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Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome
Author’s Accepted Manuscript Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome Karolina Stojanow, Martina Annekathrin Bergner, Barbara Maier
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To appear in: Mental Health & Prevention Received date: 11 April 2016 Accepted date: 3 March 2017 Cite this article as: Karolina Stojanow, Martina Rauchfuss, Annekathrin Bergner and Barbara Maier, Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome, Mental Health & Prevention, http://dx.doi.org/10.1016/j.mhp.2017.03.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome Karolina Stojanow1*, Martina Rauchfuss1, Annekathrin Bergner1, Barbara Maier2 1
Charité - University Medicine Berlin, Centre of Internal Medicine & Dermatology, Clinic for
Internal Medicine & Psychosomatics 2
Department of Obstetrics and Gynaecology, Hanusch General Hospital, Vienna, Austria
*Correspondence to:Lenbachstrasse 14, D-10245 Berlin, Germany. Tel.: +49-(0)30-
60958171. [email protected] Abstract Objective This study investigates pregnancy- and birth-giving-related fears of women of different risk groups and examines their influence on pregnancy and delivery. Study design: Prospective study. Setting: Pregnant out-patients were recruited in medical practices in Berlin. Data on perinatal outcome were obtained from the charts of the obstetric units. Participants: 589 pregnant women between 16 and 22 weeks of gestation. Methods: Pregnant women were interviewed by a semi-standardized questionnaire and related to information from the charts about perinatal outcome of the obstetric units. Results: 77 women were at risk of anxiety influencing pregnancy and perinatal outcome due to chronic diseases, 61 had a history of previous miscarriage, 38 had a history of termination of pregnancy. 288 had no risk factors. Women with previous miscarriage had the highest degree of pregnancy-related fears. Their pregnancies were significantly more often complicated by the threat of miscarriage. A relationship between high levels of pregnancyrelated fears and pregnancy complications was only found in the group of “low- risk women”. Conclusion: Women with a history of miscarriage evidently make use of special care services and social support services. For these women no correlation between pregnancy-related fears and complications was found. Low-risk pregnant women seem to have fewer means of coping with their unreasonable fear. 1. Introduction Women undergo substantial physical and psychological changes during pregnancy, affecting also partner relationship and social environment. Fears of complications during pregnancy and delivery as well as uncertainty concerning their roles as mothers are common among
pregnant women. Additionally, obstetrical and medical risk factors can be highly stressful during this maturation crisis. Thus, we assume that pregnant women with risk factors are at greater risk of anxiety and of more severe psychological and physical disorders. Howard et al. (2014) found a prevalence of 13% of any anxiety disorder during pregnancy, which is higher than the prevalence of antenatal depression (3,1%-4,9%). Both disorders are highly comorbid which also applies to the general population. There is increasing evidence that stress-related emotions such as anxiety may also be related to the risk of adverse perinatal outcomes, including low birth weight or preterm delivery (Catov et al., 2009; Ding et al., 2014; Dunkel Schetter & Tanner, 2012; Glynn et al., 2008; Orr et al., 2007, Rauchfuss et al., 2011). Several studies investigated the course and outcome of pregnancies after previous miscarriage. In particular, the prognosis is dependent on the number of previous spontaneous abortions (Clifford et al., 1997). Women with a history of three or more consecutive miscarriages had a significantly higher risk for obstetrical complications. In contrast, women with a single previous miscarriage did not show an increase of risk for complications of subsequent pregnancies (Thom et al., 1992). Other studies also found a correlation between a history of spontaneous abortions and the risk for prematurity and low birth weight infants (Buchmayer et al., 2004; Field & Murphy, 2015; Jivraj et al., 2001). Only a few studies did not (Dempsey et al., 2014; Jivraj et al., 2001). King et al. (2010) assessed the emotional state of women with pre-existing medical disorders during pregnancy, such as diabetes mellitus type 2 as well as with pregnancy-induced disorders, such as pre-eclampsia or hyperemesis gravidarum. Women with a pre-existing medical disorder showed a significantly higher (Spielberger 1970) state and trait anxiety compared to healthy women. While numerous studies took a statistical as well as epidemiological approach towards the courses and outcomes of pregnancies after a history of spontaneous abortion, only few investigators addressed emotional issues. Some authors investigated psychological risk factors for antenatal anxiety disorders. Unfortunately, they often do not differenciate between depression and anxiety due to the high rate of comorbidity or to different degrees of severity. Moreover, they often apply common anxiety scales that are not adjusted to pregnant women. As to the different course of anxiety and depression in pregnancy, Heron et al. (2004) found that anxiety and depression persisted for about 8 weeks postpartum. Both disorders decreased over time. However, there was one difference. Anxiety during pregnancy predicted anxiety and depression postpartum, but antenatal depression only predicted postpartum depression. Biaggi et al. (2016) identified several psychological risk factors for antenatal depression and anxiety: previous history of mental illness or history of treatment during previous pregnancy, childhood abuse, family history of mental illness, lack of social support, domestic violence, socio-demographic variables such as young age or old age, low education, poor working conditions, low income,
ethnicity (belonging to a minority ethnic group), adverse life experiences, traumatic events and personality factors, such as low self-esteem and low self-efficacy, high levels of neuroticicm and psychoticism, maternal attitudes towards motherhood. Meijer et al. (2014) found that pregnancy-related events were especially associated with greater degree of anxiety whereas non-pregnancy related events were associated with symptoms of depression. In their study adverse events were testing for congenital anomalies, test results indicating that the baby might have abnormalities, being told that it is a twin pregnancy, finding out that the partner might not want the baby, bleeding and being afraid of miscarrying, trying to get an abortion, finding out that something that happened might harm the baby. The aforementioned results are based on a heterogeneous population of pregnant women. Evidence of pronounced anxiety during pregnancy has been reported particularly in women with a history of pregnancy loss (Blackmore et al., 2011; McCarthy et al., 2015; Statham & Green, 1994; Theut et al., 1988). Some authors suggest that pronounced anxiety, presumably mediated by neuroendocrine and psycho-immunological mechanisms may lead to pregnancy complications, even to pregnancy loss (Coussons-Read et al., 2012). Despite clinical experiences of higher risk for anxiety and depression in a pregnancy following recurrent miscarriages, only few investigations dealt with them so far. Anxiety, for example, emerges as physical symptoms, subjective stress or lack of self-confidence. Authors hypothesize that women’s anxiety relates especially to the course of their current pregnancy. Specifically, pregnancy-related anxiety can be defined as “fears about the health and well-being of one’s baby, the impending childbirth, of hospital and health-care experiences, birth and postpartum, and of parenting or the maternal role” (Dunkel Schetter, 2011, p. 534). Prettyman et al. (1993) focused on anxiety three months after a spontaneous abortion in terms of future pregnancies. Other authors have shown that anxiety may be correlated with the anticipation of future events (Tunaley et al., 1993). In women with recurrent pregnancy loss, a higher degree of pregnancy-related anxiety was found, but not a higher degree of general anxiety (Theut et al., 1988). On the contrary, Woods-Giscombé et al. (2010) did not find any significant differences in pregnancy-related anxiety comparing pregnant women with and without a history of miscarriage. They found differences in state anxiety, but only in the second and third trimester. Overall, the anxiety levels decreased through the course of pregnancy. However, the authors see a limitation of their study in the assessment and definition of pregnancy-related distress. It rather captures the burden associated with pregnancy, such as changes of the body and low energy, which may apply both to women with and without a miscarriage, but it does not capture concerns and worries about the health status of oneself or the babies`. Another study suggests that miscarriages may lead to higher levels of pregnancy-related fear and of state anxiety and concludes that pregnancy-related fear may have a negative impact on the course of pregnancy and delivery
(Fertl et al., 2009). However, more anxious or, to put it positively, more careful behavior during pregnancy can also be protective. In a prospective study, state anxiety did not seem to be correlated to pregnancy complications, including preterm labor (Andersson at al., 2004; Norbeck & Anderson, 1989). In a group of 88 primigravidae, low trait anxiety was correlated with a higher incidence of chorioamnionitis and premature delivery as well as lower birth weight. The pregnant women participating in this study completed a questionnaire on anxiety at intervals of six weeks during pregnancy. Women were recruited for the study between 8 to 28 weeks of gestation (GW). The lowest degree of anxiety was measured between 22 and 26 gestational weeks (Bhagwanani et al., 1997). In contrast, other authors reported preterm labor and premature deliveries more often in women with increased trait anxiety (Hosseini et al., 2009; Loomans et al., 2012). Shapiro et al. (2013) found that trait anxiety was a protective factor but combined with chronic or acute stressors or traumatic events it raised the risk of preterm birth. Using a scale for pregnancy-related anxiety containing five items, Wadhwa et al. (1993) discovered that a high level of pregnancy-related anxiety was associated with a higher rate of preterm deliveries. The items focused on the course of pregnancy and delivery and included questions about the respondent’s relationship to her physician. For a more accurate evaluation of the relationship between psychological burden during pregnancy on the one hand and obstetrical history and complications during pregnancy and delivery on the other, it is necessary to distinguish between different risk groups. That is the aim of the present study.
