PSICOLOGIA CLÍNICA E PSICANÁLISE

 

Denial of pregnancy: a literature review and case report in Brazil

 

Negação da gravidez: revisão de literatura e relato de caso no Brasil

 

Negación del embarazo: revisión de literatura y relato de caso en Brasil

 

Thomás Gomes Gonçalves^*

Universidade Federal do Rio Grande do Sul - UFRGS, Porto Alegre, Rio Grande do Sul, Brasil

Endereço para correspondência

 

 

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RESUMO

Este artigo apresenta o primeiro relato de caso oriundo da América Latina sobre o fenômeno da negação da gravidez, situação a qual uma mulher descobre a própria gestação tardiamente ou em alguns casos, somente na hora do parto. O relato de caso apresentado diz respeito a uma jovem que passou nove meses sem saber que estava grávida. Tal experiência é discutida à luz da literatura científica sobre o fenômeno.

Palavras-chave: negação da gravidez, relato de caso, revisão de literatura, gravidez desconhecida.

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ABSTRACT

This article presents the first case report from Latin America on the phenomenon of denial of pregnancy. This situation concerns the fact of a woman who discovers about her pregnancy at an advantage stage or only when she gives birth. The case report concerns a young woman who spent nine months without knowing that she was pregnant. Such experience is discussed based on the scientific literature of the phenomenon.

Keywords: denial of pregnancy, case report, literature review, unknown pregnancy.

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RESUMEN

Ese artículo presente el primero relato de caso oriundo de América Latina sobre el fenómeno de la negación del embarazo, situación en la cual una mujer descubre el propio embarazo tardíamente o en algunos casos, solamente en el parto. El relato de caso presentado es sobre una joven que pasó nueve meses sin saber que estaba embarazada. Esa experiencia es discutida a la luz de la literatura científica sobre el fenómeno.

Palabras-clave: negación del embarazo, relato de caso, revisión de literatura, embarazo desconocido.

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1 Introduction

Denial of pregnancy can be found in three different types: as concealment of pregnancy, as a non-psychotic pregnancy, or a psychotic pregnancy (Gonçalves & Macedo, 2012). The first type, concealment of pregnancy, refers to the situation in which women fake and hide their own child-bearing (Miller, 2003). The second type, non-psychotic pregnancy, alludes to those cases in which women do not know they are pregnant for a great period of time or until labor. In this type of denial, symptoms are commonly associated with many other causes not linked to pregnancy (Chaulet, 2011). The last type, psychotic pregnancy, designates women who have a psychotic condition. In this situation, pregnancy symptoms are interpreted as delusions or hallucinations (Miller, 2003).

This paper, however, will focus in the non-psychotic denial of pregnancy. The term denial of pregnancy will be referred to this condition, which is not rare, as Wessel, Endrikat and Buscher (2002) indicate a rate of 1 case per 475 deliveries in Germany. The authors state that this situation can happen with adolescent or adult females, married or unmarried women, and primiparous or multiparous mothers. Brezinka, Huter, Bielbl and Kinzl (1994) estimate the frequency of 1 case per 400 deliveries in Austria, and Friedman, Heneghan and Rosenthal (2007) suggest the rate of 1 case per 500 deliveries in the United States. The first Latin American empirical study on denial of pregnancy was conducted in Brazil by Gonçalves (2015). However, there is no case report presentation from Latin America in the scientific literature of this phenomenon, as most studies are concentrated in Europe and in the United States (Gonçalves, 2014a). Thus, the case portrayed in this article is the first case report in Latin America.

Denial of pregnancy is not a recent phenomenon. Ferragu (2002) asserts that, in 1681, the French gynecologist François Mauriceau observed that irregular and continuous non menstrual bleeding could lead some women to misinterpret and ignore their own pregnancy. The very first time that the term denial of pregnancy appeared in the scientific literature was in 1970 and, since then, researches have been continuously increasing (Seguin, 2011).

