Pregnancy is a unique experience for a woman and her family. Although pregnancy-related changes occur progressively and sequentially, psychological changes do not follow this pattern. This period demands many psychological and social adjustments that considering them can lead to the improved mental health in the pregnant woman and prevent future social problems in the family (1). Pregnant women's fear and stress about adaptation to a new situation can make them anxious and put them at some risks (2).
High anxiety and stress during pregnancy can have long-term consequences for the mother and the fetus. Anxiety affects the fetus by a particular mechanism. Stress hormones (catecholamines, corticotrophin-rel-easing hormones and adrenal steroids) which are rel-eased due to the mother’s anxiety and stress, cross the placenta and affect fetal brain development at the 12-22 weeks of pregnancy by constricting the placental artery and limiting oxygen supply and nutrition of the fetus. This is one of the reasons of the limitation of the fetal growth and fetal asphyxia, which can lead to me-dical interventions, such as cesarean section. Further-more, stress hormones stop the immune system. There-fore, anxious mothers are more likely to have infants with infections including respiratory infections (3).
The prevalence of anxiety disorders during preg-nancy is high (4). In Iran, the prevalence of these disor-ders during pregnancy has been reported to be 64% (5). Dunkel Schetter (6) also found that anxiety, depre-ssion, and stress during pregnancy were associated with side effects for the mother and the fetus, which can lead to low birth weight and negative effects on fetal and child nervous development.
The most common and important stresses experie-nced by pregnant women include anxiety and stress about fetal health, communication problem with the spouse, anxiety about the experience of childbirth and motherhood (7). This can have reverse effects on fetal and neonatal outcomes (4). For example, anxiety dur-ing this period may have consequences such as low birth weight and low Apgar score (8).
In another study by Ost, Nisell, Frenckner, Burgos and Ojmyr-Joelsson (9), 34 pregnant women with diaphragmatic herniated fetuses were assessed by an anxiety questionnaire over four years. They revealed that mothers were more anxious than fathers and the prenatal diaphragmatic hernia diagnosis and the low parental literacy were two factors that were associated with higher levels of parental anxiety. In a study, Bazrafshan and Mahmoudi Rad (10) assessed the anxiety of pregnant women, their Apgar score and the infant weight. A number of 150 pregnant mothers were enrolled in the study and they completed the Spielberger State-Trait Anxiety Inventory. Findings showed that there was a significant relationship between low birth weight and the hidden anxiety of mothers. Also, there was a significant relationship between Apgar scores at first and fifth minutes after birth and the mother's overt anxiety. In another study by Bazrafshan and Mahmoudi Rad (11), findings indicated that there was a significant relationship between previous abortions and the overt and covert anxiety history, between history of difficult childbirth and covert anxiety and finally between low birth weight and covert anxiety history. In another study, Shayeghian, Rasoulzadeh Tabatabaei and Sedighey Loyeh (12) investigated the effect of maternal anxiety on infant's mental health. The results showed that growth indices in infants of mothers with high anxiety were significantly lower than the control group.
On the other hand, the diagnosis of diseases or abnormalities during pregnancy, for example, fetal cardiac anomaly, can be one of the main reasons of the anxiety or exacerbation of anxiety in mothers. A congenital heart defect (CHD) is the most common congenital anomaly in the fetus. Its incidence rate is from0.08 to 0.10 per thousand live births. According to the World Health Organization report, from 1950 to 1994, 42% of infant deaths were due to heart problems. One of the most difficult prenatal diagnoses is screening for fetal cardiac defect (13). The presence of known and unknown teratogens and the increased gestational age can be considered as the reasons. On the other hand, despite the development of modern diag-nostic methods during pregnancy, the diagnosis, treat-ment and identification of patients with these abnor-malities remain a serious problem in the fetal and mate-rnal medicine (14).
Although our knowledge of CHDs is high, studies on the role of parental psychological effects on fetuses with congenital heart diseases and birth outcomes are limited (7). Parental awareness of the fetal cardiac ano-maly puts them in sudden physiological stress. Severe stress can be related to adrenal-pituitary-hypothalamic axis and sympathetic nervous system function. In this way, cortisol and adrenocorticotropic secretion are affected by stress plasma cortisol level is increased (15). Finally, they are exposed to preterm labor, intraut-erine growth restriction (IUGR), or small for gestate-onal age (SGA) and this may even disrupt the child's neurological development.
Accurate and rapid diagnosis of fetal cardiac anomaly can help to make the best decision in preg-nancy management and it can result in increased survival and decreased postnatal mortality and morbi-dity. Studies have shown that infants with a prenatal diagnosis of CHDs have better hemodynamic status and outcomes than those who have not been diagnosed (16). Given the importance of screening and evaluating fetal health in the current population in cases of high-risk pregnancies and indications of fetal heart echoc-ardiography, fetal echocardiography is recommended and doing it quickly and on time will have benefits for the family including choosing the treatment and educating them on the disease. They can decide whether to continue or terminate the pregnancy or even make a decision about a legal abortion. In addition, it is possible to plan more appropriately by following the recommendations of a pediatric cardiologist and delivering a baby at a Level 3 center with the necessary preparations and, if necessary, considering prenatal and early postnatal treatment.
Very few studies have been conducted in this area. In particular, no internal research was found to investigate the relationship between maternal anxiety and fetal cardiac anomalies. This study was conducted to determine the anxiety levels during pregnancy in moth-ers whose fetuses were diagnosed with a cardiac ano-maly. This helps to consider an appropriate inter-vention with the amount of anxiety at a particular stage of pregnancy. Therefore, the purpose of this study was to investigate the severity of changes in anxiety levels in different stages of pregnancy in mothers with a cardiac anomaly for their fetus.

