Psychological Reactions in Women

Undergoing Fetal Magnetic Resonance

Imaging
Katharina Leithner, MD, Susanne Prnbacher, MS, Eva Assem-Hilger,
Elisabeth Ponocny-Seliger, PhD, and Daniela Prayer, MD
OBJECTIVE: To investigate womens psychological reactions when undergoing fetal magnetic resonance imaging
(MRI), and to estimate whether certain groups, based on
clinical and sociodemographic variables, differ in their
subjective experiences with fetal MRI and in their anxiety
levels related to the scanning procedure.
METHODS: This study is a prospective cohort investigation of 62 women before and immediately after fetal MRI.
Anxiety levels and subjective experiences were measured
by questionnaires. Groups based on clinical and sociodemographic variables were compared with regard to
anxiety levels and to the scores on the Prescan and
Postscan Imaging Distress Questionnaire.
RESULTS: Anxiety scores before fetal MRI were 8.8
points higher than those of the female, nonclinical, norm
population (P<.001). The severity of the referral diagnosis
showed a linearly increasing effect on anxiety level before MRI (weighted linear term: F1,595.325, P.025).
Magnetic resonance imaging was experienced as unpleasant by 33.9% (95% confidence interval [CI] 21.2
46.6%) and as hardly bearable by 4.8% (95% CI 0 17.5%)
of the women. Physical restraint (49.9%, 95% CI 37.4
62.4%), noise level (53.2%, 95% CI 40.7 65.7%), anxiety
for the infant (53.2%, 95% CI 40.7 65.7%), and the
duration of the examination (51.6%, 95% CI 39.1 64.1%)
were major distressing factors.

From the Departments of Psychoanalysis and Psychotherapy, Neurology, Obstetrics and Feto-Maternal Medicine, and Radiology, Medical University Vienna,
Austria.
Supported in part by Philips Austria.
Corresponding author: Katharina Leithner, MD, Department of Psychoanalysis
and Psychotherapy, Medical University of Vienna, Wahringer Gurtel 18-20,
1090 Vienna, Austria; e-mail: katharina.leithner@meduniwien.ac.at.
Financial Disclosure
The authors have no potential conflicts of interest to disclose.
2008 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/08

396

VOL. 111, NO. 2, PART 1, FEBRUARY 2008

MD,

Elisabeth Krampl,

MD,

CONCLUSION: Women who undergo fetal magnetic

resonance imaging experience considerable distress, especially those with poor fetal prognoses. Ongoing technical developments, such as a reduction of noise, shortening the duration of the MRI, and a more comfortable
position in open MRI machines, may have the potential
to improve the subjective experiences of women during
fetal MRI.
(Obstet Gynecol 2008;111:396402)

LEVEL OF EVIDENCE: III

etal magnetic resonance imaging (MRI) has become an important part of the diagnostic protocol
in tertiary referral centers, especially in cases where
ultrasonography does not provide sufficient information.1,2 However, data on the psychological impact of
fetal MRI are rare.
Michel et al3 investigated the psychological reactions of 15 pregnant women and 15 controls who
underwent pelvimetry and compared patient acceptability for an open 0.5-T and a closed 1.5-T magnetic
resonance system. Regardless of the system and the
preimaging information provided, 33% percent of
pregnant women reported fear of fetal harm. With
regard to psychological reactions during MRI procedures in general, the prevalence rates for claustrophobic reactions during scanning vary between 5% and
10%.4 6 Anxiety reactions were found in up to 37% of
the patients who undergo scanning procedures.7,8
High initial levels of anxiety, long examination time,
high noise, and temperature level were found to be
predictive for the development of psychological problems during MRI.4,9,10,11 Preimaging information by
the referring doctor has been shown to be one of the
major determinant factors that influence a patients
experience of MRI.9 Similar results were found for
psychological experiences during ultrasonography in
pregnancy.12,13 In general, the psychological conse-

OBSTETRICS & GYNECOLOGY

quences of prenatal diagnostic procedures may frequently be underestimated.14

The aim of the present study was to assess
womens psychological reactions when undergoing
fetal MRI and to estimate whether groups based on
clinical variables (referral diagnoses, MRI diagnoses,
presence of the partner during MRI) and sociodemographic variables (age, education, marital, and occupational status) differ in their subjective experiences
with fetal MRI and in their anxiety levels related to
the scanning procedure.

