Pregnant Lady In Distress

Pregnant Lady In Distress
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Historically, the term fetal distress has been used to describe when the fetus does not receive adequate amounts of oxygen during pregnancy or labor . It is oftentimes detected through an abnormal fetal heart rate. However, while the term fetal distress is commonly used, it is not well defined. This makes it more difficult to make an accurate diagnosis and provide proper treatment. Because of the term’s ambiguity, its use has the potential to lead to improper treatment.
Fetal distress is commonly confused with the term birth asphyxia. Birth asphyxia occurs when the baby does not have adequate amounts of oxygen before, during, or after labor. This may have multiple causes, some of which include low oxygen levels in the mother’s blood or reduced blood flow due to compression of the umbilical cord .
As many have incorrectly used fetal distress and birth asphyxia as interchangeable terms, the Committee on Obstetric Practice of the American Congress of Obstetricians and Gynecologists (ACOG) has expressed concern regarding the use of the two terms. ACOG recommends that the term fetal distress be replaced with “non-reassuring fetal status.”
Along with this new term, ACOG further recommends physicians add to the diagnosis a list of additional findings such as fetal tachycardia, bradycardia, repetitive variable decelerations, low biophysical profile , and late decelerations. ACOG’s Committee on Obstetric Practice has also stated that the term birth asphyxia should no longer be used as it is too vague of diagnosis for medical use.
It is important for physicians to monitor the fetus throughout pregnancy to detect any potential complications. One of the more widely used methods of monitoring is electronic fetal heart rate (FHR) monitoring.
Benefits of FHR monitoring include:
Nonetheless, FHR monitoring does come with risks as well, including an increased likelihood of having a cesarean section due to misinterpretation of FHR monitoring results.
Potential precursors to fetal distress or non-reassuring fetal status may include:
The primary treatment used for non-reassuring fetal status is intrauterine resuscitation. This will help prevent any unnecessary procedures.
Some means of intrauterine resuscitation include:
Nonetheless, there are cases in which an emergency cesarean section is necessary. However, due to the over-diagnosis of fetal distress and potential misinterpretation of the fetal heart rate, it is recommended to confirm a potential fetal distress diagnosis with a fetal blood acid-base study. Overall, this condition points to the importance of prenatal care and proper monitoring of the mother and fetus throughout pregnancy.
Compiled from the following References:
ACOG Committee on Obstetric Practice. (2005). Inappropriate use of the terms of fetal distress and birth asphyxia. Committee Opinion, 326.
Beckmann, C. R. B., Ling, F. W., Barzansky, B. M., Herbert, W. N. P., Laube, D. W., & Smith, R. P. (2010). Obstetrics and gynecology (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Bucklin, B. A., Gambling, D. R., & Wlody, D. J. (2009). A practical approach to obstetric anesthesia. Gravlee, G. P. (Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Kaur, J., & Kaur, K. (2012). Conditions behind fetal distress. Annals of Biological Research, 3 (10). Retrieved from https://scholarsresearchlibrary.com/ABR-vol3-iss10/ABR-2012-3-10-4845-4851.pdf
Mayo Clinic. (2012). Biophysical profile: Why it’s done .
Merck Manuals. (n.d.) Fetal distress .
The American Congress of Obstetricians and Gynecologists (ACOG). (2013, October 22). Ob-gyns redefine the meaning of “term pregnancy.”
University of California San Francisco Benioff Children’s Hospital. (n.d.). Birth asphyxia . Retrieved from https://www.ucsfbenioffchildrens.org/conditions/birth_asphyxia/
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by
Judy George,

