Evaluation of maternal anxiety and depression levels in pregnancies with fetal anomalies

doi:10.21203/rs.3.rs-2577192/v1

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Evaluation of maternal anxiety and depression levels in pregnancies with fetal anomalies

https://doi.org/10.21203/rs.3.rs-2577192/v1

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Purpose

This study aimed to document depression and anxiety levels in pregnant women with intrauterine fetal anomalies based on objective measurement inventories, raise awareness of this issue and provide the necessary support to patients.

Methods

Forty pregnant women between the ages of 18–41 who were diagnosed with a major fetal anomaly, and decided their pregnancy to continue were included in the study group. Forty pregnant women with a healthy fetus and gestational week and maternal age matched with the study group were included as the control group. The Beck Depression Inventory (BDI) and the Spielberger State-Trait Anxiety Inventory (STAI) were applied to pregnant women.

Results

Anxiety and depression levels were compared between pregnant women diagnosed with an intrauterine fetal anomaly and the control group. The mean BDI score was statistically significant in the study group (P = 0.008). In the STAI scoring, the mean state anxiety level (P<0.001) and the mean trait anxiety score was (P = 0.001) and found to be statistically significant in the study group.

Conclusion

The depressive symptom scores and the state and trait anxiety levels of pregnant women with the intrauterine fetal anomaly, increased compared to the healthy pregnant women. These women should be provided with professional psychological support and necessary medical assistance during this difficult period.

anxiety

depression

high-risk pregnancy

fetal anomaly

While pregnancy is a desired and planned situation for many women, pregnancy is a physiological condition that also includes some risks for the mother and the infant. Pregnancy is a process in which there may be factors that can cause many anxiety and stress. Anxiety disorder is a psychiatric condition characterized by the continuous or intermittent intense and disturbing state of concern, distress, fear, and feelings of fear and anxiety during the day. Depression is a mood disorder with deep sadness, loss of interest in the environment, pessimistic thoughts, and an increased risk of suicide. It has been found that the frequency of anxiety and depression during pregnancy increases compared to the normal population [1]. Depression is a common complication of pregnancy and the postpartum period. Maternal depression, anxiety, and stress are reported to be associated with preterm delivery, low birth weight, fetal growth retardation, and adverse fetal neurodevelopmental outcomes [2, 3]. Factors such as the psychosocial status of the pregnant woman, socioeconomic condition, exposure to trauma, unplanned pregnancy, advanced age pregnancy, high-risk pregnancy, and the lack of social support are among the etiological causes [3].

The frequency of detecting major fetal congenital anomalies during pregnancy or the postpartum period is 2–3%. These anomalies generally include chromosomal or structural anomalies. Recently, the rate of intrauterine detection of fetal anomalies increases due to the development of antenatal screening tests and obstetric ultrasonography techniques. Some studies reported that women whose pregnancy has been terminated due to fetal anomaly experience significant emotional stress [4]. There is also a systematic review stated that 20 to 100% of pregnant women with obstetric complications had increased levels of state anxiety, and high maternal anxiety levels might be associated with poor maternal outcomes [5]. Pregnancy is a special period when the physical and mental health of the mother and fetus are closely related. It requires careful consideration of mental well-being while taking care of the physical health of the mother and the fetus. Pregnancies with fetal or maternal risk, adversely affect the antepartum and postpartum periods of patients and may even cause them to spend their reproductive years under psychological and physiological stress. This study aimed to determine depression and anxiety levels in pregnant women who continue their pregnancies with intrauterine fetal anomalies, raise awareness of this issue, and provide patients with the necessary support during the antenatal and postpartum periods.

2.1. Study Design

This study was designed as a prospective case-control study.

2.2. Participants

Forty pregnant women between the ages of 18–41 who presented to Ankara City Hospital Perinatology outpatient clinic which is a tertiary referral center, between January 2022 and April 2022, were diagnosed with major fetal anomalies during their antenatal follow-ups (congenital heart disease, central nervous system anomaly, chromosomal anomaly), were in the second and third trimesters of their pregnancy, were included in this case-control study. Fetal anomaly diagnosis was confirmed by ultrasonographic anomaly screening or an invasive prenatal diagnostic test (amniocentesis, CVS, cordocentesis). Pregnant women who wanted to continue their pregnancy were included in the study group. Their diagnoses were categorized as structural multiple malformations (40%), central nervous system anomalies (25%), congenital heart anomalies (27.5%), and chromosomal anomalies (7.5%). We could not include first trimester pregnancies in the study, because of waiting for invasive prenatal test results and waiting 4 weeks after diagnosis to apply the questionnaires. Forty pregnant women with a singleton pregnancy who presented to the antenatal outpatient clinic for routine check-ups, did not have any chronic disease or suspected fetal anomaly and were in the same age range and gestational week were included as the control group. Pregnant women who did not volunteer to participate in the study had a diagnosis of mental illness, and had a chronic or pregnancy-related systemic disease were excluded from the study.

