Stress and anxiety in pregnant women exposed to ultrasound

The effect of home ultrasound on maternal anxiety in patients with previous recurrent pregnancy loss: A randomized control trial

BACKGROUND

Patients with previous recurrent pregnancy loss are subject to increased maternal anxiety and reduced antenatal attachment during the subsequent pregnancy. Maternal anxiety is associated with worse pregnancy and neonatal outcomes. Home ultrasound is a feasible tool with the potential to alleviate maternal anxiety by ensuring fetal well-being.

OBJECTIVE

This study aimed to investigate the impact of complementing standard prenatal care with twice-weekly telemedicine visits incorporating home ultrasound on maternal anxiety and antenatal attachment in individuals with a history of recurrent pregnancy loss.

STUDY DESIGN

In this randomized controlled trial, patients with a history of 2 or more prior abortions were randomized early in their subsequent pregnancy in a 1:1 ratio into either the control group, which received standard high-risk prenatal care, or the study group, which received additional twice-weekly home-ultrasound sessions. The home-ultrasound scans assessed fetal pulse, movements, and amniotic fluid volume, aiming to provide maternal reassurance. Patients performed the scans themselves using the Pulsenmore device, with real-time guidance from a physician. Maternal anxiety was assessed using the validated State-Trait Anxiety Inventory Scale (STAI-S) and the Revised Prenatal Distress Questionnaire (NuPDQ), while maternal attachment was measured with the validated Maternal Antenatal Attachment Scale (MAAS-2) at 3 time points during pregnancy. The primary outcome was the STAI-S score at the final prenatal visit. A sample size of 50 patients was calculated to detect a 20% difference in the primary outcome.

RESULTS

Of the 57 patients recruited, 50 completed the follow-up, 25 in each group. There were no significant differences in demographics between the groups. The primary outcome (STAI score at the last visit) was significantly lower in the device group compared to the control group (P=.037). In addition, the study group exhibited a greater reduction in STAI scores between the first and last visits (P=.045), and a significantly higher MAAS score at the end of the follow-up period (P=.046).

CONCLUSION

Integrating routine home-ultrasound telemedicine visits into prenatal care can significantly reduce maternal anxiety during pregnancy and contribute to greater maternal attachment in individuals with a history of recurrent pregnancy loss. These results emphasize the potential benefits of home ultrasound as a tool to alleviate anxiety, provide a sense of control, and foster a deeper maternal connection among pregnant individuals who have experienced previous pregnancy loss.

A prospective cohort study providing insights for markers of adverse pregnancy outcome in older mothers

Background

Advanced maternal age (≥35 years) is associated with increased rates of adverse pregnancy outcome. Better understanding of underlying pathophysiological processes may improve identification of older mothers who are at greatest risk. This study aimed to investigate changes in oxidative stress and inflammation in older women and identify clinical and biochemical predictors of adverse pregnancy outcome in older women.

Methods

The Manchester Advanced Maternal Age Study (MAMAS) was a multicentre, observational, prospective cohort study of 528 mothers. Participants were divided into three age groups for comparison 20–30 years (n = 154), 35–39 years (n = 222) and ≥ 40 years (n = 152). Demographic and medical data were collected along with maternal blood samples at 28 and 36 weeks’ gestation. Multivariable analysis was conducted to identify variables associated with adverse outcome, defined as one or more of: small for gestational age (< 10th centile), FGR (<5th centile), stillbirth, NICU admission, preterm birth < 37 weeks’ gestation or Apgar score < 7 at 5 min. Biomarkers of inflammation, oxidative stress and placental dysfunction were quantified in maternal serum. Univariate and multivariable logistic regression was used to identify associations with adverse fetal outcome.

Results

Maternal smoking was associated with adverse outcome irrespective of maternal age (Adjusted Odds Ratio (AOR) 4.22, 95% Confidence Interval (95%CI) 1.83, 9.75), whereas multiparity reduced the odds (AOR 0.54, 95% CI 0.33, 0.89). In uncomplicated pregnancies in older women, lower circulating anti-inflammatory IL-10, IL-RA and increased antioxidant capacity (TAC) were seen. In older mothers with adverse outcome, TAC and oxidative stress markers were increased and levels of maternal circulating placental hormones (hPL, PlGF and sFlt-1) were reduced (p < 0.05). However, these biomarkers only had modest predictive accuracy, with the largest area under the receiver operator characteristic (AUROC) of 0.74 for placental growth factor followed by TAC (AUROC = 0.69).

Conclusions

This study identified alterations in circulating inflammatory and oxidative stress markers in older women with adverse outcome providing preliminary evidence of mechanistic links. Further, larger studies are required to determine if these markers can be developed into a predictive model of an individual older woman’s risk of adverse pregnancy outcome, enabling a reduction in stillbirth rates whilst minimising unnecessary intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04178-6.

Women's experiences of counselling in cases of a screen-positive prenatal screening result

OBJECTIVE

To study women's apprehensions, understanding and experiences of counselling concerning a screen-positive result in screening for fetal chromosomal defects.

METHODS

A questionnaire study including different steps of the prenatal screening process was carried out in Helsinki University Hospital. Women's experiences concerning counselling immediately after a screen-positive result and during further examinations in the Fetal Medicine Unit (FMU) were analyzed.

RESULTS

143 women filled in the questionnaire. Less than half of the women considered the primary counselling after a screen-positive result to be explicit (43.9%) and sufficient (43.1%). In the FMU, 88.3% and 89.8% of women were satisfied with the explicitness and sufficiency of counselling. Most women (75%) experienced worry before further examinations but less than half (45%) had considered their personal values concerning diagnostic tests. Half (50.5%) of women expected the worry to continue even if diagnostic tests turn out normal. Most (81%) women were aware that diagnostic tests are voluntary and were confident (85.3%) with their decision to participate.