As these women did not know they were pregnant, they had poor or absent prenatal care. Thus, the chances for negative outcomes for the mothers and children in these cases were higher. Wessel et al. (2002) assert that children who are born under this condition, when compared to general population, have more chances to present high mortality, mental retardation, premature labor, and lower weight at birth. The authors state that these women also undergo risky situations during unknown pregnancy as a lack of x-ray exams and alcohol, tobacco and drug use, for example. The most dangerous consequence in cases of pregnancy denial is the occurrence of neonaticide. This is a situation where a parent, most commonly the mother, kills the newborn in their first 24 hours of life. In cases of unknown pregnancy, women giving birth to an unknown baby can panic due to this overwhelming and surprising situation, and, therefore, kill their newborn (Resnick, 1969). Libert (2008) affirms that some labors may take place at home or in public places, which might bring some consequences to mother-child health, as there are no proper facilities to help them out.

Below, a case of non-psychotic denial of pregnancy which took place in Brazil is presented and discussed.

 

2 Case Report ¹

A 22-year-old college student named Nathalie arrived at the hospital feeling a lot of pain, so a doctor performed an ultrasound in order to find out its cause. While doing the procedure, the doctor asked her: "you know that there is a baby inside of you, don't you?". Nathalie did not know she was pregnant, and when the doctor revealed this astonishing information, she thought that she could have been in the early stages of pregnancy, and the pain she was feeling was being caused by a spontaneous abortion. When the ultrasound was ended up, a nurse approached her with a wheel chair and took her to the obstetric room, where she was to have her baby delivered; it was at this time Nathalie found out that she was nine-months pregnant. She spent this whole period without knowing she was bearing a child.

Nathalie was terrified and asked for a cesarean procedure, but this option was denied since she already had 7 centimeters of dilatation and was about to give birth. She could not focus on anything but the pain she was feeling. She gave birth to a girl measuring in at 45 centimeters and weighing 2.690 kilograms. After the baby was born, she started to think about what was going on with her, about the unexpected pregnancy, and about the baby. When a nurse asked her how she was going to name her baby girl, she replied "I didn't even know that I was pregnant and you ask me about a baby's name?" Soon, Nathalie had to deal with that dramatic situation—not only naming her baby, but also all the dealing with the consequences of suddenly being a mother.

Nathalie named her daughter after her best friend who had committed suicide four months before Nathalie found out she was pregnant.

"The last time I was in a hospital it was because of a death situation, because my friend committed suicide, and then I wanted to honor my friend by giving her name to my daughter, because my baby represents the opposite situation, she represents life…".

When she went to the room to rest after giving birth, Nathalie was overwhelmed with a number of feelings and emotions. How was she going to explain that situation to her parents? How was she going to even explain that situation to herself, since she did not have a clue she was pregnant throughout those nine unknown months of pregnancy? Thus, she had to reflect on her past experience in order to comprehend her situation. Nathalie is homosexual and often goes to gay parties. One day, she accepted the invitation of some friends to go to a straight party in a city nearby. At this party, she became intoxicated and met a man, with whom she left the party and had unprotected sex. She did not consider the consequences, such as pregnancy or any other venereal diseases. The possibility that she could be pregnant was not something she even considered. Moreover, she was not sure what that man's name was or where he was from; hence, she did not know anything about her daughter's father.

Nathalie reported that her first days as a mother were shocking. She did not know how to tell her relatives and friends about what had happened. She preferred to send them messages via the internet because the situation was too embarrassing for her. Moreover, she could not get affectively involved with her daughter. She knew she was a mother because she had a newborn in her arms, but that did not make any sense for some time after the birth.

Concerning the typical bodily changes that women go through pregnancy, Nathalie stated that she gained only 4 kilograms, and, as she had never carefully observed her weight, this specific weight gain did not preoccupied her. She also never felt any intrauterine movements: "I used to drink a lot, so probably my daughter was in the middle of the alcohol that I used to take… she did not move because she was with a hangover". Nathalie attributed other pregnancy symptoms, such as tiredness, sleepiness, and dizziness, to her work. The first sign that reveals that women are pregnant is amenorrhea; in Nathalie's case, however, this symptom was not a concern because she stated that her period had always been irregular. She also explained that she had some bleedings throughout the unknown pregnancy, leading her to think that she was menstruating normally. Therefore, all pregnancy symptoms Nathalie experienced were always associated to other causes.

