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Maternal psychological impact of fetal echocardiography
Maternal Psychological Impact of Fetal Echocardiography Mark Sklansky, MD, Alvin Tang, BS, Denis Levy, MD, Paul Grossfeld, MD, Iraj Kashani, MD, Robin Shaughnessy, MD, and Abraham Rothman, MD, San Diego, California
The maternal psychological impact of fetal echocardiography may be deleterious in the face of newly diagnosed congenital heart disease. This questionnaire-based study prospectively examined the psychological impact of both normal and abnormal fetal echocardiography. Normal fetal echocardiography decreased maternal anxiety, increased happiness, and increased the closeness women felt toward their unborn children. In contrast, when fetal echocardiography detected congenital heart disease, maternal anxiety typically increased, and mothers commonly felt less happy
F
or the high-risk pregnancy, fetal echocardiography (FE) represents a sophisticated and accurate technique for evaluating fetal cardiac structure and function.1-3 Because FE affects obstetric management in only a minority of cases, the clinical value and overall impact of this expensive and time-consuming technique have recently come under scrutiny. Many investigators have begun evaluating whether FE impacts the outcome of fetuses diagnosed with congenital heart disease (CHD). Thus far, most studies suggest that FE decreases neonatal morbidity and, possibly, mortality associated with CHD.4-7 Although many investigators have examined the impact of FE on the outcome of infants born with CHD, little attention has been focused on the psychological impact of FE on the pregnant woman herself.8-10 For the woman whose last child died of CHD, normal FE can be tremendously reassuring. In contrast, although the prenatal diagnosis of a major fetal anomaly may facilitate psychological adjust-
From the Department of Pediatrics, University of California, San Diego. Reprint requests: Mark Sklansky, MD, Associate Professor, Division of Pediatric Cardiology, Department of Pediatrics, 200 W Arbor Dr—8445, San Diego, CA 92103-8445 (E-mail: [email protected]). Copyright © 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 + 0 27/1/116310 doi:10.1067/mje.2002.116310
about being pregnant. However, among women who had recently delivered infants with congenital heart disease, those who had had fetal echocardiography during the pregnancy felt less responsible for their infants’ defects and tended to have improved their relationships with the infants’ fathers after the prenatal diagnosis of congenital heart disease. Further study of the psychological and medical impact of fetal echocardiography will be necessary to define and optimize the clinical value of this powerful diagnostic tool. (J Am Soc Echocardiogr 2002;15:159-66.)
ment and preparation, it may also precipitate a long period of stress, anxiety, or despair.11 Furthermore, the psychological impact of FE, beyond itself being important and worthy of study, may actually impact the outcome of the pregnancy. The purpose of this study was to examine, for the first time, the acute maternal psychological impact of both normal and abnormal FE.
METHODS This prospective questionnaire-based study evaluated 2 groups of women: pregnant women referred for FE, and mothers of infants recently born with CHD. All FE was performed by the same pediatric cardiologist (M.S.). Subjects were informed of the research purposes of the study, and that approval had been obtained from the Institutional Review Board. Fetal Study During an 8-month period (October 1, 1998 through May 31, 1999), all pregnant women referred for FE at the University of California, San Diego, or at the Kaiser Zion Hospital, San Diego, were asked to participate in the fetal portion of the study. The indications for FE reflected national standards and have been previously described.12 Immediately after FE, a questionnaire was given to each pregnant woman to complete anonymously. Questionnaires were returned confidentially utilizing a self-addressed,
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Table 1 Indications for fetal echocardiography
Indication
DM Previous child Other FH Abn 4 ch ECM 2VC Arrhythmia Teratogen Aneuploidy Bradycardia Right-sided stom Any
No. of studies
% of all studies
51 32 32 21 20 15 14 12 9 6 1 213
24% 15% 15% 10% 9% 7% 6.5% 6% 4% 3% 0.5% 100%
No. of % of abnormal studies studies abnormal
3 1 1 10 7 0 1 1 3 2 1 29
6% 3% 3% 48% 35% 0% 7% 8% 33% 33% 100% 14%
DM, Diabetes mellitus; FH, family history; Abn 4 ch, abnormal 4-chamber view; ECM, extracardiac malformation; 2VC, 2 vessel umbilical cord; stom, stomach.
stamped envelope.Women with “normal” or “probably normal” FE received the “normal” questionnaire, and women with “abnormal” or “probably abnormal” FE received the abnormal questionnaire (Appendix). Abnormal FE was defined as definite structural CHD; isolated premature atrial contractions, prominence to the flap of the foramen ovale, and mild tricuspid or pulmonary regurgitation were considered to be normal variants. Neonatal Study During the same 8-month period, the mothers of all infants with structural CHD admitted to the neonatal intensive care unit at the University of California, San Diego, were asked to participate in the neonatal portion of the study. Structural CHD specifically excluded an isolated patent ductus arteriosus or bicommissural aortic valve. Mothers who had not undergone FE were given one questionnaire, and mothers who had undergone FE were given another (Appendix). Self-addressed, stamped envelopes were provided to expedite confidential return of the anonymous questionnaires. Analysis and Statistics Statistical analysis was performed with independent 2tailed t tests and chi-square analysis (SPSS 8.0 for Windows).A P value of < .05 was considered significant. Data are presented as mean ± SD.
RESULTS Subjects Among 244 fetal and 28 neonatal questionnaires distributed, 213 (87%) and 22 (79%) were returned,
respectively. Women with normal FE tended to be more likely to return questionnaires than were women with abnormal FE (89% vs 78%). Among returned questionnaires, the mean gestational age (23.7 ± 4.2 weeks) did not vary statistically between women with normal FE (23.6 ± 4.2) and women with abnormal FE (24.0 ± 4.5). The study group included 213 (184 normal, 29 abnormal) fetal and 22 neonatal questionnaires; 5 women participated in both the fetal and neonatal studies. Indications for FE Indications for FE have been listed in Table 1. The most common indications included diabetes mellitus (24%), previous child with CHD (15%), other family history of CHD (15%), and an abnormal 4-chamber view (10%). The indications with the highest percentage of abnormals included an abnormal 4-chamber view (48%), extracardiac abnormalities (35%), and aneuploidy or sustained bradycardia (33% each). The 1 fetus referred because of a right-sided stomach had CHD. Diagnosis Fetal diagnoses have been listed in Table 2. Among 29 subjects with abnormal FE, 10 were classified as mild (not anticipated to require cardiac catheterization or surgery), 14 as moderately abnormal (anticipated to require cardiac catheterization or surgery, but with a 2-ventricle long-term outlook), and 5 as severely abnormal (anticipated to require surgery, with a single-ventricle long-term outlook). Four fetuses had an abnormal karyotype (all trisomy 21). Four women underwent termination of pregnancy (TOP); each had a fetus with either a severe cardiac defect or trisomy 21 with a moderate or severe cardiac defect. Among 184 normal FE studies, 22 (12%) were considered to be “probably normal,” with such a result communicated to the pregnant woman. In most cases, the physiological interatrial communication, right ventricular dominance, or tricuspid regurgitation appeared mildly exaggerated (Table 3). In 4 studies, technical limitations (usually maternal habitus) prevented giving the mother a definitive diagnosis without a follow-up study.All such “probably normal” studies underwent either a follow-up FE or a postnatal echocardiogram. Of 28 neonatal questionnaires distributed to mothers of newborns with CHD, 22 (79%) were returned for inclusion in the study. Of these 22 cases (Table 4), CHD was mild in 3 (14%), moderate in 16 (72%), and severe in 3(14%). Additionally, 12 of 22 (55%) had undergone FE.
