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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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4 authors, including:

Ersel Gulec
Cukurova University


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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
Anesthesiology Clinic, Adana Numune Training and Research Hospital, 01260, Adana, Turkey
Department of Anesthesiology, Cukurova University Faculty of Medicine, 01380, Adana, Turkey

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

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-
sarean surgery has an effect on clinical outcome of the newborn.
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: (T. Sahin),, (E. Gulec),
(M.S. Ahrazoglu), (S. Tetiker).
0952-8180/© 2016 Elsevier Inc. All rights reserved.
124 T. Sahin et al.

1. Introduction After intravenous cannulation was established, all patients

were monitored using noninvasive blood pressure, electrocar-
Preoperative anxiety is a common undesirable state associ- diography, peripheral oxygen saturation monitoring (SPo2).
ated with adverse physiological response in patients undergo- Thirty minutes before surgery, all patients received at a rate
ing surgery [1]. Preoperative anxiety activates neuroendocrine of 10 mL kg− 1 h−1 crystalloid fluid infusion. Spinal anesthe-
systems resulting in an increased heart rate, blood pressure, sia was performed in the sitting position at L3-4 or L4-5 level,
and cardiac excitation [2]. Preoperative anxiety is associated and 12.5 mg intrathecal heavy bupivacaine 0.5% was admin-
with elevated plasma catecholamine levels [3], electrolyte im- istered via a 25-gauge quincke spinal needle. Supplemental
balance [4], increased postoperative pain, analgesic require- oxygen was administered by a face mask. We used a pinprick
ment, and prolonged hospital stay [5]. The experiences of test to determine sensory block level, and patients with sensory
childbirth, cesarean delivery, and anesthesia can produce anx- block level of T4-T6 were included in the study. Systolic
iety in a pregnant woman. Maternal anxiety has a positive re- blood pressure was maintained over 90 mm Hg after spinal an-
lationship with a higher risk of negative outcomes for esthesia. A bolus dose of 10 mg intravenous ephedrine was
newborns such as preterm birth and low birth weight [6]. An administered if systolic blood pressure falls below that level.
autonomic stress response triggered by anxiety can cause a fe- Systolic blood pressure (SBP), diastolic blood pressure
tal distress by vasoconstriction in the uterine arteries [3,6–8]. (DBP), heart rate (HR), and SpO2 were recorded at baseline,
Recently, midazolam has been shown to reduce preopera- skin incision, and childbirth and at 10, 15, and 30 minutes af-
tive maternal anxiety without adverse outcome in new- ter skin incision. Apgar scores were recorded at 1 and 5 mi-
borns [9]. However, there is a lack of data about the effect of nutes after delivery. We evaluated the well-being of neonates
preoperative maternal anxiety on newborn's outcome after using the 10-point Apgar score consisting of 5 assessments
cesarean delivery. (HR, respiratory effort, muscle tone, reflex irritability, and col-
We aimed to assess whether there is a relationship or) with an assigned value of 0 to 2 for each of them. If the total
between the preoperative maternal anxiety levels and the new- scores are 7 or higher, it denotes that the condition of the new-
born outcomes after cesarean delivery. If maternal anxiety born is normal. A value between 4 and 6 is considered as a
could lead to negative consequences on neonatal outcomes, poor condition, and a score of 3 or lower indicates a critical
anxiety may need to be treated with pharmacologic and/or level. The number of patients having hypotension and nausea
nonpharmacologic interventions before surgery to improve and vomiting and requiring ephedrine was recorded. After sur-
clinical outcomes. gery, patients were observed in the postoperative care unit for
30 minutes and then discharged to the ward.

2.1. Statistical analysis

2. Materials and methods
The data were analyzed using SPSS 20.0 software.
After obtaining approval of the Ethics Committee of Adana Categorical variables were summarized as numbers and
Numune Training and Research Hospital (approval no. 49 on percentages, and numerical variables were presented as mean
August 14, 2014) and written informed consent from all pa- and SD (as median and minimum-maximum where neces-
tients, 60 pregnant women aged 18 to 49 years, with American sary). Repeated-measures analysis was used to compare the
Society of Anesthesiologists physical status I-II and scheduled change in time of continuous variables (hemodynamic
for elective cesarean surgery, were included into this prospec- measurements) performed on the same individuals at
tive observational study. Exclusion criteria were psychiatric or different times. The variables were investigated using visual
neurologic disorder, nonelective surgery, preterm pregnancies, (histograms, probability plots) and analytical methods
diabetes mellitus, hypertension, obstetric complications in- (Kolmogorov-Simirnov/Shapiro-Wilk's test) to determine
cluding antepartum hemorrhage and congenital malforma- whether they are normally distributed. While investigating
tions, contraindication for spinal anesthesia or refusal for the associations between nonnormally distributed variables,
spinal anesthesia, fetal anomalies, fetal growth retardation, the correlation coefficients and their significance were calcu-
and meconium aspiration. lated using the Spearman test. A %5 type I error level was used
An anesthesiologist performed a State-Trait Anxiety Inven- to infer statistical significance.
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. 3. Results
Responses to State Anxiety Scale are as follows: (1) not at all,
(2) somewhat, (3) moderately so, and (4) very much so. The The average age of the patients was 28.9 ± 5.4 years. The
Trait Anxiety Scale measures incidence of feelings in general. number of primiparous and multiparous women were 10
Responses for Trait Anxiety Scale are as follows: (1) almost (16.7%) and 50 (83.3%), respectively. We did not find any sig-
never, (2) sometimes, (3) often, and (4) almost always (7). 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
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 T. Sahin et al.

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