Psychosomatic effects of ultrasound in pregnancy – the known unknowns of prenatal medicine

When ultrasound in pregnancy began, it was a disruptive technology. It completely changed the relationship between the pregnant mother, the unborn child and the doctor/midwive. An image that had since time immemorial only existed in the imagination suddenly appeared on a screen and the foetus became something the doctor could relate to – a patient! Medicine of the past 200 years is full of disruptive technologies sweeping established practices and conventions away. Even the introduction of the stethoscope in the early 19th century was a disruptive technology. Ever since the discovery of x-rays, imaging technologies have had a dual and quite contradictory impact – the image could be reassuring by telling the observer (and the patient) that all was fine, or it could be frightening by showing hithero invisible threats to the health and well-being of the patient.

With the advent of ultrasound imaging in the mid 1960ies the features of the foetus as a living being, that had, until then, only been guessed at by touching and palpating the maternal abdomen (with the exception of the ill-judged foetal x-rays in the 1920ies), became a visual presence, shown to future generation of physicians in the lecture halls of medical schools but also to the lay public through countless newspaper articles, on television programmes and newsreels. By the mid 1980ies, the technology had spread to an extent that the majority of babies that were born worldwide had been evaluated, measured and possibly gender-diagnosed at least once by ultrasound while still in utero.

Patients wanted ultrasound and physicians were convinced that they should get it. As always when a new technological fashion – from mobile phones to GPS-systems – is adopted with enthusiasm, when market forces are pushing and pulling for an ever wider application and ever easier accessibility, considerations about the psychological impact both on the individual and on society take some time to be heard and even longer to be taken seriously.

Summing up the small but steady stream of publications that were assessing the psychosomatic aspects of ultrasound in pregnancy over the past 40 years, three distinct approaches and topics consistently show up:

1. Ultrasound in pregnancy has a positive, reassuring effect that enables parents to bond earlier with their baby, ultrasound sessions are experienced as ‘visiting the foetus'. Seeing the foetus on a screen helps the mother to desist from behaviour that might potentially damage the infant – like smoking or alcohol consumption. The recent advent and widespread introduction of 3D/4D ultrasound with its gold-tinted images of cuddly foetal faces and their delicate little hands have very much reinforced the widely held assumption that such a nice technology can have only positive effects. This has even led to legislation proposals on state and federal level in the US whose proponents from the pro-life lobby try to make it mandatory for any woman seeking an abortion to have a forced 3D/4D ultrasound of her foetus before, in order to make her reconsider her request.

2. Ultrasound in pregnancy has a disturbing effect, creating anxiety in the expectant mother. Anxiety is caused by the fact that the creature the woman sees on the screen does not at all correspond to the inner image she has formed of her child, the fact that later in pregnancy the whole foetus no longer ‘fits' on the imaging screen and only extremities, part of the trunk and the head are shown, create subconscious phantasies of amputation and mutilation that the woman dare not express because the doctor is so proud of the ultrasound pictures he manages to produce and she is meant to feel happy and reassured by these technical marvels. The flickering red, blue and orange colour bursts against a shady, dark background produced by obstetrical colour Doppler are very similar to the pixels and images that the special effects technicians in horror films use to create fearsome scenes, thus adding to the scary, otherworldly experience of an ultrasound exam. This critical assessment of the deep psychosomatic effect has received more attention and debate in France than in English- and German-speaking countries (but has in no way prevented France from being one of the countries where the most enthusiastic uptake of pregnancy ultrasound by the population has taken place).

3. By being primarily an instrument for screening for anomalies, ultrasound imbues the first half of pregnancy with an aura of scared anticipation as a succession of ever more detailed examinations aimed at finding possible undesirable features in the foetus are performed. Bonding is prevented as the mother is implicitly being forced to view the foetus as an object to be aborted once its nuchal translucency is too thick or its heart or cerebellum not perfect. Bonding may only start once all possible malformations have been excluded (often after making the woman sign a written statement that she has understood that there might be other malformations, not visible at the time of ultrasound) but the negative images of physical and mental imperfection created during that time of suspense will not got away. Physicians blame this development on the many ‘wrongful life’ lawsuits that contend that certain foetal malformations should have been recognised on ultrasound, thus enabling the woman to have an abortion. Statistically marginal, extreme cases thus dominate doctor–patient communication in all pregnancies.

Pregnancy has always been a time of anxiety. Countless votive offerings, pilgrimages and prayers, all meant to help safeguard a happy outcome for mother and child testify to this in all religions and in all cultures. Whereas ultrasound as an integral part of modern medicine has been able to take some anxieties away, even the greatest ultrasound enthusiast will have to concede that the technology has the potential to create new anxieties in the pregnant woman.

In this issue of the JPOG there are three very different contributions on the subject of the psychosomatic effects of ultrasound in pregnancy. Donnenfeld et al. from Philadelphia compared maternal reaction to 2-D ultrasound as opposed to 3-D ultrasound in 24–36 weeks [1]. Excitement, relief, amazement, satisfaction were the feelings elicited, more so by 3-D than by 2-D ultrasound. However, 3% of the women examined said they felt frightened by the 3-D images.

Williams et al. from New York studied anxiety in women being referred for foetal echocardiography during pregnancy. The referral alone created heightened anxiety, the less the woman knew about the indication and the condition that was being investigated, the higher their anxiety [2].

Finally, Conde et al. from Portugal used ultrasound to study foetal behavioural patterns in depressed and anxious women compared to non-depressed and non-anxious women. They found higher foetal activity and less coordinated single limb movements in foetuses of depressed and anxious mothers [3]. This study follows in the wake of a number of highly promising foetal behavioural state studies using ultrasound in the 1980ies and 1990ies mostly from the Netherlands and from Japan, with interest waning in the new millennium, despite the availability of new techniques like 3D/4D ultrasound and better Doppler applications. The group from Porto is to be commended for taking up this almost discarded topic and also for using an original approach to make the examination less time consuming.

All three studies show how much we still have to learn and how little we know about the consequences of our ultrasound examinations. By narrowing our own priorities to ‘by no means miss a trisomic foetus, by no means overlook a hypoplastic left heart’ we in the ultrasound laboratories in hospitals and in our offices are overlooking most of the effect that the ultrasound we perform in pregnancy has on our patients.

As they often say in the conclusion section of articles ‘further studies will be necessary’ – and if they are properly conducted the JPOG will be there to publish them!

Christoph Brezinka, MD PhD

Universitäts-Frauenklinik,

Medizinische Universität Innsbruck,

A-6020 Innsbruck, Austria

[email protected]