Senior Staff Writer, MedPage Today

January 29, 2020

Psychological distress -- a term encompassing anxiety, stress, and depression -- was more prevalent than expected in a sample of healthy, well-educated pregnant women and was associated with impaired fetal brain development, a prospective study suggested.
Among 119 pregnant women with uncomplicated pregnancies, 27% scored high on a perceived stress questionnaire, 26% had high scores for anxiety, and 11% had elevated symptoms of depression, according to Catherine Limperopoulos, PhD, of the Center for the Developing Brain at Children's National Hospital in Washington, D.C., and colleagues.
Increases in trait anxiety scores were associated with reductions in left hemisphere fetal brain volume, and elevated maternal stress and anxiety levels were tied to increased fetal gyrification (cortical folding) in frontal and temporal lobes, they reported in JAMA Network Open . Elevated maternal depression scores also were associated with reductions in fetal creatine and choline levels.
The study involved a group of well-resourced, well-educated women, and while the research is preliminary, "it points to prenatal psychological distress being alarmingly prevalent and clinically under-recognized," Limperopoulos said.
"We did not expect these findings among women expecting normal babies. These women had no indication of any mental health disorder, which leads us to worry that many women with similar maternal distress are slipping below the radar during routine clinical encounters," she told MedPage Today.
"Fetal brain development ramps up late in pregnancy, at the time when these women were recruited into the study," Limperopoulos added. "Introducing fetuses to this prenatal stressor at that vulnerable time has the potential to derail what should be a uniquely timed and organized program of fetal brain development."
"Reduced brain volume and increases in gyrification could have profound implications for behavioral development," noted Charles Nelson III, PhD, of Boston Children's Hospital, in an accompanying editorial . "Although white matter is potentially malleable, a reduction in gray matter before birth could foreshadow potentially permanent consequences for behavioral development."
In this study, Limperopoulos and colleagues followed 119 patients recruited from low-risk obstetric clinics in Washington from January 2016 to April 2019. These women had normal prenatal medical history, no chronic or pregnancy-related physical or mental illness, and normal fetal ultrasounds and blood tests. Fetal brain MRIs were performed at two time points between 24 and 40 weeks gestation.
Researchers measured maternal distress with the Perceived Stress Scale ( PSS ), Edinburgh Postnatal Depression Scale ( EPDS ), and Spielberger State Anxiety Inventory (SSAI) and Spielberger Trait Anxiety Inventory (STAI) tests , which participants completed the same day as each MRI visit. The SSAI assessed state anxiety ("how you feel right now"), while the STAI assessed trait anxiety ("how you generally feel").
The average age of participants was about 34. Overall, 84% reported professional employment, 83% were college graduates, and 52% had a graduate degree. Most women (56%) were carrying male fetuses.
Maternal trait anxiety (STAI) scores were negatively correlated with fetal left hippocampal volume on MRI (-0.002 cm 3 , P =0.004).
Anxiety and perceived stress scores were tied to increased fetal cortical gyrification in the frontal lobe (β for SSAI score: 0.004, P =0.002; β for STAI score: 0.004, P <0.001; β for PSS score: 0.005, P =0.005). Anxiety scores also were linked to increased fetal cortical gyrification in the temporal lobe (β for SSAI score: 0.004, P =0.004; β for STAI score: 0.004, P =0.01).
In addition, prenatal depression was negatively associated with fetal creatine levels (β for EPDS: -0.04; P =0.005) and choline levels (β for EPDS: -0.03, P =0.02) on magnetic resonance spectroscopy (MRS).
The findings have "enormous scientific, clinical, and public health implications," Nelson observed. "It remains to be seen whether these prenatal effects are subsequently mitigated after birth, leaving little functional trace behind.
"From a public health perspective, we know that anxiety, depression, and stress affect a huge percentage of the U.S. population," he continued. "Should we be doing a better job of screening pregnant women for psychological distress and mental health issues? If so, how early do we start, who do we target, and what resources can be offered to these women?"
Earlier studies are needed to identify the timing and onset of maternal psychological distress and its association with fetal brain development, Limperopoulos and colleagues noted. The cohort was mostly educated and employed; findings might not apply to other populations. Challenges inherent in fetal imaging meant that 8% of MRI scans could not be used because of severe fetal motion and 19% of MRS scans were unsuccessful, they added.
The study was funded by the NIH and the Thrasher Research Fund.
Limperopoulos and co-authors, as well as Nelson, disclosed no relevant relationships with industry.
The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
© 2022 MedPage Today, LLC. All rights reserved. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission.

