Fetal magnetic resonance imaging (MRI) has become an important part of the diagnostic protocol in tertiary referral centers, especially in cases where ultrasonography does not provide sufficient information.1,2 However, data on the psychological impact of fetal MRI are rare.
Michel et al3 investigated the psychological reactions of 15 pregnant women and 15 controls who underwent pelvimetry and compared patient acceptability for an open 0.5-T and a closed 1.5-T magnetic resonance system. Regardless of the system and the preimaging information provided, 33% percent of pregnant women reported fear of fetal harm. With regard to psychological reactions during MRI procedures in general, the prevalence rates for claustrophobic reactions during scanning vary between 5% and 10%.4–6 Anxiety reactions were found in up to 37% of the patients who undergo scanning procedures.7,8 High initial levels of anxiety, long examination time, high noise, and temperature level were found to be predictive for the development of psychological problems during MRI.4,9,10,11 Preimaging information by the referring doctor has been shown to be one of the major determinant factors that influence a patient's experience of MRI.9 Similar results were found for psychological experiences during ultrasonography in pregnancy.12,13 In general, the psychological consequences of prenatal diagnostic procedures may frequently be underestimated.14
The aim of the present study was to assess women's psychological reactions when undergoing fetal MRI and to estimate whether groups based on clinical variables (referral diagnoses, MRI diagnoses, presence of the partner during MRI) and sociodemographic variables (age, education, marital, and occupational status) differ in their subjective experiences with fetal MRI and in their anxiety levels related to the scanning procedure.
PATIENTS AND METHODS
We conducted a prospective cohort investigation. Sample size considerations focused on a global standard of error for the description of categorical variables of no more than 6.5 percentage points. Therefore, an active sample of at least n=60 was chosen. During a 6-month period of investigation between February 2006 and July 2006, 72 consecutive patients scheduled to undergo fetal MRI at the Department of Radiology at Vienna Medical University were investigated. Patients were referred from four different Fetal Medicine Units. Magnetic resonance imaging was performed with a 1.5T superconducting unit (Philips Intera, Release 11, Philips Medical Systems, Vienna, Austria). Using a sense-cardiac coil, T2-weighted, fast spin-echo sequences were performed in three orthogonal section planes, and T1-weighted, diffusion-weighted sequences, thick-slab T2-weighted sequences, and dynamic sequences were also obtained. Protocols were adjusted based on clinical questions.15,16 Total imaging times varied due to the clinical questions being addressed, and sequences were repeated in case of fetal movements. Women were placed in a position they indicated that they would tolerate best, with a slight left tilt to prevent supine hypotension. The diameter of the tunnel was 60 cm. The average temperature was 25°C, with the availability of additional ventilation when required. Ear plugs or head phones, with music available, were provided.
All questionnaires were completed during the waiting time before and after the scan. Women were tested immediately after scanning. Preliminary information about the results of the MRI scan was not provided. Women were informed about the final MRI diagnosis by their referring obstetrician after the radiological analyses had been completed.
Ten (13.9%) patients were not included in the study. Six (8.3%) women had to be excluded because of language problems. Four (5.6%) women refused to participate for private reasons. All patients gave written informed consent. The study protocol was approved by the ethical board at the Medical University of Vienna.
The final sample consisted of 62 women. Mean age was 30.2 (standard deviation ±4.8) years. All women were involved in a relationship, and 43.5% (n=27) had already had children. Twenty-one (33.9%) women completed compulsory school (until 15 years), 24 (38.7%) attended A-level (high school degree), and 17 (27.4%) women had a university degree. The educational level of our cohort was higher than the Austrian average, which was probably a consequence of the older age of our sample and of the fact that we had to exclude those women who were not able to speak and understand German well enough to participate. The obstetric history of our study group is included in Table 1.
Three women (4.8%) had previously suffered from claustrophobic symptoms. None of the women had a psychiatric history. Twelve (19.3%) women had previously undergone MRI for other indications. The rather high figure of 19% of women with previous MRI experience is not unusual for an Austrian population. Magnetic resonance imaging is commonly used for primary diagnoses (eg, in patients with severe headache or orthopedic complaints) because the costs of MRI investigation are completely covered by the Austrian public health insurance system.