PATIENTS AND METHODS

We conducted a prospective cohort investigation.
Sample size considerations focused on a global standard of error for the description of categorical variables of no more than 6.5 percentage points. Therefore, an active sample of at least n60 was chosen.
During a 6-month period of investigation between
February 2006 and July 2006, 72 consecutive patients
scheduled to undergo fetal MRI at the Department of
Radiology at Vienna Medical University were investigated. Patients were referred from four different
Fetal Medicine Units. Magnetic resonance imaging
was performed with a 1.5T superconducting unit
(Philips Intera, Release 11, Philips Medical Systems,
Vienna, Austria). Using a sense-cardiac coil, T2weighted, fast spin-echo sequences were performed in
three orthogonal section planes, and T1-weighted,
diffusion-weighted sequences, thick-slab T2-weighted
sequences, and dynamic sequences were also obtained. Protocols were adjusted based on clinical
questions.15,16 Total imaging times varied due to the
clinical questions being addressed, and sequences
were repeated in case of fetal movements. Women
were placed in a position they indicated that they
would tolerate best, with a slight left tilt to prevent
supine hypotension. The diameter of the tunnel was
60 cm. The average temperature was 25C, with the
availability of additional ventilation when required.
Ear plugs or head phones, with music available, were
provided.
All questionnaires were completed during the
waiting time before and after the scan. Women were
tested immediately after scanning. Preliminary information about the results of the MRI scan was not
provided. Women were informed about the final
MRI diagnosis by their referring obstetrician after the
radiological analyses had been completed.
Ten (13.9%) patients were not included in the
study. Six (8.3%) women had to be excluded because
of language problems. Four (5.6%) women refused to
participate for private reasons. All patients gave writ-

VOL. 111, NO. 2, PART 1, FEBRUARY 2008

ten informed consent. The study protocol was approved by the ethical board at the Medical University
of Vienna.
The final sample consisted of 62 women. Mean
age was 30.2 (standard deviation 4.8) years. All
women were involved in a relationship, and 43.5%
(n27) had already had children. Twenty-one
(33.9%) women completed compulsory school (until
15 years), 24 (38.7%) attended A-level (high school
degree), and 17 (27.4%) women had a university
degree. The educational level of our cohort was
higher than the Austrian average, which was probably
a consequence of the older age of our sample and of
the fact that we had to exclude those women who
were not able to speak and understand German well
enough to participate. The obstetric history of our
study group is included in Table 1.
Three women (4.8%) had previously suffered
from claustrophobic symptoms. None of the women
had a psychiatric history. Twelve (19.3%) women had
previously undergone MRI for other indications. The
rather high figure of 19% of women with previous

Table 1. Sociodemographic and Clinical

Characteristics
Characteristics

(n62)

Age (y, meanSD)

Education
Compulsory (until 15 years)
A-level (high school degree)
University degree
Current job status
Full/part-time work
Unemployed/maternity leave
Partner
Yes
Children
Yes
No
Week of gestation (wk, meanSD)
Obstetric history
Births
None
One
2 or more (maximum3)
Unknown
Miscarriage
None
One
2 or more (maximum3)
Interruption
None
One
Four

30.24.8
21 (33.9)
24 (38.7)
17 (27.4)
17 (27.4)
45 (72.6)
62 (100)
27 (43.5)
35 (56.5)
26.94.6

35 (56.5)
16 (25.8)
10 (16.1)
1 (1.6)
48 (77.4)
9 (14.5)
5 (8.1)
55 (88.7)
6 (9.7)
1 (1.6)

Data are expressed as n (%) or meanstandard deviation (SD), as

indicated.

