Two North Carolina doctors have been reprimanded for performing a caesarian on a woman, only to discover she wasn't pregnant at all.
The woman reportedly appeared at the hospital with her husband asking for a C-section. A resident in charge made the pregnancy diagnosis and doctors agreed to surgery after trying to induce labor for two days.
Neither doctor independently confirmed the pregnancy.
In January, after studying the case for more than a year, the North Carolina Medical Board sent "letters of concern," the lowest level of discipline, to Dr. Gerianne Geszler, who was the on-call physician, and Dr. Dorrette Grant, who performed the caesarian in 2008.
When they saw an empty uterus, they "closed her back up," Geszler told ABC News. Pseudocyesis can "fool people," said Paul Paulman, assistant dean for clinical skills and quality at the University of Nebraska College of Medicine, "but you open someone's abdomen, you make darn sure you know what you're doing," he said. "It's a potentially life-changing event."
Paulman wrote about a similar 1990 case in the Journal of Family Practice.
The medical board in North Carolina said the resident at Cape Fear Medical Center did not have enough experience to make the pregnancy diagnosis and doctors should have conducted their own exam.
Dena Konkel, assistant director of public affairs for the medical board, said the case was "unique."
"The board was mostly concerned about the management of patient care," she said. "It may have fallen below the standard of care."
"Some would argue that this is not disciplinary in nature -- it doesn't limit their ability to practice medicine," said Konkel. But, "it creates a public record, something that can be looked up and read about what happened."
Neither doctor has been disciplined publicly before. Both still practice medicine, but with a warning from the board that similar complaints could lead to formal disciplinary proceedings.
Grant did not return calls from ABCNews.com, but the board's Web site indicates she is still delivering babies at Women's Health Haven Obstetrics and Gynecology.
"I do not want to criticize anyone else involved with this case," said Geszler. "I was covering the residents when the patient arrived, and she reported the case to me. I did not actually see the patient as this is not necessarily a protocol that the attending examine the patient."
Pseudocyesis Can Be Deceptive, Say Doctors
She said the ob-gyn resident was a medical doctor and trained in ultrasound.
"Residency and supervision of residents is very complicated," said Geszler, who is now practicing at Breezewood's Center for Health and Restoration. "To let them make appropriate evaluation and decisions, yet without harm to the patient. Do you second guess everything? Do you repeat everything?"
Other doctors familiar with pseudocyesis, say the disorder can be deceptive.
Although it is a psychiatric condition, women can have all the physiological symptoms of pregnancy -- cessation of menstruation, distended abdomen, swollen breasts, morning sickness and food cravings, and even labor pains.
Pseudocyesis is considered rare, occurring at a rate of 1 to 6 for every 22,000 births. It often strikes women with a "strong desire" to become pregnant, according to Paulman.
"On face value, it's bad care and unconscionable," he said. "If I am a first-year resident, buried and swamped, working hard and that week I get a high amount of emotion from a family, I can see how the error was made. But it shouldn't have happened."
Pregnancy can be ruled out by an abdominal exam -- "you can feel the unmistakable bony head" -- or the rapid fetal heartbeat [120 beats per minute, unlike the mother's 70-80 per minute] or through a sonogram image, he said.
False pregnancies have been known throughout history, dating back to 300 B.C. when Hippocrates treated 12 women who were convinced they were pregnant.
The English queen "Bloody" Mary Tudor, the oldest daughter of Henry VIII, experienced pseudocyesis, perhaps because of her father's reputation for beheading childless wives.
Sigmund Freud's most famous patient, "Anna O," believed she was pregnant with the child of her former psychiatrist, Josef Breuer, which led the father of modern psychiatry to expound on the theory of "transference" or attachment.
Doctors Can Be Fooled by False Pregnancy
Capable doctors can be fooled. In the mid-1960s, Dr. John Radebaugh got a call one night to tend to a woman in labor at a clinic for migrant workers in Rochester, N.Y.
The woman, with a "melon-sized stomach, groaning and writhing in pain," was convincing enough to rush to the hospital. She even drenched the doctor in clear liquid, leading him to believe she had broken her water.
"From the condition she was in, we thought she was going to deliver right then and there," he told The New York Times in 2008 .
But the next day, the hospital told him she had been treated for a full bladder and discharged.
In another case reported in the journal Psychosomatics, a woman experienced labor pains and even the final push sensation at the same time her son's girlfriend was giving birth to her grandchild.
Paulman treated a 30-year-old woman who claimed she was 13.5 weeks pregnant. Her belly was swollen and she told him she felt fetal movement. But upon examination, he discovered she had no uterus or cervix because of a previous hysterectomy.
He said false pregnancies are living proof of the mind-body connection when conscious thoughts can cause the brain's pituitary gland to create the pregnancy hormone, oxytocin.
"It is psychosomatic, but probably not a delusional state or psychotic," said Paulman. "But there is probably some neurosis going on, they are living in a dream world."
Though there are few studies on pseudocyesis, some suggest that elevated estrogen and prolactin levels can cause physical symptoms like abdominal swelling and even milk secretion, as well as the desire to bond with a baby.
Others say pseudocyesis may have cultural origins. It is more common in Africa where poverty and relational instability exists in communities that "treasure children for economic survival and generational continuity," according to a 2008 report in the Indian Journal of Psychiatry.
In the North Carolina case, doctors were chastised for taking the false pregnancy one step too far: "Your inappropriate reliance on their diagnosis and the failure to conduct your own examination were contributing factors in the unnecessary attempt at a caesarian delivery," said the board letter.
Cape Fear Medical Center did not return calls from ABCNews.com, but Geszler said the hospital had instituted new guidelines.
"It will never happen again," she told the Fayetteville Observer.
The patient at the center of this case had not been identified.
In her defense, Geszler told ABC News the night the patient was admitted, she was on duty, but multiple other doctors were in charge over the course of two days while the patient was being induced.
In 2008, she gave up obstetrics after 20 years due to "exhaustion and increasing morbidity and patient potential litigation in a country where people are becoming more obese and less healthy." She now focuses on preventive and integrative medicine.
"Certainly we are all humans and subject to error but in no way do I take what I do in a casual manner," said Geszler.
"I have always tried to treat everyone as if they were a member of my family," she said. "I believe this has been blown way out of proportion and why it made the front page of our local paper is beyond me. In my 20-year career I would like to think I have helped so many more people, but you never seem to hear about the good, only the bad."