Nathalie affirmed that no one in her circle of family or friends suspected she was pregnant. She recalls, however, that a month before she gave birth, a friend noticed that her belly was different after touching it. By that time, Nathalie explained to her friend that her belly was different because she had drunk too much alcohol in the past days. Moreover, she states that she took drugs and drank alcohol during the unknown pregnancy. The birth of Nathalie's daughter's has significantly changed her attitude about herself, and she started to change her lifestyle and to be more careful about her attitudes.

Interviews with Nathalie indicated that she did not have a close relationship with her mother. She said that since she was a child, she never felt connected to her. Her father is a truck driver and never spent too much time at home. She has visited him once a month since she was young. Nathalie does not have a good relationship with her twin sister, either. She explains that her sister does not accept her homosexuality, and this is a common discussion fact between them.

 

3 Discussion

Denial of pregnancy is surely an intriguing phenomenon. Common sense tells us that every woman is conscious about her own pregnancy. However, this experience must be taken into account. Nathalie's case reveals that all typical pregnancy symptoms were linked to other causes. Usually, these signs are clues to any woman to consider the possibility of a pregnancy. Gonçalves and Macedo (2011) posit that the psychic defense mechanism called disallow ² is a phenomenon that is present when women associate common pregnancy symptoms with other causes. In the dynamic of this mechanism, perception is not denied, but what is actually denied is the transitive process capacity, since it could lead to a traumatic memory. Thus, these women perceive that they are, for instance, gaining weight or feeling tired, but they do not come to any concrete conclusion related these symptoms to pregnancy, which would be an undesirable perception. But why should pregnancy perception be avoided and denied? Some authors have proposed some psychic explanations to for the denial of pregnancy. Gonçalves (2015) understands denial of pregnancy in a psychoanalytical perspective, using the conceptualization of trauma described by psychoanalyst Sandor Ferenczi. Gonçalves (2015) considers that, in the life of women who denied their pregnancy, there was often a traumatic situation experienced at an early age, in which their mother perceived them as unwelcome and unwanted daughters. At the same time, their fathers, instead of addressing this maternal aversion, remained silent and, therefore, did not offer support to their daughters, who were facing this situation. This experience composed abandonment, a traumatic situation which ruined and fractured their selves. The author states that the experience of denying a pregnancy combines two abandonments: the woman who experiences it at early age and the fetus who was abandoned in the uterus. So denial of pregnancy could be thought as a situation of uterine abandonment. Women who face a pregnancy denied go through, according to the author the following movement: "from being abandoned (passive before the abandonment) to becoming abandoners (agents of an abandonment action). Thus, the uterine abandonment denounces the parental abandonment suffered by these women who go through this experience of unawareness of their own gestation" (p.126).

Seguin (2011) states that in the lives of women who have experienced denied pregnancy it is possible to find out and to perceive a symbiotic relationship with their own mothers. Moreover, their fathers seem to play a more maternal than paternal role, or are absent. Thus, denial of pregnancy could be an attempt to gain autonomy, to become free from their mother. The ideas of these two authors follow a similar understanding of the phenomenon that demonstrates the need to investigate these women's psychic lives to comprehend what is inherent in this experience.

Bonnet (1993) states that the link between a sexual relationship and the possibility of being pregnant seems to be erased from the psyche of these women. Therefore, the author notes that, when these women talk about their denial, they never connect the existence of the baby to a corresponding sexual relationship.

After finding out about an unknown pregnancy, mothers may face some struggle with their newborn. As pregnancy is a preparation time for women to get used to the new situation she will experience after the baby is born; women who deny pregnancy, however, do not have this precious preparation time. These women suddenly have to deal with this unknown baby. As a result, they might face some difficulty naming their children or bonding with them. Sometimes, they name their children after a doctor or a nurse who helped them out during labor (Brezinka et al., 1994; Chaulet, 2011).

