Introduction
This paper is devoted to the case of a woman I know personally. S. is a 31-year-old single mother with a family history of anxiety disorders that had her first pregnancy and gave birth to a healthy girl in January 2020. After being left by her partner while pregnant, she developed an abnormal fear to do something wrong and finally noticed other symptoms affecting her daily life, such as difficulty falling asleep, increased irritability, and food aversion.
After a mental health screening performed during the second trimester of her pregnancy, S. was diagnosed with a mild perinatal generalized anxiety disorder (GAD). The treatment included weekly individual CBT sessions for about two months, dietary changes, and taking the lowest effective dose of Unisom for three weeks to improve sleep quality.
Elevated Stress/Anxiety and Fetal Development
Poor appetite and undernutrition can be the dangerous effects of anxiety and stress in pregnancy since the reduced transfer of nutrients to a developing fetus places severe limitations on fetal growth, thus causing low birth weight. The inability of a fetus to reach the optimal birth weight is often cited among the most common and well-studied consequences of anxiety in pregnancy (Hasanjanzadeh & Faramarzi, 2017).
The recommendations to eat less spicy food and try different combinations of products gradually helped S. to reduce food aversion and increase her caloric intake, but some negative effects of her temporary undernutrition on fetal growth were still present. For example, during the 26th week of pregnancy, the fetus was a bit smaller than average, and the tendency continued until vaginal delivery at 38 weeks – the child’s birth weight was 2.85kg.
Apart from birth weight, maternal stress and anxiety are associated with other health effects on a fetus, including heart rate irregularities, preterm birth, and respiratory issues. For instance, it is believed that anxiety in pregnancy can increase the risks of fetal tachycardia and other complications, including fetal distress and different types of congenital anomalies (Hasanjanzadeh & Faramarzi, 2017).
Although multiple researchers report links between the mental health issues above and the risks of adverse consequences for women and unborn children, to get more accurate results, it is imperative to make corrections for confounding factors. These factors may include maternal substance abuse prior and during pregnancy, antidepressant use, and concomitant disease in pregnancy.
If GAD is managed without pharmacological treatment just like in the case of S., it rarely causes adverse pregnancy outcomes. At the same time, the use of SSRIs and benzodiazepines in patients with GAD affects fetal development by causing slight reductions in the duration of human gestation, especially if exposure to these medications takes place early in pregnancy (Yonkers et al., 2017).
Also, there is evidence that GAD in pregnancy causes significant reductions in brain-derived neurotrophic factor in a developing fetus, which probably has implications for fetal neurological development (Misri et al., 2015). Considering that, it is possible that reliance on non-pharmaceutical interventions reduced the risks of fetal abnormalities and preterm birth in the case being reviewed.
Neonatal Outcomes
Elevated stress and anxiety have influences on neonatal outcomes by affecting pregnant women’s everyday functioning and requiring the use of medications with adverse effects. The woman’s GAD was mild and did not severely affect her ability to engage in self-care activities. CBT was effective in reducing her cognitive distortions, which is why anti-anxiety pharmaceutical treatment was considered as an unnecessary risk.
In this situation, timely treatment and the absence of severe maternal chronic diseases probably explain the absence of adverse outcomes, but it is not the case for all pregnant women with GAD. Common adverse neonatal outcomes that can be associated with GAD are presented by preterm deliveries and birth weight abnormalities (Misri et al., 2015).
Next, regarding the epigenetic factors, anxiety disorders usually have an earlier onset age compared to other types of mental illness. The disorders of this class typically manifest themselves in childhood and adolescence (Schiele & Domschke, 2018). S. remembers worrying about grades much more than her peers did, but she only decided to get help at the age of 30 when unwanted thoughts became strong enough. Anxiety disorders, including GAD, are known to be able to aggregate in families; particularly, having a first-degree relative with these disorders increases the risk of having a disorder of this class up to six times (Schiele & Domschke, 2018).
As for S., her elderly sister received the same diagnosis (GAD) at the age of 21 after a car accident, so heritability is probably manifested in this woman’s case. Regarding specific mechanisms, DNA hypermethylation in “the promoter region of the glucocorticoid receptor gene” has been found in a sample of patients with GAD receiving no pharmaceutical treatment (Schiele & Domschke, 2018, p. 5). Thus, as of now, in human subjects, DNA methylation is the most researched epigenetic mechanism in relation to anxiety.
In terms of attachment, there are some data regarding the way of how GAD during and after pregnancy impacts the formation of parent-infant attachment. The symptoms of anxiety and GAD present in the late weeks of pregnancy can be predictive of the risks of postnatal depression, and this condition often gives rise to bonding difficulties (Hasanjanzadeh & Faramarzi, 2017; Misri et al., 2015).
The promotion of parent-infant attachment is possible in the absence of maternal mental health issues and emotional problems. Excessive worries and negative thoughts in GAD have been shown to make new mothers less responsive to their infants’ needs and unwilling to interact with babies (Misri et al., 2015). Depressive disorders, such as postnatal depression, can even find reflection in strong negative feelings towards newborns, including the desire to hurt one’s baby. S. does not report challenges in communicating and engaging in physical contact with the child.
