Denial of pregnancy: a review and case reports

Pregnancy Denial: Toward a New Understanding of the Underlying Mechanisms

PURPOSE OF REVIEW

Pregnancy denial is the lack of awareness of being pregnant. The aim of the review is to understand why the affected women do not recognize the signs of pregnancy.

RECENT FINDINGS

Twelve case reports of pregnancy denial were published in the last ten years. While in five cases the women had an underlying mental disorder, the rest of the cases involved women who either exhibited no physical symptoms or perceived themselves to be not pregnant despite the symptoms (i.e., repression mechanisms). Pregnancy denial is considered to be a pathological issue, a likely consequence of trauma, the wish to not have a child, or a psychiatric problem. However, it appears that the majority of cases cannot be linked to any of the above reasons. We argue, therefore, that, in most cases, pregnancy denial is not associated with mental or physiological problems. Under certain circumstances, it can affect any woman.

[Mother brain: Bayesian theory of maternal interoception during pregnancy and postpartum]

The perinatal period, including pregnancy and postpartum, causes major morphological, endocrinal, and thermal transitions in women. As the fetus grows, abdominal muscle fibers stretch, internal organs such as the bladder or colon move, and the uterine anatomy changes. Many of these changes involve interoception, the perception of internal body signals such as muscle and visceral sensations. Despite the importance of these interoceptive signals, few studies have explored perinatal interoception. We propose an innovative theory of maternal interoception based on recent findings in neuroscience. We show that interoceptive signals processing during pregnancy is crucial for understanding perinatal phenomenology and psychopathology, such as maternal perception of fetal movements, maternal-infant bonding, denial of pregnancy, phantom fetal movements after childbirth, pseudocyesis or even puerperal delusion. Knowing the importance of these interoceptive mechanisms, clinicians in obstetrics, gynecology and mental health should be particularly vigilant to maternal interoception during the perinatal period.

A case report involving the experience of pervasive pregnancy denial: detailed observation of the first 12 postpartum weeks

BACKGROUND

Pervasive pregnancy denial is a rare condition associated with distress and unassisted delivery.

CASE PRESENTATION

The case involves a 38-year-old woman (NN), with two older children (ages 8 and 11), who was unaware, until delivery, that she had been pregnant. The case is discussed in the context of a 12-week observation of postpartum mood, stress, and mother-child attachment. NN and other 558 non-depressed women (mean age 32.41 years) were selected from the pool of participants in the RIPOD (risk of postpartum depression) study. All participants were recruited within 1-6 days of delivery. In addition to surveying depressed mood at childbirth, remote assessments of mood, mother-child attachment, and perceived stress were conducted at 3, 6, 9, and 12 weeks postpartum. Every other day, the participants also reported their current perceived stress levels based on a scale from 1 (low) to 10 (high). During the entire period of postpartum observation, NN reported no symptoms on the Edinburgh Postpartum Depression Scale, similar to only 1.6% of the sample, no stress as 0.7% of the sample, and above-average mother-infant bonding akin to only 4.6% of the sample. Her daily stress levels showed no disturbance, which was the case for only 3.32% of the total sample. On the day of delivery, NN reported a stress level of 1 (the minimum possible level), which was reported by only 4.2% of the total sample. However, NN reported the experience of delivery to be traumatic given that the child had fallen to the floor.

CONCLUSION

The experience of a denied pregnancy did not appear to disturb NN at any time point, not even on the day of delivery. Compared to NN, the other non-depressed participants reported wide fluctuations in stress levels during the observation period. NN did not report any risk factors for denied pregnancy. Thus, she belonged neither to any group of typical pregnancy deniers, as reported in the literature, nor to a typical postpartum group. We postulate, therefore, that the extent to which pregnancy denial can be deemed a normal variation, unrelated to a psychological or physiological condition, depends largely on personal traits.

