Delusions of pregnancy in older women: geriatrician, special interest obstetrics?

aaShaun O’Keeffe is a geriatrician in Galway University Hospitals. In this blog, he introduces his recent Age & Ageing paper on delusions of pregnancy in older women.

Back in the ‘what will I do?’ period of my career, I spent six months as an Obstetrics and Gynaecology house officer: and I have the Diploma to prove it!  Although I enjoyed this time enormously, until now it never really seemed to fit with my subsequent career as a geriatrician.  Reports in recent years of IVF pregnancies in women aged 65 or more (which may, incidentally, at least dissuade obstetricians from their previous habit of referring to women who became pregnant after 34 years as ‘elderly’) did lead to the occasional fantasy of being ideally qualified to pioneer the field of obstetric geriatrics. Thankfully, perhaps, this seems unlikely; instead my colleagues and I present my career-to date experience of delusions of pregnancy in older women.

Delusions of pregnancy chiefly arise in women of child-bearing age, often associated with schizophrenia or psychotic depression. Psychosocial factors, in particular wish fulfilment, often in the context of cultural pressures on women to have children, are common triggers and many of the reports make very sad, even harrowing, reading. The occasional cases of men who believe they are pregnant are also often attributed to psychological factors such as frustrated creativity, envy of a wife’s ability to have children or a form of mother-fixation.

The explanation in our five women, all of whom had had one or more babies, is more prosaic, not requiring recourse to Freud, and the remedy is more immediately apparent: all subjects were very constipated and the delusions abated as the bowels emptied.  (In one case the bowel movement resulted in a new delusion that a baby, later named by the patient, had been born). Of course, this does not mean that all such delusions in older women are due to constipation, but physical factors, including other causes of a distended abdomen and use of medications that can raise prolactin levels, should always be considered.

Finally, this series supports the value of maintaining a file or record of patients with potentially interesting problems, and of prospectively obtaining permission to report in the literature. This is the advice of a late learner: as a junior doctor, I saw a sixth case in which a delusion of pregnancy in an older woman with dementia was due to an abdominal tumour. A single case suggesting an association may not be sufficient to warrant a case report: two or more may be. Earlier this year, the same approach (and battered folder) yielded a report of three patients I had seen over the years with excessive fear of being buried alive (taphophobia). Tales from the crypt indeed!

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