Australian & New Zealand Journal of Psychiatry 1–1 © The Royal Australian and New Zealand College of Psychiatrists 2016 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com Australian & New Zealand Journal of Psychiatry Pregnancy denial or concealement: A case report highlighting risks and forensic aspects Ester di Giacomo 1,2,3 , Manuela Calabria 2,4 , Fabrizia Colmegna 3 , Maria Fotiadou 5 , Barbara Pucci 6 , Patrizia Vergani 2,7 and Massimo Clerici 2,3 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 una- wareness of one’s own pregnancy’ (inci- dence 1:475 within the 20th week, and 1: 2455 after the 20th week of gesta- tion) 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 preg- nancy denial: Affective (intellectual acknowledgement without emotional/ behavioral changes), Pervasive (preg- nancy existence is kept from aware- ness, 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 pre- cipitously, after less than 1 hour of labor, but few deliver at home (6% with denial, and 15% with concealment). The violent implications of ‘preg- nancy denial’ may result in neonaticide (associated with pain denial, short and unassisted deliveries), while conceal- ment 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 admit- ted to Obstetrical Department and referred for psychiatric evaluation. She had no psychiatric history, there was no evidence of any symptoms of mental ill- ness 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 hav- ing concealed the pregnancy, and there were no signs or symptoms of Intimate Partner Violence at admission and fol- low-up. Her female newborn was healthy without consequences of oes- trogen/progesteron absorption (hypo- plastic 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 fac- tors and characteristics associated with pervasive denial and subsequent infanti- cide. The impact in terms of health, both for mother and child, suggests the need for higher awareness and knowl- edge of the phenomenon in terms of etiology and presentation and the need for timely and urgent psychiatric evalu- ation and clinical monitoring in order to prevent possible adverse outcomes. Declaration of Conflicting Interests The author(s) declared no potential con- flicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial sup- port for the research, authorship, and/or publication of this article. References Miller LJ (2003) Denial of Pregnancy in Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Washington, DC: American Psychiatric Publishing, Inc. Spinelli MG (2001) A systematic investigation of 16 cases of neonaticide. American Journal of Psychiatry 158: 811–813. Waller DK, Gallaway MS, Taylor LG, et al. (2010) Use of oral contraceptives in pregnancy and major structural birth defects in offspring. Epidemiology 21: 232–239. Letter 1 Doctorate School, University of Milano- Bicocca, Milano, Italy 2 School of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy 3 Psychiatric Department, S.Gerardo Health Care Trust, Monza, Italy 4 Pediatric Department, S.Gerardo Health Care Trust, Monza, Italy 5 Female Medium Secure Forensic Service, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK 6 Fondazione Monza e Brianza per il Bambino e la Sua Mamma, Monza, Italy 7 Obstetric and Gynecology Department, S.Gerardo Health Care Trust, Monza, Italy Corresponding author: Ester di Giacomo, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy. Email: ester.digiacomo@yahoo.com DOI: 10.1177/0004867416636242 636242ANP 0 0 10.1177/0004867416636242ANZJP CorrespondenceANZJP Correspondence research-article 2016 Letter at Middle East Technical Univ on May 8, 2016 anp.sagepub.com Downloaded from