[The invisible pregnancy: Clinical characteristics and perspectives about denial of pregnancy]

Denial of pregnancy is a public health problem due to maternal, fetal, and neonatal morbidity, affecting both physical and mental health. It generally involves an absence of the physical signals associated with pregnancy such as abdominal swelling, amenorrhea, weight gain, or even perception of fetal movements. Despite the potential consequences for mother and child, there is still little data on its clinical features and the neurocognitive mechanisms involved. In this paper, we provide an update on the clinical, socio-demographic, and psychopathological characteristics of pregnancy denial based on contemporary scientific literature. We first define denial of pregnancy by referring to the history of the concept, previous definitions, and nosographic classifications. We then detail the clinic of denial by distinguishing the physical and psychological symptoms of this disorder, then the socio-demographic, gynecological, and psychiatric characteristics. We describe the consequences of denial on the mother, infant, and the dyad, referring to situations of cryptic neonaticide. Finally, we show the importance of perinatal neuroscience research on maternal interoception to understand the mechanisms involved in denial of pregnancy, and improve their medical management in clinical practice.

Psychotic pregnancy denial: a review of the literature and its clinical considerations

BACKGROUND

Pregnancy denial can be broken into two major types, non-psychotic and psychotic deniers, and further classified into pervasive, affective and persistent sub-types. It can lead to increased morbidity and mortality of the mother and neonate. Psychotic pregnancy denial is rare and the medical literature existing on the subject is limited to a small number of case reports and case series. No formal recommendation exists on the clinical management of psychotic pregnancy denial in the antenatal or postpartum period. The authors provide a comprehensive review of the literature regarding psychotic pregnancy denial, present an example of an unpublished case and provide suggestions for clinical management.

CASE

A 33-year-old primigravida at 37 6/7 weeks gestation presented with new-onset psychotic pregnancy denial with no prior history of psychosis. She had a negative medical work-up for organic causes of psychosis. Using a multidisciplinary approach, the decision was made to deliver the fetus at 38 1/7 weeks via cesarean section due to concerns for patient and fetal safety. Following delivery, she was admitted to an inpatient psychiatric facility and underwent 16 bilateral electroconvulsive therapy (ECT) treatments to which she showed complete response.

CONCLUSION

Psychotic pregnancy denial is rare and potentially dangerous. Delivery prior to 39 weeks gestation is reasonable for worsening psychiatric disease but careful consideration of the risk-benefit analysis and ethical framework must be deliberated.Teaching points: In cases of worsening psychiatric disease in pregnancy, a multidisciplinary approach is necessary for comprehensive care. Psychotic denial of pregnancy leads to increased maternal and neonatal morbidity and mortality. Delivery prior to 39 weeks gestational age is reasonable to expedite psychiatric treatment.PrecisUsing a multidisciplinary approach, the decision to deliver before 39 weeks gestation is reasonable for worsening psychiatric disease.

Denial of Pregnancy in a Patient With a History of Pseudocyesis

Denial of pregnancy is a condition in which a pregnant patient does not believe she is pregnant. This case describes a 23-year-old Caucasian female, with a past psychiatric history of pseudocyesis, stimulant use disorder, and schizophrenia, who was admitted to the inpatient psychiatric unit for the treatment of psychosis, suicidal thoughts, and homicidal ideation. During her hospitalization, an intrauterine pregnancy was confirmed with three serum quantitative human chorionic gonadotropin (hCG) levels and a transabdominal ultrasound. Despite definitive evidence of pregnancy, the patient reported it was impossible she was pregnant and stated she had not had intercourse for more than a year. The patient was treated with IM haloperidol decanoate and PO haloperidol. Care was coordinated with the obstetrics team to ensure the patient and her fetus received adequate prenatal care. After acute stabilization, the patient was discharged with close follow-up. This case presentation describes one of the few documented cases of pregnancy denial in a patient with a history of pseudocyesis. Additionally, this case highlights the ethical issues associated with the treatment of pregnancy denial patients. Additional studies are necessary to fill in the gaps in the literature on this unique condition.

Unexpected delivery: a case report of cryptic pregnancy in Nigeria

The etiology of cryptic pregnancy has not been fully elucidated and there exist misconceptions about this phenomenon in our contemporary Nigerian society. This case presents the first case report of cryptic pregnancy in sub-Saharan Africa. A case of a 19 year old overweight female student who presented to the sick bay at 01: 30 hours with a 3-day history of lower back pain, abdominal discomfort and constipation. At the sick bay the general practitioner on call asked if she was pregnant and she vehemently said no, recounting that she sees her menstruation regularly. Abdominal examination however, revealed a gravid uterus of about 36 weeks and vaginal examination showed a fully dilated cervix. She was surprised, terrified and confused and only remembered having unprotected sexual intercourse many months earlier. Barely two hours later, she gave birth via spontaneous vaginal delivery, to a live female infant at 03: 14 hours. This case emphasizes the need for general practitioners and specialists in sub-Saharan Africa to be aware of the phenomenon of cryptic pregnancy, which involves women not being conscious of their gravid state until final weeks of gestation or at delivery, to reduce neonatal and maternal complications.

