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Association between preoperative maternal anxiety and neonatal outcomes: A

prospective observational study

Article  in  Journal of Clinical Anesthesia · September 2016

DOI: 10.1016/j.jclinane.2016.03.022

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Journal of Clinical Anesthesia (2016) 33, 123–126

Original contribution

Association between preoperative maternal

anxiety and neonatal outcomes: a prospective
observational study☆,☆☆
Tuna Sahin MD (Specialist, Anesthesiology)a ,
Ersel Gulec MD (Assistant Professor, Anesthesiology)b,⁎,
Meziyet Sarac Ahrazoglu MD (Specialist, Anesthesiology)a ,
Sibel Tetiker MD (Specialist, Anesthesiology)a
a
Anesthesiology Clinic, Adana Numune Training and Research Hospital, 01260, Adana, Turkey
b
Department of Anesthesiology, Cukurova University Faculty of Medicine, 01380, Adana, Turkey

Received 10 December 2015; revised 23 February 2016; accepted 1 March 2016

Keywords:
Abstract
Anxiety;
Study objective: Preoperative anxiety can be associated with poor postoperative clinical outcomes. We
Cesarean delivery;
aimed to assess whether preoperative maternal anxiety level of obstetric patients scheduled for elective ce-
Newborn;
sarean surgery has an effect on clinical outcome of the newborn.
Pregnancy
Design: A prospective observational study.
Setting: Operating room.
Patients: Sixty pregnant women with American Society of Anesthesiologists physical status 1 and 2 sched-
uled for elective cesarean surgery were enrolled.
Interventions: All patients received spinal anesthesia with hyperbaric bupivacaine 12.5 mg.
Measurements: We performed a State-Trait Anxiety Inventory questionnaire to evaluate preoperative ma-
ternal anxiety. We used the Apgar scoring system to assess the physical condition of the newborn. Hemo-
dynamic measurements (heart rate, systolic and diastolic blood pressure) were recorded at baseline, skin
incision, childbirth, and 10, 15, and 30 minutes after skin incision. The use of ephedrine, nausea, and vomit-
ing were recorded as well.
Main results: Average preoperative maternal state anxiety score was 41.1 ± 4.6, and trait anxiety score was
50.9 ± 5.7. Average Apgar scores of newborns were 7.6 ± 0.8 and 9.2 ± 0.6, at first minute and fifth min-
ute, respectively. We found no significant relationship between the anxiety scores and Apgar scores at first
and fifth minute. Forty-two patients required ephedrine, 5 patients had nausea, and 5 patients had vomiting.
Conclusions: We concluded that there was no relationship between preoperative maternal anxiety scores
and Apgar scores at the first and fifth minute.
© 2016 Elsevier Inc. All rights reserved.

☆
Disclosures: There is no financial support to the research contained in the manuscript.
☆☆
Conflict of interest: There is no conflict of interest for all authors.
⁎ Corresponding author. Tel.: +90 3223386060 3289.
E-mail addresses: drtunas@hotmail.com (T. Sahin), gulecersel@yahoo.com, gulecersel@gmail.com (E. Gulec), meziyetahrazoglu@gmail.com
(M.S. Ahrazoglu), sibeltet@hotmail.com (S. Tetiker).