2.3. Data collection

The age, height, weight, education and employment status, monthly income level, history of smoking and alcohol use, and sociodemographic characteristics of the patients who volunteered to participate in the study were recorded. The number of pregnancies, the history of miscarriage, the number of living children, whether the pregnancy was planned or not, the history of a fetal anomaly in previous pregnancies, and kinship with the spouse were questioned and recorded. The form of the detected fetal anomaly was examined and classified. Obstetric ultrasonographic examinations of all patients were performed. The case follow-up form was prepared and filled out separately for both groups. The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) were applied to pregnant women. These questionnaires were applied to pregnant women in the study group 4 weeks after the diagnosis of a fetal anomaly to rule out possible symptoms related to an acute stress reaction.

2.4. Study Instruments

Beck Depression Inventory (BDI): It is a depression rating scale consisting of 21 questions, which was developed by Aaron T. Beck in 1961 and revised in 1996, and whose validity and reliability study was conducted in Turkey by Hisli et al. [6]. By the score ranges corresponding to the patient's answers, the scale is rated as minimal depressive symptoms between 0–9 points, mild depressive symptoms between 10–16 points, moderate depressive symptoms between 17–29 points, and severe depressive symptoms between 30–63 points.

State-Trait Anxiety Inventory (STAI): Its original form was developed by Charles Spielberger et al. and revised over the years. It was adapted to Turkey by Öner and LeCompte [7]. Individuals respond to each 20-item scale with the instruction of how he/she "usually" feels. The STAI has two types of statements. Direct statements express negative emotions, and reversed statements express positive emotions. After the total weights of the direct and reversed statements are found separately, the total weight score of the reversed statements is subtracted from the total weight score obtained for the direct statements. Scores range from 20 (low anxiety) to 80 (high anxiety). High scores indicate high anxiety levels, and low scores indicate low anxiety levels. The State Anxiety Inventory (SAI) is used to evaluate reactions due to sudden excitement. The Trait Anxiety Inventory (TAI) is a sensitive scale used to measure the continuity of anxiety experienced by a person.

2.5. Statistical analysis

Statistical analyses were performed using IBM SPSS for Microsoft Windows 25.0 (SPSS Inc., Chicago, IL, USA). For categorical variables, frequency (n) and percentage (%), and for numerical variables, mean (X) and standard deviation (sd) statistics were calculated. The conformity of the variables to the normal distribution was examined using visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk tests). Descriptive analyses were given using the mean and standard deviations for normally distributed variables. Independent groups were compared using the Student's t-test. The ratios among independent groups were given using the chi-squared test and cross tables. Cases with a p-value less than 0.05 were considered statistically significant results. Correlation coefficients and statistical significance were calculated with Spearman's test for the relationships between the non-normally distributed variables. Type-1 error level was used as 5% for statistical significance.

Sociodemographic characteristics were compared between the study and control groups. Considering the educational status, the educational level was found to be similar between the groups (P = 0.479). It was observed that the pregnant group with fetal anomaly mostly consisted of multiparous pregnant women by 67.5% (27/40), while the control group mostly consisted of primiparous pregnant women by 57.5% (23/40). This result was a statistically significant difference (P = 0.004). When the case group was compared with the control group, it was observed that pregnant women constituting the case group contributed statistically less to their working life (P = 0.032). There was no difference between the groups in terms of consanguineous marriage (P = 1.0) and the history of abortus (P = 0.655). However, when the history of infants with an anomaly was examined, it was determined that there was a history of infants with an anomaly at a level that would cause a statistically significant difference in the group with intrauterine fetal anomaly (P = 0.040). The mean age between the groups was similar by 28.67±6.33 in the case group and 26.55±5.57 in the control group (P = 0.115), and there was no difference in monthly income level (P = 0.584) (Table 1).

Table 1

The intergroup comparison of sociodemographic characteristics
		Fetal anomaly group N:40 n (%)	Control group N:40 n (%)	P value
Education N (%)				0.479
	illiterate	1 (2.5%)	1 (2.5%)
	primary	14 (35%)	8 (20%)
	High school	16 (40%)	18 (45%)
	University and above	9 (22.5%)	13 (32.5%)
Parity N (%)				0.004
	primiparity	13 (32.5%)	23 (57.5%)
	multiparity	27 (67.5%)	17 (42.5%)
Employment Status N (%)				0.032
	employed	5 (12.5%)	13 (32.5%)
	housewife	35 (87%)	27 (67.5%)
Consanguineous Marriage N (%)				1.00
	yes	9 (22.5%)	9 (22.5%)
	no	31 (77.5%)	31 (77.5%)
Previous fetal anomaly history N (%)				0.040
	yes	4 (%10)	0 (0%)
	no	36 (90%)	40 (100%)
Abortion history N (%)				0.655
	yes	9 (22.5%)	12 (30%)
	no	31 (77.5%)	28 (70%)
Monthly** income N (%)				0.584
	1*	20 (50%)	18 (45%)
	2*	15 (37.5%)	19 (47.5%)
	3*	5 (12.5%)	3 (7.5%)
Age Mean±std.				0.115
Age Mean±std.		28.67±6.33	26.55±5.57	0.115
** Prepared according to the data of TurkStat on June 15, 2021 [22].
*1 = minimum wage and below income, 2 = income between minimum wage and poverty threshold, 3 = income above the poverty threshold