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Table 2 Fetal diagnoses Subject
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Age at diagnosis (wk)
23 27 25 20 20 23 21 25 28 27 21 21 19 24 31 21 29 20 20 27 20 22 27 20 37 30 18 19 25
Indications
Diaphragmatic hernia Abn 4 ch Abn karyotype Hydrops fetalis DM Diaphragmatic hernia Omphalocele Abn 4 ch; brady Abn karyotype Abn 4 ch Omphalocele Abn 4 ch Abn 4 ch Abn 4 ch Right-sided stom/brady CAM Abn 4 ch ECM Abn 4 ch Infant’s mother : D-TGA Abn karyotype Tegretol Arrhythmia Abn 4 ch DM Diaphragmatic hernia Abn 4 ch Previous child - CHD DM
Findings
Dextrocardia Rhabdomyomas CAVC Twin-twin transfusion Coarctation Dextro/LV compression Secundum ASD CAVC, DORV PM VSD L-TGA, VSD, PA TOF CAVC/HLHS DORV/hypoplastic Ao TAPVR AS, ASD Muscular VSD TA/VSD Muscular VSD CAVC Dysplastic TV CAVC Muscular VSD PA/IVS DORV/PS Muscular VSD VSD/hypo LV HLHS Coarctation/VSD Muscular VSD
Severity
Mild Mild Moderate Mild Moderate Mild Mild Moderate Moderate Moderate Moderate Severe Moderate Moderate Moderate Mild Severe Moderate Moderate Mild Moderate Mild Severe Moderate Mild Severe Severe Moderate Mild
Karyotype
TOP
Normal Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Normal Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Trisomy 21 Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Normal Normal
No No No No No No No No No No No Yes No No No No No No Yes No Yes No No No No No Yes No No
TOP, Termination of pregnancy; Abn 4 ch, abnormal 4-chamber view; Abn karyotype, abnormal karyotype; DM, diabetes mellitus; brady, sustained bradycardia; stom, stomach; CAM, cystic adenomatoid malformation; D-TGA, D-transposition of the great arteries; CHD, congenital heart disease; CAVC, complete atrioventricular canal; Dextro, dextrocardia; ASD, atrial septal defect; DORV, double outlet right ventricle; PM, paramembranous; VSD, ventricular septal defect; PA, pulmonary atresia; TOF, tetralogy of Fallot; HLHS, hypoplastic left heart syndrome; Ao, aorta; TAPVR, total anomalous pulmonary venous return; AS, aortic stenosis; TA, tricuspid atresia; TV, tricuspid valve; IVS, intact ventricular septum; PS, pulmonary stenosis; Hypo, hypoplastic; L-TGA, L-transposition of the great arteries.
Psychological Impact: Fetal Study The fetal study data on the psychological impact of prenatal diagnosis are summarized in Table 5.Among all 213 subjects (including normal and abnormal studies), 56% noted that FE made them feel happier about being pregnant, 74% felt less anxious as a result of FE and, after FE, 57% felt closer to their babies. Ninety-six percent of women felt glad to have undergone FE, and no woman indicated regret. Clinically important and statistically significant differences were found between those who had had normal studies and those whose studies were abnormal. First, among women with normal studies, 61% felt happier as a result of FE, and no woman felt less happy; in contrast, among abnormal studies, 21% felt happier, and 24% felt less happy as a result of FE (P < .015). Second, among normal studies, 82% felt less anxious, and 5% more anxious as a result of the FE; in contrast, among abnormal studies, 48% felt more
anxious and 28% less anxious as a result of the FE (P < .001). In terms of whether the FE made women feel more or less close to their unborn children, no significant difference was identified between normal and abnormal studies. Finally, among normal studies, 23% of women indicated they would have considered TOP had there been a significant abnormality, and 68% said they would not have considered TOP. Similarly, among abnormal studies, 17% of women indicated they would consider TOP, and 72% indicated they would not. In fact, 14% of women with abnormal FE chose to undergo TOP. Differences were found between women with planned pregnancies and those with unplanned pregnancies.Women with planned pregnancies were significantly more likely to be married than women with unplanned pregnancies (55% vs 33%, P < .001). Similarly, the intent to consider TOP after abnormal FE was significantly more common with planned
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Table 4 Neonatal diagnoses
Table 3 Probably normal fetal studies Finding
Possible ASD Possible coarctation Possible aortic dilation Tricuspid regurgitation Mesocardia Technically limited Total
Number of studies
10 3 1 2 2 4 22
ASD, atrial septal defect.
pregnancies than with unplanned pregnancies (22% vs 9%, P = .019). The psychological impact of normal FE was compared with that of probably normal FE. The data demonstrated trends that suggest clinically important differences, but the numbers in this study were too small to demonstrate statistically significant differences. After normal FE, 70% of women felt happier to be pregnant, 82% felt less anxious, and 60% felt closer to their unborn children. In contrast, after probably normal FE, only 50% of women felt happier to be pregnant (9% felt less happy), 73% felt less anxious, and 45% felt closer to their babies. Psychological Impact: Neonatal Study Neonatal questionnaires demonstrated trends toward differences between subjects who had undergone FE and those who had not (Table 6). Although 91% of those who had undergone FE were married, only 20% of those who had not undergone FE were married (P < .001).Women who had not had FE tended to have a greater expectation for psychological benefit from FE than that actually experienced by those who did have FE. Among the 12 cases in whom FE had been performed, 25% of women felt that FE had made them feel happier about being pregnant, 50% felt that FE had made them feel more anxious, and 75% felt closer to their unborn children as a result of FE. In contrast, among those 10 women who had not undergone FE, 60% speculated that FE would have made them feel happier about being pregnant, 50% thought that FE would have made them feel more anxious, and 90% felt that FE would have made them feel closer to their babies during the pregnancy. Among those who had undergone FE, 92% indicated that they were glad to have undergone FE, and 8% indicated that they were not. The mother’s relationship with the unborn child’s father was felt to have improved as a result of FE in 50% of the cases, and to have worsened in no case. Every woman who had not undergone FE wished that she had. A feeling of responsibility for the unborn child’s heart defect was
Subject
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Diagnosis
L-TGA Interrupted IVC/polysplenia Rhabdomyomas DORV/PS AS/hypoplastic aorta AS, ASD PM VSD Coarctation HLHS TOF HLHS AS/coarctation TOF/PA CAVC Coarctation RPA off ascending aorta TA/VSD Valvar PS Coarctation PA/IVS PM VSD D-TGA
Severity
Fetal echo
Mild Mild Mild Moderate Moderate Moderate Moderate Moderate Severe Moderate Moderate Moderate Moderate Moderate Moderate Moderate Severe Moderate Moderate Severe Moderate Moderate
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No
Echo, Echocardiogram; RPA, right pulmonary artery; all other abbreviations as in legend for Table 2.