Addressing Crises in Teenage Pregnancy

Background:

Adolescent pregnancy is a major public health concern with medical, psychiatric, and social implications. Within this population, there is an elevated rate of co-occurring psychiatric conditions including mood disorders, anxiety disorders, suicidality, and substance use. However, little is known about the assessment and treatment of adolescent pregnancy within the context of these co-occurring psychiatric conditions, particularly in an emergency situation.

Objective:

This article utilizes a case report to illustrate the challenges faced in consultative psychiatry in the assessment and treatment of a pregnant suicidal youth with a complex psychosocial history. Topics addressed include: 1) The role of childhood trauma and suicidality in adolescent pregnancy 2) A consideration of the risks and benefits of treating adolescents with psychotropics during pregnancy.

Method:

A literature search was performed with the key words of adolescent, pregnancy, child sexual abuse and psychiatric illness. In addition, expert opinions of a reproductive psychiatrist and a psychiatrist who had specialized in addiction and adolescents were enlisted on key aspects of the case formulation and treatment.

Results:

Several studies were found that focused on depression, substance abuse and trauma in adolescent pregnancy. There were more studies that looked at psychopharmacological treatment in adult pregnant women and a few that focused on adolescents.

Conclusion:

Addressing the crisis of psychiatric illness in adolescent pregnancy requires a thorough approach in understanding the severity of the illness and the contribution of child abuse and suicidality. Psychotherapeutic interventions are most certainly always necessary and beneficial when dealing with this population. Deciding when to start and maintain medication during pregnancy should be individualized, with considerations of the risks of untreated illness and of medication exposure.

Denial of Pregnancy: Psychopathology and Clinical Management

Denial of pregnancy (DOP) is a challenging condition with poorly understood psychopathology. DOP is reported to be associated with problems such as severe psychological conflicts, obstetric complications, risks to the newborn, and difficulties in bonding with the infant. In this paper, we present and discuss the clinical manifestations of a severe form of DOP that lasted until the time of delivery with resultant multifaceted complications. Our paper highlights the severity of psychopathology and the need for coordinated management. Descriptions from different cultural backgrounds would improve the conceptual understanding of DOP.

‘Om Langs Die Pad Te Kraam’: A Feminist Psychoanalytic Perspective on Undisclosed Pregnancy

This article focuses on the phenomenon of pregnant women not acknowledging their pregnancies. Such women typically enter the health care system at a late stage and thus get little or no prenatal care. The phenomenon of undisclosed pregnancy is explored by focusing on two case studies of pregnant research participants in a project concerned with the psychological distress of female farm workers in the Western Cape. These two pregnant women were interviewed for a total of ten hours about topics such as psychological distress and well-being, coping and resilience, family and personal history, physical health, interpersonal relationships, reproductive issues (specifically pregnancy and motherhood), and sexuality and body, but did not reveal to their interviewers that they were pregnant. Follow-up interviews were conducted with the participants in an attempt to form a psychological understanding of their failure to disclose their pregnancies during the interviews. In the follow-up interviews, it became clear that the participants also did not reveal that they were pregnant to their families, their friends, their employers, or any health care workers. The interview data suggested that these two participants construed pregnancy as something to feel guilty, ashamed, and anxious about. Their conscious or unconscious response to this material bodily event was to not recognise or acknowledge it, neither to others nor to themselves. This finding is analysed in the context of the literature concerning the subjective experience of and psychological responses to pregnancy, with specific reference to reports of ‘motivated unawareness’ or ‘denial of pregnancy’ in the pregnancy literature. The question of how to understand the participants' experiences and response to pregnancy is then analysed within a postmodern paradigm, using a feminist psychoanalytic perspective.

Concealed pregnancy: a concept analysis

AIM/DESIGN

A concept analysis of concealed pregnancy was undertaken using Walker and Avant's framework to examine the attributes, characteristics and uses of the concept in maternity care.