The BDI score was found to be statistically significantly higher in the pregnant group with a diagnosis of a fetal anomaly compared to the control group (P = 0.008). While the mean score was compatible with minimal depressive symptoms by 8.17±6.34 (28/40 70%) in the control group, it was found to be compatible with mild depressive symptoms by 12.42±7.59 (16/40 40%) in the pregnant group with fetal anomaly (P = 0.008). In the STAI scoring, state anxiety (P = 0.000) and trait anxiety (P = 0.001) scores were found to be statistically significantly different from the control group (Table 2).

Table 2

The intergroup comparison of the BDI, STAI-S, STAI-T inventories
	Fetal anomaly group mean ±std.	Control group mean ±std.	P value
BDI score	12.42±7.59	8.17±6.34	0.008
STAI-S score	50.65±10.03	35.95±9.97	0.000
STAI-T score	46.00±7.93	39.90±7.70	0.001
Total	40	40
BDI: Beck Depression Inventory; STAI-S: State-Trait Anxiety Inventory-State; STAI-T: State-Trait Anxiety Inventory- Trait

The correlation between the patients' sociodemographic characteristics and their anxiety and depression states was examined. There was a positive correlation between the state anxiety level and the patient's age and gravity. It was determined that the state anxiety scores of the patients increased as their age increased (P = 0.036) and the state anxiety levels of the patients increased as gravity increased (P = 0.034). No correlation was found between educational status, gestational week, and anxiety and depression scores (Table 3).

Table 3

Correlation of sociodemographic characteristics with anxiety, depression, and stress states
	BDI score		STAI-S score		STAI-T score
	r	p	r	P	r	p
Age	0.138	0.224	0.235	0.036	-0.018	0.876
Gestational Age	0.063	0.580	0.082	0.470	-0.015	0.895
Education	-0.108	0.340	-0.131	0.246	-0.199	0.078
Gravida	0.167	0.140	0.237	0.034	0.102	0.366
BDI: Beck Depression Inventory; STAI-S: State-Trait Anxiety Inventory-State; STAI-T: State-TraitAnxiety Inventory- Trait

Depression and anxiety scores between the second and third trimesters were compared in the study group. There was no difference in depression score and trait anxiety level. However, the level of state anxiety was found to be significantly higher in the third trimester of pregnancy compared to the second trimester (P = 0.018) (Table 4).

Table 4

Depression and anxiety levels between the trimesters
	Second trimester Mean±std. N:22/40 (55%)	Third trimester Mean±std. N:18/40 (45%)	P value
BDI score	10.77±4.47	14.44±9.99	0.130
STAI-S score	47.31±9.17	54.72±9.76	0.018
STAI-T score	45.27±6.53	46.88±9.49	0.528
BDI: Beck Depression Inventory; STAI-S: State-Trait Anxiety Inventory-State; STAI-T: State-Trait Anxiety Inventory- Trait

This study aimed to compare the depression and anxiety levels of pregnant women diagnosed with intrauterine fetal anomaly and pregnant women with healthy fetuses. The present study showed that depression, state, and trait anxiety levels of pregnant women diagnosed with intrauterine fetal anomaly increased compared to pregnant women with healthy fetuses.

According to the present study, carrying a fetus with an anomaly was found to be associated with an increased level of anxiety during pregnancy. This result is consistent with previous studies [8–10]. One of these studies was based on retrospective reporting and children included in the study follow up to three years old. These points were different from the present study [8]. According to the results of the survey conducted 6 weeks after the termination, it was observed that more post-traumatic stress symptoms occurred in women who had a pregnancy termination in the second trimester due to fetal anomaly compared to first-trimester terminations. This study reported that state anxiety levels were higher in pregnant women with a diagnosis of fetal anomaly requiring surgery in the neonatal period 6 weeks after termination compared to pregnant women with a healthy fetus [10]. In this study, questionnaires were applied to the individuals just after the diagnosis. In the present study, we applied the tests 4 weeks after the diagnosis of a fetal anomaly to rule out possible symptoms related to an acute stress reaction. A study indicated that undergoing a prenatal screening test independently of the diagnosis of fetal anomaly did not affect the level of anxiety, but pregnant women with a positive screening test result had higher state anxiety levels [11]. In another study, the anxiety levels of 60 pregnant women with positive biochemical Trisomy 21 screening results before and after the amniocentesis procedure were measured, and it was observed that the state anxiety levels of patients increased significantly more during the waiting period for karyotype results [12].

