Cent. Eur. J. Med. • 6(6) • 2011 • 720-722 DOI: 10.2478/s11536-011-0086-1 Central European Journal of Medicine Pseudocyesis as a cause of abdomen enlargement in a female adolescent Case Report Veselin Škrabić*1, Željka Vlastelica1, Zoran Vučinović2 1 Department of Pediatrics, Split University Hospital Centre, 21000 Split, Croatia 2 Department of Endocrinology, Split University Hospital Centre, 21000 Split, Croatia Received 10 October 2010; Accepted 20 July 2011 Abstract: Pseudocyesis is a rare condition in the pediatric population characterized by all signs and symptoms of pregnancy except the ex- istence of a fetus [1]. In some patients it is associated with organic etiology, in others with mental disorders, also occurs in those without disorders in their medical history. Pseudocyesis occurs in both sexes, but more frequently in women. An effective treatment is a combination of psychotherapy and pharmacotherapy with antidepressants and antipsychotics [2]. We present a 15,9-year old girl with pseudocyesis as a cause of abdomen enlargement, who comes from an ordinary family with a negative history of psychiat- ric illness. The organic etiology of her condition was excluded, and therefore she was treated with antidepressants which contributed to the resolution of her case. Keywords: Abdomen enlargement • Adolescent • Pseudocyesis © Versita Sp. z o.o. hypochondriasis (Münchausen syndrome). Modern 1. Introduction classification categorize it into somatoform disorders [1]. Pseudocyesis occurs in patients with confirmed or- Pseudocyesis is a condition in which a non-pregnant per- ganic cerebral or endocrinologic dysfunction, in patients son believes that they are pregnant, with the presence with chronic mental illnesses, as well as in patients of all objective signs of pregnancy except the existence without mental or organic illnesses [2]. of the fetus. It is a syndrome reported since Hippocrates’ Numerous mechanical factors can convince a times, who 300 B.C. described 12 women who ˝believed woman that she is pregnant, for example: retention they were pregnant ˝ [3]. The most famous person who of intestinal gases, urine retention, abdominal tumor, had this syndrome was Mary Tudor, daughter of Henry tumor of uterus, ovarian tumor, hydatid mole, papillar VIII and Queen of England in the 16th century. renal carcinoma, inflammatory processes, as well as Pseudocyesis is also mentioned in literature under numerous causes of primary infertility [2]. the names pseudopregnancy or false pregnancy [4]. In patients with a false pregnancy, a wish for pre- The term ˝pseudocyesis˝ was introduced by John gnancy and fear of pregnancy are often present at the Mason Good in 1823. based on Greek words pseudes same time, and usually occurs in women at the begin- = pseudo (false), and kyesis = pregnancy [2]. Some ning of menopause [2]. There are also several cases of authors classify it under psychosomatic disorders, pseudopregnancy in men described in literature. They others consider it a manifestation of depression, while all had an underlying psychotic and neuroendocrinolo- according to the third group it is a monosymptomatic gical disorders, incomprehension of society, social iso- lation, confusion of sexual identity. In some cases they * E-mail: [email protected] 720 V. Škrabić et al. can even simulate childbirth [2]. Pseudocyesis in men marijuana once, and was consuming alcohol on rare is often connected to ˝Couvade˝ syndrome, also known occasions. During the diagnostic procedure she under- as the ˝emphatic pregnancy˝, occurs in the husband or went gynecological ultrasound and examination, thyroid other close relatives of the pregnant women [2,3]. and abdominal ultrasound, MSCT of the abdomen In treatment of pseudopregnancy throughout history and pelvis with contrast; laboratory findings including there were used purgatives, baths, massages, curetta- hematological and biochemical tests, tumor markers, ge, surgical procedures, leeches, emetics, tonics and thyroid hormones analysis, cortisol and ACTH in rhythm, opiates. Nowadays a treatment that consists of psy- Synacten test, FSH, LH, prolactin, total and free testo- chotherapy, pharmacotherapy with antidepressants or sterone, SHBG, androstendione, DHEA-S and 17-OHP antipsychotics, hormonal therapy and uterine curettage were within the reference values. All the mentioned test is effective in almost all the patients. It is recommended results ruled out the existence of pregnancy. After the to analyse beta-HCG, thyroid gland hormones, to do the diagnostic procedure the girl herself believed she was ultrasound and tomografy of the pelvis and present the not pregnant, wanted to “lose” the belly and weight. After results to the patient in order to persuade her that there the psychiatric examination she began taking an antide- is no pregnancy [2]. In 5% of the cases false pregnan- pressant ˝sertraline hydrochloride˝. One month after the cy recidivates. It is important to point out the forensic discharge from the hospital the patient had contractions, meaning of the disorder due to possible accusation of „amniotic fluid“ began to leak, and she was re-hospitali- infanticide [2]. zed. In the nineth month of pregnancy she went through simulated labour and the belly eventually withdrew. 