BACKGROUND

Understanding the concept of concealed pregnancy is critical as failing to do so adds the risk of maternal and neonatal morbidity and mortality. Reviewing the literature and selected empirical referents indicated that concealed pregnancy has been predominantly viewed through a biomedical lens. Confusion exists around the definitions of denied and concealed pregnancy.

DATA SOURCES

A systematic search of five bibliographic databases using keywords from the years 1960-2014.

METHODS

Walker and Avant's framework was used to guide the concept analysis. A thematic analysis of reviewed papers identified the main characteristics of concealed pregnancy.

RESULTS

Concealed pregnancy was conceptualized as a process and the critical attributes are secrecy, hiding, daytime story, staying away and avoidance. This process involves avoidance and if this includes failing to access healthcare can lead to catastrophic outcomes such as maternal and neonatal death. Antecedents, attributes and consequences of concealed pregnancy are also identified.

CONCLUSIONS

Understanding the concept of concealed pregnancy and its antecedents, attributes and consequences may assist in risk identification of women who conceal a pregnancy. This concept analysis has identified a need for further exploration of the coping styles and psychosocial processes involved in women concealing and revealing a pregnancy.

Prevalence and phenomenology of neonaticide in Switzerland 1980-2010: a retrospective study

For a child, the likelihood of being murdered is highest during the first year of life, and many such cases are neonaticides. Although several recent studies have examined neonaticide in different countries and cultures, there has been no in-depth analysis of Swiss cases, even though this country has special neonaticide legislation and four "baby hatches" have been opened to prevent such killings. The primary objective of this retrospective study was to analyze the prevalence and phenomenon of neonaticide in Switzerland. Using data from judicial files, 11 cases were identified in 15 German-speaking cantons between 1980 and 2010. The sample included two uncommon cases of nonmaternal neonaticide. The discussion addresses possible prevention strategies.

Psychosomatic disorders of gravida status: false and denied pregnancies

OBJECTIVE

The authors review the literature on two dramatic psychosomatic disorders of reproduction and offer a potential classification of pregnancy denial.

METHOD

Information on false and denied pregnancies is summarized by comparing the descriptions, differential diagnoses, epidemiology, patient characteristics, psychological factors, abdominal tone, and neuroendocrinology. Pregnancy denial's association with neonaticide is reviewed.

RESULTS

False and denied pregnancies have fooled women, families, and doctors for centuries as the body obscures her true condition. Improvements in pregnancy testing have decreased reports of false pregnancy. However, recent data suggests 1/475 pregnancies are denied to 20 weeks, and 1/2455 may go undiagnosed to delivery. Factors that may contribute to the unconscious deception include abdominal muscle tone, persistent corpus luteum function, and reduced availability of biogenic amines in false pregnancy, and posture, fetal position, and corpus luteum insufficiency in denied pregnancy. For each condition, there are multiple reports in which the body reveals her true pregnancy status as soon as the woman is convinced of her diagnosis. Forensic literature on denied pregnancy focused on the woman's rejection of motherhood, while psychiatric studies have revealed that trauma and dissociation drive her denial.

CONCLUSIONS

False pregnancy has firm grounding as a classic psychosomatic disorder. Pregnancy denial's association with neonaticide has led to misleading forensic data, which obscures the central role of trauma and dissociation. A reappraisal of pregnancy denial confirms it as the somatic inverse of false pregnancy. With that perspective, clinicians can help women understand their pregnancy status to avoid unexpected deliveries with tragic outcomes.

Antipsychotic-induced amenorrhea

BACKGROUND

Many antipsychotic drugs used to treat schizophrenia can cause amenorrhea in a significant proportion of women. The overall impact of this side effect has been little studied.

AIM

To review the literature on the meaning of menstruation to women.

METHOD

This is a literature review of the meanings of menstruation to women in general, to women of different cultures, and to women with schizophrenia.

RESULTS

Many women feel ambivalent with respect to menstruation. Its loss can produce difficulties for women suffering from schizophrenia, such as failure to use contraception, pseudocyesis, denial of pregnancy, erroneous perception of early menopause, or loss of the feeling of femininity.

CONCLUSION

Attempts should be made to avoid the antipsychotic side effect of amenorrhea.

