Woman Discovers She's Pregnant—On The Day of Delivery!
A 19-year-old female student presented to the emergency room with a 4-day history of abdominal and lower back pain and discomfort. She and her doctor were shocked when they found out she was 37 weeks pregnant and about to become a mother.
CP is a 19-year-old student living with her parents and an older brother in a small village on the outskirts of Ethiopia. She regularly attends high school and is an excellent student with top grades and she plans to enroll in a medical school in town after finishing high school.
CP has a boyfriend of 3 years who is also planning to become a physician one day.
Her daily routine mostly consists of studying for exams since she competes with other students for a position at the medical school.
CP is a healthy young woman with only one problem: being overweight. Due to constant stress from the exams, she developed an eating disorder. CP is aware that she is overeating. She tried exercising several times but couldn't stay consistent and quickly gave up. With the midterm approaching, CP gained even more weight and didn't change her eating habits.
One day, CP started developing malaise and frequent attacks of headaches. After the midterm exams passed, CP visited her general practitioner, who suspected that CP had malaria and consequently treated her with antimalarial drugs.
Several weeks passed, and her malaise persisted.
One morning, CP experienced severe abdominal pain with lower back pain. These symptoms subsided only to reappear several hours later. On the fourth day, CP decided to call emergency medical services, which brought her to the ER.
In the ER, a doctor found out that CP had abdominal pain, lower back pain, and constipation for the last four days. After the doctor asked her if she was pregnant, she confidently said no since she had regular menstruation and had no unprotected intercourse.
Abdominal examination, however, revealed a gravid uterus of about 37 weeks and vaginal examination showed a fully dilated cervix, ready for labor.
CP was in absolute shock since she had no clue she was pregnant.
Abdominal ultrasound showed that the baby was in a frank breech position. Frank breech position is when the baby's buttocks are aimed at the vaginal canal with its legs sticking straight up in front of its body and its feet near its head. To facilitate delivery, a Pinard maneuver was done. The Pinard maneuver is a maneuver in which pressure in the popliteal space of the knee is applied, which causes an external rotation of the thigh and flexion of the knee and is used to assist delivery of the legs.
CP gave birth via spontaneous vaginal delivery to a live male baby weighing 2.5 kg with minimal labor and delivery pain.
CP refused to touch or even look at the baby because she struggled to accept that she had become a mother.
But how could this happen? Let me explain…
Our patient suffered from a medical condition known as cryptic pregnancy- a condition in which a woman doesn’t recognize that she is pregnant, usually until late in the pregnancy or during labor.
Several factors can influence the possible presentation of cryptic pregnancy.
The first factor is that the patient was overweight before the pregnancy, so her abdominal swelling wasn't as noticeable as it would be in leaner women. The second factor was the onset of malaise and nausea, which CP attributed to stress due to midterm exams. The most important factor was her apparent regular menstruation.
A woman’s menstrual cycle is comprised of two main events: ovulation and menstruation.
Ovulation is when an egg is released from the ovary into the fallopian tube, where fertilization occurs (if there is a sperm in the first place). Fertilization represents a fusion between a sperm cell and an egg and produces an embryo that consequently travels to the uterus, ready to be implanted. Once in the uterus, the embryo attaches itself to the uterine lining in a process called implantation, and pregnancy begins.
Menstruation is a woman’s monthly bleeding, and it represents the discarded blood and lining of the uterus as a consequence of the lack of implantation of the embryo. In a normal menstrual cycle, hormones such as estrogen and progesterone, along with hormones from the pituitary gland, work together to prepare your uterus for the possible implantation of the embryo.
Even though estrogen is the main female sex hormone that is responsible for the proliferation of the uterus lining (in other words, it prepares the uterus to feed the newly formed embryo), progesterone is the hormone that promotes pregnancy.
The main source of progesterone is called the corpus luteum, a cell mass that is a remnant of a group of cells surrounding the egg before ovulation.
Although the corpus luteum releases progesterone, it cannot do it by itself forever. Another hormone called HCG that is released from the placenta keeps the corpus luteum alive until the placenta is ready to produce its own progesterone.
If fertilization or implantation doesn't occur, the placenta isn't formed, HCG isn't produced, the corpus luteum isn't kept alive, and levels of progesterone get low.
Since there is no progesterone, there is no hormone to keep the thick, well-vascularised uterine tissue intact, so it quickly crumbles and is released as menstrual blood.
Our patient, for some reason, had a period as consistent as before the pregnancy.
Or did she?
The menstrual period is a complex biological process that is easily influenced by various factors such as hormones, diet, stress, physical activity, and so on. Remember that CP mentioned to her doctor that she had regular menstrual periods. Even though she didn't lie, she didn't quite tell the whole truth.
With a combination of immense stress and an unhealthy diet, CP had her periods, but they were quite irregular, something that is not uncommon for her during the exam period. This irregular bleeding can happen in pregnancy, especially at its onset.
During the implantation of the embryo, the uterine tissue is highly vascularised and the implantation process can cause breakage of the uterine blood vessels and consequently appear as a period-like bleeding.
Another theory of this pregnancy mystery is the hormonal dip that sometimes happens in these cases. It is possible that CP’s corpus luteum sometimes didn’t respond as effectively to the stimulation of the HCG from the placenta. This would lead to a lower concentration of progesterone and only a part of the uterine wall to be shed, resembling normal menstruation.
These symptoms didn't cause an alarm to CP since she had no unprotected intercourse, and thus she safely ruled out pregnancy. The problem is that methods of mechanical contraception, such as condoms, are not 100 percent effective.
According to data, condoms, if used perfectly every time, are about 98 percent effective. When we add the manufacturer error and inappropriate usage of condoms, this efficacy falls to about 85 percent. So even if CP and her boyfriend used condoms perfectly in every sexual intercourse they had, pregnancy still could occur.
Even though cryptic pregnancies were considered extremely rare in the past, new data suggests that 1 in 400 or 500 women are 20 weeks into pregnancy before realizing it, and 1 in 2,500 women reach labor before realizing they're pregnant.
Luckily for us, these pregnancies are, in most cases, without complications.
The main concern is the lack of prenatal care, which includes a series of tests such as measuring the mother's blood pressure and glucose levels, pelvic exam, ultrasound diagnostics, and monitoring of fetal heart rate. These tests are critical to prevent possible negative outcomes of the pregnancy such as miscarriage, growth retardation, and infection but to also evaluate the possibility of chromosome anomalies such as Down syndrome.
Although the patient's baby was born alive and well, she had to be taken from her mother for a few days since she was in such shock and disbelief, which is one of the reasons for the higher incidence of infanticide in cryptic pregnancies.