 

In this causal-comparative study, the study popu-lation included mothers who went to the heart disease clinic of Amir al-Momenin Hospital in Semnan, Iran and suspected a cardiac anomaly in their fetuses. This study was performed on 80 pregnant women with the ges-tational age of 18-22 weeks, who were qualified for inclusion during a one year period in 2018-2019. In their screening ultrasound (NT ultrasound and scan anomaly), the possibility of a congenital heart problem was raised and they underwent fetal echocardiography by a pediatric cardiologist. Inclusion criteria were as follows: aging over 18 years old, having at least a middle school degree, lacking maternal systemic diseases (including diabetes, hypertension, collagen, and vascular diseases before and during pregnancy), not smoking, not using alcohol, not having drug abuse, not being addicted to drugs, not using any medication, lacking psychological problems, single pregnancy, consenting to the pregnancy continuation, consenting to participate in the research and a score lower than 23 on the General Health Questionnaire. Exclusion criteria included not having the inclusion criteria and the termination of pregnancy before 35th week. Accessible sampling was used in the study. Initially, informed consent was obtained and the demographic information questionnaire and general health questi-onnaire were administered to evaluate the inclusion criteria. Then, Spielberger State-Trait Anxiety Invent-ory (STAI) was completed half an hour before the first echocardiography. Of the total number, 10 embryos with a CHD or other extra cardiac major anomalies were excluded from the study. Also during the study, 20 mothers were excluded because of the exclusion criteria or the lack of co-operation and finally, 50 pregnant women whose fetuses had non-complex CHD were studied. After 5 days, the Cambridge Worry Scale (CWS) was performed. Finally, the Pregnancy Conce-rns Questionnaire (PCQ) was completed at 35th week.

Research Instrument

Questionnaires to Assess the Anxiety of Pregnant Mothers

General Health Questionnaire (GHQ-28)
The questionnaire was developed by Goldberg and Hillier and is one of the most well-known screening tools in psychiatry (17) to distinguish health from mental illnesses. Questions on this questionnaire are scored on a Likert scale (0 to 3). Questions include the scale of physical complaints, anxiety, social dysfun-ctions, and depression. On each scale, separately, a score above 6 and overall, a score above 23 indicates symptoms. The validity of the questionnaire was obtained using test-re-test and Cronbach's alpha 0.70 and 0.90, respectively (18). Individuals whose scores are above 23 in General Health Questionnaire are more likely to have a mental disorder.
Spielberger State-Trait Anxiety Inventory (STAI)
This inventory (19) consists of two separate 20-item scales measuring state anxiety (dependent on the state and the mood of the current anxiety) and trait (general anxiety of the individual). A 4-degree Likert scale (never-to-a lot) was used for scoring. Cronbach's alpha for this inventory was reported to be 0.91 (20). In this study, state anxiety scale is one of the main tools for measuring the severity of anxiety in pregnancy.
Cambridge Worry Scale (CWS)
This scale, developed by Green et al. has 17 items (21). The Cambridge Worry Scale measures pregnant women's anxiety about the infant health, the childbirth and the relationships with others and it is set on the 6-degree Likert scale. Following the evaluation of the psychometric properties of the Persian version, six items were added to Mortazavi and Akaberi's (22) research and finally, after the factor analysis, 22 items remained. Cronbach's alpha coefficient was obtained as 0.88. For the 17-item scale, the Cronbach's alpha coefficient was reported to be 0.76 (21). In this study, an Iranian version of the questionnaire with 22 items was used.
Pregnancy Concerns Questionnaire (PCQ)
The questionnaire was developed by Alderidice and Lynn (23) and is used to measure specific pregnancy concerns. There are three sub-scales for it: concerns about the birth and the infant, concerns about the body weight and the body image and concerns about the emotions and the relationships. In Yousefi's study (24), Cronbach's alpha coefficient for this questionnaire was 0.78 and its correlation with Spielberger State Anxiety Inventory was reported to be 0.53.
Echocardiography Device
Echocardiography is one of the imaging devices that are dedicated to image the cardiovascular system. The basis of this device is imaging by ultrasound waves. In fact, echocardiography is an audio image of the heart. In this method, using ultrasound waves, one-dime-nsional, two-dimensional and three-dimensional imag-es of the walls and valves of the heart are obtained simultaneously, which is used in the diagnosis of cardi-ovascular failure. The echocardiograph device displays images of different parts of the heart, vessels, and even the bloodstream into the veins. The echo unit has a high-resolution monitor. It displays 2D and 3D images based on the test results. This test does not require any preparation and it can be performed on the patient at any time. This test lasts from 15 to 20 minutes (25).