Abstract

Maternal stress during pregnancy has been related to adverse short- and long-term maternal and perinatal outcomes. The study is aimed at investigating perceived stress and hyperarousal, a psychophysiological index of stress responsiveness, in a sample of women with uncomplicated and complicated pregnancy.  Participants in the study were recruited on a voluntary basis from family counselling centers, obstetrician/gynaecologists offices and outpatients’ units and asked to fill an online survey Google® form ensuring anonymity and including a questionnaire for socio-demographic and clinical variables, the Perceived Stress Scale, and the Hyperarousal Rating Scale. 326 pregnant women, aged between 18-45 years, were included in the study; 214 subjects were classified as Uncomplicated pregnancy, and 112 as Complicated pregnancy. The Uncomplicated pregnancy group reported higher levels of perceived stress (p = .003), and the Complicated pregnancy women scored significantly higher at the Reactivity dimension of Hyperarousal scale (p = .022); Reactivity predicted perceived stress (β = 3.144; p = .004) in the Complicated pregnancy group, as indicated by a linear regression analysis. Stress during pregnancy is frequently a response to the occurrence of gestational complications; in such cases, hyperarousal can be suitable for predicting perceived stress levels. Findings also suggests that a percentage of women with uncomplicated pregnancies may also be at risk for experiencing elevated stress levels. The assessment of vulnerability and predictive factors of high perceived stress should be included in a multidimensional evaluation of maternal health during pregnancy.

BACKGROUND

Pregnancy is a physiological condition characterized by substantial modifications in neuroendocrine, cardiovascular and immune functions, along with emotional, psychological, and cognitive adjustments to changes in self- and body image, attitudes, motivations, environmental balance and social role. Thus, for many women pregnancy can be a period of considerable psychological turmoil, anxiety, and perceived stress, possibly fuelled by feelings and/or fear of inadequacy for not being able to carry the baby safely or to cope with the demands of motherhood, apprehension and concerns for both their own and the child’s health, the risk of abortion, miscarriage, or peripartum complications and accidents 1,2.

Previous studies have highlighted that stress exposure during pregnancy, especially when persistent, may be related to adverse short-term maternal and perinatal outcomes, also increasing the chances of preterm birth and low birth weight 3; furthermore, maternal stress may be also related to long-term perinatal outcomes which can be seen in the late neonatal life or infancy, consisting of adverse neurodevelopmental outcomes, including an increased risk of cognitive, emotional, behavioral disturbances 4,5, along with the increased risk for infectious and non-infectious diseases 6. Nevertheless, when evaluating the role of stress during pregnancy and its potential impact on mother and child health, it should be considered that perception of stress is highly subjective and dependent on the individual capacity to elaborate or tolerate stressors and/or triggers, and this can be mediated both by individual factors, such as personality features and traits, past experiences, cognitive styles, psychopathological vulnerabilities, and by socioeconomic and relational issues, such as lack of a family support network, low income, poverty, and intimate partner violence 7.

Examining individual factors, one of the psychophysiological indexes of stress responsiveness is hyperarousal, defined as an abnormal state of higher reactivity to stimuli deriving from the deregulation of the Autonomic Nervous System (ANS) and resulting in sympathetic hyper-reactivity in response to stimuli. It is characterized by various physiological and psychological symptoms, such as increased heart rate and startle reaction, shortness of breath, hypervigilance and alertness, constant irritability, anxiety, and difficulty in relaxing 8,9. Although described as a core feature in patients with fear/anxiety (i.e., generalized anxiety disorder, panic disorder, social anxiety) and stress-related disorders (i.e., post-traumatic stress disorder), hyperarousal can be seen as a dimensional trait potentially characterizing individuals with undiagnosed and/or subthreshold conditions within the internalizing spectrum symptoms 10. Hyperarousal has been described in the postpartum, immediately after the birth, whether the birth was traumatic or not, and up to eight weeks later 11; postpartum is a period in which hypervigilance, anxiety, and parental preoccupation with the newborn are frequently observed, and this process is probably mediated by oxytocin that should increase alertness along with the parental bond 12. Nevertheless, hyperarousal, both in its physiological and cognitive-emotional components, may be a pre-existing trait feature, that can predispose pregnant women to vulnerability to perceived stress.

Based on this background, the aim of the present study is to assess perceived stress and hyperarousal in women with complicated and uncomplicated pregnancy.

METHODS

Participants were recruited from family counselling centers, obstetrician/gynecologists’ offices, and outpatients’ units in the cities of Messina and Catania. Information leaflets, brochures, and advertising about the Google® form for the online survey were available in waiting rooms and medical offices and secretaries; additional information on research aims and objectives were provided by research assistants at the recruiting centers. The link to the form to be filled was sent via messaging applications such as Whatsapp© and mailing lists. Data collection took place from September 4, 2023 to December 22, 2023. The selection criteria used were: (a) minimum age of 18 years old; (b) less than 30 weeks pregnant at recruitment; (c) conception achieved naturally; (d) able to read and understand Italian. Participants were classified as having “complicated” versus “uncomplicated” pregnancy on the basis of self-reported statements without any medical recording within the survey form.