2. Patient Report 3. Discussion A 15,9-year old female patient was admitted due to an abdominal distension of unknown cause. The patient is Pseudocyesis as a cause of abdomen enlargement is a from a family without a history of psychiatric illnesses. condition characterized by the presence of all the signs The mothers pregnancy and birth was normal and had and symptoms of pregnancy except the existence of the a normal psychomotoric development. In elementary fetus. Throughout history it was a relatively common school she was a very good student, with appropriate disorder, though its number has been significantly re- behavior, but at the end of primary education she started duced due to the development of prenatal care [1]. In to behave impulsively. his autobiographical book Freud described the case of a Eight months before admission to the hospital she woman with a false pregnancy in the final phase of psy- had her first and only sexual intercourse with a 19-year- choanalysis. Similar cases were described by Groddeck -old boy. During the next three months she started to 1923rd, Briehl and Kulka 1935th, and Abram 1969th, have irregular menstrual bleeding, she noticed the interpreting them as a positive transfer from patients to growth of her abdomen and said to the friends that she the therapist, because of a separation anxiety due to the was pregnant. She had nausea with vomiting only one imminent termination of the treatment [2]. morning, two weeks after the intercourse. Psychological changes are caused by hypotha- One of the home pregnancy tests she made lamic-hypophysial-ovarian dysfunction and can be was positive. described as galactorrhoea-amenorrhea-hyperprolac- Her appetite increased, and her breasts enlarged tinemia syndrome (GAHS). In this syndrome there is simultaneously with the abdominal distension. She had an abnormality in the growth hormone, prolactin, ACTH no galactorrhoea, and did not feel fetal movements. She and cortisol, and it is similar to a depressive disorder. did not have enhanced pigmentation on her abdomen Catecholamine and dopamine deficit is responsible (linea nigra) nor areolar hyperpigmentation. During the for hyperprolactinemia and gonadal dysfunction. Basal last 1.5 months before admission she gained 15 kg, and level of prolactin increases in pseudocyesis, similar to had a lumbar lordosis. Her body measurements at the hypothyroidism. High prolactin level leads to lactation, day of admission were: body height: 165.5 cm, body we- prolongs the existence of the corpus luteum, and also ight: 74 kg, BMI 27.2 kg/m2 (+1.87 SDS). She had acne results in amenorrhea, which could explain some of on the forehead and back, and was a slightly hirsute the symptoms of pseudopregnancy. Corpus luteum is a (Ferriman-Gallwey score 9). During the conversation primary source of progesterone, a hormone responsible she was oriented and communicative, responding to for initiating and maintaining pregnancy in mammals [4]. all the questions without hesitation. Thus we found out Therefore pseudocyesis must be taken into con- she was smoking cigarettes for last five years, tried sideration as a differential diagnosis in secondary 721 Pseudocyesis in a female adolescent amenorrhea. All the patients with described GAH syn- Demaret so described the pseudopregnancy in patients drome do not necessarily believe they are pregnant, with anorexia nervosa [2,6]. whereas in patients with pseudocyesis it is primary [1]. These features were not present in our patient, as All the symptoms of pseudocyesis (irregularity of her appetite increased, and she gained weight. During menstruation, amenorrhea, abdominal distension, the conversation our patient was showing no fantasies changes in breast size and shape, lactation, areolar hy- of pregnancy nor suicide tendencies, accepting her con- perpigmentation, medial linea nigra, inverted umbilicus, dition as it was with aspiration of resolving it. However, increased appetite and increased body weight, lumbar during simulated labor she believed in her pregnancy, lordosis, nausea and vomiting, insisting on pregnancy which lasted until after the ˝delivery˝ took place and the and feeling fetal movements) were seen in our patient belly withdrew. except galactorrhea, linea nigra, areolar hyperpigmenta-