Phantom Pregnancy in A Postmenopausal Tongan Traditional Healer in New Zealand: A Case Report

Case report

A previously healthy 56-year-old married Tongan immigrant woman presented to a general practitioner and gynecologist reporting symptoms of pregnancy and vaginal bleeding. Her symptoms included abdominal enlargement, nausea, anorexia, fetal movements, breast engorgement, food aversions and heightened olfactory sensitivity. She ascribed her symptom complex to being similar to her previous eight pregnancies including the episode of bleeding. Her husband and family bore witnesses to her reported symptomatology, and they too affirmed the so-called pregnancy. She was 6 years post menopause.

Her abdominal and pelvic examinations were unremarkable except for abdominal distension. Beta-HCG, tumor HCG and other tumor markers were normal. A pelvic ultrasound revealed a 5mm echogenic focus within the uterine cavity.

She was touted as a prominent traditional healer in the Tongan community, of Christian faith and provided her remedial practices at no charge, which were consistent with cultural norms [2]. She had a brief admission to a psychiatric unit 10 years ago in the context of psychosocial stressors but had not required further mental health input. Her social circumstances had been challenging with frequent familial and marital conflict.

She was upset with medical personnel and adamant that she was pregnant despite being aware that tests had shown otherwise. She attributed the pregnancy to be a gift from God. She recounted an episode of “labour pains”, vaginal bleeding and discharge with passage of clots after 9 months. She referred to this incident as the “birthing event” wherein she lost her twins followed by a resolution of her pregnancy symptoms. Her husband contacted emergency services due to the loss of blood and was then taken to the local public hospital in an ambulance.

In its aftermath, she became highly distressed and agitated, developing an adjustment disorder with mixed disturbance of emotions and conduct. In the emergency department, she was referred to mental health crisis services and was subsequently involuntarily hospitalized to manage her heightened level of emotional arousal. She settled within a day with use of a hypnotic to aid sleep and no other psychotropics.

A transvaginal and transabdominal US was repeated upon advice from gynecology, which demonstrated no change over 7 months although the exact nature of the mass was indiscriminate. She was reluctant to have further gynecological input due to her insistence that she was asymptomatic following the “birth”. She continued to pursue vocational interests of studying and placement in a caregiving capacity at a rest home. Whilst she continued to report that she was previously pregnant in subsequent months, she was no longer preoccupied by it.

Discussion

In 2007, the incidence of pseudocyesis was reported to be less than 10 cases per 22,000 deliveries in the US which is lower than the previously described, 1 case per 250 pregnancies in 1940 [3]. This condition is thought to be rare in postmenopausal women.

While exact aetiology is unclear, psychological pressures such as loss of reproductive capacity, emotional turmoil, troubled relationship with significant others may alter the hypothalamicpituitary- ovarian axis leading to symptoms of pregnancy [4]. Depression or stress can also alter brain biogenic amines, which regulate reproductive hormones [5]. The somatopsychic hypothesis postulates that primary somatic sensations can be misinterpreted as signs of pregnancy [6]. Symptoms of breast engorgement, abdominal enlargement, subjective weight gain and fetal movements individually have been reported in over 40% of patients with pseudocyesis [6] and was observed in this case. This misconception of pregnancy was perpetuated by her selfproclaimed identity of a “healing mother”.

Cases of pseudocyesis described in Saudi Arabia have highlighted the belief in supernatural forces inducing pregnancy [6]. Cultural factors such as social standing, future continuation of a generation and hope for financial support, which pressure women to procreate, are exemplified by case reports in India and Africa [7], [8,9]. Socially, women of low socioeconomic standing and lower educational attainment seem preferentially affected [9].

Her identity as a mother and healer, superimposed upon her background of being a Tongan Christian, who are culturally known for being very devout and religious, subscribe to being the diathesis for her phantom pregnancy. A similar case of delusional pregnancy in a 59-year-old post-menopausal religious woman had been described wherein the patient had symptoms of pregnancy and a belief she was going to give birth to a deity. Patients sometimes employ “face saving” explanations such as a miscarriage to rationalise remission of symptoms [3]. The patient described in this report also believed her twins were taken to heaven and she grieved their demise.

Pseudocyesis despite being documented since antiquity remains elusive pertaining to its diagnosis and management. To exclude underlying pathology and to provide holistic care requires a multidisciplinary effort by general practice, psychiatry and gynecology. Mental health intervention is infrequent due to lack of psychiatric pathology when they come into contact with primary care or obstetric services. The side effect of hyperprolactinemia with antipsychotics leading to galactorrhea and amenorrhea may reinforce the belief of pregnancy [10]. Hormonal restoration of menses in younger patients can aid in relinquishing the false belief. Ultimately, intervention is focused on supportive therapy and avoiding excessive confrontation if the false belief persists.

Conflict of Interest

No Conflict of interest..

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