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Psychological Reactions to Fetal MRI

397

MRI experience is not unusual for an Austrian population. Magnetic resonance imaging is commonly
used for primary diagnoses (eg, in patients with severe
headache or orthopedic complaints) because the costs
of MRI investigation are completely covered by the
Austrian public health insurance system.
At the time of imaging, women were, on average,
at 26.9 (4.6) weeks of gestation. We categorized
referral diagnoses, after ultrasound examination, according to severity, as follows: without any overt
pathology, but with the potential for developing
problems, such as, for instance, monochorionicity in
twins (n6; 9.7%) or premature rupture of membranes (PROM, after gestational week 29) (n2;
3.2%); suspicion of a fetal pathology compatible with
survival (n40; 64.5%); and suspicion of a fetal
pathology probably not compatible with survival
(n14; 22.6%). Fetal pathology that was rated as
compatible with survival included twin pregnancy
with premature rupture of membranes before gestational week 29, renal cysts, meningocele, cardiac
rhythm abnormalities in the fetus, and cystic lung
lesion. Fetal pathology probably not compatible with
survival comprised suspected rhombencephalosynapsis, suspected cystic fibrosis with bowel obstruction,
suspected
renal
agenesis,
and
suspected
chondrodysplasia.
Anxiety levels were measured before and after
the scan using the German version of the Spielberger
State-Trait Anxiety Inventory, a widely used instrument for the assessment of the current (state) and
inherent (trait) level of anxiety.17 The Beck Depression Inventory, a widely accepted screening instrument for depression, was used to exclude an underlying depressive disorder.18 To assess patients
attitudes and expectations toward, and their experiences of, MRI, women completed the modified version of the Prescan and Postscan Imaging Distress
Questionnaire.11 The Prescan Imagining Distress
Questionnaire compromises questions about anxiety
concerning the examination, worries about the technical apparatus, worries about the outcome of the
examination, the subjective appraisal of the importance of the MRI for further treatment, and general
confidence in modern medicine. In the modified
version, two questions about anxiety with regard to
the possible negative effects of the MRI, for the infant
and for the mother, were added. The Postscan Imaging Distress Questionnaire focuses on the subjective
appraisal of the overall experience of the MRI, the
duration of the examination, the noise level, the
narrowness of the tunnel, the temperature, and
the necessity of being immobile. Moreover, women

398

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Psychological Reactions to Fetal MRI

were asked whether they would undergo such an

examination once more, if necessary. Two questions concerning the body position during MRI and
their anxiety for the infant during the procedure
were added in the modified version. In addition,
women rated their anxiety about the examination
and about the outcome of the MRI on a 10-point
visual analog scale (VAS) before and after the scan.
Sociodemographic data and obstetric and medical
information were documented, as well as details of
the MRI investigation.
To describe the sample, pre- and post-MRI, the
meanstandard deviation was used for continuous
variables. Frequencies, percentages, and the 95% confidence intervals are reported for categorical variables. Group comparisons for continuous variables
were done by using independent sample t tests or
analysis of variance (ANOVA) models when normality (Kolmogorov-Smirnov goodness-of-fit test) and
homogeneity of variances (Levines test) were assumed; otherwise, Mann-Whitney and Kruskal-Wallis
tests were used. For categorical data, group differences were evaluated with Fisher exact tests. Pre- and
post-MRI changes were evaluated by using paired
sample t tests. For a simultaneous analysis of group
differences and for pre- and post-MRI changes, repeated-measures ANOVA models with a one-between subject factor were used. The statistical software package SPSS 15.0. (SPSS Inc., Chicago, IL),
including the Exact-Tests module, was used. For all
categorical data analyses, the exact P values and odds
ratios were reported. P values .05 were considered
significant.

RESULTS
Total scan time was 41.5 (12.2) minutes. Thirty-six
(58.1%) women were accompanied by their partners
(n34; 54.8%) or a medical staff member (n2; 3.2%)
who was present in the examination room during
scanning. Three (4.8%) scans had to be interrupted
due to claustrophobia and breathing problems. Two
(3.2%) of these patients were unable to complete the
scan. Two (3.2%) women received a short-acting
sedative medication before MRI in agreement with
the referring obstetrician.
Magnetic resonance imaging diagnoses were categorized according to severity as follows: no fetal
malformation (23; 37.1%); fetal pathology compatible with survival (24; 38.7%) (eg, arachnoidal cyst,
congenital cystic adenomatoid malformation of the
lung, distal bowel stenosis without cystic fibrosis); and
fetal pathology probably not compatible with sur-

