnancy, or phantom pregnancy.

The term "Pseudocyesis" was introduced by JohnMason Good in 1823 based on Greekwords pseudes = pseudo (false); and kyesis = pregnancy. Pseudocyesis is a state in which a woman, who is not pregnant, firmly believes that she is pregnant. At the same time she has almost all the signs and symptoms of pregnancy

Pseudo-pregnancy are widely reported in a number of mammalian species, including dogs, cats, bears, rodents, pig, horse, monkey and experimentally in rabbit, mice. So pseudopregnacy is a pathological condition characterized by an accumulation of aseptic fluid in the uterus and it is associated with the presence of a persistent corpus luteum and consequently, a high concentration of progesterone in the plasma for more than 25 days. Hydrometra is a synonum for pseudopregnancy. It is also known that certain naturally occurring chemicals, such as zearalenone (which is produced by moulds, e.g. Fusarium spp.) can cause pseudocyesis in some species (e.g. domestic pigs) can also cause hormonal changes in animals that could perhaps induce pseudocyesis. Pseudopregnancy has been diagnosed both in mated and non-mated animal during the breeding season, but it also occurs outside the reproductive season. Stressful environments can also cause hormonal changes in animals that could perhaps induce pseudocyesis.

 History

Cases of pseudocyesis have been documented since antiquity. Hippocrates gave the first written account around 300 B.C. when he recorded 12 cases of women with the disorder. Mary I (1516–1558), Queen of England, was suspected to have had two phantom pregnancies, but this is strongly disputed; some historians believe that the queen's physicians mistook fibroid tumors in her uterus for a pregnancy, while others suspect either a molar pregnancy (proceeding to choriocarcinoma) or ovarian cancer was to blame.

Some authors classify pseudocyesis into psychosomatic disorders, others consider it a manifestation of depressive disorder, whereas the third group refer to it as a monosymptomatic hypochondriasis (Munchausen syndrome). Modern classifications categorize it into somatoform disorders, DSM IV TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisited), code 300.82 (undifferentiated somatoform disorder), whereas ICD 10 (International Classification of Diseases, Tenth Edition) encodes it as F45.9 (somatoform disorder, undifferentiated)3,4. Pseudocyesis should be distinguished from gestational pychosis characterized by the existence of pregnancy, however, these patients show no physical signs of pregnancy that are observed in patients suffering from pseudocyesis (except for the fetus).

Pseudo-pregnancy in human:

Pseudo-pregnancy is a psychological and physiological process which occurs rarely in humans. False pregnancy is a rare condition in which a non-pregnant woman believes that she is pregnant, even though there is no physical evidence of pregnancy. False pregnancy (sometimes called phantom pregnancy), or pseudocyesis, is the belief that you are expecting a baby when you are not really carrying a child. People with pseudocyesis have many or all of the common symptoms of pregnancy, with the exception of an actual foetus. This condition is very rare, occurring in only one to six out of every 22,000 births. It is most common in women aged 20 to 44, although it can affect women of all ages.

Causes of pseudo-pregnancy in human

Doctors have been aware of pseudocyesis for centuries, but only recently have they begun to understand the strong emotional, psychological and physical issues that are at the root of the condition. Although the exact causes still aren't known, doctors suspect that psychological factors may trick the body into "thinking" that it's pregnant.

Psychologists believe that when a woman feels an intense desire to get pregnant, which may be because of infertility, repeat miscarriages, impending menopause or a desire to get married, her body may produce some of the signs of pregnancy (such as a swollen tummy, enlarged breasts and even the sensation of foetal movement).

Some researchers have suggested that poverty, a lack of education, childhood sexual abuse or relationship problems might play a role in triggering false pregnancy. Having a false pregnancy is not the same as claiming to be pregnant for a benefit (such as for profit) or having delusions of pregnancy (such as in patients with schizophrenia).

And in pathological condition the corpus luteum (the remains of an ovulated ovarian follicle) is responsible for the development of maternal behavior and lactation, which are mediated by the continued production of progesterone by the corpus luteum through some or all of pregnancy.

In most species the corpus luteum is degraded in the absence of a pregnancy. However, in some species, the corpus luteum may persist in the absence of pregnancy and cause "pseudopregnancy", in which the female will exhibit clinical signs of pregnancy.