expressed by 25% of those who had undergone FE, and by 50% of those who had not. Ten percent of those who had not undergone FE would have considered TOP had the diagnosis been made prenatally. The acute psychological response to FE may be compared with the more chronic or long-lasting impact by comparing the responses of women with abnormal FE (Fetal Study: Table 5) with those of mothers of infants with CHD who had had FE (Neonatal Study:Table 6).Although an increase in maternal anxiety related to abnormal FE persisted throughout pregnancy, FE tended to have a more favorable impact on maternal happiness in the long-term than it did acutely. The increased closeness women felt toward their unborn children persisted throughout the pregnancy, as did the overall positive feeling toward having had FE.This comparison of a woman’s acute (Fetal Study) and long-term (Neonatal Study) psychological response to FE is consistent with the findings among the 5 subjects who participated in both the fetal and neonatal studies (Table 7).
DISCUSSION Medical Impact of FE Over the last 25 years, FE has grown from an investigative technique into a sophisticated clinical tool,
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Table 5 Fetal questions Normal (184)
Probably normal† (22)
Abnormal (29)
Total (213)
61% more, 0% less 5% more, 82% less 58% more, 0% less NA NA 23% yes, 68% no
50% more, 9% less (NS) 5% more, 73% less (NS) 45% more, 0% less (NS) NA NA NA
21% more, 24% less (P < .015) 48% more, 28% less (P < .001) 52% more, 3% less (NS) NA 31% yes, 66% no NA
56% more, 3% less 11% more, 74% less 57% more, 0.5% less 96% yes, 0% no NA NA
NA
NA
17% yes, 72% no
NA
Question*
Happiness (A1, B1) Anxiety (A2, B2) Closeness (A3, B3) Glad (A5, B5) Responsible (B8) Would Have Considered TOP (A4) Will Consider TOP (B4)
*See Appendix for questionnaires. †“Probably normal” studies represent a subset of “normal” studies. NS, Not statistically significant compared with normals; NA, not applicable; TOP, termination of pregnancy.
Table 6 Neonatal questions Question*
Happiness (C1,D1) Anxiety (C2, D2) Closeness (C3, D3) Glad (C5) Responsible (C8, D8) Would have considered TOP (D4) Married (C6, D6) Relationship with father (C4) Wish had had FE (D5)
FE performed (12)
FE not performed (10)
Overall (22)
25% more, 8% less 50% more, 25% less 75% more, 0% less 92% yes, 8% no 25% yes, 58% no NA 91% yes, 9% no 50% better, 0% worse NA
60% more, 20% less (NS) 50% more, 50% less (NS) 90% more, 0% less (NS) NA 50% yes, 40% no (NS) 10% yes, 80% no 20% yes, 80% no (P < .001) NA 100% yes
41% more, 14% less 50% more, 36% less 82% more, 0% less NA 36% yes, 50% no NA 59% yes, 41% no NA NA
*See Appendix for questionnaires. NA, Not applicable; FE, fetal echocardiogram; TOP, termination of pregnancy; NS, not statistically significant compared with FE performed group.
Table 7 Subjects returning both fetal and neonatal questionnaires (fetal/neonatal responses*)
Subject
1 2 3 4 5
Diagnosis
Happiness (B1, C1)
Anxiety (B2, C2)
Closeness (B3, C3)
Responsible (B8, C8)
Would choose FE again (B5, C5)
Rhabdomyomas DORV/CAVC PM VSD TOF AS/ASD
NC/more NA/NC NC/NC NC/NC NC/NC
More/less More/more Less/NC More/more More/more
More/more More/more NC/NC More/more NC/NC
Yes/yes NA/NA No/no Yes/yes Yes/no
Yes/yes NA/yes Yes/yes Yes/yes Yes/yes
*See Appendix for questionnaires. NA, Not answered; NC, no change; FE, fetal echocardiogram; all other abbreviations as in legend for Table 2.
