Unexpected delivery: cryptic pregnancy

Cryptic pregnancy was first described in the early 17th century and occurs when the pregnant person is unaware of their pregnant state and discovers this late in pregnancy or when labour starts. Historically, the term 'concealed pregnancy' has been used synonymously. In a concealed pregnancy, the patient is aware of their pregnancy but chooses to hide it. Cryptic pregnancies can be divided into psychotic or non-psychotic types (affective, pervasive or persistent); however, it can also occur without any clinical manifestation of a psychiatric disorder. Lack of antenatal care may result in adverse maternal and fetal outcomes such as pre-eclampsia, small for gestational age babies or untreated diabetes. The risk factors for pregnancy denial include young age, low level of education, a precarious work situation and being single. The psychological and developmental impact of pregnancy denial on children and mothers is still unknown. The authors present the case of a nulliparous woman with polycystic ovary syndrome (PCOS) in her early 40s presenting to the Emergency Department with abdominal pain and hypertension with proteinuria. Her body mass index (BMI) was 51.6 kg/m² Physical examination revealed a gravid uterus, and the woman was in labour. Further investigation with a transabdominal ultrasound scan confirmed a term fetus. She was unaware that she was pregnant. She was diagnosed with pre-eclampsia and commenced treatment with labetalol. The woman presented to primary care with non-specific symptoms of weight gain, lethargy, carpal tunnel syndrome and acid reflux over a 6-month period. Despite being sexually active and not using contraception, a pregnancy test was not offered. She was delivered of a live neonate by an emergency lower segment caesarean section at 9 cm dilatation. The neonate plotted on the 45.2nd centile. This case emphasises the need for doctors to request a pregnancy test in women of reproductive age who present with recurrent pregnancy-related symptoms irrespective of their BMI, history of PCOS or inability to conceive over a long period. This case also highlights the need for primary care and emergency physicians to be aware of the phenomenon of cryptic pregnancy. It also provides a cautionary reminder of having a high index of clinical suspicion to establish the diagnosis due to the paucity of cases in the literature.