Denial of pregnancy: a literature review and discussion of ethical and legal issues

Denial of pregnancy is an important condition that is more common than expected, with an incidence at 20 weeks gestation of approximately 1 in 475. The proportion of cases persisting until delivery is about 1 in 2500, a rate similar to that of eclampsia. Denial of pregnancy poses adverse consequences including psychological distress, unassisted delivery and neonaticide. It is difficult to predict which women will develop denial of pregnancy. There are a number of forms of denial of pregnancy, including psychotic and non-psychotic variants. Denial of pregnancy is a 'red flag' that should trigger referral for psychiatric assessment. A national registry may help to provide more information about this condition and implement appropriate care. This condition poses challenging legal and ethical issues including assessment of maternal capacity, evaluation of maternal (and possibly fetal) best interests and the possibility of detention in hospital.

Characteristics of Women Who Deny or Conceal Pregnancy

In order to assess characteristics of women with denial or concealment of pregnancy until delivery, the authors conducted a retrospective study of women with no history of prenatal care who presented to their institution for delivery or immediately postpartum. Among these women, 29% had denied pregnancy, and 9% had concealed pregnancy. Authors constructed models predicting denial or concealment of pregnancy and further elucidated subtypes of denial and concealment of pregnancy. Strikingly, psychiatric consultation was rare for women who had denied or concealed their pregnancies, and yet they would often subsequently take responsibility for their infants.

Delusional denial of pregnancy as a special form of Cotard's syndrome: case report and review of the literature

The following case report describes a pregnant woman who was convinced that her pregnancy was non-existent despite being in an advanced stage of clinically obvious pregnancy. The nosologically unspecific syndrome of denial of pregnancy is discussed by reviewing the literature. Based on the existing literature it will be explained why this specific syndrome is considered to indicate a special form of Cotard's syndrome.

The evolutionary biology of cryptic pregnancy: A re-appraisal of the “denied pregnancy” phenomenon

Previous research on 'denied pregnancy', i.e. lack of subjective awareness of pregnancy until the end of gestation in pregnant women, is reviewed and reinterpreted in an evolutionary biological framework. Recent epidemiological studies show that this condition has a much higher incidence than previously thought (about 1:475). Very often, bodily symptoms of pregnancy (nausea, amenorrhea and abdomen swelling) are absent or greatly reduced, and neonates tend to be underweight; in many cases, pregnancy goes undetected also by relatives and physicians. Current explanations in the clinical literature are based on psychodynamic hypotheses about pregnancy-related unconscious conflicts; the lack of symptoms is accounted for by 'somatic denial'. I argue that such psychodynamic accounts are misguided for two reasons: (1) they rest on a failure to recognize the active biological role of the fetus in determining the course of pregnancy, and (2) they ignore the many levels of mother-fetus conflict over resource allocation described by biological theories of parent-offspring conflict. Here I propose to redefine this condition as 'cryptic pregnancy', and begin to explore its possible physiological correlates and evolutionary significance. In the light of parent-offspring conflict theory, cryptic pregnancy appears to reduce the costs of pregnancy, both energetic and ecological (mobility, dependence on kin/mate, etc.), thus favoring the mother at the expense of the fetus. Reduced hCG production and/or effectiveness is likely to be involved in the process. I propose and discuss three nonexclusive evolutionary hypotheses to account for this phenomenon: (1) cryptic pregnancy could be a nonadaptive outcome of conflict resolution processes over resource allocation in pregnancy, possibly related to minor disruptions of genomic imprinting mechanisms. (2) Cryptic pregnancy could result from missed spontaneous abortions of low-quality fetuses. (3) Finally, cryptic pregnancy could be an adaptive pattern of 'forced cooperation' between mother and fetus in stressful or threatening ecological circumstances, as suggested by the reported association with elevated psychosocial stress. In case of reduced survival probability, both mother and fetus would benefit if the mother reduced investment in pregnancy in order to maximize her chances of surviving and reaching delivery.

Denial of pregnancy as a reproductive dysfunction: a proposal for international classification systems

OBJECTIVE

To propose a new Diagnostic and Statistical Manual (DSM) and International Classification of Diseases (ICD) category concerning reproductive dysfunctions not caused by organic disorder.

METHODS

Forensic (n=93) and obstetrical cases (n=78) of denied and concealed pregnancies are compared and discussed.