with the ability to detect (or rule out) CHD with a high degree of accuracy.1-3 However, given the limited ability prenatally to change the course of most forms of CHD, the benefit to prenatal diagnosis of CHD has been questioned. In its defense, FE has been shown to be medically important in several ways. First, the early diagnosis of CHD with FE has been shown to lead to the detection of associated extracardiac fetal anomalies.1,13 Second, the prenatal diagnosis of major CHD may have implications for the optimal route, location, or timing of delivery, and may bring critically ill infants to medical attention quick-
er than they would have been without a prenatal diagnosis. Many studies have suggested improved outcome in infants diagnosed prenatally with CHD in comparison with those not diagnosed until after birth.4-7 These studies suggest that early diagnosis can lead to improved preoperative hemodynamic status, less end-organ dysfunction, less preoperative morbidity and mortality, and less long-term morbidity. Finally, in some cases, FE allows women the opportunity to terminate severely affected pregnancies, which ultimately may affect the postnatal prevalence of major CHD.14-16
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Psychological Impact of FE Beyond these strictly medical benefits, FE may have important psychological implications, some beneficial and others potentially deleterious.Although previous work has demonstrated that the knowledge that a pregnant woman is at risk for fetal anomalies increases maternal anxiety,17 relatively little work has been done to evaluate the maternal psychological impact of FE. Normal FE in a high-risk pregnancy can offer reassurance, provide emotional comfort, and lower maternal anxiety. Bjorkhem et al9 studied the psychological effect of normal FE in 65 families, each with a previous child with CHD, and Barton et al10 studied the effect of normal FE in 72 pregnant women at risk for fetal heart disease. Both groups found that normal FE resulted in decreased maternal anxiety. On the other hand, abnormal FE, while providing an opportunity for emotional and intellectual preparation for the birth of a critically ill infant, may precipitate a prolonged period of heightened stress and anxiety. This concern has previously been raised regarding the prenatal diagnosis of major fetal anomalies,11,18 and Rona et al8 demonstrated an elevated level of anxiety 6 to 10 months after the diagnosis of CHD. However, to our knowledge, no study to date has addressed the acute psychological impact of and maternal attitudes toward abnormal FE. Moreover, although the potential psychological impact of a “possibly abnormal” fetal sonogram has been previously described in general terms,19 the maternal psychological impact of a “probably normal” FE has not previously been formally examined. As expected, happiness tended to increase and anxiety tended to decrease after normal or probably normal FE, whereas happiness tended to decrease and anxiety tended to increase after abnormal FE. In all groups, women felt closer to their unborn children after FE, and were consistently glad to have had FE, regardless of the findings. We found that 10% to 25% of women would consider terminating a pregnancy complicated by significant CHD, consistent with previous studies of FE and TOP.12 To our surprise, women with planned pregnancies were statistically more likely to consider TOP than were women with unplanned pregnancies. We suspect that married women, who are more likely to have planned pregnancies than single women, may be more likely to have a well-developed expectation of their perfect child and may find it more difficult to accept anything less.11
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Interdependence of Psychological and Medical Impact The adverse psychological impact of abnormal FE (greater anxiety and less happiness), beyond being important in its own right, may actually have an adverse impact on pregnancy outcome. In several independent studies, anxiety has been shown to increase not only obstetric complications,20 but also the incidence of CHD, specifically conotruncal defects.21-23 Investigators have speculated that early psychosocial stress may lead to an increase in CHD by increasing (1) deleterious coping behaviors (poor diet, less exercise, and smoking), (2) endogenous corticosteroids (which may be teratogenic), and (3) endogenous catecholamines (which may decrease uterine blood flow and predispose to fetal hypoxia).21 Regardless of the mechanism, psychological stress related to FE may adversely affect the medical outcome of a pregnancy.Although cardiac embryogenesis occurs before routine FE, the potential adverse impact of FE-related maternal stress on obstetric outcome deserves further study. Limitations Several limitations of this study deserve comment. First, a selection bias may have affected which distributed questionnaires were returned. Only 78% of abnormal FE questionnaires and 79% of neonatal questionnaires were returned compared with 89% of normal FE questionnaires.Those women who felt the most adverse psychological impact from abnormal FE may have been the least likely to return completed questionnaires. This study cannot definitely rule out this possibility; however, anger at the finding of a defect in her unborn child may actually increase a woman’s motivation to complete and return a questionnaire. Second, selection bias may have affected which questions a given woman may have answered and which she left blank.Although women with negative psychological impact may have been more reluctant to document their feelings, the use of anonymous, self-addressed, stamped envelopes would have facilitated the candid documentation of negative responses that women may have been particularly eager to report. Third, psychological responses to FE may be related, in part, to the personal characteristics of the physician involved with scanning and counseling, so our results may not be those found by others. Finally, although this study represents the largest study to date evaluating the psychological impact of FE, the number of abnormal studies remains relatively small. One area of particular concern, in this regard, remains women who have a
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“probably normal” FE. Such a diagnosis, which occurs not infrequently, may generate anxiety and other psychological stresses, despite this study’s inability to demonstrate statistically significant differences in psychological impact between normal and probably normal FE.
CONCLUSION In summary, this study demonstrates that the maternal psychological impact of FE is mostly beneficial, but may be deleterious in the face of newly diagnosed CHD. Normal FE decreases anxiety, increases happiness, and increases the closeness a woman feels toward her unborn child. In contrast, when FE detects CHD, maternal anxiety typically increases, and mothers commonly feel less happy about being pregnant. However, abnormal FE tends to have a more favorable impact on maternal happiness in the long-term than it does acutely. In addition, among women who have recently delivered infants with CHD, those who have had FE feel less responsible for their infants’ defects, and tend to have improved their relationships with the infants’ fathers after the prenatal diagnosis of CHD. Among all groups of women, those with normal or abnormal FE, and those who have recently delivered babies with CHD (with or without FE), an overwhelming majority would choose to have FE on subsequent pregnancies. Further study of the psychological, as well as the closely related medical impact of FE, is needed to help define and optimize the clinical value of FE. We thank Cynthia Hoecker, MD, for her assistance with statistical analysis.
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APPENDIX: QUESTIONNAIRES A. Fetal Study: Normal Echocardiogram 1. The results of this fetal echocardiogram have made me feel (more/less) happy to be pregnant. (No change) 2. The results of this fetal echocardiogram have made me feel (more/less) nervous about this pregnancy. (No change) 3. The results of this fetal echocardiogram have made me feel (more/less) close to my baby. (No change) 4. Had a serious heart defect been found, I (would/ would not) have considered terminating the pregnancy (abortion). 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have this test done again were I to become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/not planned). B. Fetal Study: Abnormal Echocardiogram 1. The results of this fetal echocardiogram have made me feel (more/less) happy to be pregnant. (No change) 2. The results of this fetal echocardiogram have made me feel (more/less) nervous about this pregnancy. (No change) 3. The results of this fetal echocardiogram have made me feel (more/less) close to my baby. (No change) 4. Because a heart defect has been found, I (may/ will not) consider terminating the pregnancy (abortion). 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have this test done again were I to become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/unplanned). 8. I (feel/do not feel) responsible for my baby’s heart defect.
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C. Neonatal Study: Fetal Echocardiogram Performed 1. The results of my fetal echocardiogram made me feel (more/less) happy to be pregnant. (No change) 2. The results of my fetal echocardiogram made me feel (more/less) nervous during the pregnancy. (No change) 3. The results of my fetal echocardiogram made me feel (more/less) close to my baby during the pregnancy. (No change) 4. The results of my fetal echocardiogram (improved/ worsened) my relationship with the baby’s father. (No change) 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have the test done again if I become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/not planned). 8. I (feel/do not feel) responsible for my baby’s heart defect. D. Neonatal Study: Fetal Echocardiogram Not Performed 1. A fetal echocardiogram likely would have made me feel (more/less) happy to be pregnant. (No change) 2. A fetal echocardiogram likely would have made me feel (more/less) nervous during the pregnancy. (No change) 3. A fetal echocardiogram likely would have made me feel (more/less) close to my baby during the pregnancy. (No change) 4. Had I known that my baby had a heart defect, I (would/would not) have considered terminating the pregnancy (abortion). 5. I (wish/do not wish) I had had a fetal echocardiogram during this pregnancy. 6. I am (single/married). 7. This pregnancy was (planned/not planned). 8. I (feel/do not feel) responsible for my baby’s heart defect.