OBSTETRICS & GYNECOLOGY

Table 2. Fetal Magnetic Resonance Imaging,

Diagnostic Groups
MRI Diagnoses
Singleton pregnancies without
MRI-proven pathology
Twins without MRI-proven
pathology
Cerebral malformations
Urogenital malformations
Other malformations
Acquired pathology (eg, placenta
changes, inadequate lung
maturation)
Dropouts

n62

12

19.4

6
13
5
16

9.7
21.0
8.1
25.8

8
2

12.9
3.2

MRI, magnetic resonance imaging.

vival (13; 21.0%) (eg, megacystic microcolon,

rhombencephalosynapsis, renal agenesis) (Table 2).
Before the scan we found state-anxiety levels
(46.914.4) in our patient group that were 8.8 points
higher than those of the female nonclinical norm
population (n1,278) that is described in the test
manual (38.110.3; t1,3386.431, P.001), which significantly (38.913.5; t615.433, P.001) decreased
to a level comparable to that of the norm population
(t1,3380.588, P.556) after the scan.17 Trait-anxiety
levels were significantly lower (32.57.6) than those
of the norm population (37.010.9; t1,3383.494,
P.001).17 In the Beck Depression Inventory, two
women showed minor depression. In the VAS, the
womens self-perception of anxiety concerning the
examination was at a level of 2.1 (2.6). Anxiety with
regard to the results of the MRI was rated on a level
of 5.1 (3.4) by the patients.
In the Prescan Imaging Distress Questionnaire,
31 women (50.0%, 95% CI 38.7 61.7%) were found
to be very anxious about the outcome of the examination (Tables 3 and 4). Anxious feelings concerning
the procedure and the technical apparatus were mentioned in only a few cases (3.2%, 95% CI 0 7.6%).
Forty-nine (79%, 95% CI 68.9 89.1%) women rated
the fetal MRI as very important for their further

treatment. Twenty-two (35.5%, 95% CI 23.1 47.9%)

women were worried about possible negative effects
of the MRI on the infant, and finally, seven (11.2%,
95% CI 0 23%) women worried about possible negative effects of the MRI on their own health.
In the Postscan Imaging Distress Questionnaire,
the MRI procedure was experienced as an unpleasant
event by 33.9% (95% CI 21.2 46.6%) and as hardly
bearable by 4.8% (95% CI 0 17.5%) of the women.
The physical restraint (49.9%, 95% CI 37.4 62.4%),
noise level (53.2%, 95% CI 40.7 65.7%), and the
duration of the examination (51.6%, 95% CI 39.1
64.1%) were reported as major disturbing factors. The
fear for the infant was rated as hardly bearable by
nine women (14.5%, 95% CI 2.726.3%) and as
unpleasant by 24 (38.7%, 95% CI 26.9 50.5%)
women.
Women who were accompanied by their partners
or medical staff members showed significantly higher
anxiety scores before scanning (without an accompanying person: 41.514.2, with an accompanying person: 50.713.5; t602.594, P.012). The three
women who had to interrupt the examination did not
show anxiety levels or adverse perceptions toward
scanning that were any higher than the women who
completed the MRI, nor did they have a history of
claustrophobia. The two dropouts had a referral diagnosis of suspicion of a fetal pathology compatible
with survival.
The severity of the referral diagnosis showed a
linearly increasing effect on the womens anxiety
before MRI (without any overt pathology, n8:
35.813.1; suspicion of a fetal pathology compatible
with survival, n40: 47.613.6; suspicion of a fetal
pathology probably not compatible with survival,
n14: 51.115.3; weighted linear term: F1,595.325,
P.025). After the scan, anxiety was significantly
reduced in all three groups (without any overt pathology, n8: 27.06.3; suspicion of a fetal pathology compatible with survival, n40: 40.812.4;
suspicion of a fetal pathology probably not compat-