The report of menstruation is another mystery in denial of pregnancy. Wessel and Endrikat (2005) investigated pseudomenstruation in 65 women, and 38 of them reported that they had regular bleeding during unknown pregnancy. Blood samples for hormonal verification were performed up to 144 hours after birth. The authors compared these women with a control group of 126 healthy women who had a normal pregnancy and labor. The results showed no causal explanation for those who denied their pregnancies. Therefore, the authors conclude that the understanding of this pseudomenstruation cannot be explained by endocrinological mechanisms.

Another issue related to this phenomenon is that the uterus does not develop itself forward. Navarro (2009) affirms that mothers must recognize that they are pregnant in order to develop their womb. As in cases of denial of pregnancy, the baby will eventually develop, but backwards along spinal column towards the diaphragm. Rozan (2008) states that, in cases which pregnancy is discovered before birth, a body metamorphoses may truly happen, as the uterus comes forwards within hours. When the recognition happens before labor, women can experience, for example, intrauterine movements for the very first time in the same night they find out they are pregnant (Sandoz, 2011). Thus, consciousness has permission to experience these typical pregnancy signals.

The characteristics of labor are very peculiar. Women who went through this experience report that labor was not painful and also that labor was performed with 5 centimeters of dilatation, while in general population it is common to perform it with 10 centimeters (Grangaud, 2001). Another factor concerning labor in denial of pregnancy is that they usually occur in the winter (Nirmal, Thijs, Bethel, and Bhal, 2006).

Family circle and health professionals play an important role in these experiences, as they also deny the situation. Chaulet (2011) names this situation as denial of the denial. Wessel, Endrikat and Kastner (2003) affirm that the defense mechanism of projective identification proposed by the psychoanalyst Melanie Klein is involved when physicians do not detect pregnancy in these women. This mechanism occurs in denial of pregnancy when women project their unconscious wish of not being pregnant towards physicians, and then doctors become identified with this projection. Therefore, they will commit a diagnostic error by not examining the women in a proper way. Doctors will not deeply verify if the symptoms presented by the patients are related to pregnancy or not. The authors refer to these dynamics as iatrogenic participation. Brezinka (2009) affirms that when doctors cannot detect pregnancy, they are possibly under middle knowledge effect, which means they only take into account certain parts of a woman's report and ignoring the rest.

Brezinka (2009) considers that there is a situation of folie a deux when someone in the family does not suspect of a possible pregnancy, especially between mothers and daughters. The author states that mothers and daughters reinforce each other's denials by using sentences like: "I thought I was pregnant, but as my mother never said anything about it…" or "I suspected that my daughter was pregnant, but as she never said anything about it, I did not question". Even though, folie a deux is commonly related to psychosis cases, this dynamic is not restricted to this psychopathology and could be found in other psychic structures as well. Chaulet (2011) states that family circles help women rationalize their own symptoms in unknown pregnancies cases.

 

4 Conclusion

This article presents and discusses a case of denial of pregnancy that occurred in Brazil. As stated in the introduction, there is a lack of studies about this phenomenon in Latin America. More investigations should be provided in order to understand the elements of this phenomenon; epidemiological studies, for instance, and case reports originated in this continent will enrich and inform our understanding of pregnancy denial.

Denial of pregnancy may bring dangerous consequences to mothers and children. Health practitioners should be aware of the existence of this unusual situation for the sake of mothers' and babies' psychic and physical health. Studies should consider deep unconscious investigation, because this kind of study could lead researchers to some helpful clues to understand why these women denied their pregnancies. In other words, investigating the unconscious might allow researchers to determine what pregnancy represents to women experiencing pregnancy denial and why they feel the need to deny it. Psychoanalysis could be a useful theoretical and technical tool to accomplish it. Considering the idea of Gonçalves (2015) as denial of pregnancy being a uterine abandonment, it is important to consider how is going to be the relationship between child and mother. Will this abandonment be present after birth?

