International Journal of Gynecology and Obstetrics 121 (2013) 123126

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Effectiveness of psychological intervention for treating symptoms of anxiety and depression among pregnant women diagnosed with fetal malformation
Renata P. Gorayeb a,, Ricardo Gorayeb a, Aderson T. Berezowski b, Geraldo Duarte b
a b

Department of Neurosciences and Behavioral Sciences, School of Medicine at Ribeiro Preto, University of So Paulo, So Paulo, Brazil Department of Gynecology and Obstetrics, School of Medicine at Ribeiro Preto, University of So Paulo, So Paulo, Brazil

a r t i c l e

i n f o

a b s t r a c t
Objective: To determine the effectiveness of a psychological intervention targeting pregnant women with fetal malformation. Methods: A clinical study was conducted that enrolled 65 pregnant women attending Clinics Hospital at Ribeiro Preto, University of So Paulo, Brazil, between February 2004 and May 2008. Participants were allocated to 1 of 4 groups: normal pregnancy (NP), fetal malformation (FM), fetal or neonatal death (FD), and control (CG). Psychological interventionincluding support, empathy, education, and desensitization was provided to the NP, FM, and FD groups. Women in CG did not receive the intervention and were assessed in the postnatal period only. Anxiety was measured using the Hospital Anxiety and Depression (HAD) scale. Depression was measured by HAD and the Edinburgh Postnatal Depression Scale. Results: Signicant reductions from baseline were observed in anxiety and depression scores after psychological intervention in the NP and FM groups. Symptom scores in the postnatal period were also signicantly reduced among these groups (P b 0.001). Conclusion: Psychological intervention was effective in relieving symptoms of anxiety and depression experienced by pregnant women with fetal malformation. 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Article history: Received 2 August 2012 Received in revised form 10 December 2012 Accepted 25 January 2013 Keywords: Anxiety Depression, Fetal malformation Intervention Pregnancy Psychology

1. Introduction Pregnancy, birth, and the postnatal phases are periods of life often experienced in a positive manner by parents and their close relatives. Complicated pregnancies or intrauterine impaired fetal development can negatively alter these feelings and sometimes cause psychological manifestations that require specialized intervention [1]. Fetal developmental disturbances or malformations increase the risk of maternal depression [24]. Mothers of children with congenital heart disease are appreciably more likely than mothers of healthy children to have puerperal and post-puerperal depression and anxiety, and the magnitude of fetal disease is associated with the severity of depression [2]. Fetal and neonatal deaths are also associated with negative reactions, such as depression, difculty in sleeping, irritability, eating disorders, and delusional symptoms [5]. A study conducted in Niger found that all women who had experienced spontaneous abortions exhibited depressive symptoms, and approximately 14% of them experienced symptoms of severe depression [1]. Such effects, however, tend to be minimized over the rst 2 years following loss of the fetus. A study by Leon indicated that bereaved parents gradually

Corresponding author at: Departamento de Neurocincias e Cincias do Comportamento da Faculdade de Medicina de Ribeiro Preto da Universidade de So Paulo, Avenida Bandeirantes 3900, Ribeiro Preto, So Paulo 14.049 000, Brazil. Tel.: +55 16 3602 2320; fax: +55 16 3602 2385. E-mail address: renatagorayeb@gmail.com (R.P. Gorayeb).

resume their daily activities and are eventually able to experience pleasure in life again [3]. Despite this recovery, the experience of spontaneous abortion completely alters the manner in which an individual regards life, relationships, and the future; this observation suggests that spontaneous abortion is an experience with important psychological impact [3]. Studies have also focused on the association between mental health and adverse responses to events occurring during pregnancy or in the puerperium [6,7]. Illnesses such as depression, anxiety, schizophrenia, and suicidal ideation seem to be risk factors for impaired fetal development and death [7]. Another important aspect for pregnant women with fetal malformation is the strong psychological effect of the decision to either proceed with the pregnancy or abort it. Many international studies have investigated the emotions involved in making this difcult decision [810]. Aune and Mller noted that numerous elements are involved in the process a woman goes through before she is able to choose whether or not to end the pregnancy [10]. These elements include the emotional connection with the fetus, social pressures, feelings of guilt, and a perceived lack of control over the situation. The necessity to make choices about her own future and that of her fetus can cause a pregnant woman to experience a variety of feelings and an emotional crisis, which Summerseth and Sundby have termed a "continuous state of chaos" [8]. In Brazil, issues surrounding the decision to undergo induced abortion affect only a small portion of the population because laws, which