http://dx.doi.org/10.1016/j.jclinane.2016.03.022
0952-8180/© 2016 Elsevier Inc. All rights reserved.
124
1. Introduction
Preoperative anxiety is a common undesirable state associ-
ated with adverse physiological response in patients undergo-
ing surgery [1]. Preoperative anxiety activates neuroendocrine
systems resulting in an increased heart rate, blood pressure,
and cardiac excitation [2]. Preoperative anxiety is associated
with elevated plasma catecholamine levels [3], electrolyte im-
balance [4], increased postoperative pain, analgesic require-
ment, and prolonged hospital stay [5]. The experiences of
childbirth, cesarean delivery, and anesthesia can produce anx-
iety in a pregnant woman. Maternal anxiety has a positive re-
lationship with a higher risk of negative outcomes for
newborns such as preterm birth and low birth weight [6]. An
autonomic stress response triggered by anxiety can cause a fe-
tal distress by vasoconstriction in the uterine arteries [3,6–8].
Recently, midazolam has been shown to reduce preopera-
tive maternal anxiety without adverse outcome in new-
borns [9]. However, there is a lack of data about the effect of
preoperative maternal anxiety on newborn's outcome after
cesarean delivery.
We aimed to assess whether there is a relationship
between the preoperative maternal anxiety levels and the new-
born outcomes after cesarean delivery. If maternal anxiety
could lead to negative consequences on neonatal outcomes,
anxiety may need to be treated with pharmacologic and/or
nonpharmacologic interventions before surgery to improve
clinical outcomes.
2. Materials and methods
After obtaining approval of the Ethics Committee of Adana
Numune Training and Research Hospital (approval no. 49 on
August 14, 2014) and written informed consent from all pa-
tients, 60 pregnant women aged 18 to 49 years, with American
Society of Anesthesiologists physical status I-II and scheduled
for elective cesarean surgery, were included into this prospec-
tive observational study. Exclusion criteria were psychiatric or
neurologic disorder, nonelective surgery, preterm pregnancies,
diabetes mellitus, hypertension, obstetric complications in-
cluding antepartum hemorrhage and congenital malforma-
tions, contraindication for spinal anesthesia or refusal for
spinal anesthesia, fetal anomalies, fetal growth retardation,
and meconium aspiration.
An anesthesiologist performed a State-Trait Anxiety Inven-
tory (STAI) questionnaire to all patients at 1 hour before enter-
ing the operating room. The STAI consists of 2 subscales. The
State Anxiety Scale assesses the current state of anxiety at that
time. The STAI includes 40 items, with 20 items per subscales.
Responses to State Anxiety Scale are as follows: (1) not at all,
(2) somewhat, (3) moderately so, and (4) very much so. The
Trait Anxiety Scale measures incidence of feelings in general.
Responses for Trait Anxiety Scale are as follows: (1) almost
never, (2) sometimes, (3) often, and (4) almost always (7).
T. Sahin et al.
After intravenous cannulation was established, all patients
were monitored using noninvasive blood pressure, electrocar-
diography, peripheral oxygen saturation monitoring (SPo2).
Thirty minutes before surgery, all patients received at a rate
of 10 mL kg− 1 h−1 crystalloid fluid infusion. Spinal anesthe-
sia was performed in the sitting position at L3-4 or L4-5 level,
and 12.5 mg intrathecal heavy bupivacaine 0.5% was admin-
istered via a 25-gauge quincke spinal needle. Supplemental
oxygen was administered by a face mask. We used a pinprick
test to determine sensory block level, and patients with sensory
block level of T4-T6 were included in the study. Systolic
blood pressure was maintained over 90 mm Hg after spinal an-
esthesia. A bolus dose of 10 mg intravenous ephedrine was
administered if systolic blood pressure falls below that level.
Systolic blood pressure (SBP), diastolic blood pressure
(DBP), heart rate (HR), and SpO2 were recorded at baseline,
skin incision, and childbirth and at 10, 15, and 30 minutes af-
ter skin incision. Apgar scores were recorded at 1 and 5 mi-
nutes after delivery. We evaluated the well-being of neonates
using the 10-point Apgar score consisting of 5 assessments
(HR, respiratory effort, muscle tone, reflex irritability, and col-
or) with an assigned value of 0 to 2 for each of them. If the total
scores are 7 or higher, it denotes that the condition of the new-
born is normal. A value between 4 and 6 is considered as a
poor condition, and a score of 3 or lower indicates a critical
level. The number of patients having hypotension and nausea
and vomiting and requiring ephedrine was recorded. After sur-
gery, patients were observed in the postoperative care unit for
30 minutes and then discharged to the ward.
2.1. Statistical analysis
The data were analyzed using SPSS 20.0 software.
Categorical variables were summarized as numbers and
percentages, and numerical variables were presented as mean
and SD (as median and minimum-maximum where neces-
sary). Repeated-measures analysis was used to compare the
change in time of continuous variables (hemodynamic
measurements) performed on the same individuals at
different times. The variables were investigated using visual
(histograms, probability plots) and analytical methods
(Kolmogorov-Simirnov/Shapiro-Wilk's test) to determine
whether they are normally distributed. While investigating
the associations between nonnormally distributed variables,
the correlation coefficients and their significance were calcu-
lated using the Spearman test. A %5 type I error level was used
to infer statistical significance.
3. Results
The average age of the patients was 28.9 ± 5.4 years. The
number of primiparous and multiparous women were 10
(16.7%) and 50 (83.3%), respectively. We did not find any sig-
nificant difference for state and trait anxiety scores in terms of
The effect of maternal anxiety on newborn 125