Research has also linked false pregnancy to the pituitary gland (which is the centre of hormone production during pregnancy) and specifically, to an unusually high level of hormones. This hormone imbalance is often sparked by stress and anxiety, which in turn causes the emotional and psychological shifts that lead a woman to falsely believe she is expecting. The woman's brain then misinterprets those signs as pregnancy, and triggers the release of hormones (such as oestrogen and prolactin) that lead to actual pregnancy symptoms.

Pathophysiological – organic causes

Numerous mechanical factors, which affect abdominal disturbances, can cause a woman to believe she is pregnant, for instance: retention of intestinal gasses, urine retention, abdominal neoplasia, tumor of uterus, ovarian tumor, hydatid mole, papillar renal carcinoma, inflammatory processes, and numerous causes of primary infertility (Rosenfeld, 1990). César describes pseudopregnancy in a female patient who was suffering from hepatomegaly, toxic hepatitis, and alcohol induced disturbances of liver functions and consecutive ascites. In her anamnesis there was early separation from her mother, a series of symbiotic relationships, two successful pregnancies and a third that ended with premature childbirth, and alcoholism. The paracentesis, which was done in order to determine the etiology of ascites, she misunderstood for amniocentesis and asked for determination of her child's sex. In alcoholic males, along with ascites, gynecomastia also occurs often, and feminization as a result of testicular atrophia and impotence, which can also take part in the development of the syndrome of pseudopregnancy. The often-toxic effect of psychopharmacologic drugs leads to iatrogenically induced lactation, i.e. galactorrhea and amenorrhea, in persons treated with antipsychotics that can also cause pseudocyesis, especially if a person wants to have a child and starts to believe that she is pregnant.

Neuroendocrinological causes

Pseudocyesis has a central hypothalamic – hypophysial background. It is a hypothalamic-hypophysial-ovarian dysfunction, and can be described as galactorrhea-amenorrhea-hyperprolactinemia syndrome (GAHS). It is important to emphasize that patients suffering from classic GAH-syndrome do not necessarily believe to be pregnant, while it is primarily in pseudopregnancy. GAHS means that there is abnormality in the hormone of growth, prolactin, ACTH, cortisol, similar to a depressive disorder. The neurotransmitter deficit of catecholamine

and dopamine is responsible for hyperprolactinemia and gonadic dysfunction. Prolactin is a phylogenetic old pituitary hormone, which plays an essential role in the complex behavior during maternity. In pseudopregnancy his basal level rises. Such a change can also be found in hypothyroidism. The increased level of prolactin leads to lactation and enables the persistence of the corpus luteum that can also lead to amenorrhea, which hypothetically explains some symptoms of pseudopregnancy. The corpus luteum is a primary source of circulating progesterone during the estrous cycle, pregnancy and pseudopregnancy. Progesterone is a steroid of initiation and maintaining pregnancy in mammals. From the pituitary gland and placenta Lutheotrophic factors are extracted. They include prolactin and LH during the first half of pregnancy, and estradiol and placental lactogenic hormone during the other half of the pregnancy. Gonadotropins, estrogen and progesterone manifest variations of level in the serum, which affects the luteal function. So, the depression of the cortical and limbic system causes a decreased level of biogenic amines, which results in an abnormal release of the luteinizing-hormone releasing factor (LRF), FSH releasing factor (FRF) and prolactin inhibiting factor (PIF) in medial eminence of the hypothalamus. It results in a decreased level of the luteinizing hormone (LH) and FSH, which leads to the suppression of ovulation and results in amenorrhea. It is interesting that the hormonal answer is normalized at the beginning of pseudocyesis.

Hormonally, it is caused by the superproduction of progesterone and the abnormal persistence of the corpus luteum.

In rare cases, even men can have a false pregnancy. Some men experience a related phenomenon known as couvade, or sympathetic pregnancy. They will develop many of the same symptoms as their pregnant partners - including weight gain, nausea and backache.

Symptoms of pseudopregnancy

Like during a normal pregnancy, symptoms of a false pregnancy may vary from one woman to another. They will also usually have the same symptoms as a pregnant woman and may feel these symptoms for several weeks, months or even years:

·         Amenorrhea- Stopping of menstrual period

• ·         Enlarged and tender breasts, changes in the nipples and possibly milk production.
•       Feeling of foetal movements
•       Nausea and Vomiting
•      Morning sickness
•      Swollen tummy
•      Weight gain
•      Fatigue

·      Cravings- A food craving is an intense desire to consume a specific food, and is different from normal hunger.It may or may not be related to specific hunger, the drive to consume particular nutrients that is well-studied in animals.