0020-7292/$ see front matter 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.12.013

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were primarily written according to Christian culture, state that it is illegal to abort a pregnancy on the grounds of fetal malformation. Induced abortions are only legally allowed in instances of rape, risk of maternal death, or fetal anencephaly. Therefore, the need to make a decision on the future of a pregnancy is not experienced by an appreciable number of Brazilian women. The main concerns that pregnant Brazilian women face are those related to coping with the situation. In addition, issues related to the maternalfetal bond, social acceptance, and guilt experienced in the wake of avoidable neonatal death or delivery of a child with long-term malformation must also be faced [810]. These data reinforce the importance of investigating the psycho-emotional coping mechanisms that pregnant women display in response to fetal malformation. Such studies might facilitate the development of tools to assist and guide clinical teams on how to provide the best possible care and how to prevent the anxiety and depression that so frequently occur in these situations. Nonetheless, very little is known about the complex patterns of psychological response among pregnant women who are informed that they may face a spontaneous abortion or that their fetus could have serious developmental problems. Furthermore, few studies have addressed the efcacy of supportive psychological techniques that aim to mitigate the negative effect of receiving this kind of information during pregnancy. Limited evidence suggests women facing such situations benet from psychological support, which mainly manifest through decreases in the severity and duration of symptoms related to depression and anxiety [11]. These studies [811] are relevant in order to test interventions that may offer support to women while facing adversity, thereby increasing their ability to cope with severe stress. The aim of the present study was to determine the effectiveness of a psychological intervention targeting anxiety and depression among pregnant women with fetal malformation. 2. Materials and methods A clinical study was conducted that enrolled a convenience sample of 65 pregnant women attending Clinics Hospital, University of So Paulo, So Paulo, Brazil, between February 1, 2004, and May 31, 2008. The study design was approved by the Ethics in Research Committee of the University of So Paulo. All women who agreed to participate signed informed consent forms after learning details of the present study. For minors, the parents or guardians were also required to sign the consent form. Inclusion criteria were age of at least 18 years (minors could participate if accompanied by consenting guardians), no history of pregnancy malformations, and no legal option to abort the pregnancy. Women with impaired cognition who might not be able to understand the present study or participate in the assessments were excluded, as were women who missed 3 consecutive prenatal visits. As shown in Table 1, the 65 participants were divided into 4 groups: normal pregnancy (NP), fetal malformation (FM), fetal or neonatal death (FD), and control (CG). Women allocated to CG underwent prenatal care at centers that did not provide psychological assistance; therefore, they only contributed to the postnatal assessment. These women were selected
Table 1 Denition of the 4 study groups. Group Normal pregnancy (n = 15) Fetal malformation (n = 16) Fetal or neonatal death (n = 15) Control (n = 19) Inclusion criteria No fetal malformation and receiving prenatal care in the hospital where the present study was conducted Fetal malformation and receiving prenatal care in the hospital where the present study was conducted Women excluded from the fetal malformation group owing to death of the fetus or newborn Fetal malformation but not receiving prenatal care in the hospital where the present study was conducted