Table 3. Results of the Prescan Imaging Distress Questionnaire

Pre-MRI Items
The forthcoming examination makes me feel anxious
The technical apparatus worries me
I am worried about negative effects of the MRI for my health
I am worried about negative effects of the MRI for my baby
The forthcoming examination is important for my further treatment
I am worried about the outcome of this examination
I have confidence in modern medicine

Not at All

Somewhat

Very Much

Missing

52 (83.9)
58 (93.6)
55 (88.7)
40 (64.5)
2 (3.2)
23 (37.1)
2 (3.2)

6 (9.7)
2 (3.2)
3 (4.8)
14 (22.6)
11 (17.7)
8 (12.9)
9 (14.5)

4 (6.4)
2 (3.2)
4 (6.4)
8 (12.9)
49 (79)
31 (50.0)
51 (82.3)

0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)

MRI, magnetic resonance imaging.

Data are expressed as n (%); standard error6%.

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Psychological Reactions to Fetal MRI

399

Table 4. Results of the Postscan Imaging Distress Questionnaire

Post-MRI Items
The examination was overall . . .
The duration of the examination was . . .
The noise level during the examination was . . .
The narrowness of the tunnel was . . .
The temperature during the examination was . . .
The body position during the examination was . . .
Being not allowed to move was . . .
The anxiety for my baby during the examination was . . .
If necessary I would undergo such an examination once more
Yes
No

Easy to
Tolerate

Unpleasant

37 (59.7)
29 (46.8)
28 (45.1)
34 (54.8)
32 (51.6)
35 (56.4)
30 (48.4)
28 (45.1)

21 (33.9)
26 (41.9)
31 (50.0)
18 (29.0)
24 (38.7)
20 (32.3)
19 (30.6)
24 (38.7)

Hardly
Bearable Missing
3 (4.8)
6 (9.7)
2 (3.2)
9 (14.5)
5 (8.1)
6 (9.7)
12 (19.3)
9 (14.5)

1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
1 (1.6)
58 (93.5)
3 (4.8)

MRI, magnetic resonance imaging.

Data are expressed as n (%); standard error6%.

ible with survival, n14: 40.416.4; effect of time:

F1,5923.304, P.001; interaction effect time referral diagnosis: F2,590.635, P.534; effect of referral
diagnosis: F2,594.259, P.019). In the VAS, women
with the referral diagnosis without any overt pathology rated their anxiety significantly lower than the
other two groups (without any overt pathology,
n8: 1.93.8; suspicion of a fetal pathology compatible with survival, n40: 5.23.2; suspicion of a
fetal pathology probably not compatible with survival, n14: 6.63.2; F2,574.941, P.011). Women
with the referral diagnosis without any overt pathology also considered the examination less stressful
with regard to the noise level (odds ratio10.6,
P.002) of the scan.
Based on the severity of the MRI diagnoses, we
found significant group differences in state-anxiety
post-MRI between the three groups (F2,575.2,
P.009). Women with an MRI diagnosis of fetal
pathology probably not compatible with survival
scored higher than women in the other two groups
(no fetal malformation, n23: 33.79.8; fetal pathology compatible with survival, n24: 37.711.7;
fetal pathology probably not compatible with survival, n13: 47.015.5).
Women with an MRI diagnosis of a fetal malformation showed high state-anxiety levels after the
scan (without pathology, n18: 31.78.8; fetal
malformation, n34: 42.414.0; acquired pathology, n8: 35.08.0, F2,573.4, P.010). Anxiety levels before the scan, based on diagnostic
groups, showed no significant difference. Group
comparisons based on sociodemographic variables
showed no significant differences related to subjective experiences or to the anxiety level of women
during an MRI examination.

