Reducing Amniocentesis Anxiety: The Role of Pre-Procedural Video Information

Introduction

Pregnancy is one of the most annoying and stressful states in a woman’s lifetime [1]. Any variation in the prenatal follow-up test results from normal superpose further anxiety. Prenatal screening and diagnostic investigations of fetal aneuploidies commonly performed in contemporary perinatal medicine. Aneuploidy screening uses a combined screening test in the first trimester, a quadruple test in the second trimester, and cell-free placental DNA evaluation after 9 weeks of gestation. In cases of high-risk pregnancies, such as those with positive screening test results for aneuploidy, advanced maternal age (>35 years), ultrasound-detected fetal abnormalities, elevated alpha-fetoprotein levels, acetylcholinesterase activity, or suspected fetal infections or chorioamnionitis [2], invasive diagnostic procedures, including chorionic villus sampling (CVS) (11–14 weeks) and amniocentesis (after 15 weeks) are recommended.

The psychosocial impacts of these invasive procedures on maternal health were previously studied. The results showed considerable psychological distress of women undergoing prenatal diagnostic investigations [3]. Amniocentesis is the most widely used invasive prenatal diagnostic method [4], but it is associated with significant stress and anxiety among pregnant women. Factors contributing to this distress include the potential risks involved in the procedure, uncertainty regarding the outcomes, fear of needles, pain, and concerns about fetal harm, infection, and preterm delivery [5]. Additionally, inadequate or unsatisfying provision of information about the condition, procedure, and associated risks can place extra pressure on pregnant women. To alleviate these concerns, strategies such as providing comprehensive verbal and written information to the family regarding the procedure, psychological support, and provision of educational materials have been employed.

Patient education has consistently been an essential and integral part of health care provider responsibility, particularly for patients to prepare themselves for pre- and post-procedural periods. However, the traditional verbal and written tools used in daily obstetric practice are far from perfect. A growing body of knowledge regarding the use of multimedia and video for patient education shows that visual informative interventions improve patient counseling [6,7].

Material and Methods

ETHICAL CONSIDERATIONS:

This study was approved by the institutional Ethics Committee (No: 16.01.2019-38) and conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent after receiving detailed information about the study.

STUDY DESIGN AND POPULATION:

This prospective, single-center study was conducted at the Perinatology Department of Akdeniz University’s Obstetrics and Gynecology. Inclusion criteria were pregnant women who underwent first or second trimester screening for aneuploidy between February 2019 and February 2020 and had a positive screening result indicating a risk greater than 1 in 100. Participants with fetal congenital anomalies, a family history of genetic diseases, suspected fetal infections, chorioamnionitis, Rh isoimmunization, maternal systemic or psychiatric diseases, multiple pregnancies, or those who declined to participate were excluded from the study. To ensure a homogenous study population, we limited our analysis to cases where amniocentesis was the sole invasive prenatal diagnostic procedure performed, excluding those who underwent chorionic villus sampling or cordocentesis. Pregnant women meeting the inclusion criteria were randomly (1: 1 ratio) assigned to the case and control groups. Recruitment was stopped when each group reached a sample size of 50, resulting in a total of 100 participants. All participants provided written informed consent after receiving detailed information about the study.

DATA COLLECTION AND DATA ANALYSIS:

Following ethical approval, a comprehensive, 5-minute video demonstrating a live amniocentesis procedure was developed (created specifically for this study by the research team). The video encompassed pre-procedural preparations, equipment used, procedural steps, potential risks and expected outcomes, including possible complications and complication rates, as well as frequently asked questions and their corresponding answers. In accordance with our department’s standard practice, all 100 participants were provided with verbal and written information and provided informed consent before undergoing the amniocentesis procedure. The amniocentesis was carried out in accordance with standard protocols, employing equipment and techniques as described in the published literature [2]. All procedures were conducted by a single, highly experienced perinatologist.

Anxiety levels of pregnant participants were assessed using the Spielberger State-Trait Anxiety Inventory (STAI) and pain and stress levels were measured with the Visual Analog Scale (VAS) before and after the amniocentesis procedure. STAI has 2 subscales, both comprising 20 items on a 4-point scale. STAI 1 assesses the current state of anxiety, whereas STAI 2 evaluates the relatively stable aspects of characteristics and anxiety proneness. The sum of the values of each patient ranges from 20 to 80 points, with higher scores demonstrating higher level of anxiety [8,9]. The Turkish version of the STAI questionnaire used in this study was validated in a Turkish population [10]. VAS is a 10-cm-long pain scale ranging from 0 (no pain/stress) to 10 (excruciating pain/stress), which is applied by asking the patient to mark a point that expresses the pain and stress levels. The distance between the point marked and the lowest end of the line is measured in centimeters and the numerical value obtained indicates the degree of emotion [11].