by the medical team to match the clinical conditions of women assigned to FM (i.e. maternal inclusion and exclusion criteria and type of fetal malformation). Surgical risk for women in FM versus CG was also assessed and included neurosurgery (50.0% vs 52.6%), cardiac surgery (25.0% vs 26.3%), orthopedic surgery (18.7% vs 15.8%), and abdominal surgery (6.2% vs 5.3%). After initial assessment, psychological intervention was provided to the NP, FM, and FD groups only and involved the pregnant woman and her family during return prenatal visits. All treatments included a welcome meeting that was targeted to the demands of each individual participant, during which the women were listened to sympathetically, their feelings about motherhood were validated, and their feelings of powerlessness to tackle the problem redirected toward coping attitudes. During these meetings, counselors and participants discussed any potential questions and ideas that did not correspond to the reality of the diagnosis of fetal malformation. The team also offered information on the diagnosis and possible preoperative, operative, and postoperative procedures when requested by participants or their relatives. In all cases, the research team used tactics to approximate the reality of the problems and the post-birth demands that the mother could face so that she could become more informed and better prepared. When necessary, systematic desensitization techniques were also employed. This approach included psychologist-accompanied visits for participants and families to the relevant hospital environments, with an introduction to the teams on the obstetric, surgical intensive care, and nursery wards. In addition, information on childbirth procedures and pediatric surgery was provided when requested by the participants. During the week of hospitalization for childbirth, all women who had received their prenatal care in the study hospital were accompanied by a psychologist. Psychological intervention lasted from the rst prenatal visit until delivery. Participants in the NP and FM groups were assessed both during pregnancy and after delivery; women in FD were assessed only during pregnancy, whereas those in CG were assessed only after the delivery. Final assessment occurred 6 months after delivery, during a routine medical visit. All 4 groups were evaluated at this time to ensure that any possible variables in mothering adequacy would not be intervening factors, as all participants had the same amount of time to adjust to their new maternal roles. The same questionnaires and assessments used in the initial visit were performed at the nal visit. The Hospital Anxiety and Depression Scale (HAD) was used to measure anxiety and depression [12]. This measure was selected because it had been broadly validated in the Brazilian population in 1995 [13]. The Edinburgh Postnatal Depression Scale (EPDS) was also used to assess depression [14]. This scale was developed to measure maternal depression in the context of relevant physiologic and metabolic changes that occur during pregnancy and puerperium. It comprises 10 items, derived from 2 other scales, HAD and the Irritability Depression and Anxiety Scale [15]. The EPDS has also been validated for use in the Brazilian population [14]. Data were analyzed using SPSS version 17.0 (IBM, Armonk, NY, USA). Variables were tested for normality by the ShapiroWilk test and the Lilliefors adjustment for signicance test. Within-group comparisons were conducted using the paired Student t test. Betweengroup comparisons were conducted using analysis of variance followed by the Bonferroni post hoc test when differences were signicant [16]. A P value of 0.05 or below was considered statistically signicant. 3. Results The majority of pregnant women (84.7%) received 4 sessions of the psychological intervention. Of the remainder, 9.2% received a lower number of sessions (minimum of 2) and 6.1% received a greater number of sessions (maximum of 8). This variance occurred according to gestational age at the time of admission to the prenatal clinic; any

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Fig. 1. Mean anxiety scores before (pre) and after (post) psychological intervention.

Fig. 3. Mean depression scores obtained using the Edinburgh Postnatal Depression Scale before (pre) and after (post) psychological intervention.

participants who did not meet the minimum requirement of at least 2 sessions were excluded from the analysis. Psychologists were present at 82.4% of deliveries and provided emotional support and strength. Fig. 1 displays the results of the HAD anxiety assessments. The baseline levels of anxiety were higher among mothers in the FM and FD groups than in the NP group (P b 0.001 and P = 0.001, respectively). After intervention, anxiety levels decreased from baseline in both the NP and FM groups (P = 0.001 and P b 0.001, respectively); however, no signicant between-group differences were observed. Women in CG displayed post-delivery anxiety levels that were significantly higher than those observed in the NP and FM groups at the same time point (P b 0.001 for both comparisons). Depression scores measured by HAD are shown in Fig. 2. Signicant differences were observed in the prenatal assessment of women in FM and FD versus those in NP (P b 0.001 and P = 0.001). In the postnatal assessment period, depression scores were higher among women in CG than in NP and FM (P b 0.001 for both comparisons). The post-intervention scores of women in FM were signicantly reduced after intervention (P b 0.001) and were similar to scores observed among women in NP. Fig. 3 displays depression scores as measured by EPDS. At baseline, scores were signicantly higher among women in FM and FD versus NP (P b 0.001 and P = 0.007, respectively). Scores for the NP and FM were both signicantly decreased from baseline in the postintervention period (P = 0.009 and P b 0.001, respectively). In the post-intervention phase, women in the NP and FM groups had depression levels that were signicantly lower than those of