Research questions 1. Do pregnant women with a history of pregnancy loss or other risk factors show a higher level of pregnancy- and delivery-related fears than pregnant women without? 2. Is there a relationship between pregnancy-related risk factors and complications of pregnancy and delivery? 3. Is there a relationship between pregnancy- and birth-giving-related fears and complications during pregnancy? 4. Is the relationship between anxiety and pregnancy complications dependent adverse obstetric history (risk group)? 2. Material and Methods 2.1 Study Design, Sample and Procedure Data were obtained from 589 pregnant women between the 16th and 22nd GW within the framework of a prospective study. A semi-standardized questionnaire was employed and
administered to women in medical practices in Berlin. The questionnaire contains items related to pregnancy- and birth-giving-related fears, physical and psychological complaints, obstetric history and sociodemographic data which were rated on a multistep rating scale. Data of obstetrical and neonatal outcomes were obtained from the charts of the obstetric units where 519 women gave birth. From this data pool, a sample of 464 women either with a medical risk factor (cardiac arrhythmia, hypertension, asthma, diabetes, chronic renal disease, n = 77) or with previous pregnancy loss (miscarriages: n = 61, termination of pregnancy: n = 38) was extracted. These risk groups were compared with a group of 288 women without any risk factor. Pregnancy- and birth-related fears were rated on six-point scales. In the following factor analysis, three items out of five with respect to pregnancy-related fears (Cr = 0.7512) were extracted. The mean of the three items was 3.7 1.3. 86 (16.6%) of the pregnant women were regarded as highly anxious (mean > 5); 433 (83.4%) were regarded as having normal to low pregnancy-related fears (mean 5). High pregnancyrelated fear is characterized by the concern that the unborn child could be harmed by a fall or an accident, by bleeding or the wrong life-style. Expectedly, birth-related fear was less prevalent than pregnancy-related fear at the time when the questionnaire was completed (four months prior to delivery). After factor analysis, four of the original five items were extracted with a mean of 2.9 1.1. 88 pregnant women (16.9%) were assigned to the highly anxious group (mean 3.95), and 426 (83.1%) were allocated to the normal to mildly anxious group (mean < 3.95) with regard to birth-related fear (Cr = 0.7415). Higher values denote greater fear of physical pain and complications during delivery or the fear of being left alone during giving birth. Information concerning pregnancy- and birth-related complications of women of the study population was obtained from patient reports of the obstetric units where they had given birth.
2.2 Statistics At first, the different risk groups and the control group were analyzed using an age-matched univariate analysis of variance (one-factor analysis of co-variance with the factor age as covariable). Subsequently, the pregnancy- and delivery-related anxiety of the different groups was compared by using multiple comparisons of the means (with regard to research question 1). In a second step, crosstabs were employed to investigate whether individual pregnancyand delivery-related anxiety occurred at a higher than chance rate in the risk groups (Chi2test) (with regard to research question 2). In a further step, we tested whether there would be a correlation between pregnancy- and delivery-related anxiety and obstetrical complications,
irrespective of the risk group (with regard to research question 3) and in the risk groups (with regard to research question 4). For this purpose, two groups were formed, divided in high versus medium or low pregnancy- and delivery-related anxiety. 3. Results 3.1 Research Question 1 The factor risk group had a significant influence on the variable pregnancy-related anxiety (F = 3.860, df1 = 3, df2 = 454, p = .010). Pregnant women with a history of prior miscarriages had significantly higher pregnancy-related anxiety levels than pregnant women with other medical risk factors (mean difference = 0.583, p = .012) and women without a history of spontaneous abortion (mean difference = 0.636, p = .001). Delivery-related anxiety did not differ between the groups (F = 0.511, df1 = 3, df2 = 452, p = .675). 3.2 Research Question 2 The results of the comparison of correlations between risk group and complications, and pregnancy- and delivery-related anxiety are shown in table 1. Women with medical risk factors gave birth to low-birth-weight infants more often (< 2500 g) (observed = 4, expected = 1.5; standard residual = 2.0) and had more pregnancy-related diseases (observed = 50, expected = 41.8; standard residual = 1.3). They had more problems with hypertension and pre-eclampsia than pregnant women on average (observed = 17, expected = 8.4; standard residual = 3.0) and were more often diagnosed with fetal growth retardation (statistical trend, observed = 10, expected = 5.1; standard residual = 2.2). Women with previous spontaneous abortions had a threat of miscarriage significantly more often than women with other risk factors and significantly more often than women in the control group (observed = 19, expected = 8.8; standard residual = 3.5). Women with previous spontaneous abortions had premature rupture of membranes more often (observed = 4, expected = 2.2; standard residual = 1.2). This also applied to women with previous induced abortions (observed = 4, expected = 1.4; standard residual = 2.3).
3.3 Research Question 3 Table 2 presents the contingency between pregnancy-related anxiety and delivery-related anxiety (table 3) and obstetrical complications: According to our results, delivery-related anxiety was not correlated to obstetrical complications. A high level of pregnancy-related anxiety was associated with a higher incidence of imminent miscarriage and premature rupture of membranes prior to 37 weeks of gestation.
3.4 Research Question 4 The analysis of the relationships between pregnancy-related anxiety and obstetrical complications within the different risk groups showed a relation between a high levels of pregnancy-related anxiety and premature rupture of membranes prior to 37 weeks of gestation only in the group of women with a history of induced abortion (χ2 = 4.610, df = 1, p = .032). A significant correlation between high pregnancy-related anxiety levels and a threat of miscarriage was only found in the group of women without obstetric risk factors (χ2 = 7.342, df = 1, p = .007). Similarly, a positive relationship between pregnancy-related anxiety and premature delivery before 37 weeks of gestation only exists in the group of women without obstetric risk factors (χ 2 = 5.952, df = 1, p = .023) and not in the risk groups.