parity (P = .866, P = .921, respectively). Hemodynamic mea- Table 2 Preoperative maternal anxiety levels and newborns'
surements (SBP, DBP, and HR) recorded in time is shown in Apgar scores
Table 1. Preoperative maternal anxiety scores and Apgar Time (min) Mean SD Median Minimum Maximum
scores are shown in Table 2. There was no any significant cor-
State anxiety 41.0 4.6 40.0 32.0 51.0
relation between state anxiety scores and Apgar scores at the
Trait anxiety 50.9 5.7 51.0 41.0 65.0
first (P = .753, r = − 0.42) and fifth minute (P = .374,
Apgar score at 1 min 7.6 0.8 8.0 6.0 10.0
r = − 0.117) and between trait anxiety scores and Apgar scores Apgar score at 5 min 9.2 0.6 9.0 8.0 10.0
at the first (P = .78, r = − 0.229) and fifth minute (P = .051,
r = − 0.255). The number of patients who required ephedrine
was 42 (70%). Five patients had nausea, and 5 had vomiting.
Maternal state anxiety scores were inversely correlated with
SBP at baseline (P = .047, r = − 0.257). Maternal trait anxiety Lichtor et al [19] compared the patients' moods the after-
scores were inversely correlated with SBP at incision, SBP at noon before surgery with 1 hour before the surgery using a
10 minutes and DBP at 10 minutes (P = .023, r = − 0.292, scoring tool consisting of subscales such as anxiety, depres-
P = .048, r = − 0.256 and P = .026, r = − 0.288, respective- sion, confusion, and fatigue. They failed to show any differ-
ly). There was no relationship between hemodynamic vari- ence between those periods of time in that study [19]. We
ables and Apgar scores at 1 and 5 minutes. rated the patients with STAI questioning at 1 hour before en-
tering the operation room in our study. Midazolam premedica-
tion for maternal anxiety before cesarean delivery reduces
anxiety scores without any adverse outcomes in newborns
4. Discussion [9]. Thus, reducing maternal anxiety with midazolam does
not change the newborn outcome as compared with the no
In this observational study, we demonstrated that the level treatment group. Similarly, inhalation of 50% N2O can signif-
of preoperative maternal anxiety shows no significant associa- icantly decrease anxiety level in patients undergoing cesarean
tion with newborn's Apgar scores at 1 and 5 minutes after ce- delivery; however, no significant difference occurs between
sarean delivery. Maternal anxiety has been shown to generate Apgar scores at the first and fifth minute compared with O2 in-
adverse consequences on fetal-placental function [10]. Fur- halation [20]. Preoperative anxiety can have an effect on intra-
thermore, maternal anxiety may cause an impaired uterine operative hemodynamic responses. Maternal hypotension
function [11]. Thereby, anxiety in pregnancy may negatively depending on spinal anesthesia may be associated with several
play a significant role on perinatal outcomes [6]. However, potential factors including the amount of local anesthetic and
there are conflicting results on the association between mater- pre- or coloading fluid, patient positioning, and vasopressor
nal anxiety and neonatal adverse outcomes. A number of stud- treatment [21]. Spinal anesthesia produces more acidemia in
ies have shown a relationship between maternal anxiety during newborn than those delivered under epidural or general anes-
pregnancy and adverse birth outcomes such as preterm birth thesia [22,23]. This result may have occurred with the contri-
and low birth weight [12–14]. Conversely, in some other bution of maternal hypotension. Recent data indicated that
studies, such a significant association has not been reported such an undesirable consequence arises substantially from va-
[15–18]. Many studies investigating relationship between sopressor treatment [22,23]. The underlying mechanism re-
maternal anxiety and neonatal outcomes have only focused sponsible for maternal hypotension is the blockade of
on the anxiety observed throughout pregnancy. However, sympathetic efferent neurons due to spinal anesthesia. Spinal
we assessed a relationship between maternal anxiety and anesthesia is associated with a more prominent hypotension