We strongly suggest psychoanalytic researches on this topic to investigate if the traumatic will take part in this relationship. Researches should emphasize and consider the following elements not only on the relationship mother-child but also the psychic dynamics of these women: which other psychic mechanisms are implied? Even though denial is presented in the name of the phenomenon, many others are implicit, especially splitting of the ego as a consequence of the trauma as Ferenczi (1933) suggests. Another element is: More cases could tell us about psychic structure? We should be very precautious about this topic since we have to understand first their singularities instead of trying to fit all cases in just one structure or psychopathology, for example, consider pseudocyesis (women who think they are pregnant but they are not) belonging to hysteria. Thus, we could have cases of denial of pregnancy or pseudocyesis in neurotic or psychotic persons.

The presentation of this clinical case intended to shed some light in this complex and intriguing situation, especially concerning a specific traumatic experience suffered at early age. The elements pointed out added to the case presented and many more that the specific literature could offer would clarify the obscures elements of this phenomenon, gathering more knowledge to it, besides helping practitioners who aid mothers and children who through this dramatic experience.

 

References

Bonnet, C. (1993). Adoption at birth: Prevention against abandonment or neonaticide. Child Abuse & Neglect, 17(4), 501-513.

Brezinka, C., Huter O., Bielb, W., & Kinzl, J. (1994). Denial of pregnancy: Obstetrical aspects. Journal of Psychosomatic Obstetrics & Gynecology 15, 1-8.

Brezinka C. (2009). A propos des données épidémiologiques. In Actes du premier colloque français sur le déni de grossesse (pp. 15-23). Toulouse: Ed Universitaires du Sud.

Chaulet, S. (2011). Deni de grossesse: exploration Clinique et psychopathologique, prise en charge étude retrospective sur 5 ans au chu d'angers. Université d'Angers, Angers.

Erickson, F. (1997). Metodos cualitativos de investigación sobre la enseñanza. In Wittrock, M. (Org.). La investigación de la enseñanza (pp. 195-301). Barcelona: Paidós.

Ferenczi, S. (1933). Confusão de língua entre os adultos e a criança. Obras Completas. São Paulo: Martins Fontes.

Ferragu, G. (2002). Le déni de grossesse: une revue de litterature Tese de doutorado não publicada. Université de Rennes I, Rennes.

Friedman, S. H., Heneghan, A., & Rosenthal, M. (2007). Characteristics of women who deny or conceal pregnancy. Psychosomatics, 48, 117-122.

Gonçalves, T., & Macedo, M. (2011). A desautorização do processo perceptivo na negação não psicótica da gravidez. Revista Mal-Estar e Subjetividade, 11(1), 1521-1546.

Gonçalves, T. G., & Macedo, M. M. K. (2012). Negação não-psicótica da gravidez- especificidades de um fenômeno. In M. M. K. Macedo & B. S. G. Werlang (Orgs.), Psicanálise e Universidade: potencialidades teóricas no cenário da pesquisa (pp. 268-283). Porto Alegre: EDIPUCRS.

Gonçalves, T. (2014a). Negação não psicótica da gravidez: definições, especificidades e explicações. Estudos e Pesquisas em Psicologia (Online), 14(3), 1005-1020.

Gonçalves, T. G. (2014b). O desempoderamento da gravidez: implicações psíquicas em mulheres que não sabiam que estavam grávidas até o momento do parto. Master's dissertation, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brasil.

Gonçalves, T. (2015). Negação da gravidez: um estudo psicanalítico. Psicologia em Estudo, 20(1), 117-127.

Grangaud, N. (2001). Déni de grossesse: description clinique et essai de compréhension psychopathologique.Tese de doutorado não publicada, Université Paris VII, Paris, France.

Libert, M. (2008). Propos Introductifs. Actes du premier colloque français sur le déni de grossesse, 31-34.

Miller, L. J. (2003). Denial of pregnancy, in infanticide: Psychosocial and Legal perspectives on mothers who kill. Edited by Spinelli, M.G. Washington DC, American Psychiatric Publishing Inc, 81-104.