At the time of imaging, women were, on average, at 26.9 (±4.6) weeks of gestation. We categorized referral diagnoses, after ultrasound examination, according to severity, as follows: “without any overt pathology,” but with the potential for developing problems, such as, for instance, monochorionicity in twins (n=6; 9.7%) or premature rupture of membranes (PROM, after gestational week 29) (n=2; 3.2%); “suspicion of a fetal pathology compatible with survival” (n=40; 64.5%); and “suspicion of a fetal pathology probably not compatible with survival” (n=14; 22.6%). Fetal pathology that was rated as compatible with survival included twin pregnancy with premature rupture of membranes before gestational week 29, renal cysts, meningocele, cardiac rhythm abnormalities in the fetus, and cystic lung lesion. Fetal pathology probably not compatible with survival comprised suspected rhombencephalosynapsis, suspected cystic fibrosis with bowel obstruction, suspected renal agenesis, and suspected chondrodysplasia.
Anxiety levels were measured before and after the scan using the German version of the Spielberger State-Trait Anxiety Inventory, a widely used instrument for the assessment of the current (state) and inherent (trait) level of anxiety.17 The Beck Depression Inventory, a widely accepted screening instrument for depression, was used to exclude an underlying depressive disorder.18 To assess patients' attitudes and expectations toward, and their experiences of, MRI, women completed the modified version of the Prescan and Postscan Imaging Distress Questionnaire.11 The Prescan Imagining Distress Questionnaire compromises questions about anxiety concerning the examination, worries about the technical apparatus, worries about the outcome of the examination, the subjective appraisal of the importance of the MRI for further treatment, and general confidence in modern medicine. In the modified version, two questions about anxiety with regard to the possible negative effects of the MRI, for the infant and for the mother, were added. The Postscan Imaging Distress Questionnaire focuses on the subjective appraisal of the overall experience of the MRI, the duration of the examination, the noise level, the narrowness of the tunnel, the temperature, and the necessity of being immobile. Moreover, women were asked whether they would undergo such an examination once more, if necessary. Two questions concerning the body position during MRI and their anxiety for the infant during the procedure were added in the modified version. In addition, women rated their anxiety about the examination and about the outcome of the MRI on a 10-point visual analog scale (VAS) before and after the scan. Sociodemographic data and obstetric and medical information were documented, as well as details of the MRI investigation.
To describe the sample, pre- and post-MRI, the mean±standard deviation was used for continuous variables. Frequencies, percentages, and the 95% confidence intervals are reported for categorical variables. Group comparisons for continuous variables were done by using independent sample t tests or analysis of variance (ANOVA) models when normality (Kolmogorov-Smirnov goodness-of-fit test) and homogeneity of variances (Levine's test) were assumed; otherwise, Mann-Whitney and Kruskal-Wallis tests were used. For categorical data, group differences were evaluated with Fisher exact tests. Pre- and post-MRI changes were evaluated by using paired sample t tests. For a simultaneous analysis of group differences and for pre- and post-MRI changes, repeated-measures ANOVA models with a one-between subject factor were used. The statistical software package SPSS 15.0. (SPSS Inc., Chicago, IL), including the Exact-Tests module, was used. For all categorical data analyses, the exact P values and odds ratios were reported. P values ≤.05 were considered significant.
Total scan time was 41.5 (±12.2) minutes. Thirty-six (58.1%) women were accompanied by their partners (n=34; 54.8%) or a medical staff member (n=2; 3.2%) who was present in the examination room during scanning. Three (4.8%) scans had to be interrupted due to claustrophobia and breathing problems. Two (3.2%) of these patients were unable to complete the scan. Two (3.2%) women received a short-acting sedative medication before MRI in agreement with the referring obstetrician.
Magnetic resonance imaging diagnoses were categorized according to severity as follows: “no fetal malformation” (23; 37.1%); “fetal pathology compatible with survival” (24; 38.7%) (eg, arachnoidal cyst, congenital cystic adenomatoid malformation of the lung, distal bowel stenosis without cystic fibrosis); and “fetal pathology probably not compatible with survival” (13; 21.0%) (eg, megacystic microcolon, rhombencephalosynapsis, renal agenesis) (Table 2).
Before the scan we found state-anxiety levels (46.9±14.4) in our patient group that were 8.8 points higher than those of the female nonclinical norm population (n=1,278) that is described in the test manual (38.1±10.3; t1,338=6.431, P<.001), which significantly (38.9±13.5; t61=5.433, P<.001) decreased to a level comparable to that of the norm population (t1,338=0.588, P=.556) after the scan.17 Trait-anxiety levels were significantly lower (32.5±7.6) than those of the norm population (37.0±10.9; t1,338=3.494, P<.001).17 In the Beck Depression Inventory, two women showed minor depression. In the VAS, the women's self-perception of anxiety concerning the examination was at a level of 2.1 (±2.6). Anxiety with regard to the results of the MRI was rated on a level of 5.1 (±3.4) by the patients.