Instruments

The participants, who were guaranteed anonymity, completed the self-administered questionnaire in a single session lasting 10-20 minutes.

The questionnaire was composed of multiple sections:

  1. Socio-demographic and personal information: age, civil status, education, occupation, personal and family medical and psychiatric history, period of gestation, previous pregnancies and any diagnosed pathologies, previous abortions, either spontaneous and voluntary.
  2. Perceived Stress Scale - PSS-1013, a 10-item self-report scale consisting of 10 items, six negatively stated and four positively stated, rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often); total scores range from 0 to 40. The Italian version PSS-10 scale has shown acceptable psychometric properties, with an overall Cronbach’s alpha value of. 7414.
  3. Hyperarousal Rating Scale - H Scale15, a 26-item self-report instrument assessing hyperarousal on a 4-point Likert-type scale (0 = Not At All; 1 = A little; 2 = Quite a bit; 3 = Extremely). The scale produces a total summation score (HSUM) with scores for ‘Introspectiveness’ (6 items), ‘Reactivity’ (3 items), and ‘Extreme responses,’ referring to the total number of items checked as ‘extremely.’ Higher scores (max. 78) are representative of higher levels of hyperarousal. The Italian version of the H-Scale obtained an alpha value of 0.82, showing good psychometric properties 8.

STATISTICS

Priority sample size estimation was calculated using G*Power 3.1.9.2. software: by assuming an effect size of 0.5, a significance level of 0.05 with a power of 0.95, a total sample size of 176 was determined.

Descriptive statistics (mean ± standard deviation; frequency and percentages) were used to summarize continuous and non-continuous demographic and psychometric data, as requested; differences between groups were assessed by Student’s t-test for independent samples or Chi-square test, as appropriate, after checking that he distribution of variables had a normal distribution. A partial correlational analysis controlling for potentially confusing factors, such as social and demographic characteristics (age and offspring number) was performed to evaluate possible correlations between hyper-arousal and perceived stress. Two linear regression analysis, where PSS total score was taken as dependent variable and all H-Scale scales were entered into the equation, were proposed in the whole sample, and then separately in Complicated and Uncomplicated pregnancy to investigate which hyper-arousal dimensions were predictors of perceived stress.

RESULTS

A final sample of 326 pregnant women, aged between 18-45 years (mean age ± S.D. = 31.61 ± 4.95 years) participated in the survey and met inclusion criteria; 214 subjects (65.6%) belonged to the group of self-declared uncomplicated pregnancy”, and 112 (34.4%) defined their pregnancy as “complicated.

Regarding socio-demographic features, no significant differences between the two subgroups were documented (Tab I); Table I also shows that mean scores at the self-report scales (H-Scale and PSS) were within the normal range; however, significant differences in PSS “Total score” (p = . 003), higher in Uncomplicated pregnancy group, and in H-Scale “Reactivity” (p = . 022), higher in Complicated pregnancy group, were found.

Table II shows the partial correlation analyses, controlled for age and number of offspring, as previously reported, carried out to assess the possible associations between hyperarousal and perceived stress: no significant correlations between PSS total score and H-Scale subscales emerged .

Subsequently, all the H-scale variables (as independent variables) were analyzed in two linear regression models in order to evaluate the possible role as predictors towards the PSS total score (as dependent variables) (Tab. III): in total, predictor models accounted for 5.4% and 3.3% of the total variance respectively in self-reported “Complicated pregnancy” (F = 1.40; df = 4; p = . 196), and “Uncomplicated pregnancy” (F = 1.804; df = 4; p < . 129). Linear regression analysis indicated that in “Complicated pregnancy” only H-Scale “Reactivity” (β = 3.144; p = . 004) directly predicted “PSS total scores”, while the other H-Scale subscales did not make a significant additional contribution to prediction of perceived stress; conversely, no significant associations emerged in “Uncomplicated pregnancy”.

