Pregnancy denial or concealement: A case report highlighting risks and forensic aspects

To the Editor

Pregnancy Denial is a serious clinical underestimated problem that may adversely affect the mother–child dyad and should not be overlooked.

It is defined as ‘the complete unawareness of one’s own pregnancy’ (incidence 1:475 within the 20th week, and 1: 2455 after the 20th week of gestation) while Pregnancy Concealment is ‘the consciousness of pregnancy and active efforts to hide it’ (incidence 1:2,500/pregnancies) (Miller, 2003)

Miller described 3 types of pregnancy denial: Affective (intellectual acknowledgement without emotional/behavioral changes), Pervasive (pregnancy existence is kept from awareness, physical changes may not be present/misconstrued and labor pains misinterpreted and partners/families may also fail to notice pregnancies) and Psychotic (Miller, 2003).

Several affected women deliver precipitously, after less than 1 hour of labor, but few deliver at home (6% with denial, and 15% with concealment).

The violent implications of ‘pregnancy denial’ may result in neonaticide (associated with pain denial, short and unassisted deliveries), while concealment often occurs in situations of domestic violence—that begins or escalates during pregnancy—and implies adverse obstetric outcomes and maternal death (Spinelli, 2001).

Pregnancy denial was observed in a 25-year-old married woman after her second delivery. Contrary to the first pregnancy, she denied weight gain, body changes and baby movements. She reported using a contraceptive pill throughout the entire pregnancy. After a short home delivery (less than half an hour) without assistance, she was admitted to Obstetrical Department and referred for psychiatric evaluation. She had no psychiatric history, there was no evidence of any symptoms of mental illness at the first psychiatric evaluation and during follow-up, monitored with clinical assessment and through relevant psychiatric tests (Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID II] Interview, Beck Anxiety and Depression Interview, World Health Organization Quality of Life [WHOQoL] and Childhood Trauma Questionnaire). She denied having concealed the pregnancy, and there were no signs or symptoms of Intimate Partner Violence at admission and follow-up. Her female newborn was healthy without consequences of oestrogen/progesteron absorption (hypoplastic left heart syndrome, gastroschisis, hypospadias or congenital urinary trait anomalies) (Waller et al., 2010) in 1-year follow-up. The patient was discharged after 6 months of clinical outpatient follow-up.

This case fulfills most of the risk factors and characteristics associated with pervasive denial and subsequent infanticide. The impact in terms of health, both for mother and child, suggests the need for higher awareness and knowledge of the phenomenon in terms of etiology and presentation and the need for timely and urgent psychiatric evaluation and clinical monitoring in order to prevent possible adverse outcomes.