The incidence of antenatal depression is considered to vary between 7 and 19% [13, 14]. Another important result of the present study was that the diagnosis of the fetal anomaly was associated with increased depression symptoms in pregnant women. We found only one study evaluating the relationship between the diagnosis of fetal anomaly and depressive symptoms during pregnancy. Similar to the results of our study, it revealed that the diagnosis of the fetal anomaly was associated with increased depressive symptoms and increased anxiety, and depression symptoms also continued after delivery [8].

Studies evaluating anxiety and depression levels between the trimesters of pregnancy have reported that depression and anxiety scores are higher in the third trimester compared to other trimesters [15, 16]. Another study reported that anxiety levels were high in the first and third trimesters during pregnancy, and depressive symptoms were high in the first trimester and gradually decreased in the following trimesters [17]. Our study observed that the state anxiety levels of pregnant women with fetal anomaly in the third trimester were higher than those in the second trimester. Higher anxiety levels in the third trimester of pregnancy may be explained by the fact that the upcoming childbirth and/or the anticipations about being a parent. To face with an unknown situation about the condition of the fetus could be one of the possible reasons. Further research should be carried out to clarify this finding.

The present study demonstrated a positive correlation between maternal age, parity, and state anxiety levels in pregnant women with a diagnosis of intrauterine fetal anomaly. This result is different from the results of some studies in the literature. Contrary to our results, some studies evaluating the relationship between maternal age and anxiety level in pregnant women associated young maternal age with increased anxiety levels during pregnancy [18–20]. But, these studies evaluated only healthy pregnant women. On the other hand, it was reported that advanced age was associated with increased depression and anxiety symptoms in women who continued their pregnancy with a diagnosis of a fetal anomaly as in our study [8, 10]. When it is evaluated with the studies in the literature, the result of our study may be useful in terms of identifying high-risk groups and receiving the necessary support in the early period.

There are studies indicating that low educational level and socioeconomic level, insufficient social support, early gestational age, and first pregnancy are risk factors for the diagnoses of anxiety disorders and depression in pregnancy [17, 18, 21]. No significant difference was identified between the two groups included in our study in terms of age, educational level, and monthly income levels. Only the difference between the groups in terms of parity numbers was significant.

The small sample size is one of the major limitations of the study. The small sample size may have limited the generalizability of the study results by causing low statistical power. Furthermore, the fact that the postpartum period and spouse anxiety and depression levels were not included in the evaluation can be considered among the other limitations.

In conclusion, diagnosis of fetal anomaly increases the risk of depression and anxiety in expectant mothers during pregnancy. Considering these factors and the physiology of pregnancy, mood and anxiety disorders in expectant mothers within high risk fetal situations should be addressed carefully, and an attempt should be made to provide patients with maximum benefits through a multidisciplinary approach. Emotional state screening in the prenatal period among high risk pregnancies may help physicians better identify the potential psychological distress.

BDI

Beck Depression Inventory

STAI

State-Trait Anxiety Inventory

CVS

Chorion Villus Sampling

Acknowledgments

The authors would like to acknowledge health professionals who work in Ankara City Hospital Perinatology Department.

Funding

No funds, grants, or other support was received.

Conflict of interest disclosure

The authors declare that they have no conflicts of interest.

Ethics approval

The study protocol was approved by the Ministry of Health of the Republic of Turkey and was performed in line with the Declaration of Helsinki. The ethics committee approval was obtained from Ankara City Hospital No. 2 clinical research ethics board with the decision number E2-22-1261 and dated 19/01/2022.

Informed consent

All study participants were informed and their consent was obtained.

Author Contribution

All authors contributed to the study's conception and design. All authors read and approved the final manuscript. B Laleli Koc: Project development, Data Collection, Data analysis, Manuscript writing. D Tugrul Ersak: Data collection, Data analysis. B Elmas: Data collection, Project development. KC Can: Manuscript writing/editing. O Kara: Data analysis, Manuscript editing. D Sahin: Project development, Manuscript writing.

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Evaluation of maternal anxiety and depression levels in pregnancies with fetal anomalies

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Version 1

Abstract

Purpose

Methods

Results

Conclusion

1. Introduction

2. Materials And Methods

2.1. Study Design

2.2. Participants

2.3. Data collection

2.4. Study Instruments

2.5. Statistical analysis

3. Results

4. Discussion

Abbreviations

Declarations

References

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