Navarro, F. (2009). Negación del embarazo, una enfermedad misteriosa. Recuperado em 5 de junho, 2011, de http://www.rfi.fr/actues/articles/114/article_ 12068.asp

Nirmal, D., Thijs, I., Bethel, J., & Bhal, P. S. (2006). The incidence and outcome of concealed pregnancies among hospital deliveries: An 11-year population-based study in South Glamorgan. Journal of Obstetrics and Gynaecology, 26(2), 118-121.

Resnick, P. (1969). Child murder by parents: a psychiatric review of filicide. American Journal of Psychiatry, 126, 325-334.

Rozan, M. (2008). L'obstétricien et le déni de grossesse, Actes du premier colloque français sur le déni de grossesse, 41-45.

Sandoz, P. (2011). Reactive-homeostasis as a cybernetic model of the silhouette effect of denial of pregnancy. Medical Hypotheses, 77, 782-785.

Seguin, S. (2011). Les denis et les negations – Une voie de dégagement de l'emprise maternelle. Tese de Doutorado não publicada. Université Paris-Descartes, Paris, France.

Wessel J., Endrikat J., & Buscher, U. (2002). Frequency of denial pregnancy: results and epidemiological significance of a one-year prospective study in Berlin. Acta Obstetricia et Gynecologica Scandinavica, 81, 1021-1027.

Wessel J., Endrikat J., & Kastner, R. (2003). Projective identification and denial of pregnancy-considerations of the reasons and background of unrecognized pregnancy also undiagnosed by a physician. Zeitschrift für Geburtshilfe und Neonatologie, 207(2): 48-53.

Wessel. J., & Endrikat, J. (2005) Cyclic menstruation-like bleeding during denied pregnancy. Is there a particular hormonal cause? Gynecological Endocrinology, 21(6), 352-359.

 

 

Endereço para correspondência
Thomás Gomes Gonçalves
Universidade Federal do Rio Grande do Sul - UFRGS
Instituto de Psicologia
Rua Ramiro Barcelos, 2600 sala 108, CEP 90035-002, Porto Alegre – RS, Brasil
Endereço eletrônico: gomes.thomas@gmail.com

Recebido em: 25/04/2015
Reformulado em: 15/03/2016
Aceito para publicação em: 30/03/2016

 

 

Notas

^* Psicólogo. Membro do Centro de Estudos Psicanalíticos de Porto Alegre (CEPdePA) – Psicanalista em Formação. Mestre em Psicologia Clínica pela Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Doutorando em Psicologia pelo Programa de Pós-graduação da Universidade Federal do Rio Grande do Sul (UFRGS). Membro da Association Française pour la reconnaissance du Déni de Grossesse (Toulouse- França).
¹ This case report is portrayed in the following master's dissertation: Gonçalves, T.G. (2014b). O desempoderamento da gravidez: implicações psíquicas em mulheres que não sabiam que estavam grávidas até o momento do parto. Master's dissertation, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil. Therefore, the research that contains the case report was approved by the Research Ethics Committee from Pontifícia Universidade Católica do Rio Grande do Sul under the number: 84123. The author of dissertation who is the same of this article interviewed Nathalie three times. The participant in the first interview signed an Informed Consent authorizing the publication of data produced in the interviews. Each interview lasted 01 hour and 30 minutes. The interviews were transcribed in order to be analyzed. The data analysis was performed according to Interpretative Analysis (Erickson, 1997).
² The psychic mechanism is used according to the proposition of the psychoanalyst Luis Claudio Figueiredo (2003). This author considers that the psychic mechanism Verleugung proposed by Freud (1927) should be understood as a non-authorization of the perceptual process. Therefore, Figueiredo (2003) understands that this mechanism is present not only in psychosis and fetichism as Freud proposed, and then it should be address to other psychopathologies too. The author proposes the translation desautorização (disallow) for Verleugung since the mechanism has more elements than Freud supposed.

The author would like to thanks CNPq for supporting this research through a scholarship during his master's. Also special thanks to Rashelle Spear for reviewing English content.