Anne Helbig

Acute maternal social dysfunction, health perception and psychological distress after ultrasonographic detection of a fetal structural anomaly

Please cite this paper as: Kaasen A, Helbig A, Malt U, Næs T, Skari H, Haugen G. Acute maternal social dysfunction, health perception and psychological distress after ultrasonographic detection of a fetal structural anomaly. BJOG 2010;117:1127–1138.

Does Antenatal Maternal Psychological Distress Affect Placental Circulation in the Third Trimester

Introduction Some types of antenatal maternal psychological distress may be associated with reduced fetal growth and birthweight. A stress-mediated reduction in placental blood flow has been suggested as a mechanism. Previous studies have examined this using ultrasound-derived arterial resistance measures in the uterine (UtA) and umbilical (UA) arteries, with mixed conclusions. However, a reduction in placental volume blood flow may occur before changes in arterial resistance measures are seen. Fetoplacental volume blood flow can be quantified non-invasively in the umbilical vein (UV). Our objective was to study whether specific types of maternal psychological distress affect the placental circulation, using volume blood flow quantification in addition to arterial resistance measures. Methods This was a prospective observational study of 104 non-smoking pregnant women (gestational age 30 weeks) with uncomplicated obstetric histories. Psychological distress was measured by General Health Questionnaire-28 (subscales anxiety and depression) and Impact of Event Scale-22 (subscales intrusion, avoidance and arousal). UtA and UA resistance measures and UV volume blood flow normalized for fetal abdominal circumference, were obtained by Doppler ultrasound. Results IES intrusion scores above the mean were associated with a reduction in normalized UV volume blood flow (corresponding to –0.61 SD; P = 0.003). Adjusting for UA resistance increased the strength of this association (difference –0.66 SD; P<0.001). Other distress types were not associated with UV volume blood flow. Maternal distress was not associated with arterial resistance measures, despite adjustment for confounders. Conclusions Intrusive thoughts and emotional distress regarding the fetus were associated with reduced fetoplacental volume blood flow in third trimester. Uterine and umbilical artery resistance measures were not associated with maternal distress. Our findings support a decrease in fetoplacental blood flow as a possible pathway between maternal distress and reduced fetal growth.

Psychological distress after recent detection of fetal malformation: short‐term effect on second‐trimester uteroplacental and fetoplacental circulation

Please cite this paper as: Helbig A, Kaasen A, Malt U, Haugen G. Psychological distress after recent detection of fetal malformation: short‐term effect on second‐trimester uteroplacental and fetoplacental circulation. BJOG 2011;118:1653–1657.

The relation of psychological distress to salivary and serum cortisol levels in pregnant women shortly after the diagnosis of a structural fetal anomaly

Objective. To examine the association between psychological distress and levels of salivary cortisol (SalC) and the ratio of serum cortisol to cortisol‐binding globulin (SC/CBG) in pregnant women shortly after the diagnosis of a structural fetal anomaly. Design. A prospective, observational study. Setting. Tertiary referral center for fetal medicine. Population. Pregnant women with (study group, n=126) and without a fetal structural anomaly (comparison group, n=106) were included. Gestational age (GA) was >12weeks. Methods. Psychological distress was assessed by Impact of Event Scale (IES‐22), General Health Questionnaire (GHQ‐28) and Edinburgh Postnatal Depression Scale (EPDS). Salivary cortisol was measured in the evening and SC/CBG in the morning. Main Outcome Measures. Levels of SalC (in nanomoles per liter) and SC/CBG. Results. Median (range) GA at assessment was 19 (12–38) and 19 (13–22)weeks in the study and the comparison group, respectively. The study group had significantly higher psychological distress levels (p≤0.001) than the comparison group in all outcome measures. Salivary cortisol correlated with GA in both groups (p<0.004). In subanalyses including only women with GA 18–22weeks, and excluding smokers or women with chronic diseases or medication which might interfere with cortisol levels, there were no relations of SalC or SC/CBG with the psychometric variables in the study group. Conclusions. Women with detected fetal malformation had high psychological distress scores. The lack of association between psychological distress and SalC or SC/CBG suggests a blunted response of the hypothalamic–pituitary–adrenal axis following recent psychological stress activation in the second trimester of pregnancy.

Antenatal maternal emotional distress and duration of pregnancy.