4. Discussion In our sample, women with a history of repeated miscarriage had a significantly higher level of pregnancy-related anxiety than women with other obstetric risk factors or women without. Also, when miscarriages were due to physical causes the pregnancy loss caused substantial trauma and insecurity. Almost all women who had experienced pregnancy loss were confronted with the following questions: Am I capable of being a proper mother? Why did I fail? How will miscarriage - these dashed hopes - affect future life as a woman? Will I ever have a healthy child? Emotions emerging with spontaneous abortion are anxiety and depression. The loss of an unborn child may not only lead to bereavement, but also to feelings of guilt. Aversive perinatal outcomes may imply clinical levels of depression (Lok & Neugebauer, 2007), pregnancy-related anxiety (Tsartsara & Johnson, 2006) and problems with bonding during subsequent pregnancy (Kinsey, Baptiste-Roberts, Zhu & Kjerulff, 2014), however the latter was only relevant during the first semester. In contrast to most studies, we used specific measures for pregnancy-related anxiety. Thus, the results are not necessarily comparable to other authors who rather refer to general anxiety. Buist et al. (2011) found the highest rate of general anxiety disorder (GAD) in the first trimester. The rate declined throughout pregnancy. Sieber et al. (2006) also found an amelioration of the adjustment to pregnancy throughout pregnancy, especially in the last trimenon. Other authors found peaks of the level of anxiety in the first and third trimesters (Lee et al., 2007). Moreover, during pregnancy the hormonal system responds to stress in a different way than in nonpregnant women. Salacz et al. (2012) presume that cortisol level is associated with pregnancy itself and serves the fetal development. Thus, it does not necessarily reflect the level of stress or anxiety. According to Rothenberger et al. (2011) only in the first trimester there is a weak interrelation between emotional and hormonal stress
measures. Pregnancy-related anxiety was only partially related to hormonal stress. One explanation might be the fetal programming hypothesis, that the fetus is protected against maternal stress. However, there is no consensus on this issue. Hoffman et al. (2016) found the strongest relation between hair cortisol and perceived stress in the second trimenon. The cortisol concentration also predicted preterm birth, but only during this time period. Erickson et al. (2001) found the strongest relation between cortisol level and preterm birth between 27 and 37 weeks of gestation. Interestingly, the strongest predictor for both cortisol level and preterm birth was a history of previous preterm birth. The predictor was stronger than other social and behavioral variables, such as risk-taking behavior or education level. A few studies have demonstrated increasing anxiety in pregnancies after recurrent miscarriage (Blackmore et al., 2011; Lynn et al., 2011). Effects on subsequent pregnancies have rarely been investigated; however, recent studies have shown that prenatal anxiety might be a risk factor for preterm birth or low birth weight (Ding et al., 2014). For the majority of women, a prior miscarriage is a deeply affecting adverse life event, and anxiety about having another miscarriage is present as long as 24 months after the event. Deckardt et al. (1994) found that more than half of these women fear another miscarriage. One week after a spontaneous abortion 41% of women showed symptoms of anxiety and 22% symptoms of depression. The rate of depression declined to 8% and 6% between six and twelve weeks after the miscarriage. Anxiety symptoms also declined to 18% after six weeks but increased to 32% after twelve weeks after the event of miscarriage. The authors assume that the increase in anxiety twelve weeks after the miscarriage could possibly relate to thoughts about getting pregnant again. The medical advice is not to get pregnant before three months after miscarriage. Another study has shown that as long as two years after a miscarriage, 68% of women still feel bothered by thoughts about the miscarriage. 64% reported that the miscarriage had an influence on decisions regarding future pregnancies (Cordle & Prettyman, 1994). A review of the literature about parental experience of pregnancy after perinatal loss shows anxiety and depression for expectant mothers and, to a lesser degree, fathers as common parental responses (DeBackere et al., 2008). Data concerning anxiety as a personality trait in women with a history of spontaneous abortion are controversial. Some authors report a predisposition to general anxiety in women with prior miscarriages, whereas others do not (Rizzardo et al., 1991). Lee and Rowlands (2015) suggest that certain groups of women with socio-economic disadvantage and chronic distress are more prone to both experience a miscarriage and have a worse psychological adjustment afterwards. The observation that women with prior spontaneous abortions did not show increased general anxiety in our sample enables us to assume that the higher level of pregnancy-related anxiety was a consequence rather than a cause of the previous pregnancy loss. On the other hand, women having high levels of one kind of anxiety may be
prone towards experiencing another kind of anxiety. Experiencing several subtypes of pregnancy-related anxiety might mimic trait anxiety, whereas experiencing just one kind (e.g. fear that the baby might be disabled) is more related to state anxiety (Huizink et al., 2014). According to Gold et al. (2014), in some groups of women, anxiety symptoms may persist after stillbirth or perinatal death of a newborn and even turn into clinically relevant disorders. In subclinical groups the symptoms of sadness and excessive worry may be limited to the time period of a subsequent pregnancy and be resolved once a living child is born (Chojenta et al., 2014) or may continue in case of another miscarriage or other adverse life events, such as alienation from the partner (Swanson et al., 2007). Teixera et al. (1999) report a significant relationship between state and trait anxiety in pregnant women and higher resistance of the uterine arteries, which they interpreted as an indication of increased psychophysical reactivity. In contrast, Sikkema et al. (2001) found that pregnant women who later developed eclampsia did not have higher levels of cortisol, higher levels of trait anxiety or higher pregnancy-related anxiety in comparison to women without obstetric complications. Spontaneous abortions tend to occur in the same week of gestation of a current pregnancy as it did in a previous (Kliegman et al., 1990). In the present study, women with prior spontaneous abortion had a higher risk of miscarriage or premature rupture of membranes in the subsequent pregnancy. The latter also applies to women with a history of pregnancy termination. Premature rupture of membranes is the result of several patho-biologic processes. Currently, urogenital tract infection is held to be a major cause leading to chorioamnionitis. Further risk factors are cervical incompetence, polyhydramnion, vaginal bleeding in more than one trimester, previous preterm delivery and smoking (> 10 cigarettes per day). Trauma of the cervix with subsequent cervical incompetence can also result from curettage. There also may be genetic causes (DizonTownson, 2001). There may also be physiological consequences of fear. Tupper and Weil (1962) assume that these women “expect” to have a greatly fear it, which may result in “negative induction circle”. In a recent study of women with idiopathic recurrent miscarriage, 167 / 222 (75%) had a successful pregnancy outcome with survival beyond the 24 weeks of gestation a subsequent pregnancy. These women had physical examinations before getting pregnant again to exclude pre-existing physical causes. During the following pregnancy, the women were treated in a specialized antenatal setting. The success rate did not differ between women with one or two previous miscarriages (Brigham et al., 1999). In the present study, high levels of pregnancy-related anxiety were associated with a higher rate of threat of miscarriage and premature rupture of membranes. No relationship was found between delivery-related anxiety and complications of pregnancy or delivery. Some authors report a relationship between anxiety and premature labor and anxiety and complicated delivery (Wadhwa et al., 1993). Other authors failed to find such associations (Perkin et al.,