Perinatal Mental Health and Developmental Outcomes
Anxiety and elevated stress in pregnancy negatively affect the developing fetus in multiple ways, and some of these influences were reflected in the case of S. According to this woman, feeling anxious and bad thoughts about becoming a mother and getting used to this new role in life eventually made her a bit distracted in terms of keeping track of her physical needs, including paying less attention to hunger cues and not wanting to eat her favorite food. As this example indicates, mental health issues, such as anxiety, can make pregnant women less likely to conduct all the necessary self-care activities.
The effects of anxiety disorders on perinatal mental health are often pronounced. If the symptoms of GAD are moderate or severe, it often requires pharmaceutical treatment, so certain complications and issues may result from medication use. It is known that anxiety is more prevalent than depressive disorders in the postpartum period, and the history of mental health issues is a significant psychosocial factor that impacts perinatal mental health (Moulds et al., 2018).
As for intergenerational factors, they may include new mothers’ intergenerational conflicts – S. does not report significant conflicts with her parents. One’s marital status is another psychosocial factor impacting perinatal health and infant-parent relationships. Potentially, lack of support from a spouse can further exacerbate mental health due to tiredness, thus causing new mothers’ desire to put greater distance between themselves and their children.
Despite the success of her CBT treatment, S., a single mother, reported having increased anxiety levels for about one month after delivery, but she did not neglect her infant’s physical needs or refused to engage in physical contact with the child, so severe barriers to the girl’s healthy development were not present.
Next, there are certain factors impacting children’s developmental outcomes. Based on the Crossing Bridges Family Model, common risk factors include drug/alcohol dependencies and proneness to domestic violence combined with mental health issues (Health and Social Care Board, 2014). S. does not have dependency issues and has no romantic relationships at the moment, which minimizes these risks, but limited support from the family (her parents work full-time and cannot provide her with assistance very often) is relevant in this case.
Continuing on the risk factors, the so-called maternal preoccupation with negative thoughts is believed to contribute to the “transmission of psychopathology from a mother to her offspring” (Moulds et al., 2018, p. 162). Protective factors are not very obvious in this case, but they may include the infant’s positive relationships with her grandparents.
Early Intervention Strategies/Tools
Aside from regular weight assessments to make sure that the woman’s child gains weight healthily, an early intervention strategy should include the use of mental health screening tools. Also, making referrals to mental health and child nutrition professionals in case of ongoing challenges is of utmost importance since cross-collaboration is what allows delivering the best possible outcomes.
Perinatal GAD affects up to 11% of postpartum women; there are no specific screening tools for new mothers with this condition, so general tools (GAD-7 scale) can be used to keep track of anxiety symptoms in S. (Misri et al., 2015). Referring S. to mental health professionals would be particularly important in her case since the risks of the recurrence of her GAD symptoms are rather pronounced.
Next, it would be critical to use screening tools to evaluate the risks of mood disorders and depression. New mothers with GAD face the increased risks of developing depressive disorders, which makes screening them for depression pivotal (Misri et al., 2015). As a CFHN, it would be possible to use the Edinburg Postnatal Depression Scale to evaluate the likelihood of postpartum depression in S. and refer her for further mental health screening as soon as possible.
To continue, anxiety disorders often coexist with mood disorders, such as bipolar disorder, and the patient can be encouraged to answer the Mood Disorder Questionnaire (Ali, 2018; Misri et al., 2015). In her case, the main risk factors for developing perinatal mood disorders include the diagnosis of GAD and traumatic experiences in the past (being left while pregnant). Regarding supportive networks, aside from mental health services, S. may benefit from using support resources for single mothers. For instance, Single Mum (singlemum.com.au) is an Australian website that contains helpful articles for single parents and information on local single mother support groups.
Conclusion
To sum up, mental health issues experienced by expecting mothers should be paid enough attention to in order to promote the well-being of both the woman and her future child. Anxiety and stress can affect pregnant women’s health and fetal development by causing a loss of appetite and sleep difficulties. Postpartum mental health screening is critical when it comes to women with a history of anxiety disorders and traumatic experiences.
References
Ali, E. (2018). Women’s experiences with postpartum anxiety disorders: A narrative literature review. International Journal of Women’s Health, 10, 237-249.
Hasanjanzadeh, P., & Faramarzi, M. (2017). Relationship between maternal general and specific-pregnancy stress, anxiety, and depression symptoms and pregnancy outcome. Journal of Clinical and Diagnostic Research, 11(4), VC04-VC07.
Health and Social Care Board. (2014). The Family Model. Web.
Misri, S., Abizadeh, J., Sanders, S., & Swift, E. (2015). Perinatal generalized anxiety disorder: Assessment and treatment. Journal of Women’s Health, 24(9), 762-770.
Moulds, M. L., Black, M. J., Newby, J. M., & Hirsch, C. R. (2018). Repetitive negative thinking and its role in perinatal mental health. Psychopathology, 51(3), 161-166.
Schiele, M. A., & Domschke, K. (2018). Epigenetics at the crossroads between genes, environment and resilience in anxiety disorders. Genes, Brain and Behavior, 17(3), 1-15.
Yonkers, K. A., Gilstad-Hayden, K., Forray, A., & Lipkind, H. S. (2017). Association of panic disorder, generalized anxiety disorder, and benzodiazepine treatment during pregnancy with risk of adverse birth outcomes. JAMA Psychiatry, 74(11), 1145-1152.