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DISCUSSION
We present data derived from a study designed to
assess womens psychological reactions when undergoing fetal MRI. There is a paucity of data concerning
psychological distress related to fetal MRI scanning. In discussing our results, we will therefore
refer to studies on psychological reactions concerning MRI in different general samples and to one
study that included pregnant women without a
prenatal diagnosis.35,9,11
Our main findings can be summarized as follows:
Levels of anxiety before fetal MRI were significantly
higher in our population than those reported in the
female nonclinical norm population, but they were
close to reported prescan anxiety levels in other
samples of patients who undergo MRI.4,5,9,11 The
severity of referral diagnosis (without any overt
pathology, suspicion of a fetal pathology compatible with survival, and suspicion of a fetal pathology
probably not compatible with survival) showed a
linearly increasing effect on levels of anxiety before
MRI. Anxiety levels significantly decreased after
scanning, (again, comparable to previously reported
postscan anxiety scores4,5,9,11), although women had
not yet been informed about MRI diagnoses. The
results of the self-rating of anxiety by means of VAS
scales were consistent with these findings. With respect to the subjective experiences during the scanning procedure, the MRI examination was rated as
unpleasant by 33.9% and as hardly bearable by 4.8%
of the women (Postscan Imaging Distress Questionnaire). Thus, 59.7% of our patients found MRI easy to
tolerate, compared with 88% in a nonpregnant sample.11 Factors that were rated particularly distressing
included womens anxiety for the infant, the inability
to move, the narrowness of the tunnel, the body

OBSTETRICS & GYNECOLOGY

position, the duration of the examination, and noise

and elevated temperature. The results of the Prescan
Imaging Distress Questionnaire showed that a considerable number of women were preoccupied with
stressful emotions (mainly in terms of worries about
the possible negative effects of the MRI on the
infant; 35.5%), whereas anxious feelings concerning
the procedure and the technical apparatus were
mentioned in only a few cases (6.4%). Nevertheless,
a total number of 96.7% rated the investigation as
important for further treatment. Group comparisons based on sociodemographic variables showed
no significant differences in either anxiety levels or
in terms of subjective experiences related to the
MRI procedure.
The high anxiety scores in our sample may reflect
the psychological distress associated with the suspicion of fetal pathology, especially in those women
where ultrasonography had suggested a fetal pathology that was probably not compatible with survival.
Because only two patients showed mild depressive
symptoms in the Beck Depression Inventory, the
possibility of an underlying major depression can be
ruled out as a major additional factor that could
have influenced the levels of anxiety. Although we
were not able to control for potential differences in
the level of preimaging information given by the
referring obstetricians, we assume that a possible
reason for these anxieties may, at least in part, be the
lack of easily understandable preimaging information.
Moreover, one should consider that women who
undergo fetal MRI have already experienced a psychic stress situation before the fetal MRI when they
were confronted with the results of prenatal ultrasound examination that suggested a fetal pathology.
Of interest, women who were accompanied by
their partners during MRI had higher anxiety levels
before scanning. After scanning, anxiety levels did
not differ from those who came alone. We assume
that the attendance of the partner probably represented a strategy to cope with these intense feelings of
anxiety. However, data on the perception of the
partners attendance during the examination would
be needed to further comment on this finding.
We do acknowledge that there are several limitations to our study, such as the small sample size and the
selected sample of patients from a university hospital.
However, data derived from a study that explores
subjective experiences and feelings related to fetal MRI
may contribute to a better understanding of the precarious psychological situation of this particular patient
group. Moreover, we think that our results may be of

VOL. 111, NO. 2, PART 1, FEBRUARY 2008

clinical relevance to improve the further procedure of

fetal MRI, as well as the acceptance of this innovative
prenatal diagnostic procedure.
Our findings suggest that women who undergo
fetal MRI experience a marked psychological distress,
despite the general high acceptance of this kind of
investigation in our population. Besides the general
need for psychological assistance for women who
undergo prenatal investigations, there may be some
additional points to consider in those women who are
referred for fetal MRI. Preimaging information that
includes detailed information about the course and
duration of MRI, body position during the examination, noise, and the lack of negative effects on the fetus
may be beneficial. Future research should focus on
the effect of preimaging information on womens
subjective experiences with the fetal MRI procedure.
Given the womens distress related to noise, the
further development of so-called silent sequences
should be continued. To reduce constraints due to
body position, open MRI machines should be approved for fetal MRI. Considering womens complaints about the physical restraints during the examination, the construction of magnetic resonance coils
with receiving elements that can be deliberately
placed near the respective region of interest would
reduce the duration of the examination and, consequently, improve the tolerability of the procedure for
pregnant women.
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