In the Prescan Imaging Distress Questionnaire, 31 women (50.0%, 95% CI 38.7–61.7%) were found to be very anxious about the outcome of the examination (Tables 3 and 4). Anxious feelings concerning the procedure and the technical apparatus were mentioned in only a few cases (3.2%, 95% CI 0–7.6%). Forty-nine (79%, 95% CI 68.9–89.1%) women rated the fetal MRI as very important for their further treatment. Twenty-two (35.5%, 95% CI 23.1–47.9%) women were worried about possible negative effects of the MRI on the infant, and finally, seven (11.2%, 95% CI 0–23%) women worried about possible negative effects of the MRI on their own health.
In the Postscan Imaging Distress Questionnaire, the MRI procedure was experienced as an unpleasant event by 33.9% (95% CI 21.2–46.6%) and as hardly bearable by 4.8% (95% CI 0–17.5%) of the women. The physical restraint (49.9%, 95% CI 37.4–62.4%), noise level (53.2%, 95% CI 40.7–65.7%), and the duration of the examination (51.6%, 95% CI 39.1–64.1%) were reported as major disturbing factors. The fear for the infant was rated as hardly bearable by nine women (14.5%, 95% CI 2.7–26.3%) and as unpleasant by 24 (38.7%, 95% CI 26.9–50.5%) women.
Women who were accompanied by their partners or medical staff members showed significantly higher anxiety scores before scanning (without an accompanying person: 41.5±14.2, with an accompanying person: 50.7±13.5; t60=2.594, P=.012). The three women who had to interrupt the examination did not show anxiety levels or adverse perceptions toward scanning that were any higher than the women who completed the MRI, nor did they have a history of claustrophobia. The two dropouts had a referral diagnosis of “suspicion of a fetal pathology compatible with survival.”
The severity of the referral diagnosis showed a linearly increasing effect on the women's anxiety before MRI (“without any overt pathology,” n=8: 35.8±13.1; “suspicion of a fetal pathology compatible with survival,” n=40: 47.6±13.6; “suspicion of a fetal pathology probably not compatible with survival,” n=14: 51.1±15.3; weighted linear term: F1,59=5.325, P=.025). After the scan, anxiety was significantly reduced in all three groups (“without any overt pathology,” n=8: 27.0±6.3; “suspicion of a fetal pathology compatible with survival,” n=40: 40.8±12.4; “suspicion of a fetal pathology probably not compatible with survival,” n=14: 40.4±16.4; effect of time: F1,59=23.304, P<.001; interaction effect time × referral diagnosis: F2,59=0.635, P=.534; effect of referral diagnosis: F2,59=4.259, P=.019). In the VAS, women with the referral diagnosis “without any overt pathology” rated their anxiety significantly lower than the other two groups (“without any overt pathology,” n=8: 1.9±3.8; “suspicion of a fetal pathology compatible with survival,” n=40: 5.2±3.2; “suspicion of a fetal pathology probably not compatible with survival,” n=14: 6.6±3.2; F2,57=4.941, P=.011). Women with the referral diagnosis “without any overt pathology” also considered the examination less stressful with regard to the noise level (odds ratio=10.6, P=.002) of the scan.
Based on the severity of the MRI diagnoses, we found significant group differences in state-anxiety post-MRI between the three groups (F2,57=5.2, P=.009). Women with an MRI diagnosis of “fetal pathology probably not compatible with survival” scored higher than women in the other two groups (“no fetal malformation,” n=23: 33.7±9.8; “fetal pathology compatible with survival,” n=24: 37.7±11.7; “fetal pathology probably not compatible with survival,” n=13: 47.0±15.5).
Women with an MRI diagnosis of a fetal malformation showed high state-anxiety levels after the scan (“without pathology,” n=18: 31.7±8.8; “fetal malformation,” n=34: 42.4±14.0; “acquired pathology,” n=8: 35.0±8.0, F2,57=3.4, P=.010). Anxiety levels before the scan, based on diagnostic groups, showed no significant difference. Group comparisons based on sociodemographic variables showed no significant differences related to subjective experiences or to the anxiety level of women during an MRI examination.