women in CG (P b 0.001 for both comparisons). Indeed, the results for CG suggest that symptoms of depression persisted after delivery and during the postnatal period at higher levels than were seen at baseline among participants in the other 3 groups (Fig. 3). 4. Discussion The importance of multidisciplinary care for pregnant women diagnosed with fetal malformation is recognized by 2 areas of the published literature. Namely, that which analyzes the difculties related to the decision to either abort or complete the pregnancy, and that which assesses the development of coping and grief mechanisms in cases where pregnancy continues to term [3,5,10,17]. In countries where access to induced abortion is limited, except in certain cases prescribed by law, the importance of studying how interdisciplinary care for the pregnant woman can help her most effectively face this situation is acknowledged. The literature suggests that not treating symptoms of depression and anxiety during pregnancy increases the risk of obstetric complications, as well as postpartum depression [18]. In evaluating a group of pregnant women diagnosed with fetal malformationwhere the profound psychological impact is primarily manifested through depression and anxiety [17,19]the data recorded in the present study suggest important benets of psychological intervention in improving these symptoms. The goal of psychological intervention is to encourage the pregnant woman and her family to cope with grief associated with the reality of a diagnosis of fetal malformation. All parties involved should deal with the situation realistically and with good resources for coping with both fetal malformations and any procedures that the child may undergo once born. The aim of the present study was not to prevent pregnant women and their families from mourning. Rather, the goal was to help them cope with their grief more appropriately so that proper care for themselves, other children, and relatives during pregnancy, and for the newborn after delivery, might be maintained. The importance of multidisciplinary care is even greater in cases of spontaneous abortion or stillbirth, as the grieving is intensied and places the woman in a position of increased vulnerability [8]. The medical treatment of depression during pregnancy remains controversial [20,21]. Some studies have failed to identify an increased risk of congenital malformation among women receiving such treatment [22]. However, other studies have identied increased risk among women exposed to tricyclic antidepressants [23], selective serotonin reuptake inhibitors [23,24], and benzodiazepines [20]. Accordingly, it seems appropriate to pursue approaches that minimize fetal exposure to certain medications, while not avoiding treatment

Fig. 2. Mean depression scores obtained using the Hospital Anxiety and Depression Scale before (pre) and after (post) psychological intervention.