neonatal outcomes in perioperative conditions. The results in patients with increased baseline sympathetic drive [24,25].
obtained from our perioperative assessments have not been Anxiety has been shown to precipitate neuroendocrine stress
previously described. response such as increased cortisol and catecholamines. Theo-
retically, blood pressure is expected to rise with increase in
sympathetic activity in anxious patients; however, recent large
Table 1 Hemodynamic measurements (SBP, DBP and HR) of
general population-based studies, in contrast to previous, have
mothers
reported that anxiety is associated with a decrease in blood
Time SBP DBP HR pressure [26–28]. Furthermore, a recent prospective observa-
(min) Mean ± SD Mean ± SD Mean ± SD tional study found that preoperative anxiety has a significant
Baseline 130.2 ± 15.7 83.7 ± 11.2 100.0 ± 15.0
reducing effect on blood pressure for cesarean delivery under
Incision 113.1 ± 22.1 67.3 ± 17.1 98.7 ± 19.9 spinal anesthesia [29]. With these findings, a hypothesis
Delivery 113.5 ± 18.9 65.4 ± 15.7 101.5 ± 19.8 can be established that increased preoperative maternal anxiety
10 110.8 ± 16.9 61.7 ± 12.4 98.0 ± 14.1 would be associated with poor neonatal outcomes after spinal
15 108.8 ± 15.6 58.9 ± 14.3 100.4 ± 15.2 anesthesia.
30 110.6 ± 12.7 61.6 ± 11.8 98.2 ± 11.3 Accordingly, we obtained a negative relationship between
preoperative maternal anxiety and some hemodynamic
126
measurements. However, we thought that these hemodynamic
responses were not enough to disturb uteroplacental perfusion.
Furthermore, we did not find any correlation between hemo-
dynamic measurements and Apgar scores.
Several factors limit our study. First, the numbers of pa-
tients included were relatively small. Second, we demonstrat-
ed that there was no association between maternal anxiety
and neonatal outcome for the perioperative period, whereas
we did not assess maternal anxiety throughout pregnancy.
Thus, we were unable to exclude the effect of maternal anxiety
throughout pregnancy on newborn's outcome. Third, pregnant
women may also have reporting bias due to sociocultural dif-
ferences. Fourth, taking into consideration that parity could
be a cofactor associated with anxiety scores, our study requires
the standardized data of parity, although we achieve no signif-
icant difference in anxiety scores regarding parity. Finally, the
lack of laboratory tests such as pH and gas analysis in the new-
born's blood sample to indicate a poor clinical status, and cat-
echolamines and cortisol levels in mother's blood sample to
demonstrate an increased sympathetic response to anxiety is
a further weakness of the study.
5. Conclusion
We showed that perioperative maternal anxiety has no asso-
ciation with neonatal outcome. Future studies with a larger sam-
ple size should be performed to demonstrate clearly the role of
maternal anxiety on the prediction of negative neonatal outcome.
References
[1] McCleane GJ, Cooper R. The nature of pre-operative anxiety. Anaesthe-
sia 1990;45:153-5.
[2] Ramsay MA. A survey of pre-operative fear. Anaesthesia 1972;27:
396-402.
[3] Weissman C. The metabolic response to stress: an overview and update.
Anesthesiology 1990;73:308-27.
[4] McCleane GJ, Watters CH. Pre-operative anxiety and serum potassium.
Anaesthesia 1990;45:583-5.
[5] Badner NH, Nielson WR, Munk S, Kwiatkowska C, Gelb AW. Preoper-
ative anxiety: detection and contributing factors. Can J Anaesth 1990;37:
444-7.
[6] Ding XX, Wu YL, Xu SJ, Zhu RP, Jia XM, Zhang SF, et al. Maternal
anxiety during pregnancy and adverse birth outcomes: a systematic re-
view and meta-analysis of prospective cohort studies. J Affect Disord
2014;159:103-10.
[7] Staneva A, Bogossian F, Pritchard M, Wittkowski A. The effects of ma-
ternal depression, anxiety, and perceived stress during pregnancy on pre-
term birth: a systematic review. Women Birth 2015;28:179-93.
[8] Teixeira JMA, Fisk NM, Glover V. Association between maternal anxi-
ety in pregnancy and increased uterine artery resistance index: cohort
based study. Br Med J 1999;318:153-7.