It is medically unclear why women experiencing pseudopregnancy sometimes exhibit true physical signs of pregnancy.

These symptoms can last for just a few weeks, for nine months or even for several years. A very small percentage of patients with false pregnancy will arrive at the doctor's surgery or hospital with what feels like labour pains, but they will not deliver a baby.

Tests for pseudopregnancy

To determine whether a woman is experiencing a false pregnancy, the doctor will usually evaluate her symptoms and perform a pelvic examination and arrange for an abdominal ultrasound - the same tests used to feel and visualize the unborn baby during a normal pregnancy.

In a case of false pregnancy, no baby will be seen on the ultrasound, and there won't be any heartbeat.

Representative images from a nonpregnant/pseudo-pregnant sow with fluid accumulation and a pregnant sow with viable fetuses on day 70 of gestation using a 5.0-MHz probe. The spinal cord (sp) can be seen in the image from the pregnant animal.

Sometimes, however, the doctor will find some of the physical changes that occur during pregnancy such as an enlarged uterus and softened cervix.

Certain medical conditions can mimic the symptoms of pregnancy including ectopic pregnancy, morbid obesity and cancer. These conditions may need to be ruled out with tests.

A pregnancy test such as urine or blood test or a sonogram will usually show no pregnancy, but nevertheless women with pseudocyesis will insist they are pregnant due to a deeply-rooted desire to be pregnant.

False Pregnancy: Which Women are Most at Risk?

Women who are most at risk for pseudocyesis are:

• women in their late thirties or early forties, who have been trying to conceive for many years and who may have fertility problems.
• women who are not generally emotionally unstable but who are extremely emotional with regard to pregnancy.
• women who have suffered a miscarriage or who have lost a child.

 Treatment for pseudopregnancy 

If you have these symptoms, you should consult a doctor who will be able to help you determine your actual state by first doing a pregnancy test.

If it is indeed a false pregnancy, a doctor or gynecologist may prescribe you the most appropriate treatment depending on your history or refer you to a psychiatrist if they think you could benefit from more help.

Psychological counseling is usually recommended by psychotherapist in order to treat underlying emotional and psychological causes of false pregnancy, including stress, anxiety and depression.

It is important at the same time, however, for the treating professional not to minimize the reality of the patient's physical symptoms. The treatment that has had the most success is demonstrating to the patient that she is not really pregnant by the use of ultrasound or other imaging techniques.

When a woman believes she is pregnant, especially for a period of several months, it can be very upsetting for her to learn that she is not. Doctors need to gently break the news, and provide psychological support - including therapy - to help the patient with pseudocyesis recover from her disappointment.

Pseudocyesis is not known to have a direct underlying physical cause and there are no general recommendations regarding treatment with medications. In some cases, however, the patient may be given medications for such symptoms as the cessation of menstruation.

There have been reports of patients being cured of pseudocyesis by :

    Hypnosis, Purgatives, Massage, Opioids,

After nine months of symptoms, by experiencing "hysterical childbirth," but there are few data available on the effectiveness of these or similar procedures.

A number of clinical studies suggest that at some point of metaoestrus circulating PRL levels rise in overtly pseudo-pregnant bitches. Individual differences in sensitivity to PRL as well as the existence of molecular variants of canine PRL with different bioactivity versus immunoreactivity ratios may help clarify the aetiopathology of PSC. Diagnosis of PSC is based on the presence of typical clinical signs in metaoestrous non-pregnant bitches. Considering that PSC is a self limiting physiological state, mild cases usually need no treatment. Discouraging maternal behaviour and sometimes fitting Elizabethan collars to prevent licking of the mammary glands may suffice in these cases. Sex steroids (oestrogens, progestins and androgens) have been traditionally used to treat PSC but the side-effects usually outweigh the benefits of these medications.

Inhibition of PRL release by ergot derivatives [bromocriptine (10-100 microg/kg per day for 10-14 days], cabergoline (5 microg/kg per day during 5-10 days), metergoline (0.2 mg/kg per day during 8-10 days) has proved to be effective for the treatment of canine PSC. Although some of these ergot derivatives present some untoward side-effects, they are transient and can usually be managed. Predisposed bitches not intended for breeding should be spayed as ovariectomy is the only permanent preventive measure.