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R.P. Gorayeb et al. / International Journal of Gynecology and Obstetrics 121 (2013) 123126 [3] Leon IG. Helping families cope with perinatal loss. GLOWM 2008;10418. [4] Perosa GB, Canavez IC, Silveira FC, Padovani FH, Peraoli JC. Depressive and anxious symptoms in mothers of newborns with and without malformations. Rev Bras Ginecol Obstet 2009;31(9):4339. [5] Hughes P, Riches S. Psychological aspects of perinatal loss. Curr Opin Obstet Gynecol 2003;15(2):10711. [6] Ishida K, Stupp P, Serbanescu F, Tullo E. Perinatal risk for common mental disorders and suicidal ideation among women in Paraguay. Int J Gynecol Obstet 2010;110(3): 23540. [7] Schneid-Kofman N, Sheiner E, Levy A. Psychiatric illness and adverse pregnancy outcome. Int J Gynecol Obstet 2008;101(1):536. [8] Sommerseth E, Sundby J. Women's experiences when ultrasound examinations give unexpected ndings in the second trimester. Women Birth 2010;23(3):1116. [9] Asplin N, Wessel H, Marions L, Georgsson hman S. Pregnant women's experiences, needs, and preferences regarding information about malformations detected by ultrasound scan. Sex Reprod Healthc 2012;3(2):738. [10] Aune I, Mller A. 'I want a choice, but I don't want to decide'a qualitative study of pregnant women's experiences regarding early ultrasound risk assessment for chromosomal anomalies. Midwifery 2012;28(1):1423. [11] Carvalho AE, Linhares MB, Padovani FH, Martinez FE. Anxiety and depression in mothers of preterm infants and psychological intervention during hospitalization in neonatal ICU. Span J Psychol 2009;12(1):16170. [12] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67(6):36170. [13] Botega NJ, Bio MR, Zomignani MA, Garcia Jr C, Pereira WA. Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD. Rev Saude Publica 1995;29(5):35563. [14] Santos MFS, Martins FC, Pasquali L. Self- assessment Scale of Postpartum Depression: a study in Brazil. Rev Psiquiatr Clin 1999;26(2):905. [15] Snaith RP, Constantopoulos AA, Jardine MY, McGufn P. A clinical scale for the self-assessment of irritability. Br J Psychiatry 1978;132:16471. [16] Altman DG. Statistics in medical journals: developments in the 1980s. Stat Med 1991;10(12):1897913. [17] Coppola G, Costantini A, Tedone R, Pasquale S, Elia L, Barbaro MF, et al. The impact of the baby's congenital malformation on the mother's psychological well-being: an empirical contribution on the clubfoot. J Pediatr Orthop 2012;32(5):5216. [18] Freeman MP. Managing depression during pregnancy. J Clin Psychiatry 2009;70(7):e25. [19] Kersting A, Kroker K, Steinhard J, Hoernig-Franz I, Wesselmann U, Luedorff K, et al. Psychological impact on women after second and third trimester termination of pregnancy due to fetal anomalies versus women after preterm birtha 14-month follow up study. Arch Womens Ment Health 2009;12(4):193201. [20] Marinucci L, Balloni S, Carinci F, Locci P, Pezzetti F, Bodo M. Diazepam effects on non-syndromic cleft lip with or without palate: epidemiological studies, clinical ndings, genes and extracellular matrix. Expert Opin Drug Saf 2011;10(1):2333. [21] Gentile S, Bellantuono C. Selective serotonin reuptake inhibitor exposure during early pregnancy and the risk of fetal major malformations: focus on paroxetine. J Clin Psychiatry 2009;70(3):41422. [22] Nordeng H, van Gelder MM, Spigset O, Koren G, Einarson A, Eberhard-Gran M. Pregnancy outcome after exposure to antidepressants and the role of maternal depression: results from the Norwegian Mother and Child Cohort Study. J Clin Psychopharmacol 2012;32(2):18694. [23] Davis RL, Rubanowice D, McPhillips H, Raebel MA, Andrade SE, Smith D, et al. Risks of congenital malformations and perinatal events among infants exposed to antidepressant medications during pregnancy. Pharmacoepidemiol Drug Saf 2007;16(10):108694. [24] Bar-Oz B, Einarson T, Einarson A, Boskovic R, O'Brien L, Malm H, et al. Paroxetine and congenital malformations: meta-Analysis and consideration of potential confounding factors. Clin Ther 2007;29(5):91826. [25] Patil AS, Kuller JA, Rhee EH. Antidepressants in pregnancy: a review of commonly prescribed medications. Obstet Gynecol Surv 2011;66(12):77787.

of the mother [25]. The development of effective non-pharmacologic strategies for the treatment of women facing high-risk pregnancies is, therefore, an important area to research [18]. The present study supports the effectiveness of psychological intervention in reducing depression and anxiety symptoms among women with high-risk pregnancies. Intervention provided clear and direct information about the diagnosis, necessary medical procedures, and what to expect in these situations. The educational component may have contributed to reducing anxiety by promoting feelings of trust and safety [10,19]. The research was conducted at a teaching hospital, where the Obstetrics and Psychology Departments work together in seeking to promote more humanized care for patients. To promote patients understanding of anxiety-inducing situations and to establish effective communication, as recommended by WHO, it is often necessary to understand the types of distress and coping difculties that each pregnant woman experiences. Therefore, a professional in the analysis of human behavior is the one equipped to assess the specic needs of each patient, and may foster an environment where information is tailored to the patient and individually provided, ensuring an understanding of the guidance provided by the medical team. It is important to note that the role of the psychologist is not to provide clinical information but to ensure, through individual nuances, that the information is well assimilated by each individual patient. The present study has some limitations, mainly related to sample size, suggesting that future studies are necessary in order to replicate the ndings before generalizing claims. Furthermore, these data should be replicated in other settings, as public university hospitals in Brazil predominantly attend to the population strata with poor income and low education. Despite these limitations, the ndings of the present add an appreciable contribution to the eld. They propose an effective strategy that offers a holistic approach for targeting, through quality treatment, pregnant women in situations of psychological vulnerability owing to a diagnosis of fetal malformation. Conict of interest The authors have no conicts of interest. References
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