RESULTS

Denied pregnancies occur with a ratio of 1:475 births. An overwhelming phenomenological agreement is demonstrated between obstetrical and forensic cases. The findings were similar for denial and concealment of pregnancy, probably representing two different types of reproductive dysfunction that can be classified psychosocially together under the heading "negated pregnancy".

CONCLUSIONS

Analogous to the phenomenology of "sexual dysfunctions", "reproductive dysfunctions" could be distinguished by the extraordinariness of both reproductive experience and behavior (as part of human sexuality) and psycho-physiological changes, which characterize the reproductive course of events and cause obvious suffering and interpersonal complications. It is therefore suggested to include these entities as categories in their own right under the appropriate existing headings in DSM and ICD.

The incidence and outcome of concealed pregnancies among hospital deliveries: an 11-year population-based study in South Glamorgan

Denial of pregnancy has been implicated in potentially jeopardising prenatal care and subsequent safe planned deliveries. This population-based study of hospital deliveries over an 11-year period, reveals that concealed pregnancies have an incidence of one in 2,500 deliveries. Among this cohort, 12% were married and 58% were multiparous with 8% having had a previous caesarean section. Some 20% of women had a medical disorder complicating the antenatal period. There was a preponderance of concealed pregnancies in the winter months compared with booked deliveries (p = 0.02). Mode of delivery was similar between the booked and concealed pregnancies with a low incidence of maternal morbidity in the latter. Prematurity rates (p = 0.0002) were significantly higher in the concealed pregnancy cohort. A total of 20% of infants had depressed Apgar scores at 1 min and 8% at 5 min. There was no documentation of counselling or follow-up in this group. Despite the low incidence of maternal morbidity, these women should be regarded as high-risk labour due to the increased perinatal morbidity. Greater effort needs to be made towards ensuring these women have adequate counselling and follow-up during the postnatal period.

Preventing the Tragedy of Neonaticide

Denying a pregnancy can result in consequences as tragic as neonaticide--the killing of an infant in the first 24 hours of life. Between 150 and 300 neonaticides are committed each year but the actual prevalence of pregnancy denial is unknown. Adolescents are especially vulnerable to pregnancy denial because the unexpected event creates such enormous anxiety and fear for them. Pregnancy denial often eludes parents, teachers, and health care providers. Nurses can advocate for resources and pregnancy screening in primary care settings, and help educate parents and teachers about the problem.

Elevated risk for neonatal outcome following denial of pregnancy: results of a one-year prospective study compared with control groups

AIMS

Newborns following denied pregnancies are delivered after either late onset or total absence of antenatal care, with a presumed subsequently increased risk for neonatal outcome. For this specific group, several characteristic outcome parameters are investigated.

METHODS

During the period July 1, 1995 to June 30, 1996, a prospective case sampling was performed for denied pregnancies in Berlin. Besides determination of the parameters' frequency, comparison with two control groups is performed: a normal group (BBR, all Berlin deliveries in 1995) and a high risk group (VIR, all deliveries at a perinatal center in 1996).

RESULTS

Altogether 69 neonates occurred. For gestational age < 37 weeks, birth weight < 2500 g, small for gestational age, transferal rate of newborns to neonatal unit and surgical delivery, a statistically significant worse outcome is demonstrated for denied pregnancies versus BBR and VIR (p-level < 0.05). Neonatal mortality is 5.8% in all cases, the corrected rate is 1.5% (excluding three non-viable cases of 21st and 23rd week of gestation).

CONCLUSIONS

The data underline the elevated fetal outcome risk for newborns after denial of pregnancy. In this group, total absence or late onset of antenatal care results in a manifestation of pregnancy dependent risks. Preterm births and small for gestational age newborns, together with deaths, may be classified as at least potentially avoidable.

Frequency of denial of pregnancy: results and epidemiological significance of a 1-year prospective study in Berlin

BACKGROUND

There has been an increasing number of reports on denial of pregnancy. However, only very few studies have involved a large number of patients. To date, no reliable calculation of this condition's general frequency, also from an epidemiological perspective, has been available.

METHODS

A prospective case sampling was performed between 1 July 1995 and 30 June 1996 in the metropolitan area of Berlin. All institutions in which deliveries have taken place were engaged. The lower limit for inclusion was the 20th week of gestation as the first physician's earliest diagnosis of pregnancy. Furthermore, the woman herself must not have had any subjective perception.