CONCLUSIONS

After a screen-positive result, women have unanswered questions, experience anxiety and confusion. The possibility of an abnormal screening result is not seriously considered beforehand. To enable an informed consent for prenatal screening, improvements in prescreening counselling during the first visits of antenatal care need to be made.

Indeterminate Prenatal Ultrasounds and Maternal Anxiety: A Prospective Cohort Study

INTRODUCTION

Prenatal ultrasounds often yield indeterminate (incomplete or minor abnormality) findings with limited clinical utility. We evaluate impact of indeterminate findings on maternal anxiety.

METHODS

A single-U.S.-center prospective cohort study administered the Perinatal Anxiety Screening Scale (PASS; control mean = 13.4; > 20 denotes clinically significant anxiety) before and after prenatal ultrasounds in February-May 2017. Ultrasound reports were coded as: normal; indeterminate; or major abnormality. Primary outcome was anxiety after indeterminate vs. normal ultrasounds. Secondary outcomes included anxiety change from pre-to-post-ultrasound and relative to women's characteristics. Linear regression adjusted for confounders.

RESULTS

Of 286 ultrasounds, 51.0% were normal, 40.5% indeterminate (22.0% incomplete; 18.5% minor abnormality), and 8.0% major abnormalities. Indeterminate findings were unrelated to age, race, parity, infertility, or psychiatric history, but associated with gestational age (26.6%/45.0%/52.5% for first/second/third trimesters; p < 0.001), and obesity (48.8 vs. 37.0%; p = 0.031). Pretest anxiety was highest in second/third trimesters (p = 0.029), and in subjects aged age ≤ 24 or younger(p < 0.001), with a history of anxiety (p < 0.001),) or with prior pregnancy loss (p = 0.011). Mean anxiety score decreased pre-to-posttest across all groups. Indeterminate findings were associated with higher PASS scores than normal findings: pretest 20.1 vs. 16.4 (p = 0.026) and posttest 16.9 vs. 12.2 (p = 0.009; adjusted-p = 0.01). Versus normal ultrasounds, incomplete findings were associated with higher post-ultrasound anxiety (p = 0.007; adjusted-p = 0.01) and smaller decreases from pre-to-posttest (adjusted-p = 0.03), whereas minor abnormalities had higher pretest anxiety (p = 0.029) with larger pre-to-posttest decreases (adjusted-p =0.010).

DISCUSSION

Indeterminate ultrasounds, especially incomplete findings, are associated with significantly higher anxiety than normal findings, suggesting need for evidence-based counseling, management and strategies for decreasing number of indeterminate results.

Effects of ultrasound on anxiety and psychosocial adaptation to pregnancy

Ultrasound is a common medical care procedure during pregnancy which has psychological implications. Research has found that it reduces the mother's level of anxiety, but there is not enough literature on the effects of the ultrasound in relation to the trimester it is done (first, second, and third) and the effects on the psychosocial adaptation to pregnancy. The purpose of this study was to investigate the effects of the ultrasound in the first, second, and third trimester on anxiety and variables related to psychosocial adaptation to pregnancy. A pre-post intervention design was used. Participants were 111 pregnant women attending a prenatal diagnosis ultrasound scan procedure, State-Trait Anxiety Inventory (STAI), and Prenatal Self-Evaluation Questionnaire (PSEQ) were used to measure anxiety and psychosocial adaptation to pregnancy, respectively. Previous history was obtained through an interview. Results indicated that anxiety diminished after the ultrasound regardless of the trimester in which the ultrasound took place. However, first trimester ultrasound showed an additional benefit favoring the mother's psychosocial adaptation to pregnancy, identification with the motherhood role, and the quality of the relationship with the partner. These findings suggest that in addition to the medical value of the ultrasound, it also has an important psychological value that has to be considered in order to guarantee an integral care of the pregnant women, especially in the first trimester.

Systematic error and cognitive bias in obstetric ultrasound

Linked Comment: Ultrasound Obstet Gynecol 2019; 53: 454-464.

Does screening for Down's syndrome cause anxiety in pregnant women? A systematic review

BACKGROUND

Prenatal screening for Down's syndrome and other chromosomal abnormalities is included in prenatal care programs in many countries. However, the potential association between prenatal screening and maternal anxiety remains an issue of debate.

OBJECTIVE

To systematically review and summarize the current scientific evidence on whether screening for Down's syndrome might cause anxiety in pregnant women with a negative or a false-positive screening result.

METHODS

Five databases (PubMed, Embase, Cinahl, PsychInfo and Cochrane) were systematically searched for randomized controlled trials or cohort studies comparing screening and no screening, or comparing different types of screening for Down's syndrome. The search was limited to studies published between September 2001 and April 2013. In all, 316 studies were identified through search of databases and 40 were included for full-text assessment. Two observers independently screened the articles and seven studies satisfied the inclusion criteria. They were subsequently assessed for risk of bias and level of evidence.

MAIN OUTCOME MEASURES

Quantitative measurements of maternal anxiety or worry.

RESULTS

Two studies compared anxiety in pregnant women who accepted or declined screening and showed no difference between groups. All studies described a decrease in anxiety following a screen-negative result. Four studies reported that women's anxiety levels increased significantly upon receiving a screen-positive result. However, after a normal diagnostic result, anxiety levels declined to the same level as for screen-negative women.

CONCLUSION

Studies using quantitative, validated measures to estimate anxiety showed no association between screening and residual anxiety.