1993). It is important to differentiate between trait and state anxiety (anxiety as a personality trait and anxiety related to a situation). Anxiety related to pregnancy and delivery seems important in association with complications of pregnancy (Bhagwanani et al., 1997). However, some authors maintain that no specific form of anxiety leads to perinatal complications, only cumulated psychosocial stress encompassing further variables, such as excessive levels of state anxiety, history of mental health problems, history of abuse, and negative feelings regarding the timing of pregnancy (McDonald et al., 2014). Social support can have a mitigating effect on anxiety (Ghosh at al., 2010). Norbeck and Anderson (1989) suggest that a high level of distress and little support from the pregnant woman’s partner were associated with the highest levels of anxiety. According to Martini et al. (2015) interpersonal factors, such as the lack of partnership satisfaction and social support may even contribute to clinical levels of anxiety and depression in pregnant women. Hutti (2005) describes the need of social and professional support of families after perinatal loss. She points out that nurses may provide professional support through teaching, role modeling, encouragement, counseling and helping with problem solving. Nurses also may encourage effective social support by helping significant others to proactively support the bereaved woman or couple (Hutti 2005). Pregnancy after pregnancy loss is often defined as “high-risk” and therefore becomes an additionally decidedly medicalized experience for women. Frequently technological interventions are used to achieve a viable infant. Women experiencing fears related to “highrisk” pregnancy after perinatal loss are in need of support of nurses, midwives and all healthcare providers and especially of their assistance in coping with their fears (Simmons & Goldberg, 2011). In the present study, there was a statistically significant contingency between extreme pregnancy-related anxiety and an increased rate of threat of miscarriage. However, this applied only to the group of women without a history of risk factors. No such relation was found for the group of women with risk factors. On the one hand, non-significant relevant differences were evident in pregnant women with and without previous pregnancy failure with regard to pregnancy-related fear, on the other hand, premature labor and delivery before 37 weeks of gestation and low birth weight. Pregnant women with a history of previous pregnancy loss had a higher level of pregnancyrelated fear and a lower rate of premature labor and delivery before 37th GW. They also delivered fewer infants with a birth weight of less than 2500 g, whereas in women without pregnancy loss this correlation was reversed. Women with previous pregnancy loss received significantly more social support, were more satisfied with their partner relationship and more often used medical services during their pregnancy (Rauchfuß & Trautmann, 1998). DaCosta reports a relationship between less satisfactory social support and low birth weight (DaCosta
et al., 1999). The results of the present study show that “high-risk pregnant women” with anxiety find more people to talk to and more social support, whereas “low-risk pregnant women” seem to be left more alone with their anxiety and consequently develop more physical reactions and pregnancy complications. Our clinical experience in counseling and treating pregnant women with a history of recurrent miscarriage encompasses more than ten years on the basis of a bio-psycho-social approach. The women treated were at risk - physically as well as psychosocially. Additionally to routine prenatal care, a group of eight to twelve women led by a professional group leader (a doctor, a nurse, or a midwife) came together every two weeks during the entire pregnancy. In addition to exchanging information and experiences, the group focused on dealing with feelings and integrating them their integration into problem solving. The group sessions help the expectant mothers to adapt to their new challenges. Consequently, the participants gain competence for pregnancy and delivery. Because group sessions are of great use for the prevention of pregnancy complications they should also be offered to “low-risk pregnant women” with high levels of pregnancy related fear who are less capable of providing themselves with social support. 5. Acknowledgements This project was supported by the German Federal Ministry of Education and Research. We would like to thank all pregnant women who participated in this study and the colleagues at Charité – University Medicine who helped to perform it. References 1. Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Neonatal outcome following maternal antenatal depression and anxiety: a population-based study. Am J Epidemiol 2004;159:872–81. 2. Bergner A, Beyer R, Klapp BF, Rauchfuss M. Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping. Journal of Psychosomatic Obstetrics and Gynaecology 2008;29:105-13. 3. Bhagwanani SG, Seagraves K, Dierker LJ, Lax M. Relationship between prenatal anxiety and perinatal outcome in nulliparous women: a prospective study. Journal of the National Medical Association 1997;89:93-8. 4. Biaggi A, Conroy S, Pawlby S, Pariante C. Identifying the women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders 2016; 191: 62–77.
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58. Simmons HA, Goldberg LS. 'High-risk' pregnancy after perinatal loss: understanding the label. Midwifery 2011;27(4):452-7. 59. Statham H, Green JM. The effects of miscarriage and other unsuccessful pregnancies on feelings early in subsequent pregnancy. Journal of Reproductive and Infant Psychology 1994;12:45-54. 60. Swanson KM, Connor S, Jolley SN, Pettinato M, Wang TJ. Contexts and Evolution of women’s responses to miscarriage during the first year after loss. Research in Nursing and Health 2007;30:2-16. 61. Teixeira JM, Fisk NM, Glover V. Association between maternal anxiety in pregnancy and increased uterine artery resistance index: cohort based study. British Medical Journal 1999;318:153-7. 62. Theut SK, Pedersen FA, Zaslow MJ, Rabinovich BA. Pregnancy subsequent to perinatal loss: parental anxiety and depression. Journal of the American Academy of Child Adolescent Psychiatry 1988;27:289-92. 63. Thom DH, Nelson LM, Vaughan TL. Spontaneous abortion and subsequent adverse birth outcomes. American Journal of Obstetrics and Gynecology 1992;166:111-6. 64. Tsartsara E, Johnson MP. The impact of miscarriage on women's pregnancy-specific anxiety and feelings of prenatal maternal–fetal attachment during the course of a subsequent pregnancy: An exploratory follow-up study. Journal of Psychosomatic Obstetrics & Gynecology 2006;27(3):173-82. 65. Tunaley JR, Slade P, Duncan SB. Cognitive processes in psychological adaptation to miscarriage: a preliminary report. Psychology & Health 1993;8:369-81. 66. Tupper C, Weil RJ. The problem of spontaneous abortion IX. The treatment of habitual aborters for psychotherapy. American Journal of Obstetrics and Gynecology 1962;83: 421-4. 67. Wadhwa PD, Sandman CA, Porto M, Dunkel Schetter C, Garite TJ. The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation. American Journal of Obstetrics and Gynecology 1993;169:858-65. 68. Woods-Giscombé CL, Lobel M, Crandell J. The impact of miscarriage and parity on patterns of maternal distress in pregnancy. Research in Nursing & Health 2010;33(4):31628. Table 1: Being in a risk group and its influence on the course of pregnancy and perinatal outcome Variable
χ2
df
p (two-sided)
Pregnancy-related complaints
8.029
3
.045
hypertension in pregnancy, pre-eclampsia
13.454
3
.004
diagnosis “fetal growth retardation”
7.776
3
.051
threat of miscarriage
19.662
3
.000
cervical insufficiency
3.893
3
.273
preterm labor
5.575
3
.134
premature rupture of membranes
8.489
3
.037
preterm delivery WHO (< 37 GW and/or < 2500g)
2.760
3
.430
birth weight (< 1500g; 1500-2500g; 2500g)
11.460
6
.075
birth weight ( 2500g; < 2500 g )
8.189
3
.042
preterm delivery < 37 GW
0.683
3
.877
SGA; birth weight < vs. 10 percentile
7.096
3
.069
mode of delivery (with vs. without complications)
0.557
3
.906
umbilical cord arterial blood - pH ( 7.20; < 7.20)
2.343
3
.504
APGAR-score ( 8, < 8)
0.496
3
.920
th
Table 2: Contingency between pregnancy-related anxieties and obstetrical complications Variable
χ2
Pregnancy-related complaints
0.688 1
.407
hypertension in pregnancy /pre-eclampsia
2.480 1
.115
diagnosis “fetal growth retardation”
0.099 1
.753
threat of miscarriage
3.978 1
.046
cervical insufficiency
0.132 1
.717
preterm labor
0.449 1
.503
premature rupture of membranes prior 37 GW
4.138 1
.042
preterm delivery (WHO: < 37 GW and/or <2500g)
2.264 1
.132
birth weight (< 1500g ; 1500-2500g; 2500g)
3.874 2
.144
birth weight ( 2500g; < 2500g)
1.800 1
.180
preterm delivery < 37 GW
1.324 1
.299
SGA, birth weight < vs. 10 percentile
3.476 1
.062
mode of delivery (with vs. without complications)
0.201 1
.654
umbilical cord arterial blood - pH (> 7.20; < 7.20)
0.007 1
.935
APGAR-Score ( 8 points, <8 points)
1.195 1
.274
th
df
p (two-sided)
df … degrees of freedom, WHO … World Health Organization, GW … gestational weeks, SGA … small for gestational age, vs … versus, pH … pH value, APGAR … Appearance, Pulse, Grimace, Activity and Respiration