Objective(s) We sought to prospectively study the association between antenatal emotional distress and gestational length at birth as well as preterm birth. Study Design We followed up 40,077 primiparous women in the Norwegian Mother and Child Cohort Study. Emotional distress was reported in a short form of the Hopkins Symptom Checklist-25 (SCL-5) at 17 and 30 weeks of gestation. Gestational length at birth, obtained from the Medical Birth Registry of Norway, was used as continuous (gestational length in days) and categorized (early preterm (22–31 weeks) and late preterm (32–36 weeks) versus term birth (≥37 weeks)) outcome, using linear and logistic regression analysis, respectively. Births were divided into spontaneous and provider-initiated. Results Of all women, 7.4% reported emotional distress at 17 weeks, 6.0% at 30 weeks and 5.1% had a preterm birth. All measurements of emotional distress at 30 weeks were significantly associated with a reduction of gestational length, in days, for provider-initiated births at term. Emotional distress at 30 weeks showed a reduced duration of pregnancy at birth of 2.40 days for provider-initiated births at term. An increase in emotional distress from 17 to 30 weeks was associated with a reduction of gestational length at birth of 2.13 days for provider-initiated births at term. Sustained high emotional distress was associated with a reduction of gestational length at birth of 2.82 days for provider-initiated births. Emotional distress did not increase the risk of either early or late preterm birth. Conclusion Emotional distress at 30 weeks, an increase in emotional distress from 17 to 30 weeks and sustained high levels of emotional distress were associated with a reduction in gestational length in days for provider-initiated term birth. We found no significant association between emotional distress and the risk of preterm birth.

Umbilical artery Doppler flow velocity waveforms after transplacental amniocentesis

OBJECTIVE To assess the influence of transplacental versus nontransplacental needle passage during genetic amniocentesis on umbilical artery (UA) pulsatility index (PI) and fetal heart rate (FHR). METHODS Genetic amniocentesis was performed in 205 women with no major fetal malformations detected by prenatal ultrasound at a median gestational age of 14 weeks and 3 days (range 13 weeks and 1 day to 18 weeks and 6 days). Chromosomal abnormalities were observed in five fetuses. These pregnancies were excluded from further analyses. The study group consisted of 56 of the remaining 200 women in whom amniocentesis had been performed transplacentally. As controls two patients with nontransplacental needle passage were chosen for each woman in the study group, matched for gestational age (± 3 days) and as far as possible for the indication for amniocentesis. The UA PI and the FHR were measured immediately before and after the amniocentesis. RESULTS Amniocentesis did not cause significant changes in UA PI and FHR within or between the two groups. Division of the study population into three subgroups dependent on gestational age did not alter the results. Pregnancy outcome was similar in the two groups. CONCLUSION Transplacental needle passage during amniocentesis did not induce any changes in UA PI or FHR relative to a group with nontransplacental amniocentesis.

OP12.01: Ultrasonographic detection of fetal malformation and parental longitudinal psychological stress responses

Objectives: Treatment strategies of fetal heart beat (FHB)-positive Caesarean scar pregnancy (CSP) depend on the medical environment, social environment and gross domestic product. This study aimed to identify the most appropriate strategies by reviewing strategies that were addressed in previous studies in our country. Methods: We searched articles in these 5 years using the key word ”Caesarean scar pregnancy” from our national medical journal article retrieval system. We searched 38 articles. In these articles, we omitted articles in which the subject of the article was not FHB-positive CSP. We finally included 20 articles and reviewed them. We reviewed the treatment techniques and their order and combination as treatment strategies. Results: FHB-positive CSP cases were treated with 10 different treatment techniques. These treatments were (1) feticide (10 articles), (2) general administration of methotrexate (MTX) (10 articles), (3) local administration of MTX (5 articles), (4) misoprostol (1 article), (5) Transarterial embolisation (TAE) (5 articles), (6) laparoscopic blood vessel clipping (1 article), (7) vaginal CSP resection (7 articles), (8) laparoscopic CSP resection (2 articles), (9) hysteroscopic CSP resection (1 article), and (10) hysterectomy (2 articles). Feticide was performed in 50% (10/20) of articles. General MTX, local MTX, and misoprostol were drug therapies. TAE and laparoscopic blood vessel clipping decreased blood supply. Operative (vaginal, laparoscopic, hysteroscopic, and abdominal resection) CSP resection was performed in 12 of 20 (60%) articles. Treatment of CSP was achieved by a combination of some techniques, such as feticide, drug therapy, blood supply-decreasing techniques, and operative CSP resection, in this order. Conclusions: Feticide was considered necessary in 50% of articles. CSP resection was performed in 60% of articles. Treatment of CSP was achieved by a combination of some techniques, such as feticide, drug therapy, decreasing blood supply, and operative CSP resection. OP12: SCREENING