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Research suggests that different patterns of stress during pregnancy can either promote or impede healthy fetal development. What are the clinical implications?
“I just feel like I am broken. I am the worst pregnant woman ever.”
These are the words of a woman interviewed by Aleksandra Staneva, Ph.D., and colleagues as they conducted a study on how women experience and interpret psychological distress while they are pregnant. The study was reported in the June 2017 Health Care for Women International . What they learned is that for many women, experiencing distress during pregnancy runs smack into unrealistic cultural expectations and fuels excessive guilt. Women report feeling totally responsible for the well-being of their babies. With increasing media attention to the harmful effects of stress on fetuses, some women believe they are supposed to remain happy and serene throughout their pregnancies, and if they don’t, it’s their fault. So what does research to date actually tell us about the effect of maternal antenatal distress on offspring?
First, a word about the term “distress.” In the context of research on the effects of antenatal maternal psychological states on offspring, “distress” encompasses maternal anxiety, depression, and perceived stress. This is because studies to date have found that any of these, or any mixture of these, has similar effects on offspring. Though there are some distinctions, most researchers have found it more valuable to examine these collectively.
Delia* is a 28-year-old woman with recurrent major depression and posttraumatic stress disorder (PTSD) stemming from prolonged childhood emotional, physical, and sexual trauma. She is raising her 2-year-old daughter, Keisha, on her own with limited financial resources and housing insecurity. While pregnant with Keisha, she was highly stressed and severely depressed. Being pregnant made her feel vulnerable and intensified her PTSD symptoms. She had previously responded well to sertraline but discontinued it because she thought she shouldn’t take medication while pregnant. Her pregnancy was complicated by preeclampsia, which was frightening. Keisha was born a month early; she was a healthy baby but fussy. As a toddler, she is sensitive and reacts with fear to new situations.
Delia has just learned she is pregnant again. Recalling how difficult her last pregnancy was and how that may have affected Keisha, she sees a psychiatrist, Dr. Wilkins, for ideas about how to maintain mental health.
To provide context for how a psychiatrist can help, we’ll review some relevant information.
As a prelude to understanding the effects of distress during pregnancy, it helps to understand how bodies handle stress in general. Certain body systems need to be maintained within narrow ranges to operate effectively. Blood pH and body temperature are examples. Processes that maintain these systems within range are known as homeostasis. Stress can disturb homeostasis. To counter threats to homeostasis, our bodies mobilize the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic nervous system, and the immune system. That mobilization is known as allostasis. For example, the sympathetic nervous system prepares the body for fight or flight by activating the heart, blood vessels, and muscles, and the immune system prepares to respond to possible wounds or infection. Mobilizing these responses intermittently enhances health. Exercise is an example of healthy allostasis. As with intermittent physical challenges, intermittent cognitive and/or emotional challenges can promote health. On an emotional level, insufficient challenge can lead to boredom, an affective state that can drive a person to seek new goals and positive stimulation.
By contrast, when allostatic processes are repeatedly and chronically mobilized, we pay a price. The resultant wear and tear are known as allostatic load. High allostatic load includes physiologic dysregulation of multiple body systems that contributes to disease.
Pregnancy is itself a physiologic stressor. It is sometimes referred to as a natural stress test, bringing out vulnerabilities to cardiovascular disease, diabetes, depression, and other conditions. Adding psychological stress, trauma, and/or chronic societal strains such as economic deprivation and racism can lead to substantial allostatic load during pregnancy. This can influence the likelihood of adverse pregnancy outcomes and can influence fetal development.
Just as different patterns of stress can be healthy or unhealthy for people in general, research to date suggests that different patterns of antenatal stress can either promote or impede healthy fetal development.
How can researchers know how fetuses react when their mothers are stressed? One particularly helpful clue is how the fetal heart rate changes in response to maternal stress. To restore homeostasis under stress, it’s important for some parameters to vary flexibly (for example, heart rate) to keep others (for example, blood pressure) constant. For this reason, beat-to-beat variability of the fetal heart rate is an indicator of health. When a pregnant woman experiences mild to moderate intermittent stress, her fetus responds with a temporary increase in heart rate variability. That response to maternal stress intensifies as the fetus matures, and it becomes increasingly well coupled with fetal movement. These changes suggest that the fetus is becoming more adept at normal allostasis, which may promote healthy development later in life. Research by Janet DiPietro, Ph.D., published in the August 2012 Journal of Adolescent Health shows that newborns who were exposed to mild to moderate intermittent maternal distress in utero have faster neural conduction, consistent with the hypothesis that exposure to healthy stress in utero advanced their neural development. Similarly, toddlers who were exposed to mild to moderate intermittent maternal distress in utero show more advanced motor and cognitive development.
By contrast to the salutary effects of intermittent mild to moderate maternal stress on fetal development, severe and/or chronic maternal distress is associated with higher risks for adverse perinatal outcomes and long-term adverse effects on offspring. The difference can be detected in utero. Fetuses of pregnant women who have high anxiety tend to have heart rates that are more reactive to acute stressors. The fetuses of pregnant women with low socioeconomic status tend to have reduced beat-to-beat variability.
When maternal distress reaches the level of a clinically diagnosable disorder that remains untreated, long-term adverse effects can ensue. For example, untreated antenatal major depression is associated with increased risk of premature birth and low birth weight. Infants and toddlers exposed to maternal depression in utero show excessive crying; reduced motor and language development; and more distress, fear, and shyness than offspring not exposed to maternal depression. Children and adolescents exposed to antenatal maternal depression have an increased risk of emotional, behavioral, and cognitive problems.
There is increasing evidence that intrauterine environmental exposures can “program” a fetus to develop in a certain way. It is posited that this
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