Table 3: Contingency between delivery-related anxieties and obstetrical complications Variable
χ2
df
p (two-sided)
Pregnancy-related complaints
2.641
1
.104
hypertension in pregnancy /pre-eclampsia
2.597
1
.107
diagnosis “fetal growth retardation”
2.319
1
.128
threat of miscarriage
1.315
1
.251
cervical insufficiency
0.001
1
.980
preterm labor
2.859
1
.091
premature rupture of membranes prior 37 GW
0.065
1
.799
preterm delivery (WHO: < 37 GW and/or < 2500g) 0.582
1
.446
birth weight (< 1500g ;1500-2500g; 2500g)
1.102
2
.576
birth weight ( 2500g ; < 2500g)
0.168
1
.682
delivery prior to 37 GW
0.201
1
.644
birth weight < vs. 10 percentile
2.096
1
.148
mode of delivery (with vs. without complications)
2.828
1
.093
umbilical cord arterial blood - pH (> 7.20; < 7.20)
1.791
1
.181
APGAR-Score ( 8 points, < 8 points)
0.507
1
.477
th
df … degrees of freedom, WHO … World Health Organisation, SGA … small for gestational age, vs … versus, pH … pH value, APGAR … Appearance, Pulse, Grimace, Activity and Respiration
Rauchfuss,
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To appear in: Mental Health & Prevention Received date: 11 April 2016 Accepted date: 3 March 2017 Cite this article as: Karolina Stojanow, Martina Rauchfuss, Annekathrin Bergner and Barbara Maier, Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome, Mental Health & Prevention, http://dx.doi.org/10.1016/j.mhp.2017.03.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Anxiety in high- and low-risk pregnancies and its influence on perinatal outcome Karolina Stojanow1*, Martina Rauchfuss1, Annekathrin Bergner1, Barbara Maier2 1
Charité - University Medicine Berlin, Centre of Internal Medicine & Dermatology, Clinic for
Internal Medicine & Psychosomatics 2
Department of Obstetrics and Gynaecology, Hanusch General Hospital, Vienna, Austria
*Correspondence to:Lenbachstrasse 14, D-10245 Berlin, Germany. Tel.: +49-(0)30-
60958171. [email protected] Abstract Objective This study investigates pregnancy- and birth-giving-related fears of women of different risk groups and examines their influence on pregnancy and delivery. Study design: Prospective study. Setting: Pregnant out-patients were recruited in medical practices in Berlin. Data on perinatal outcome were obtained from the charts of the obstetric units. Participants: 589 pregnant women between 16 and 22 weeks of gestation. Methods: Pregnant women were interviewed by a semi-standardized questionnaire and related to information from the charts about perinatal outcome of the obstetric units. Results: 77 women were at risk of anxiety influencing pregnancy and perinatal outcome due to chronic diseases, 61 had a history of previous miscarriage, 38 had a history of termination of pregnancy. 288 had no risk factors. Women with previous miscarriage had the highest degree of pregnancy-related fears. Their pregnancies were significantly more often complicated by the threat of miscarriage. A relationship between high levels of pregnancyrelated fears and pregnancy complications was only found in the group of “low- risk women”. Conclusion: Women with a history of miscarriage evidently make use of special care services and social support services. For these women no correlation between pregnancy-related fears and complications was found. Low-risk pregnant women seem to have fewer means of coping with their unreasonable fear. 1. Introduction Women undergo substantial physical and psychological changes during pregnancy, affecting also partner relationship and social environment. Fears of complications during pregnancy and delivery as well as uncertainty concerning their roles as mothers are common among
pregnant women. Additionally, obstetrical and medical risk factors can be highly stressful during this maturation crisis. Thus, we assume that pregnant women with risk factors are at greater risk of anxiety and of more severe psychological and physical disorders. Howard et al. (2014) found a prevalence of 13% of any anxiety disorder during pregnancy, which is higher than the prevalence of antenatal depression (3,1%-4,9%). Both disorders are highly comorbid which also applies to the general population. There is increasing evidence that stress-related emotions such as anxiety may also be related to the risk of adverse perinatal outcomes, including low birth weight or preterm delivery (Catov et al., 2009; Ding et al., 2014; Dunkel Schetter & Tanner, 2012; Glynn et al., 2008; Orr et al., 2007, Rauchfuss et al., 2011). Several studies investigated the course and outcome of pregnancies after previous miscarriage. In particular, the prognosis is dependent on the number of previous spontaneous abortions (Clifford et al., 1997). Women with a history of three or more consecutive miscarriages had a significantly higher risk for obstetrical complications. In contrast, women with a single previous miscarriage did not show an increase of risk for complications of subsequent pregnancies (Thom et al., 1992). Other studies also found a correlation between a history of spontaneous abortions and the risk for prematurity and low birth weight infants (Buchmayer et al., 2004; Field & Murphy, 2015; Jivraj et al., 2001). Only a few studies did not (Dempsey et al., 2014; Jivraj et al., 2001). King et al. (2010) assessed the emotional state of women with pre-existing medical disorders during pregnancy, such as diabetes mellitus type 2 as well as with pregnancy-induced disorders, such as pre-eclampsia or hyperemesis gravidarum. Women with a pre-existing medical disorder showed a significantly higher (Spielberger 1970) state and trait anxiety compared to healthy women. While numerous studies took a statistical as well as epidemiological approach towards the courses and outcomes of pregnancies after a history of spontaneous abortion, only few investigators addressed emotional issues. Some authors investigated psychological risk factors for antenatal anxiety disorders. Unfortunately, they often do not differenciate between depression and anxiety due to the high rate of comorbidity or to different degrees of severity. Moreover, they often apply common anxiety scales that are not adjusted to pregnant women. As to the different course of anxiety and depression in pregnancy, Heron et al. (2004) found that anxiety and depression persisted for about 8 weeks postpartum. Both disorders decreased over time. However, there was one difference. Anxiety during pregnancy predicted anxiety and depression postpartum, but antenatal depression only predicted postpartum depression. Biaggi et al. (2016) identified several psychological risk factors for antenatal depression and anxiety: previous history of mental illness or history of treatment during previous pregnancy, childhood abuse, family history of mental illness, lack of social support, domestic violence, socio-demographic variables such as young age or old age, low education, poor working conditions, low income,
ethnicity (belonging to a minority ethnic group), adverse life experiences, traumatic events and personality factors, such as low self-esteem and low self-efficacy, high levels of neuroticicm and psychoticism, maternal attitudes towards motherhood. Meijer et al. (2014) found that pregnancy-related events were especially associated with greater degree of anxiety whereas non-pregnancy related events were associated with symptoms of depression. In their study adverse events were testing for congenital anomalies, test results indicating that the baby might have abnormalities, being told that it is a twin pregnancy, finding out that the partner might not want the baby, bleeding and being afraid of miscarrying, trying to get an abortion, finding out that something that happened might harm the baby. The aforementioned results are based on a heterogeneous population of pregnant women. Evidence of pronounced anxiety during pregnancy has been reported particularly in women with a history of pregnancy loss (Blackmore et al., 2011; McCarthy et al., 2015; Statham & Green, 1994; Theut et al., 1988). Some authors suggest that pronounced anxiety, presumably mediated by neuroendocrine and psycho-immunological mechanisms may lead to pregnancy complications, even to pregnancy loss (Coussons-Read et al., 2012). Despite clinical experiences of higher risk for anxiety and depression in a pregnancy following recurrent miscarriages, only few investigations dealt with them so far. Anxiety, for example, emerges as physical symptoms, subjective stress or lack of self-confidence. Authors hypothesize that women’s anxiety relates especially to the course of their current pregnancy. Specifically, pregnancy-related anxiety can be defined as “fears about the health and well-being of one’s baby, the impending childbirth, of hospital and health-care experiences, birth and postpartum, and of parenting or the maternal role” (Dunkel Schetter, 2011, p. 534). Prettyman et al. (1993) focused on anxiety three months after a spontaneous abortion in terms of future pregnancies. Other authors have shown that anxiety may be correlated with the anticipation of future events (Tunaley et al., 1993). In women with recurrent pregnancy loss, a higher degree of pregnancy-related anxiety was found, but not a higher degree of general anxiety (Theut et al., 1988). On the contrary, Woods-Giscombé et al. (2010) did not find any significant differences in pregnancy-related anxiety comparing pregnant women with and without a history of miscarriage. They found differences in state anxiety, but only in the second and third trimester. Overall, the anxiety levels decreased through the course of pregnancy. However, the authors see a limitation of their study in the assessment and definition of pregnancy-related distress. It rather captures the burden associated with pregnancy, such as changes of the body and low energy, which may apply both to women with and without a miscarriage, but it does not capture concerns and worries about the health status of oneself or the babies`. Another study suggests that miscarriages may lead to higher levels of pregnancy-related fear and of state anxiety and concludes that pregnancy-related fear may have a negative impact on the course of pregnancy and delivery