The maternal psychological impact of fetal echocardiography may be deleterious in the face of newly diagnosed congenital heart disease. This questionnaire-based study prospectively examined the psychological impact of both normal and abnormal fetal echocardiography. Normal fetal echocardiography decreased maternal anxiety, increased happiness, and increased the closeness women felt toward their unborn children. In contrast, when fetal echocardiography detected congenital heart disease, maternal anxiety typically increased, and mothers commonly felt less happy
F
or the high-risk pregnancy, fetal echocardiography (FE) represents a sophisticated and accurate technique for evaluating fetal cardiac structure and function.1-3 Because FE affects obstetric management in only a minority of cases, the clinical value and overall impact of this expensive and time-consuming technique have recently come under scrutiny. Many investigators have begun evaluating whether FE impacts the outcome of fetuses diagnosed with congenital heart disease (CHD). Thus far, most studies suggest that FE decreases neonatal morbidity and, possibly, mortality associated with CHD.4-7 Although many investigators have examined the impact of FE on the outcome of infants born with CHD, little attention has been focused on the psychological impact of FE on the pregnant woman herself.8-10 For the woman whose last child died of CHD, normal FE can be tremendously reassuring. In contrast, although the prenatal diagnosis of a major fetal anomaly may facilitate psychological adjust-
From the Department of Pediatrics, University of California, San Diego. Reprint requests: Mark Sklansky, MD, Associate Professor, Division of Pediatric Cardiology, Department of Pediatrics, 200 W Arbor Dr—8445, San Diego, CA 92103-8445 (E-mail: [email protected]). Copyright © 2002 by the American Society of Echocardiography. 0894-7317/2002/$35.00 + 0 27/1/116310 doi:10.1067/mje.2002.116310
about being pregnant. However, among women who had recently delivered infants with congenital heart disease, those who had had fetal echocardiography during the pregnancy felt less responsible for their infants’ defects and tended to have improved their relationships with the infants’ fathers after the prenatal diagnosis of congenital heart disease. Further study of the psychological and medical impact of fetal echocardiography will be necessary to define and optimize the clinical value of this powerful diagnostic tool. (J Am Soc Echocardiogr 2002;15:159-66.)
ment and preparation, it may also precipitate a long period of stress, anxiety, or despair.11 Furthermore, the psychological impact of FE, beyond itself being important and worthy of study, may actually impact the outcome of the pregnancy. The purpose of this study was to examine, for the first time, the acute maternal psychological impact of both normal and abnormal FE.
METHODS This prospective questionnaire-based study evaluated 2 groups of women: pregnant women referred for FE, and mothers of infants recently born with CHD. All FE was performed by the same pediatric cardiologist (M.S.). Subjects were informed of the research purposes of the study, and that approval had been obtained from the Institutional Review Board. Fetal Study During an 8-month period (October 1, 1998 through May 31, 1999), all pregnant women referred for FE at the University of California, San Diego, or at the Kaiser Zion Hospital, San Diego, were asked to participate in the fetal portion of the study. The indications for FE reflected national standards and have been previously described.12 Immediately after FE, a questionnaire was given to each pregnant woman to complete anonymously. Questionnaires were returned confidentially utilizing a self-addressed,
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Table 1 Indications for fetal echocardiography
Indication
DM Previous child Other FH Abn 4 ch ECM 2VC Arrhythmia Teratogen Aneuploidy Bradycardia Right-sided stom Any
No. of studies
% of all studies
51 32 32 21 20 15 14 12 9 6 1 213
24% 15% 15% 10% 9% 7% 6.5% 6% 4% 3% 0.5% 100%
No. of % of abnormal studies studies abnormal
3 1 1 10 7 0 1 1 3 2 1 29
6% 3% 3% 48% 35% 0% 7% 8% 33% 33% 100% 14%
DM, Diabetes mellitus; FH, family history; Abn 4 ch, abnormal 4-chamber view; ECM, extracardiac malformation; 2VC, 2 vessel umbilical cord; stom, stomach.
stamped envelope.Women with “normal” or “probably normal” FE received the “normal” questionnaire, and women with “abnormal” or “probably abnormal” FE received the abnormal questionnaire (Appendix). Abnormal FE was defined as definite structural CHD; isolated premature atrial contractions, prominence to the flap of the foramen ovale, and mild tricuspid or pulmonary regurgitation were considered to be normal variants. Neonatal Study During the same 8-month period, the mothers of all infants with structural CHD admitted to the neonatal intensive care unit at the University of California, San Diego, were asked to participate in the neonatal portion of the study. Structural CHD specifically excluded an isolated patent ductus arteriosus or bicommissural aortic valve. Mothers who had not undergone FE were given one questionnaire, and mothers who had undergone FE were given another (Appendix). Self-addressed, stamped envelopes were provided to expedite confidential return of the anonymous questionnaires. Analysis and Statistics Statistical analysis was performed with independent 2tailed t tests and chi-square analysis (SPSS 8.0 for Windows).A P value of < .05 was considered significant. Data are presented as mean ± SD.
RESULTS Subjects Among 244 fetal and 28 neonatal questionnaires distributed, 213 (87%) and 22 (79%) were returned,
respectively. Women with normal FE tended to be more likely to return questionnaires than were women with abnormal FE (89% vs 78%). Among returned questionnaires, the mean gestational age (23.7 ± 4.2 weeks) did not vary statistically between women with normal FE (23.6 ± 4.2) and women with abnormal FE (24.0 ± 4.5). The study group included 213 (184 normal, 29 abnormal) fetal and 22 neonatal questionnaires; 5 women participated in both the fetal and neonatal studies. Indications for FE Indications for FE have been listed in Table 1. The most common indications included diabetes mellitus (24%), previous child with CHD (15%), other family history of CHD (15%), and an abnormal 4-chamber view (10%). The indications with the highest percentage of abnormals included an abnormal 4-chamber view (48%), extracardiac abnormalities (35%), and aneuploidy or sustained bradycardia (33% each). The 1 fetus referred because of a right-sided stomach had CHD. Diagnosis Fetal diagnoses have been listed in Table 2. Among 29 subjects with abnormal FE, 10 were classified as mild (not anticipated to require cardiac catheterization or surgery), 14 as moderately abnormal (anticipated to require cardiac catheterization or surgery, but with a 2-ventricle long-term outlook), and 5 as severely abnormal (anticipated to require surgery, with a single-ventricle long-term outlook). Four fetuses had an abnormal karyotype (all trisomy 21). Four women underwent termination of pregnancy (TOP); each had a fetus with either a severe cardiac defect or trisomy 21 with a moderate or severe cardiac defect. Among 184 normal FE studies, 22 (12%) were considered to be “probably normal,” with such a result communicated to the pregnant woman. In most cases, the physiological interatrial communication, right ventricular dominance, or tricuspid regurgitation appeared mildly exaggerated (Table 3). In 4 studies, technical limitations (usually maternal habitus) prevented giving the mother a definitive diagnosis without a follow-up study.All such “probably normal” studies underwent either a follow-up FE or a postnatal echocardiogram. Of 28 neonatal questionnaires distributed to mothers of newborns with CHD, 22 (79%) were returned for inclusion in the study. Of these 22 cases (Table 4), CHD was mild in 3 (14%), moderate in 16 (72%), and severe in 3(14%). Additionally, 12 of 22 (55%) had undergone FE.
