A 35-year-old woman comes to the office for her first prenatal visit. The patient has been married for 8 years and has tried to conceive for the past 3 years. For the past few weeks, she has experienced morning sickness and has had abdominal distension and breast fullness. Her last menstrual period was 2 months ago and a home urine pregnancy test was positive. She has no medical problems and has had no surgeries. The patient takes a prenatal vitamin daily. She does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/60 mm Hg and pulse is 72/min. BMI is 24 kg/m². Physical examination shows a soft, nontender, tympanic abdomen with no masses. Bedside ultrasound reveals a thin endometrial stripe. Two office urine pregnancy tests are negative. Which of the following is the most likely diagnosis?

Question

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This patient presents with amenorrhea, breast fullness, morning sickness, and abdominal distension - symptoms of early pregnancy - and believes she is pregnant. However, her office examination (thin endometrial stripe, negative urine pregnancy test) excludes pregnancy. This presentation is consistent with pseudocyesis; risk factors include a history of infertility and prior pregnancy loss. Pseudocyesis likely occurs when the somatization of stress affects the hypothalamic-pituitary-ovarian axis and causes early pregnancy symptoms, or when bodily changes (eg, weight gain, amenorrhea) are misinterpreted. The end result is a nonpsychotic patient who believes she is pregnant. This belief is often strong enough that the patient misinterprets negative home pregnancy tests as being positive. Because pseudocyesis is a form of somatization, management requires psychiatric evaluation and treatment. (Choice A) Despite the positive home pregnancy test, early pregnancy is excluded in this patient by the negative office urine pregnancy tests. (Choice B) An ectopic pregnancy can present with a positive home pregnancy test and an empty uterine cavity on ultrasound. However, it also presents with an adnexal mass and a positive office pregnancy test. (Choice C) A hydatidiform mole is typically associated with severe nausea and vomiting, uterine size greater than dates, markedly elevated β-hCG levels, and an ultrasound revealing a uterus filled with a heterogeneous cystic mass. (Choice D) Patients with missed abortions frequently experience a cessation of early pregnancy symptoms. A pregnancy test is positive and an ultrasound reveals a nonviable intrauterine gestation. (Choice E) Polycystic ovary syndrome is a cause of amenorrhea and infertility. Findings include a thickened endometrium (due to chronic anovulation and endometrial proliferation) and polycystic ovaries on ultrasound. (Choice F) Premenstrual syndrome can present with breast tenderness and nausea. It is associated with regular, ovulatory menstrual cycles but not with the belief that one is pregnant. Educational objective: Pseudocyesis is a condition in which a nonpsychotic woman presents with signs and symptoms of early pregnancy (eg, amenorrhea, morning sickness, abdominal distension, breast enlargement) and the belief that she is pregnant. Evaluation excludes pregnancy, typically via a negative pregnancy test and an ultrasound that reveals a normal, empty uterus. References: Psychosomatic disorders of gravida status: false and denied pregnancies. (http://www.ncbi.nlm.nih.gov/pubmed/25624179) Endocrinology and physiology of pseudocyesis. (http://www.ncbi.nlm.nih.gov/pubmed/23672289)

A 35-Year-Old Woman Comes to the Office for Her First