(Fertl et al., 2009). However, more anxious or, to put it positively, more careful behavior during pregnancy can also be protective. In a prospective study, state anxiety did not seem to be correlated to pregnancy complications, including preterm labor (Andersson at al., 2004; Norbeck & Anderson, 1989). In a group of 88 primigravidae, low trait anxiety was correlated with a higher incidence of chorioamnionitis and premature delivery as well as lower birth weight. The pregnant women participating in this study completed a questionnaire on anxiety at intervals of six weeks during pregnancy. Women were recruited for the study between 8 to 28 weeks of gestation (GW). The lowest degree of anxiety was measured between 22 and 26 gestational weeks (Bhagwanani et al., 1997). In contrast, other authors reported preterm labor and premature deliveries more often in women with increased trait anxiety (Hosseini et al., 2009; Loomans et al., 2012). Shapiro et al. (2013) found that trait anxiety was a protective factor but combined with chronic or acute stressors or traumatic events it raised the risk of preterm birth. Using a scale for pregnancy-related anxiety containing five items, Wadhwa et al. (1993) discovered that a high level of pregnancy-related anxiety was associated with a higher rate of preterm deliveries. The items focused on the course of pregnancy and delivery and included questions about the respondent’s relationship to her physician. For a more accurate evaluation of the relationship between psychological burden during pregnancy on the one hand and obstetrical history and complications during pregnancy and delivery on the other, it is necessary to distinguish between different risk groups. That is the aim of the present study.
Research questions 1. Do pregnant women with a history of pregnancy loss or other risk factors show a higher level of pregnancy- and delivery-related fears than pregnant women without? 2. Is there a relationship between pregnancy-related risk factors and complications of pregnancy and delivery? 3. Is there a relationship between pregnancy- and birth-giving-related fears and complications during pregnancy? 4. Is the relationship between anxiety and pregnancy complications dependent adverse obstetric history (risk group)? 2. Material and Methods 2.1 Study Design, Sample and Procedure Data were obtained from 589 pregnant women between the 16th and 22nd GW within the framework of a prospective study. A semi-standardized questionnaire was employed and
administered to women in medical practices in Berlin. The questionnaire contains items related to pregnancy- and birth-giving-related fears, physical and psychological complaints, obstetric history and sociodemographic data which were rated on a multistep rating scale. Data of obstetrical and neonatal outcomes were obtained from the charts of the obstetric units where 519 women gave birth. From this data pool, a sample of 464 women either with a medical risk factor (cardiac arrhythmia, hypertension, asthma, diabetes, chronic renal disease, n = 77) or with previous pregnancy loss (miscarriages: n = 61, termination of pregnancy: n = 38) was extracted. These risk groups were compared with a group of 288 women without any risk factor. Pregnancy- and birth-related fears were rated on six-point scales. In the following factor analysis, three items out of five with respect to pregnancy-related fears (Cr = 0.7512) were extracted. The mean of the three items was 3.7 1.3. 86 (16.6%) of the pregnant women were regarded as highly anxious (mean > 5); 433 (83.4%) were regarded as having normal to low pregnancy-related fears (mean 5). High pregnancyrelated fear is characterized by the concern that the unborn child could be harmed by a fall or an accident, by bleeding or the wrong life-style. Expectedly, birth-related fear was less prevalent than pregnancy-related fear at the time when the questionnaire was completed (four months prior to delivery). After factor analysis, four of the original five items were extracted with a mean of 2.9 1.1. 88 pregnant women (16.9%) were assigned to the highly anxious group (mean 3.95), and 426 (83.1%) were allocated to the normal to mildly anxious group (mean < 3.95) with regard to birth-related fear (Cr = 0.7415). Higher values denote greater fear of physical pain and complications during delivery or the fear of being left alone during giving birth. Information concerning pregnancy- and birth-related complications of women of the study population was obtained from patient reports of the obstetric units where they had given birth.
2.2 Statistics At first, the different risk groups and the control group were analyzed using an age-matched univariate analysis of variance (one-factor analysis of co-variance with the factor age as covariable). Subsequently, the pregnancy- and delivery-related anxiety of the different groups was compared by using multiple comparisons of the means (with regard to research question 1). In a second step, crosstabs were employed to investigate whether individual pregnancyand delivery-related anxiety occurred at a higher than chance rate in the risk groups (Chi2test) (with regard to research question 2). In a further step, we tested whether there would be a correlation between pregnancy- and delivery-related anxiety and obstetrical complications,
irrespective of the risk group (with regard to research question 3) and in the risk groups (with regard to research question 4). For this purpose, two groups were formed, divided in high versus medium or low pregnancy- and delivery-related anxiety. 3. Results 3.1 Research Question 1 The factor risk group had a significant influence on the variable pregnancy-related anxiety (F = 3.860, df1 = 3, df2 = 454, p = .010). Pregnant women with a history of prior miscarriages had significantly higher pregnancy-related anxiety levels than pregnant women with other medical risk factors (mean difference = 0.583, p = .012) and women without a history of spontaneous abortion (mean difference = 0.636, p = .001). Delivery-related anxiety did not differ between the groups (F = 0.511, df1 = 3, df2 = 452, p = .675). 3.2 Research Question 2 The results of the comparison of correlations between risk group and complications, and pregnancy- and delivery-related anxiety are shown in table 1. Women with medical risk factors gave birth to low-birth-weight infants more often (< 2500 g) (observed = 4, expected = 1.5; standard residual = 2.0) and had more pregnancy-related diseases (observed = 50, expected = 41.8; standard residual = 1.3). They had more problems with hypertension and pre-eclampsia than pregnant women on average (observed = 17, expected = 8.4; standard residual = 3.0) and were more often diagnosed with fetal growth retardation (statistical trend, observed = 10, expected = 5.1; standard residual = 2.2). Women with previous spontaneous abortions had a threat of miscarriage significantly more often than women with other risk factors and significantly more often than women in the control group (observed = 19, expected = 8.8; standard residual = 3.5). Women with previous spontaneous abortions had premature rupture of membranes more often (observed = 4, expected = 2.2; standard residual = 1.2). This also applied to women with previous induced abortions (observed = 4, expected = 1.4; standard residual = 2.3).
3.3 Research Question 3 Table 2 presents the contingency between pregnancy-related anxiety and delivery-related anxiety (table 3) and obstetrical complications: According to our results, delivery-related anxiety was not correlated to obstetrical complications. A high level of pregnancy-related anxiety was associated with a higher incidence of imminent miscarriage and premature rupture of membranes prior to 37 weeks of gestation.