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Table 2 Fetal diagnoses Subject
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Age at diagnosis (wk)
23 27 25 20 20 23 21 25 28 27 21 21 19 24 31 21 29 20 20 27 20 22 27 20 37 30 18 19 25
Indications
Diaphragmatic hernia Abn 4 ch Abn karyotype Hydrops fetalis DM Diaphragmatic hernia Omphalocele Abn 4 ch; brady Abn karyotype Abn 4 ch Omphalocele Abn 4 ch Abn 4 ch Abn 4 ch Right-sided stom/brady CAM Abn 4 ch ECM Abn 4 ch Infant’s mother : D-TGA Abn karyotype Tegretol Arrhythmia Abn 4 ch DM Diaphragmatic hernia Abn 4 ch Previous child - CHD DM
Findings
Dextrocardia Rhabdomyomas CAVC Twin-twin transfusion Coarctation Dextro/LV compression Secundum ASD CAVC, DORV PM VSD L-TGA, VSD, PA TOF CAVC/HLHS DORV/hypoplastic Ao TAPVR AS, ASD Muscular VSD TA/VSD Muscular VSD CAVC Dysplastic TV CAVC Muscular VSD PA/IVS DORV/PS Muscular VSD VSD/hypo LV HLHS Coarctation/VSD Muscular VSD
Severity
Mild Mild Moderate Mild Moderate Mild Mild Moderate Moderate Moderate Moderate Severe Moderate Moderate Moderate Mild Severe Moderate Moderate Mild Moderate Mild Severe Moderate Mild Severe Severe Moderate Mild
Karyotype
TOP
Normal Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Normal Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Trisomy 21 Normal Trisomy 21 Normal Normal Normal Normal Normal Normal Normal Normal
No No No No No No No No No No No Yes No No No No No No Yes No Yes No No No No No Yes No No
TOP, Termination of pregnancy; Abn 4 ch, abnormal 4-chamber view; Abn karyotype, abnormal karyotype; DM, diabetes mellitus; brady, sustained bradycardia; stom, stomach; CAM, cystic adenomatoid malformation; D-TGA, D-transposition of the great arteries; CHD, congenital heart disease; CAVC, complete atrioventricular canal; Dextro, dextrocardia; ASD, atrial septal defect; DORV, double outlet right ventricle; PM, paramembranous; VSD, ventricular septal defect; PA, pulmonary atresia; TOF, tetralogy of Fallot; HLHS, hypoplastic left heart syndrome; Ao, aorta; TAPVR, total anomalous pulmonary venous return; AS, aortic stenosis; TA, tricuspid atresia; TV, tricuspid valve; IVS, intact ventricular septum; PS, pulmonary stenosis; Hypo, hypoplastic; L-TGA, L-transposition of the great arteries.
Psychological Impact: Fetal Study The fetal study data on the psychological impact of prenatal diagnosis are summarized in Table 5.Among all 213 subjects (including normal and abnormal studies), 56% noted that FE made them feel happier about being pregnant, 74% felt less anxious as a result of FE and, after FE, 57% felt closer to their babies. Ninety-six percent of women felt glad to have undergone FE, and no woman indicated regret. Clinically important and statistically significant differences were found between those who had had normal studies and those whose studies were abnormal. First, among women with normal studies, 61% felt happier as a result of FE, and no woman felt less happy; in contrast, among abnormal studies, 21% felt happier, and 24% felt less happy as a result of FE (P < .015). Second, among normal studies, 82% felt less anxious, and 5% more anxious as a result of the FE; in contrast, among abnormal studies, 48% felt more
anxious and 28% less anxious as a result of the FE (P < .001). In terms of whether the FE made women feel more or less close to their unborn children, no significant difference was identified between normal and abnormal studies. Finally, among normal studies, 23% of women indicated they would have considered TOP had there been a significant abnormality, and 68% said they would not have considered TOP. Similarly, among abnormal studies, 17% of women indicated they would consider TOP, and 72% indicated they would not. In fact, 14% of women with abnormal FE chose to undergo TOP. Differences were found between women with planned pregnancies and those with unplanned pregnancies.Women with planned pregnancies were significantly more likely to be married than women with unplanned pregnancies (55% vs 33%, P < .001). Similarly, the intent to consider TOP after abnormal FE was significantly more common with planned
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Table 4 Neonatal diagnoses
Table 3 Probably normal fetal studies Finding
Possible ASD Possible coarctation Possible aortic dilation Tricuspid regurgitation Mesocardia Technically limited Total
Number of studies
10 3 1 2 2 4 22
ASD, atrial septal defect.
pregnancies than with unplanned pregnancies (22% vs 9%, P = .019). The psychological impact of normal FE was compared with that of probably normal FE. The data demonstrated trends that suggest clinically important differences, but the numbers in this study were too small to demonstrate statistically significant differences. After normal FE, 70% of women felt happier to be pregnant, 82% felt less anxious, and 60% felt closer to their unborn children. In contrast, after probably normal FE, only 50% of women felt happier to be pregnant (9% felt less happy), 73% felt less anxious, and 45% felt closer to their babies. Psychological Impact: Neonatal Study Neonatal questionnaires demonstrated trends toward differences between subjects who had undergone FE and those who had not (Table 6). Although 91% of those who had undergone FE were married, only 20% of those who had not undergone FE were married (P < .001).Women who had not had FE tended to have a greater expectation for psychological benefit from FE than that actually experienced by those who did have FE. Among the 12 cases in whom FE had been performed, 25% of women felt that FE had made them feel happier about being pregnant, 50% felt that FE had made them feel more anxious, and 75% felt closer to their unborn children as a result of FE. In contrast, among those 10 women who had not undergone FE, 60% speculated that FE would have made them feel happier about being pregnant, 50% thought that FE would have made them feel more anxious, and 90% felt that FE would have made them feel closer to their babies during the pregnancy. Among those who had undergone FE, 92% indicated that they were glad to have undergone FE, and 8% indicated that they were not. The mother’s relationship with the unborn child’s father was felt to have improved as a result of FE in 50% of the cases, and to have worsened in no case. Every woman who had not undergone FE wished that she had. A feeling of responsibility for the unborn child’s heart defect was
Subject
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Diagnosis
L-TGA Interrupted IVC/polysplenia Rhabdomyomas DORV/PS AS/hypoplastic aorta AS, ASD PM VSD Coarctation HLHS TOF HLHS AS/coarctation TOF/PA CAVC Coarctation RPA off ascending aorta TA/VSD Valvar PS Coarctation PA/IVS PM VSD D-TGA
Severity
Fetal echo
Mild Mild Mild Moderate Moderate Moderate Moderate Moderate Severe Moderate Moderate Moderate Moderate Moderate Moderate Moderate Severe Moderate Moderate Severe Moderate Moderate
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No
Echo, Echocardiogram; RPA, right pulmonary artery; all other abbreviations as in legend for Table 2.
