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Prenatal stress and hemodynamics in pregnancy: a systematic review

Abstract

Maternal prenatal stress is associated with preterm birth, intrauterine growth restriction, and developmental delay. However, the impact of prenatal stress on hemodynamics during pregnancy remains unclear. This systematic review was conducted in order to assess the quality of the evidence available to date regarding the relationship between prenatal stress and maternal–fetal hemodynamics. The PubMed/Medline, EMBASE, PsycINFO, Maternity and Infant Care, Trip, Cochrane Library, and CINAHL databases were searched using the search terms pregnancy; stress; fetus; blood; Doppler; ultrasound. Studies were eligible for inclusion if prenatal stress was assessed with standardized measures, hemodynamics was measured with Doppler ultrasound, and methods were adequately described. A specifically designed data extraction form was used. The methodological quality of included studies was assessed using well-accepted quality appraisal guidelines. Of 2532 studies reviewed, 12 met the criteria for inclusion. Six reported that prenatal stress significantly affects maternal or fetal hemodynamics; six found no significant association between maternal stress and circulation. Significant relationships between prenatal stress and uterine artery resistance (RI) and pulsatility (PI) indices, umbilical artery RI, PI, and systolic/diastolic ratio, fetal middle cerebral artery PI, cerebroplacental ratio, and umbilical vein volume blood flow were found. To date, there is limited evidence that prenatal stress is associated with changes in circulation. More carefully designed studies with larger sample sizes, repeated assessments across gestation, tighter control for confounding factors, and measures of pregnancy-specific stress will clarify this relationship.

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Abbreviations

CPR:

Cerebroplacental ratio

GHQ-28:

General Health Questionnaire

HADS:

Hospital Anxiety and Depression Scale

HAM-A:

Hamilton Rating Scale for Anxiety

IES:

Impact of Event Scale

K-10:

Kessler Psychological Distress Scale

MCA:

Middle cerebral artery

PES-Brief:

Pregnancy Experiences Scale

PI:

Pulsatility index

PSS:

Perceived Stress Scale by Sheldon Cohen

RI:

Resistance index

S/D:

Systolic/diastolic ratio

STAI:

State–Trait Anxiety Inventory

UA:

Umbilical artery

UtA:

Uterine artery

UVVBF:

Umbilical vein volume blood flow

WHO-5:

World Health Organization Five Well-Being Index

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Contributors’ statement

Terri A. Levine conducted the systematic review, drafted the initial manuscript, revised the manuscript critically for important intellectual content, and approved the final manuscript as submitted. Fiona A. Alderdice and Ruth E. Grunau aided in quality assessment of included studies, revised the manuscript critically for important intellectual content, and approved the final manuscript as submitted. Fionnuala M. McAuliffe supervised the systematic review process, aided in quality assessment of included studies, revised the manuscript critically for important intellectual content, and approved the final manuscript as submitted.

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Correspondence to Fionnuala M. McAuliffe.

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This manuscript does not contain clinical studies or patient data.

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Terri Levine receives a PhD studentship from Queen’s University Belfast in Northern Ireland.

Appendices

Appendix 1. Example search strategy

("pregnancy"[MeSH Terms] OR "pregnancy"[All Fields]) AND ("Stress"[Journal] OR "stress"[All Fields]) AND ("blood"[Subheading] OR "blood"[All Fields] OR "blood"[MeSH Terms]) AND ("foetus"[All Fields] OR "fetus"[MeSH Terms] OR "fetus"[All Fields]) AND Doppler[All Fields] AND ("ultrasonography"[Subheading] OR "ultrasonography"[All Fields] OR "ultrasound"[All Fields] OR "ultrasonography"[MeSH Terms] OR "ultrasound"[All Fields] OR "ultrasonics"[MeSH Terms] OR "ultrasonics"[All Fields])

Appendix 2

Table 4 Guidelines for assessing quality in prognostic studies on the basis of framework of potential biases (Hayden et al. 2006)

Appendix 3. Standardized stress measures

  1. 1.

    Cohen Perceived Stress Scale (PSS-10) (Cohen et al. 1983; Cohen and Williamson 1988; DiPietro et al. 2008): a ten-item self-report measure that assesses the extent to which life is experienced by the participant as unpredictable, uncontrollable, and demanding. Participants rate their distress during the last month, and higher scores indicate higher perceived stress. PSS-10 was used in three of the included studies (Harville et al. 2008; Roos et al. 2015; Vythilingum et al. 2010).