RESULTS

Recruited women were divided into three groups. Altogether 62 cases and 29 462 deliveries within the 1-year study period were valid for the frequency calculation, leading to a ratio of 1 : 475 (all cases) and of 1 : 2455 for totally unexpected births with a viable newborn (intrapartal diagnosis of the pregnancy).

CONCLUSIONS

This first prospective, population-based study has also certain epidemiological relevance. From projecting the ratio of 1 : 475 for all of Germany, approximately 1600 cases of denied pregnancies per year are diagnosed, at the earliest, from the 20th week of gestation. Totally unexpected deliveries of a viable fetus without any presumption of being pregnant with 300 projected yearly births would occur threefold more often than triplets. Occurrence of denied pregnancy seems yet to be similar across different socio-demographic conditions. The common view that denied pregnancies are exotic and rare events is no longer valid. More studies of similar design are needed.

The Child Abuse Potential Inventory and pregnancy outcome in expectant adolescent mothers

OBJECTIVE

The study explores the prenatal Child Abuse Potential (pCAP) scores derived from the Child Abuse Potential Inventory administered to expectant adolescent mothers. The aim of the study was to assess the association of the pCAP scores with maternal negative prenatal behaviors, and evaluate the contribution of the pCAP scores to neonatal morbidity.

METHOD

The pCAP scores, demographic data, and self-report on prenatal behaviors were obtained during the second half of the pregnancy in a sample of 45 poor single adolescent mothers. A pediatrician blind to the prenatal data reviewed the neonatal records to assess neonatal morbidity. Maternal prenatal records were reviewed for obstetric risk assessment by an obstetrician who was blind to the rest of the data. The relations among the pCAP scores, prenatal behaviors, and neonatal morbidity were analyzed.

RESULTS

In the prenatal period, the pCAP scores were positively correlated with self-reported prenatal smoking and substance use. The multiple linear regression analysis showed that the pCAP scores significantly contributed to neonatal morbidity independently of obstetric risk factors.

CONCLUSIONS

The Child Abuse Potential scores obtained during pregnancy in poor single adolescent mothers reflect domains of maternal functioning that are associated with negative prenatal behaviors and appear to be important for predicting neonatal morbidity. Further studies are warranted to validate the prenatal use of the Child Abuse Potential Inventory.

Neonaticide: an appropriate application for therapeutic jurisprudence?

Might therapeutic jurisprudence, a perspective that attempts to study interaction between the legal and mental health disciplines, be brought to bear effectively with respect to neonaticide, the murder of a newborn infant in the first 24 hours of its life? This is a crime that leads to sentencing that is now rarely therapeutic, rehabilitative, or corrective. An examination of the crime, its motives, and its perpetrators precedes a discussion of ways in which the mental health viewpoint in this matter might be brought to the active attention of the courts in order to promote sentencing that is appropriate to both the crime and the transgressor.

Perinatal complications and child abuse in a poverty sample

OBJECTIVE

Perinatal medical illness has been associated with child maltreatment. Using a Child Protective Service (CPS) report as the defining event, this study explores to what extent perinatal morbidity is a risk factor for maltreatment.

METHOD

Medical charts of 206 children ages 0-3 years were reviewed. Data regarding birth history were collected and analyzed in three groups of children: children whose medical record indicated a report to CPS based on prenatal findings (Early Maternal Inadequacy group [EMI]), children whose medical record indicated a report to CPS based only on postnatal findings (Child Maltreatment group [CM]), and a control group without CPS report (NM).

RESULTS

Compared to the CM and the NM groups, children in the EMI group showed significantly lower birth weight and higher neonatal morbidity as measured by Apgar scores, frequency of oxygen requirement and intubation at birth, frequency of admission to Neonatal Intensive Care unit, and frequency of neonatal medical problems. There was no significant difference between the CM and the NM groups in birth weight, gestational age, and other measures of morbidity.

CONCLUSION

The results of the study suggest that perinatal complications are associated with prenatal maltreatment. Previously reported strong associations between neonatal morbidity and child abuse are more likely a result of antecedent prenatal maternal behaviors (early maternal inadequacy). Early maternal inadequacy, a clinically and demographically distinct phenomenon, is important due to serious health, development and financial implications and deserves further exploration.