Paula Moyer, MA

June 03, 2006

June 3, 2006 (Toronto) — Women who are in denial about pregnancy or who have concealed the pregnancy from others typically leave the hospital without having had any mental health screen other than for substance abuse, according to investigators who presented their findings here at the 159th annual meeting of the American Psychiatric Association.

"Regardless of the circumstances, women who would present with no apparent awareness of pregnancy have a variety of needs," said principal investigator Susan J. Hatters-Friedman, MD. "Denial or concealment of pregnancy should be a red flag that such women need to be seen and evaluated by a psychiatrist." Dr. Hatters-Friedman is a senior instructor in psychiatry at Case Western Reserve University in Cleveland, Ohio.

Of the women who denied or concealed pregnancy in the study, the largest proportion (36%) had pervasive denial of pregnancy, which is often caused by severe mental illness. Only a few had mental retardation or major depression, which are often characterized by pervasive denial. Others may have gotten pregnant as the result of rape, or the woman may have considered aborting or placing the baby for adoption, but without the screening, some of those data were lacking. Denial of pregnancy is a risk factor for infanticide; therefore, it is crucial that women in these circumstances get a psychiatric consult, Dr. Hatters-Friedman said.

In all of these cases, the women would benefit from counseling, she said. Conversely, fewer women will be in this difficult scenario if physicians rule out pregnancy in women of childbearing age, even if they are lacking conventional pregnancy signs.

The investigators wanted to further understand some issues regarding women who denied or concealed pregnancy, and who therefore typically presented at the hospital complaining of abdominal pain or vaginal bleeding and were either in active labor or had just given birth. They had had no prenatal care and were typically unaware that they were or had been pregnant.

After reviewing the records of more than 30,000 deliveries at their institution during a 7-year period, the investigators identified 81 women who had had no prenatal care before they presented at the hospital. Among the women, 61 had denial of pregnancy and 20 had concealment of pregnancy. Of interest, the women were older than expected, tending to be young women, in the 18- to 29-year-old age group, rather than adolescents. Most stated on intake that their mothers were supportive of them. Although the investigators had assumed that the women would be having their first babies, but most had had prior pregnancies and most did not have a history of abuse.

Surprisingly, psychiatry consultations occurred in less than 10% of cases, despite sudden and sometimes unexpected childbirth. Almost one third of the mothers were referred to child protective services; however, the vast majority retained custody of their infants.

"This is a difficult situation for psychiatrists to get a handle on if we are not called in on consults," Nada Stotland, MD, MPH, a vice president of the American Psychiatric Association, told Medscape in a phone interview. "We need to urge obstetricians and certified nurse-midwives to let us know when people in these circumstances come in." Dr. Stotland is a professor of psychiatry at Rush Medical College in Chicago, Illinois. She was not involved in the study.

"Some mothers in denial or concealment of pregnancy do okay without any intervention, but we need to be concerned, because it takes some psychic effort not to notice that you are pregnant or that a family member or loved one is pregnant," she added.

Dr. Stotland expressed concern that so few of the women received complete psychiatric evaluations and urged treating physicians to get the consultations in place before the women are discharged. She also stressed that the consults should be complete evaluations designed to determine the type of help the women need, rather than routinely confining them to substance abuse screens and reports to child protection services.

Women in these circumstances are unlikely to return for such evaluations after their discharge, both because of their behavior around their pregnancies and because it will be even more difficult for them to return for such consultations after they are at home, convalescing from childbirth and carrying for a newborn infant, Dr Stotland pointed out. To get the consult before the woman is discharged, the physician should tell the woman, "I'm not comfortable discharging you without the consult," she said.

Because some women who enter labor unaware of being pregnant have psychotic disorders, it is critical that these women not be discharged without an evaluation and therefore an identification of their needs, Dr. Stotland said.

Conversely, to identify these women earlier in their pregnancies so that they can receive proper care, Dr. Stotland urged all physicians who care for women in their childbearing years to have a high index of suspicion for pregnancy and to determine their pregnancy status before treating them.

APA 159th Annual Meeting: Abstract NR930. Presented May 25, 2006.

Reviewed by Elizabeth Saenger, PhD


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