expressed by 25% of those who had undergone FE, and by 50% of those who had not. Ten percent of those who had not undergone FE would have considered TOP had the diagnosis been made prenatally. The acute psychological response to FE may be compared with the more chronic or long-lasting impact by comparing the responses of women with abnormal FE (Fetal Study: Table 5) with those of mothers of infants with CHD who had had FE (Neonatal Study:Table 6).Although an increase in maternal anxiety related to abnormal FE persisted throughout pregnancy, FE tended to have a more favorable impact on maternal happiness in the long-term than it did acutely. The increased closeness women felt toward their unborn children persisted throughout the pregnancy, as did the overall positive feeling toward having had FE.This comparison of a woman’s acute (Fetal Study) and long-term (Neonatal Study) psychological response to FE is consistent with the findings among the 5 subjects who participated in both the fetal and neonatal studies (Table 7).
DISCUSSION Medical Impact of FE Over the last 25 years, FE has grown from an investigative technique into a sophisticated clinical tool,
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Table 5 Fetal questions Normal (184)
Probably normal† (22)
Abnormal (29)
Total (213)
61% more, 0% less 5% more, 82% less 58% more, 0% less NA NA 23% yes, 68% no
50% more, 9% less (NS) 5% more, 73% less (NS) 45% more, 0% less (NS) NA NA NA
21% more, 24% less (P < .015) 48% more, 28% less (P < .001) 52% more, 3% less (NS) NA 31% yes, 66% no NA
56% more, 3% less 11% more, 74% less 57% more, 0.5% less 96% yes, 0% no NA NA
NA
NA
17% yes, 72% no
NA
Question*
Happiness (A1, B1) Anxiety (A2, B2) Closeness (A3, B3) Glad (A5, B5) Responsible (B8) Would Have Considered TOP (A4) Will Consider TOP (B4)
*See Appendix for questionnaires. †“Probably normal” studies represent a subset of “normal” studies. NS, Not statistically significant compared with normals; NA, not applicable; TOP, termination of pregnancy.
Table 6 Neonatal questions Question*
Happiness (C1,D1) Anxiety (C2, D2) Closeness (C3, D3) Glad (C5) Responsible (C8, D8) Would have considered TOP (D4) Married (C6, D6) Relationship with father (C4) Wish had had FE (D5)
FE performed (12)
FE not performed (10)
Overall (22)
25% more, 8% less 50% more, 25% less 75% more, 0% less 92% yes, 8% no 25% yes, 58% no NA 91% yes, 9% no 50% better, 0% worse NA
60% more, 20% less (NS) 50% more, 50% less (NS) 90% more, 0% less (NS) NA 50% yes, 40% no (NS) 10% yes, 80% no 20% yes, 80% no (P < .001) NA 100% yes
41% more, 14% less 50% more, 36% less 82% more, 0% less NA 36% yes, 50% no NA 59% yes, 41% no NA NA
*See Appendix for questionnaires. NA, Not applicable; FE, fetal echocardiogram; TOP, termination of pregnancy; NS, not statistically significant compared with FE performed group.
Table 7 Subjects returning both fetal and neonatal questionnaires (fetal/neonatal responses*)
Subject
1 2 3 4 5
Diagnosis
Happiness (B1, C1)
Anxiety (B2, C2)
Closeness (B3, C3)
Responsible (B8, C8)
Would choose FE again (B5, C5)
Rhabdomyomas DORV/CAVC PM VSD TOF AS/ASD
NC/more NA/NC NC/NC NC/NC NC/NC
More/less More/more Less/NC More/more More/more
More/more More/more NC/NC More/more NC/NC
Yes/yes NA/NA No/no Yes/yes Yes/no
Yes/yes NA/yes Yes/yes Yes/yes Yes/yes
*See Appendix for questionnaires. NA, Not answered; NC, no change; FE, fetal echocardiogram; all other abbreviations as in legend for Table 2.
with the ability to detect (or rule out) CHD with a high degree of accuracy.1-3 However, given the limited ability prenatally to change the course of most forms of CHD, the benefit to prenatal diagnosis of CHD has been questioned. In its defense, FE has been shown to be medically important in several ways. First, the early diagnosis of CHD with FE has been shown to lead to the detection of associated extracardiac fetal anomalies.1,13 Second, the prenatal diagnosis of major CHD may have implications for the optimal route, location, or timing of delivery, and may bring critically ill infants to medical attention quick-
er than they would have been without a prenatal diagnosis. Many studies have suggested improved outcome in infants diagnosed prenatally with CHD in comparison with those not diagnosed until after birth.4-7 These studies suggest that early diagnosis can lead to improved preoperative hemodynamic status, less end-organ dysfunction, less preoperative morbidity and mortality, and less long-term morbidity. Finally, in some cases, FE allows women the opportunity to terminate severely affected pregnancies, which ultimately may affect the postnatal prevalence of major CHD.14-16
164 Sklansky et al
Psychological Impact of FE Beyond these strictly medical benefits, FE may have important psychological implications, some beneficial and others potentially deleterious.Although previous work has demonstrated that the knowledge that a pregnant woman is at risk for fetal anomalies increases maternal anxiety,17 relatively little work has been done to evaluate the maternal psychological impact of FE. Normal FE in a high-risk pregnancy can offer reassurance, provide emotional comfort, and lower maternal anxiety. Bjorkhem et al9 studied the psychological effect of normal FE in 65 families, each with a previous child with CHD, and Barton et al10 studied the effect of normal FE in 72 pregnant women at risk for fetal heart disease. Both groups found that normal FE resulted in decreased maternal anxiety. On the other hand, abnormal FE, while providing an opportunity for emotional and intellectual preparation for the birth of a critically ill infant, may precipitate a prolonged period of heightened stress and anxiety. This concern has previously been raised regarding the prenatal diagnosis of major fetal anomalies,11,18 and Rona et al8 demonstrated an elevated level of anxiety 6 to 10 months after the diagnosis of CHD. However, to our knowledge, no study to date has addressed the acute psychological impact of and maternal attitudes toward abnormal FE. Moreover, although the potential psychological impact of a “possibly abnormal” fetal sonogram has been previously described in general terms,19 the maternal psychological impact of a “probably normal” FE has not previously been formally examined. As expected, happiness tended to increase and anxiety tended to decrease after normal or probably normal FE, whereas happiness tended to decrease and anxiety tended to increase after abnormal FE. In all groups, women felt closer to their unborn children after FE, and were consistently glad to have had FE, regardless of the findings. We found that 10% to 25% of women would consider terminating a pregnancy complicated by significant CHD, consistent with previous studies of FE and TOP.12 To our surprise, women with planned pregnancies were statistically more likely to consider TOP than were women with unplanned pregnancies. We suspect that married women, who are more likely to have planned pregnancies than single women, may be more likely to have a well-developed expectation of their perfect child and may find it more difficult to accept anything less.11