Maternal psychological responses during pregnancy after ultrasonographic detection of structural fetal anomalies: A prospective longitudinal observational study

In this longitudinal prospective observational study performed at a tertiary perinatal referral centre, we aimed to assess maternal distress in pregnancy in women with ultrasound findings of fetal anomaly and compare this with distress in pregnant women with normal ultrasound findings. Pregnant women with a structural fetal anomaly (n = 48) and normal ultrasound (n = 105) were included. We administered self-report questionnaires (General Health Questionnaire-28, Impact of Event Scale-22 [IES], and Edinburgh Postnatal Depression Scale) a few days following ultrasound detection of a fetal anomaly or a normal ultrasound (T1), 3 weeks post-ultrasound (T2), and at 30 (T3) and 36 weeks gestation (T4). Social dysfunction, health perception, and psychological distress (intrusion, avoidance, arousal, anxiety, and depression) were the main outcome measures. The median gestational age at T1 was 20 and 19 weeks in the group with and without fetal anomaly, respectively. In the fetal anomaly group, all psychological distress scores were highest at T1. In the group with a normal scan, distress scores were stable throughout pregnancy. At all assessments, the fetal anomaly group scored significantly higher (especially on depression-related questions) compared to the normal scan group, except on the IES Intrusion and Arousal subscales at T4, although with large individual differences. In conclusion, women with a known fetal anomaly initially had high stress scores, which gradually decreased, resembling those in women with a normal pregnancy. Psychological stress levels were stable and low during the latter half of gestation in women with a normal pregnancy.

OP27.06: Does maternal psychological distress affect feto-placental volume blood flow in third trimester?

Results: A total of 101 twin pregnancies were evaluated in the analyses. The percentages of spontaneous and IVF twins were 22.8% and 77.2% respectively. Mean gestational age was 22.41 ± 3.30 weeks in IVF twin group and 21.55 ± 3.56 weeks in spontaneous twin group. The difference of the gestational age between groups was not statistically significant. Mean uterine artery impedance was found as 0.82 ± 0.28 and 0.97 ± 0.29 in IVF and spontaneous twins respectively. Mean values were significantly lower in the IVF twins (P < 0.05). Conclusions: The uterine artery impedance in the second trimester is significantly lower in IVF twins compared to the spontaneous twins.

OP37.07: Paternal psychological response shortly after ultrasonographic detection of structural fetal anomaly

Objectives: To compare predictive performance of obstetric physicians (OP) vs. pediatric physicians (PP), judging standardized high quality US images of omphalocele in terms of the likelihood of primary surgical closure. To establish the key information guiding that judgment. Methods: Cases with an omphalocele, isolated or with minor anomalies, with ≥ 1 complete investigation between 12–23 weeks of gestation (n = 21) were drawn from our US database. Additional prenatal characteristics and postnatal outcome data were collected. We devised a standardized presentation of each case on a form, providing: images, image related data (defect Ø; 2 ratios: cele circumference/abdominal circumference and defect Ø/abdominal Ø), and prenatal data. Respondents were required to state the likelihood of primary closure in terms of quantitative probability (6 range categories: 0–20%, 20–40%, 40–60% and 80–100%) An ‘unable to predict’ category was included. Respondents were: 10 OP vs. 9 PP. All respondents were blinded towards the patient and unaware of postnatal outcome. Results: The 19 physicians provided 399 answers for 21 cases (complete). In retrospect primary closure was observed in 13/21, and predicted correctly (majority of respondents predicted 60% or more answer) in 5/13 cases. In the remaining 8/21 cases of non closure, in 1/8 the majority predicted failure (20% or less answer). From a predictive point of view, in 92% of the > 60% responses, this prediction was correct. However, in only 60% of the < 20% predictions, primary closure actually failed. Prediction failure did not differ according to specialty, yet individuals showed pessimism/optimism differences. Individual accuracy ranged from 2/21 to 13/21. The cele content was the primary information tag according to 17/19 respondents, while only 4/19 mentioned the diameter and 8/19 the ratios. Conclusions: Antenatal judgment on primary closure of an omphalocele by OP and PP shows no inter-professional differences. However, these experts were too pessimistic as 40% predicted non closures actually closed. This may affect counseling results.