  2. 2.

    General Health Questionnaire (GHQ) (Goldberg 1978): a measure of the prevalence of mental disorders in a given population, or of psychological distress and well-being in clinical and non-clinical populations. The 28-item version has four subscales rated on a Likert scale of 0–3, with subscale scores ranging from 0 to 21. Scores of ≥6 are considered clinically relevant. The four subscales are Somatization, Social Dysfunction, Anxiety and Insomnia, and Depression. The GHQ was used in two of the included studies (Helbig et al. 2011, 2013).

  3. 3.

    Hamilton Rating Scales of Anxiety (HAM-A) (Hamilton 1959): a 17-item scale that measures symptoms of anxiety, including items related to mood, tension, concentration, insomnia, memory, fears, and somatic symptoms. The HAM-A was used in two of the included studies (Maina et al. 2008; Monk et al. 2012).

  4. 4.

    Hospital Anxiety and Depression Scale (HADS) (Aylard et al. 1987; Wilkinson and Barczak 1988; Zigmond and Snaith 1983): a self-rating scale designed for use in hospital and community settings with a threshold score for definite cases of anxiety (≥11 on a 0–28 scale). The HADS was used in one of the included studies (Kent et al. 2002).

  5. 5.

    Impact of Event Scale (IES) (Horowitz et al. 1979): a 22-item scale that measures subjective psychological distress after a specific traumatic event using three subscales—Intrusion (seven items, 0–35 range), dealing with unbidden thoughts, emotions, and memories; Avoidance (seven items, 0–35 range), dealing with emotional numbness and avoiding stimuli or thoughts related to the event; and Arousal (eight items, 0–40 range), dealing with symptoms of psychophysiological activation such as hypervigilance, irritability, and heightened startle response. Subscale scores ≥20 indicate clinical relevance. The IES was used in two of the included studies (Helbig et al. 2011, 2013).

  6. 6.

    John Henryism (James 1994): a 12-item scale that assesses coping in an active way, overcoming obstacles, and “making one’s own way in the world.” John Henryism was used in one of the included studies (Harville et al. 2008).

  7. 7.

    Kessler-10 (K-10) (Kessler et al. 2002; Kessler 2003; Spies et al. 2009): a ten-item self-report measure that assesses general distress. Participants rate statements about their feelings during the last month on a five-point Likert scale. A cutoff score of 20 is considered clinically significant. The K-10 was used in two of the included studies (Roos et al. 2015; Vythilingum et al. 2010).

  8. 8.

    Pregnancy Experiences Scale (PES-Brief) (DiPietro et al. 2004): the PES-Brief includes the ten most frequently endorsed hassles and uplifts from the full PES. Each item is rated on a 0–4 Likert scale and then averaged—higher values reflect higher perceived intensity of negative or positive feelings about the pregnancy. The PES-Brief was used in one of the included studies (Mendelson et al. 2011).

  9. 9.

    Sarason’s Life Experiences Survey (LES) (Sarason et al. 1978): a 39-item scale designed to measure life events and their perceived impact. The LES was used in one of the included studies (Harville et al. 2008).

  10. 10.

    Spielberger’s State–Trait Anxiety Inventory (STAI) (DiPietro et al. 2008; Spielberger 1983): a widely used 40-item self-report inventory of the current (state, S) and inherent (trait, T) level of anxiety. Twenty items are dedicated to evaluating state anxiety; the other 20 evaluate trait anxiety. The S score indicates how anxious the patient is feeling in response to a defined situation, while the T score indicates how anxious the individual generally feels. Each item is scored 1–4, and total scores range between 20 and 80. The STAI was used in seven of the included studies (Caliskan et al. 2009; Harville et al. 2008; Mendelson et al. 2011; Roos et al. 2015; Sjostrom et al. 1997; Teixeira et al. 1999; Vythilingum et al. 2010).

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Levine, T.A., Alderdice, F.A., Grunau, R.E. et al. Prenatal stress and hemodynamics in pregnancy: a systematic review. Arch Womens Ment Health 19, 721–739 (2016). https://doi.org/10.1007/s00737-016-0645-1

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Keywords

  • Blood flow
  • Doppler ultrasound
  • Fetal well-being
  • Hemodynamics
  • Middle cerebral artery
  • Pregnancy
  • Pregnancy-specific stress
  • Psychological distress
  • Stress
  • Umbilical artery
  • Uterine artery