3.4 Research Question 4 The analysis of the relationships between pregnancy-related anxiety and obstetrical complications within the different risk groups showed a relation between a high levels of pregnancy-related anxiety and premature rupture of membranes prior to 37 weeks of gestation only in the group of women with a history of induced abortion (χ2 = 4.610, df = 1, p = .032). A significant correlation between high pregnancy-related anxiety levels and a threat of miscarriage was only found in the group of women without obstetric risk factors (χ2 = 7.342, df = 1, p = .007). Similarly, a positive relationship between pregnancy-related anxiety and premature delivery before 37 weeks of gestation only exists in the group of women without obstetric risk factors (χ 2 = 5.952, df = 1, p = .023) and not in the risk groups.
4. Discussion In our sample, women with a history of repeated miscarriage had a significantly higher level of pregnancy-related anxiety than women with other obstetric risk factors or women without. Also, when miscarriages were due to physical causes the pregnancy loss caused substantial trauma and insecurity. Almost all women who had experienced pregnancy loss were confronted with the following questions: Am I capable of being a proper mother? Why did I fail? How will miscarriage - these dashed hopes - affect future life as a woman? Will I ever have a healthy child? Emotions emerging with spontaneous abortion are anxiety and depression. The loss of an unborn child may not only lead to bereavement, but also to feelings of guilt. Aversive perinatal outcomes may imply clinical levels of depression (Lok & Neugebauer, 2007), pregnancy-related anxiety (Tsartsara & Johnson, 2006) and problems with bonding during subsequent pregnancy (Kinsey, Baptiste-Roberts, Zhu & Kjerulff, 2014), however the latter was only relevant during the first semester. In contrast to most studies, we used specific measures for pregnancy-related anxiety. Thus, the results are not necessarily comparable to other authors who rather refer to general anxiety. Buist et al. (2011) found the highest rate of general anxiety disorder (GAD) in the first trimester. The rate declined throughout pregnancy. Sieber et al. (2006) also found an amelioration of the adjustment to pregnancy throughout pregnancy, especially in the last trimenon. Other authors found peaks of the level of anxiety in the first and third trimesters (Lee et al., 2007). Moreover, during pregnancy the hormonal system responds to stress in a different way than in nonpregnant women. Salacz et al. (2012) presume that cortisol level is associated with pregnancy itself and serves the fetal development. Thus, it does not necessarily reflect the level of stress or anxiety. According to Rothenberger et al. (2011) only in the first trimester there is a weak interrelation between emotional and hormonal stress
measures. Pregnancy-related anxiety was only partially related to hormonal stress. One explanation might be the fetal programming hypothesis, that the fetus is protected against maternal stress. However, there is no consensus on this issue. Hoffman et al. (2016) found the strongest relation between hair cortisol and perceived stress in the second trimenon. The cortisol concentration also predicted preterm birth, but only during this time period. Erickson et al. (2001) found the strongest relation between cortisol level and preterm birth between 27 and 37 weeks of gestation. Interestingly, the strongest predictor for both cortisol level and preterm birth was a history of previous preterm birth. The predictor was stronger than other social and behavioral variables, such as risk-taking behavior or education level. A few studies have demonstrated increasing anxiety in pregnancies after recurrent miscarriage (Blackmore et al., 2011; Lynn et al., 2011). Effects on subsequent pregnancies have rarely been investigated; however, recent studies have shown that prenatal anxiety might be a risk factor for preterm birth or low birth weight (Ding et al., 2014). For the majority of women, a prior miscarriage is a deeply affecting adverse life event, and anxiety about having another miscarriage is present as long as 24 months after the event. Deckardt et al. (1994) found that more than half of these women fear another miscarriage. One week after a spontaneous abortion 41% of women showed symptoms of anxiety and 22% symptoms of depression. The rate of depression declined to 8% and 6% between six and twelve weeks after the miscarriage. Anxiety symptoms also declined to 18% after six weeks but increased to 32% after twelve weeks after the event of miscarriage. The authors assume that the increase in anxiety twelve weeks after the miscarriage could possibly relate to thoughts about getting pregnant again. The medical advice is not to get pregnant before three months after miscarriage. Another study has shown that as long as two years after a miscarriage, 68% of women still feel bothered by thoughts about the miscarriage. 64% reported that the miscarriage had an influence on decisions regarding future pregnancies (Cordle & Prettyman, 1994). A review of the literature about parental experience of pregnancy after perinatal loss shows anxiety and depression for expectant mothers and, to a lesser degree, fathers as common parental responses (DeBackere et al., 2008). Data concerning anxiety as a personality trait in women with a history of spontaneous abortion are controversial. Some authors report a predisposition to general anxiety in women with prior miscarriages, whereas others do not (Rizzardo et al., 1991). Lee and Rowlands (2015) suggest that certain groups of women with socio-economic disadvantage and chronic distress are more prone to both experience a miscarriage and have a worse psychological adjustment afterwards. The observation that women with prior spontaneous abortions did not show increased general anxiety in our sample enables us to assume that the higher level of pregnancy-related anxiety was a consequence rather than a cause of the previous pregnancy loss. On the other hand, women having high levels of one kind of anxiety may be
prone towards experiencing another kind of anxiety. Experiencing several subtypes of pregnancy-related anxiety might mimic trait anxiety, whereas experiencing just one kind (e.g. fear that the baby might be disabled) is more related to state anxiety (Huizink et al., 2014). According to Gold et al. (2014), in some groups of women, anxiety symptoms may persist after stillbirth or perinatal death of a newborn and even turn into clinically relevant disorders. In subclinical groups the symptoms of sadness and excessive worry may be limited to the time period of a subsequent pregnancy and be resolved once a living child is born (Chojenta et al., 2014) or may continue in case of another miscarriage or other adverse life events, such as alienation from the partner (Swanson et al., 2007). Teixera et al. (1999) report a significant relationship between state and trait anxiety in pregnant women and higher resistance of the uterine arteries, which they interpreted as an indication of increased psychophysical reactivity. In contrast, Sikkema et al. (2001) found that pregnant women who later developed eclampsia did not have higher levels of cortisol, higher levels of trait anxiety or higher pregnancy-related anxiety in comparison to women without obstetric complications. Spontaneous abortions tend to occur in the same week of gestation of a current pregnancy as it did in a previous (Kliegman et al., 1990). In the present study, women with prior spontaneous abortion had a higher risk of miscarriage or premature rupture of membranes in the subsequent pregnancy. The latter also applies to women with a history of pregnancy termination. Premature rupture of membranes is the result of several patho-biologic processes. Currently, urogenital tract infection is held to be a major cause leading to chorioamnionitis. Further risk factors are cervical incompetence, polyhydramnion, vaginal bleeding in more than one trimester, previous preterm delivery and smoking (> 10 cigarettes per day). Trauma of the cervix with subsequent cervical incompetence can also result from curettage. There also may be genetic causes (DizonTownson, 2001). There may also be physiological consequences of fear. Tupper and Weil (1962) assume that these women “expect” to have a greatly fear it, which may result in “negative induction circle”. In a recent study of women with idiopathic recurrent miscarriage, 167 / 222 (75%) had a successful pregnancy outcome with survival beyond the 24 weeks of gestation a subsequent pregnancy. These women had physical examinations before getting pregnant again to exclude pre-existing physical causes. During the following pregnancy, the women were treated in a specialized antenatal setting. The success rate did not differ between women with one or two previous miscarriages (Brigham et al., 1999). In the present study, high levels of pregnancy-related anxiety were associated with a higher rate of threat of miscarriage and premature rupture of membranes. No relationship was found between delivery-related anxiety and complications of pregnancy or delivery. Some authors report a relationship between anxiety and premature labor and anxiety and complicated delivery (Wadhwa et al., 1993). Other authors failed to find such associations (Perkin et al.,