Prior to the amniocentesis procedure, both the case (n: 50) and control (n: 50) groups completed the STAI and VAS. These baseline assessments were labeled “Pre-amniocentesis”. After completing baseline assessments (Pre-amniocentesis), the case group viewed a 5-minute educational video developed by the research team. The control group did not receive this intervention. Subsequently, the case group was reassessed using the STAI and VAS, and these assessments were labeled “Post-Video”. Both the case and control groups underwent a final assessment using the STAI and VAS following the amniocentesis procedure. These post-procedure assessments were labeled “Post-amniocentesis.” The clinical and demographic characteristics of pregnant women were obtained from the hospital database.

STATISTICAL ANALYSIS:

SPSS 21.0 was used to analyze the data. Continuous variables are presented as mean±standard deviation, and categorical variables are given as percentages. The Shapiro-Wilk test was used to detect normal distribution. The independent-sample t test was used to compare the demographic and clinical characteristics of the participants. The Mann-Whitney U test was used to evaluate the effect of video-based patient information and to compare intra-group change, and the Wilcoxon signed-rank test was used to compare inter-group change. Categorical data were analyzed by Pearson chi-square test and chi-square for trend. In addition, when there were 2 groups and the expected frequencies were not met, Fisher’s exact test was used to complete the analysis. When there were ≥3 groups and the expected frequencies were not met, Fisher’s exact test was used with rearranging the group number as 2. Finally, Spearman correlation analysis was used to assess correlations among variables. In all the tests, the value of P<0.05 was accepted as statistically significant.

Results

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS:

A total of 100 patients were randomly (1: 1 ratio) assigned to 2 groups: a case group (n: 50) and a control group (n: 50). There were no significant differences between the groups in terms of demographic and clinical characteristics, including STAI 2 scores (Table 1).

INTRA-GROUP COMPARISONS:

Table 2A shows intra-group comparison of “Pre-amniocentesis” and “Post-amniocentesis” scores (the data for the case group and the control group were analyzed separately). The STAI 1 and VAS scores showed significant differences between “Pre-amniocentesis” and “Post-amniocentesis” in the case group (P<0.05 for all). However, the only significant difference was the VAS score for pain in the control group (0.85±0.74 vs 1.85±1.39, P: 0.005).

INTER-GROUP COMPARISONS:

Table 2B shows inter-group comparison of “Pre-amniocentesis” and “Post-amniocentesis” scores. “Pre-amniocentesis” assessment: The mean STAI-1 score for the case group (50.35±6.46) was slightly higher than the control group (48.08±9.72), although this difference was not statistically significant (P: 0.065). Additionally, there was no significant difference in VAS scores between the 2 groups. “Post-amniocentesis” assessment: The mean STAI-1 score was significantly lower in the case group (38.35±7.50) compared to the control group (45.25±8.58, P<0.001). Additionally, the case group reported significantly lower levels of stress (2.18±3.06 vs 4.20±2.86, P<0.001) compared to the control group. While the pain scores were similar between the 2 groups, the case group tended to report lower pain levels.

DELTA CHANGE ANALYSIS:

Table 3 shows the comparison of average delta change analysis between groups. The reduction in STAI-1 and VAS stress scores was substantially larger in the case group when compared to the control group.

CASE GROUP ASSESSMENTS:

Table 4 denotes the comparison of the results of case group “Pre-amniocentesis”, post-video and “post-amniocentesis”. All results of these tests regarding STAI-1 and VAS were significantly different (P<0.001 for all).

PATIENT FEEDBACK:

All the patients in the case group found the video informative and 80% indicated the video was effective for decreasing anxiety (Table 5).

Discussion

STUDY LIMITATIONS:

This was a single-center study with a relatively small sample size; higher number of participants would reveal more conclusive results. The educational level of our participants was relatively high, and different subgroups with different education levels may have had different reslts from video education. On the other hand, our case group performed the tests for 3 times (1 just after the video education but before amniocentesis).

STUDY STENGTHS:

Prospective study design, a highly homogeneous group of pregnant women who underwent amniocentesis only.

Conclusions

While written and verbal pre-amniocentesis counseling can mitigate patient anxiety and stress, video-based education has demonstrated a more significant impact on reducing these negative emotions. Given its ease of implementation and informative nature, video-based education can be effectively integrated into routine clinical practice to enhance the patient experience.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.