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Interdependence of Psychological and Medical Impact The adverse psychological impact of abnormal FE (greater anxiety and less happiness), beyond being important in its own right, may actually have an adverse impact on pregnancy outcome. In several independent studies, anxiety has been shown to increase not only obstetric complications,20 but also the incidence of CHD, specifically conotruncal defects.21-23 Investigators have speculated that early psychosocial stress may lead to an increase in CHD by increasing (1) deleterious coping behaviors (poor diet, less exercise, and smoking), (2) endogenous corticosteroids (which may be teratogenic), and (3) endogenous catecholamines (which may decrease uterine blood flow and predispose to fetal hypoxia).21 Regardless of the mechanism, psychological stress related to FE may adversely affect the medical outcome of a pregnancy.Although cardiac embryogenesis occurs before routine FE, the potential adverse impact of FE-related maternal stress on obstetric outcome deserves further study. Limitations Several limitations of this study deserve comment. First, a selection bias may have affected which distributed questionnaires were returned. Only 78% of abnormal FE questionnaires and 79% of neonatal questionnaires were returned compared with 89% of normal FE questionnaires.Those women who felt the most adverse psychological impact from abnormal FE may have been the least likely to return completed questionnaires. This study cannot definitely rule out this possibility; however, anger at the finding of a defect in her unborn child may actually increase a woman’s motivation to complete and return a questionnaire. Second, selection bias may have affected which questions a given woman may have answered and which she left blank.Although women with negative psychological impact may have been more reluctant to document their feelings, the use of anonymous, self-addressed, stamped envelopes would have facilitated the candid documentation of negative responses that women may have been particularly eager to report. Third, psychological responses to FE may be related, in part, to the personal characteristics of the physician involved with scanning and counseling, so our results may not be those found by others. Finally, although this study represents the largest study to date evaluating the psychological impact of FE, the number of abnormal studies remains relatively small. One area of particular concern, in this regard, remains women who have a
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“probably normal” FE. Such a diagnosis, which occurs not infrequently, may generate anxiety and other psychological stresses, despite this study’s inability to demonstrate statistically significant differences in psychological impact between normal and probably normal FE.
CONCLUSION In summary, this study demonstrates that the maternal psychological impact of FE is mostly beneficial, but may be deleterious in the face of newly diagnosed CHD. Normal FE decreases anxiety, increases happiness, and increases the closeness a woman feels toward her unborn child. In contrast, when FE detects CHD, maternal anxiety typically increases, and mothers commonly feel less happy about being pregnant. However, abnormal FE tends to have a more favorable impact on maternal happiness in the long-term than it does acutely. In addition, among women who have recently delivered infants with CHD, those who have had FE feel less responsible for their infants’ defects, and tend to have improved their relationships with the infants’ fathers after the prenatal diagnosis of CHD. Among all groups of women, those with normal or abnormal FE, and those who have recently delivered babies with CHD (with or without FE), an overwhelming majority would choose to have FE on subsequent pregnancies. Further study of the psychological, as well as the closely related medical impact of FE, is needed to help define and optimize the clinical value of FE. We thank Cynthia Hoecker, MD, for her assistance with statistical analysis.
Sklansky et al 165
6.
7.
8.
9. 10.
11.
12.
13.
14.
15.
16.
17.
18.
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APPENDIX: QUESTIONNAIRES A. Fetal Study: Normal Echocardiogram 1. The results of this fetal echocardiogram have made me feel (more/less) happy to be pregnant. (No change) 2. The results of this fetal echocardiogram have made me feel (more/less) nervous about this pregnancy. (No change) 3. The results of this fetal echocardiogram have made me feel (more/less) close to my baby. (No change) 4. Had a serious heart defect been found, I (would/ would not) have considered terminating the pregnancy (abortion). 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have this test done again were I to become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/not planned). B. Fetal Study: Abnormal Echocardiogram 1. The results of this fetal echocardiogram have made me feel (more/less) happy to be pregnant. (No change) 2. The results of this fetal echocardiogram have made me feel (more/less) nervous about this pregnancy. (No change) 3. The results of this fetal echocardiogram have made me feel (more/less) close to my baby. (No change) 4. Because a heart defect has been found, I (may/ will not) consider terminating the pregnancy (abortion). 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have this test done again were I to become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/unplanned). 8. I (feel/do not feel) responsible for my baby’s heart defect.
Journal of the American Society of Echocardiography February 2002
C. Neonatal Study: Fetal Echocardiogram Performed 1. The results of my fetal echocardiogram made me feel (more/less) happy to be pregnant. (No change) 2. The results of my fetal echocardiogram made me feel (more/less) nervous during the pregnancy. (No change) 3. The results of my fetal echocardiogram made me feel (more/less) close to my baby during the pregnancy. (No change) 4. The results of my fetal echocardiogram (improved/ worsened) my relationship with the baby’s father. (No change) 5. I (am/am not) glad that I had a fetal echocardiogram and (would/would not) choose to have the test done again if I become pregnant again. 6. I am (single/married). 7. This pregnancy was (planned/not planned). 8. I (feel/do not feel) responsible for my baby’s heart defect. D. Neonatal Study: Fetal Echocardiogram Not Performed 1. A fetal echocardiogram likely would have made me feel (more/less) happy to be pregnant. (No change) 2. A fetal echocardiogram likely would have made me feel (more/less) nervous during the pregnancy. (No change) 3. A fetal echocardiogram likely would have made me feel (more/less) close to my baby during the pregnancy. (No change) 4. Had I known that my baby had a heart defect, I (would/would not) have considered terminating the pregnancy (abortion). 5. I (wish/do not wish) I had had a fetal echocardiogram during this pregnancy. 6. I am (single/married). 7. This pregnancy was (planned/not planned). 8. I (feel/do not feel) responsible for my baby’s heart defect.