[9] Senel AC, Mergan F. Premedication with midazolam prior to caesarean
section has no neonatal adverse effects. Braz J Anesthesiol 2014;64:16-21.
View publication stats
T. Sahin et al.
[10] Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnan-
cy: implications for mothers, children, research, and practice. Curr Opin
Psychiatry 2012;25:141-8.
[11] Ryding EL, Wijma B, Wijma K, Rydhstrom H. Fear of childbirth during
pregnancy may increase the risk of emergency cesarean section. Acta
Obstet Gynecol Scand 1998;77:542-7.
[12] Dole N, Savitz DA, Hertz-Picciotto I, Siega-Riz AM, McMahon MJ,
Buekens P. Maternal stress and preterm birth. Am J Epidemiol 2003;
157:14-24.
[13] Orr ST, Reiter JP, Blazer DG, James SA. Maternal prenatal pregnancy-
related anxiety and spontaneous preterm birth in Baltimore, Maryland.
Psychosom Med 2007;69:566-70.
[14] Nasreen HE, Kabir ZN, Forsell Y, Edhborg M. Low birth weight in off-
spring of women with depressive and anxiety symptoms during pregnan-
cy: results from a population based study in Bangladesh. BMC Public
Health 2010;10:515.
[15] Littleton HL, Breitkopf CR, Berenson AB. Correlates of anxiety symp-
toms during pregnancy and association with perinatal outcomes: a
meta-analysis. Am J Obstet Gynecol 2007;196:424-32.
[16] Field T, Diego M, Hernandez-Reif M, Schanberg S, Kuhn C, Yando R,
et al. Pregnancy anxiety and comorbid depression and anger: effects on
the fetus and neonate. Depress Anxiety 2003;17:140-51.
[17] Andersson L, Sundstrom-Poromaa I, Wulff M, Astrom M, Bixo M. Neo-
natal outcome following maternal antenatal depression and anxiety: a
population-based study. Am J Epidemiol 2004;159:872-81.
[18] Berle JO, Mykletun A, Daltveit AK, Rasmussen S, Holsten F, Dahl AA.
Neonatal outcomes in offspring of women with anxiety and depression
during pregnancy. A linkage study from the Nord-Trondelag Health
Study (HUNT) and medical birth registry of Norway. Arch Womens
Ment Health 2005;8:181-9.
[19] Lichtor JL, Johanson CE, Mhoon D, Faure EA, Hassan SZ, Roizen MF.
Preoperative anxiety: does anxiety level the afternoon before surgery pre-
dict anxiety level just before surgery? Anesthesiology 1987;67:595-9.
[20] Manouchehrian N, Bakhshaei MH. Nitrous oxide effect on relieving anx-
iety and pain in parturients under spinal anesthesia for caesarean section.
Anesth Pain Med 2014;4, e16662.
[21] Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Tech-
niques for preventing hypotension during spinal anaesthesia for caesare-
an section. Cochrane Database Syst Rev 2006;4:1-235, CD002251.
[22] Reynolds F, Seed PT. Anaesthesia for caesarean section and neonatal
acid-base status: a meta-analysis. Anaesthesia 2005;60:636-53.
[23] Tonni G, Ferrari B, De Felice C, Ventura A. Fetal acid-base and neonatal
status after general and neuraxial anesthesia for elective cesarean section.
Int J Gynecol Obstet 2007;97:143-6.
[24] Hanss R, Bein B, Ledowski T, Lehmkuhl M, Ohnesorge H, Scherkl W,
et al. Heart rate variability predicts severe hypotension after spinal
anesthesia for elective cesarean delivery. Anesthesiology 2005;102:
1086-93.
[25] Hanss R, Ohnesorge H, Kaufmann M, Gaupp R, Ledowski T, Steinfath
M, et al. Changes in heart rate variability may reflect sympatholysis dur-
ing spinal anaesthesia. Acta Anaesthesiol Scand 2007;51:1297-304.
[26] Hildrum B, Romild U, Holmen J. Anxiety and depression lowers blood
pressure: 22-year follow-up of the population based HUNT study, Nor-
way. Bmc Public Health 2011;11.
[27] Hildrum B, Mykletun A, Stordal E, Bjelland I, Dahl AA, Holmen J. As-
sociation of low blood pressure with anxiety and depression: the Nord-
Trondelag Health Study. J Epidemiol Community Health 2007;61:53-8.
[28] Roth WT, Doberenz S, Dietel A, Conrad A, Mueller A, Wollburg E, et al.
Sympathetic activation in broadly defined generalized anxiety disorder. J
Psychiatr Res 2008;42:205-12.
[29] Orbach-Zinger S, Ginosar Y, Elliston J, Fadon C, Abu-Lil M, Raz A,
et al. Influence of preoperative anxiety on hypotension after spinal
anaesthesia in women undergoing caesarean delivery. Br J Anaesth
2012;109:943-9.