We present data derived from a study designed to assess women's psychological reactions when undergoing fetal MRI. There is a paucity of data concerning psychological distress related to fetal MRI scanning. In discussing our results, we will therefore refer to studies on psychological reactions concerning MRI in different general samples and to one study that included pregnant women without a prenatal diagnosis.3–5,9,11
Our main findings can be summarized as follows: Levels of anxiety before fetal MRI were significantly higher in our population than those reported in the female nonclinical norm population, but they were close to reported prescan anxiety levels in other samples of patients who undergo MRI.4,5,9,11 The severity of referral diagnosis (“without any overt pathology,” “suspicion of a fetal pathology compatible with survival,” and “suspicion of a fetal pathology probably not compatible with survival”) showed a linearly increasing effect on levels of anxiety before MRI. Anxiety levels significantly decreased after scanning, (again, comparable to previously reported postscan anxiety scores4,5,9,11), although women had not yet been informed about MRI diagnoses. The results of the self-rating of anxiety by means of VAS scales were consistent with these findings. With respect to the subjective experiences during the scanning procedure, the MRI examination was rated as unpleasant by 33.9% and as hardly bearable by 4.8% of the women (Postscan Imaging Distress Questionnaire). Thus, 59.7% of our patients found MRI easy to tolerate, compared with 88% in a nonpregnant sample.11 Factors that were rated particularly distressing included women's anxiety for the infant, the inability to move, the narrowness of the tunnel, the body position, the duration of the examination, and noise and elevated temperature. The results of the Prescan Imaging Distress Questionnaire showed that a considerable number of women were preoccupied with stressful emotions (mainly in terms of worries about the possible negative effects of the MRI on the infant; 35.5%), whereas anxious feelings concerning the procedure and the technical apparatus were mentioned in only a few cases (6.4%). Nevertheless, a total number of 96.7% rated the investigation as important for further treatment. Group comparisons based on sociodemographic variables showed no significant differences in either anxiety levels or in terms of subjective experiences related to the MRI procedure.
The high anxiety scores in our sample may reflect the psychological distress associated with the suspicion of fetal pathology, especially in those women where ultrasonography had suggested a fetal pathology that was probably not compatible with survival. Because only two patients showed mild depressive symptoms in the Beck Depression Inventory, the possibility of an underlying major depression can be ruled out as a major additional factor that could have influenced the levels of anxiety. Although we were not able to control for potential differences in the level of preimaging information given by the referring obstetricians, we assume that a possible reason for these anxieties may, at least in part, be the lack of easily understandable preimaging information. Moreover, one should consider that women who undergo fetal MRI have already experienced a psychic stress situation before the fetal MRI when they were confronted with the results of prenatal ultrasound examination that suggested a fetal pathology.
Of interest, women who were accompanied by their partners during MRI had higher anxiety levels before scanning. After scanning, anxiety levels did not differ from those who came alone. We assume that the attendance of the partner probably represented a strategy to cope with these intense feelings of anxiety. However, data on the perception of the partner's attendance during the examination would be needed to further comment on this finding.
We do acknowledge that there are several limitations to our study, such as the small sample size and the selected sample of patients from a university hospital. However, data derived from a study that explores subjective experiences and feelings related to fetal MRI may contribute to a better understanding of the precarious psychological situation of this particular patient group. Moreover, we think that our results may be of clinical relevance to improve the further procedure of fetal MRI, as well as the acceptance of this innovative prenatal diagnostic procedure.
Our findings suggest that women who undergo fetal MRI experience a marked psychological distress, despite the general high acceptance of this kind of investigation in our population. Besides the general need for psychological assistance for women who undergo prenatal investigations, there may be some additional points to consider in those women who are referred for fetal MRI. Preimaging information that includes detailed information about the course and duration of MRI, body position during the examination, noise, and the lack of negative effects on the fetus may be beneficial. Future research should focus on the effect of preimaging information on women's subjective experiences with the fetal MRI procedure. Given the women's distress related to noise, the further development of so-called “silent sequences” should be continued. To reduce constraints due to body position, open MRI machines should be approved for fetal MRI. Considering women's complaints about the physical restraints during the examination, the construction of magnetic resonance coils with receiving elements that can be deliberately placed near the respective region of interest would reduce the duration of the examination and, consequently, improve the tolerability of the procedure for pregnant women.
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© 2008 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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