Denying Gravidity

Virtual

Presenting Author(s)

Paige V. Mastalerz, MD (she/her/hers)

Psychiatry Resident PGY 2
Baystate Medical Center
Worcester, Massachusetts

PDF

Co-Author(s)

MS

Maria Sarmiento, DO

Resident
UMass Chan Baystate
Suffield, Connecticut
AM

Arjun Mann, DO

Psychiatry Resident Physician
UMass Baystate
Northampton, Massachusetts
Brianna D. Rowan, MD

Psychiatry PGY II Resident
UMass Chan Baystate
Springfield, Massachusetts
JB

Jamison Bradshaw, DO

Medical Director
Baystate Medical Center
Springfield, Massachusetts

Abstract:

Background:

Pregnancy denial, psychotic or nonpsychotic, is present in 1 of 475 pregnancies. Denial persists until delivery in about 1 in 2500 of pregnancies, similar to eclampsia (Jenkins, 2011). Even with this frequency of pregnancy denial, a shortage of literature and a lack of agreed-upon guidelines regarding the ethical management remains.

Case:

A 25 year-old G4P1 woman with a history of schizophrenia, intellectual disability, and an extensive trauma history was brought to the hospital after community workers deemed her home unsuitable for living. Additionally, she was 31 weeks pregnant. Despite having extensive support services, the patient minimized interactions with her workers, leading to an unnoticed pregnancy. Ultimately, she was admitted for inpatient psychiatric treatment and it was adjudicated that she lacked capacity. She became adherent with court mandated antipsychotics, and a temporary guardian was appointed. The patient denied being pregnant due to taking emergency contraception and described this as a “blockage.” She intermittently acknowledged her pregnancy and then advocated for termination. Coordination between consult liaison psychiatry, OBGYN, ethics, and the inpatient team facilitated the optimization of patient care.

Discussion:

The psychiatric team collaborated with OBGYN, outpatient providers, two ethicists, and the temporary guardian. This interdisciplinary team considered each core ethical principle:

Autonomy: She denies being pregnant but expresses a preference for surgical removal of the “blockage”

Beneficence: Wanting to provide for her physical and mental wellbeing, with particular attention to her trauma history including prior DCF removal of a previous child. The patient expressed a preference for termination rather than reexperiencing this separation.

Nonmaleficence: Comparing a C-section vs vaginal delivery to minimize emotional and physical harms.

Justice: Provision of prenatal care in line with standards of care.

She participated in prenatal care, including labs and ultrasounds, despite pregnancy denial. At 38 weeks, the patient became acutely distressed due to pregnancy-related discomfort, prompting the decision for a C-section. She chose between general anesthesia and an epidural, was provided nonanesthetic options to reduce awareness of the procedure, and was given the choice to visualize the “blockage” following removal. She opted for an epidural and asked to see the blockage, at which point she happily accepted she had been pregnant and developed a caring relationship with the infant.

Summary:

The phenomenon of pregnancy denial, particularly of a psychotic nature, requires careful ethical consideration to ensure physical and psychological safety for both the patient and fetus. As pregnancy denial is associated with an increase in assisted vaginal and C-section deliveries (Chase, 2021), a proactive, ethically-focused, and collaborative approach involving OBGYN, ethics, outpatient providers, and the patient themself is essential for comprehensive care.

References:

Jenkins A, Millar S, Robins J. Denial of pregnancy: a literature review and discussion of ethical and legal issues. J R Soc Med. 2011 Jul;104(7):286-91. doi: 10.1258/jrsm.2011.100376. PMID: 21725094; PMCID: PMC3128877.

Chase T, Shah A, Maines J, Fusick A. Psychotic pregnancy denial: a review of the literature and its clinical considerations. J Psychosom Obstet Gynaecol. 2021 Sep;42(3):253-257. doi: 10.1080/0167482X.2020.1789584. Epub 2020 Jul 30. PMID: 32729360.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: In this case, this patient is a woman of color with an intellectual disability who was raised in foster care. She has general mistrust of the medical system, especially after her previous experiences of psychiatric hospitalizations and DCF removal of her previous child. This case highlights the collaborative nature of Consult Liaison work and illustrates patient advocacy. Our presenting team also comes from diverse backgrounds that allowed us to various ways to approach this specific patient's case.