1993). It is important to differentiate between trait and state anxiety (anxiety as a personality trait and anxiety related to a situation). Anxiety related to pregnancy and delivery seems important in association with complications of pregnancy (Bhagwanani et al., 1997). However, some authors maintain that no specific form of anxiety leads to perinatal complications, only cumulated psychosocial stress encompassing further variables, such as excessive levels of state anxiety, history of mental health problems, history of abuse, and negative feelings regarding the timing of pregnancy (McDonald et al., 2014). Social support can have a mitigating effect on anxiety (Ghosh at al., 2010). Norbeck and Anderson (1989) suggest that a high level of distress and little support from the pregnant woman’s partner were associated with the highest levels of anxiety. According to Martini et al. (2015) interpersonal factors, such as the lack of partnership satisfaction and social support may even contribute to clinical levels of anxiety and depression in pregnant women. Hutti (2005) describes the need of social and professional support of families after perinatal loss. She points out that nurses may provide professional support through teaching, role modeling, encouragement, counseling and helping with problem solving. Nurses also may encourage effective social support by helping significant others to proactively support the bereaved woman or couple (Hutti 2005). Pregnancy after pregnancy loss is often defined as “high-risk” and therefore becomes an additionally decidedly medicalized experience for women. Frequently technological interventions are used to achieve a viable infant. Women experiencing fears related to “highrisk” pregnancy after perinatal loss are in need of support of nurses, midwives and all healthcare providers and especially of their assistance in coping with their fears (Simmons & Goldberg, 2011). In the present study, there was a statistically significant contingency between extreme pregnancy-related anxiety and an increased rate of threat of miscarriage. However, this applied only to the group of women without a history of risk factors. No such relation was found for the group of women with risk factors. On the one hand, non-significant relevant differences were evident in pregnant women with and without previous pregnancy failure with regard to pregnancy-related fear, on the other hand, premature labor and delivery before 37 weeks of gestation and low birth weight. Pregnant women with a history of previous pregnancy loss had a higher level of pregnancyrelated fear and a lower rate of premature labor and delivery before 37th GW. They also delivered fewer infants with a birth weight of less than 2500 g, whereas in women without pregnancy loss this correlation was reversed. Women with previous pregnancy loss received significantly more social support, were more satisfied with their partner relationship and more often used medical services during their pregnancy (Rauchfuß & Trautmann, 1998). DaCosta reports a relationship between less satisfactory social support and low birth weight (DaCosta
et al., 1999). The results of the present study show that “high-risk pregnant women” with anxiety find more people to talk to and more social support, whereas “low-risk pregnant women” seem to be left more alone with their anxiety and consequently develop more physical reactions and pregnancy complications. Our clinical experience in counseling and treating pregnant women with a history of recurrent miscarriage encompasses more than ten years on the basis of a bio-psycho-social approach. The women treated were at risk - physically as well as psychosocially. Additionally to routine prenatal care, a group of eight to twelve women led by a professional group leader (a doctor, a nurse, or a midwife) came together every two weeks during the entire pregnancy. In addition to exchanging information and experiences, the group focused on dealing with feelings and integrating them their integration into problem solving. The group sessions help the expectant mothers to adapt to their new challenges. Consequently, the participants gain competence for pregnancy and delivery. Because group sessions are of great use for the prevention of pregnancy complications they should also be offered to “low-risk pregnant women” with high levels of pregnancy related fear who are less capable of providing themselves with social support. 5. Acknowledgements This project was supported by the German Federal Ministry of Education and Research. We would like to thank all pregnant women who participated in this study and the colleagues at Charité – University Medicine who helped to perform it. References 1. Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Neonatal outcome following maternal antenatal depression and anxiety: a population-based study. Am J Epidemiol 2004;159:872–81. 2. Bergner A, Beyer R, Klapp BF, Rauchfuss M. Pregnancy after early pregnancy loss: a prospective study of anxiety, depressive symptomatology and coping. Journal of Psychosomatic Obstetrics and Gynaecology 2008;29:105-13. 3. Bhagwanani SG, Seagraves K, Dierker LJ, Lax M. Relationship between prenatal anxiety and perinatal outcome in nulliparous women: a prospective study. Journal of the National Medical Association 1997;89:93-8. 4. Biaggi A, Conroy S, Pawlby S, Pariante C. Identifying the women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders 2016; 191: 62–77.
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χ2
df
p (two-sided)
Pregnancy-related complaints
8.029
3
.045
hypertension in pregnancy, pre-eclampsia
13.454
3
.004
diagnosis “fetal growth retardation”
7.776
3
.051
threat of miscarriage
19.662
3
.000
cervical insufficiency
3.893
3
.273
preterm labor
5.575
3
.134
premature rupture of membranes
8.489
3
.037
preterm delivery WHO (< 37 GW and/or < 2500g)
2.760
3
.430
birth weight (< 1500g; 1500-2500g; 2500g)
11.460
6
.075
birth weight ( 2500g; < 2500 g )
8.189
3
.042
preterm delivery < 37 GW
0.683
3
.877
SGA; birth weight < vs. 10 percentile
7.096
3
.069
mode of delivery (with vs. without complications)
0.557
3
.906
umbilical cord arterial blood - pH ( 7.20; < 7.20)
2.343
3
.504
APGAR-score ( 8, < 8)
0.496
3
.920
th
Table 2: Contingency between pregnancy-related anxieties and obstetrical complications Variable
χ2
Pregnancy-related complaints
0.688 1
.407
hypertension in pregnancy /pre-eclampsia
2.480 1
.115
diagnosis “fetal growth retardation”
0.099 1
.753
threat of miscarriage
3.978 1
.046
cervical insufficiency
0.132 1
.717
preterm labor
0.449 1
.503
premature rupture of membranes prior 37 GW
4.138 1
.042
preterm delivery (WHO: < 37 GW and/or <2500g)
2.264 1
.132
birth weight (< 1500g ; 1500-2500g; 2500g)
3.874 2
.144
birth weight ( 2500g; < 2500g)
1.800 1
.180
preterm delivery < 37 GW
1.324 1
.299
SGA, birth weight < vs. 10 percentile
3.476 1
.062
mode of delivery (with vs. without complications)
0.201 1
.654
umbilical cord arterial blood - pH (> 7.20; < 7.20)
0.007 1
.935
APGAR-Score ( 8 points, <8 points)
1.195 1
.274
th
df
p (two-sided)
df … degrees of freedom, WHO … World Health Organization, GW … gestational weeks, SGA … small for gestational age, vs … versus, pH … pH value, APGAR … Appearance, Pulse, Grimace, Activity and Respiration
Table 3: Contingency between delivery-related anxieties and obstetrical complications Variable
χ2
df
p (two-sided)
Pregnancy-related complaints
2.641
1
.104
hypertension in pregnancy /pre-eclampsia
2.597
1
.107
diagnosis “fetal growth retardation”
2.319
1
.128
threat of miscarriage
1.315
1
.251
cervical insufficiency
0.001
1
.980
preterm labor
2.859
1
.091
premature rupture of membranes prior 37 GW
0.065
1
.799
preterm delivery (WHO: < 37 GW and/or < 2500g) 0.582
1
.446
birth weight (< 1500g ;1500-2500g; 2500g)
1.102
2
.576
birth weight ( 2500g ; < 2500g)
0.168
1
.682
delivery prior to 37 GW
0.201
1
.644
birth weight < vs. 10 percentile
2.096
1
.148
mode of delivery (with vs. without complications)
2.828
1
.093
umbilical cord arterial blood - pH (> 7.20; < 7.20)
1.791
1
.181
APGAR-Score ( 8 points, < 8 points)
0.507
1
.477
th
df … degrees of freedom, WHO … World Health Organisation, SGA … small for gestational age, vs … versus, pH … pH value, APGAR … Appearance, Pulse, Grimace, Activity and Respiration