DISCUSSION

The aim of the present study was to examine the dimensions of hyperarousal and perceived stress in pregnant women; results have shown that reactivity, a component of hyperarousal, was significantly higher in women with self-reported complicated pregnancy and a reliable predictor of perceived stress. This finding is in line with previous studies, as changes in arousal and reactivity, hypervigilance, along with negative changes in thoughts and mood, anxiety and sleep disturbances have been described in pregnant women, independently from pregnancy complications16. For uncomplicated pregnancies, antenatal anxiety and depressive symptoms and fear of childbirth and/or labour pain have been indicated as the main predictive factors of the intensity of hyperarousal symptoms and disordered eating patterns during pregnancy 17. Furthermore, a form of “pre-traumatic” stress condition has been found in pregnancy complicated by hyperemesis gravidarum, as shown by a cross-sectional study aimed at examining stress symptoms and negative maternal outcomes after pregnancy 18. It should be highlighted that the majority of studies on this topic has focused on hyperarousal as a core component of the Posttraumatic Stress Disorder (PTSD) following both complicated and uncomplicated pregnancies, including pregnancy loss, miscarriages, and traumatic childbirth19. As shown by our findings, although categorically listed within the diagnostic criteria of PTSD, hyperarousal can be viewed as a trait or state basic dimension that can be autonomously recognized and measured, resulting a predictive factor of perceived stress during pregnancy. On the other hand, it should be also considered that, according to our results, perceived stress can occur independently from pregnancy complications and from hyperarousal or some component of it, since our subgroup of women with uncomplicated pregnancy reported higher levels of perceived stress, as documented by the PSS total score, unrelated with hyperarousal also after controlling for age and number of offspring. For attempting an explanation of this quite unexpected finding, it should be recalled that, in a lower or higher intensity, pregnancy itself, also in the absence of gestational complications, is a period of emotional changes and switches resulting from physiological, psychological, and social factors ; even if some stressors can be related to specific pregnancy-related events, still individual, subjective components and/or further variables could have been missed out and left undetected in a punctual, cross-sectional evaluation. Although the socio-demographic questionnaire included a part on medical and psychiatric history, this was designed to recall official records, thus possible subthreshold and subclinical conditions, or temperamental and personality traits predisposing to negative emotions have not been recorded. Furthermore, women with complicated pregnancy may have received more psychosocial, emotional and practical support and protection from partners and family, resulting in lower levels of perceived stress.

Strengths and limitations

Several limitations to this study should be considered. The sample, including subjects from a restricted catchment area, and the cross-sectional design could limit the generalizability of the findings that may need to be replicated in longitudinal studies on larger and more representative samples, especially with face-to-face assessments. Hyperarousal and perceived stress have been assessed by self-report scales, and it cannot be excluded that subjective rated perceptions, self-serving biases on positive personal traits, social desirability, and defensive response style may have partially filtered and influenced answers. Moreover, if perceived stress is a mainly subjective dimension, hyperarousal assessment may have benefited by objective and neurophysiological measures. Despite its limitations, our study suggests that research on the psychopathology of pregnancy should not only investigate negative emotional states such anger, depression, and anxiety 20, but also simple, distinct, and trans-categorical basic dimensions, such as hyperarousal and perceived stress that can affect women’s psychological adjustment during the course of pregnancy even in the absence of a full-blown affective disorder or a gestational complication, thus representing potential antenatal vulnerability factors for future outcomes.

CONCLUSION

If in common view pregnancy is thoroughly considered as a transitory process, maternity implies many changes in a woman; the progressive adjustment to this condition starts from the beginning of pregnancy and can be affected by several biological, psychological, and social factors. It is widely recognized that the experience of higher stress during pregnancy is frequently a response to the occurrence of gestational complications, even not enough severe to harm the mother/foetus life and/or well-being. In those cases, hyperarousal can be an easy-to-assess index suitable for predicting perceived stress levels. This study also suggests that gestational complications are only partly responsible for perceived stress during pregnancy, and that a proportion of women with uncomplicated pregnancies may also be at risk for experiencing elevated stress levels. The search for vulnerability factors and early predictors of high perceived stress during pregnancy should be included in a comprehensive, multidimensional evaluation of maternal health during pregnancy, aimed at developing effective interventions, such as emotion regulation and cognitive reappraisal strategies, that can help to reduce the experience and the impact of stress during complicated and uncomplicated pregnancy.

Conflict of interest

The authors declare no conflict of interest..

Funding

None.

Authors contributions

M.C.S.: Writing – original draft, Writing – review & editing. F. T.: Data curation, Formal analysis, Methodology. F.I.: Methodology, Writing – review & editing. G.G.: Methodology, Writing – review & editing. C.L.: Methodology, Writing – review & editing. R.G.: Data curation, Writing – review & editing. G.F.: Data curation, Writing – review & editing. A.B.: Conceptualization, Supervision, Writing – review & editing. M.R.A.M.: Conceptualization, Supervision, Writing – review & editing. G.P.: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing.

Ethical consideration

Adherence to the survey included the acquisition of informed consent. The study was conducted in conformity with the ethical principles of research according to the Declaration of Helsinki.

Figures and tables

Total sample (n = 326) Complicated pregnancy (n = 112) Uncomplicated pregnancy (n = 214) p
Age (mean ± S.D.) 31.67 5.17 31.8 5.72 31.6 4.87 .740*
Level of Education (n/%)
Primary school 0 0 0 0 0 0 .551†
Secondary School 45 13.8 17 15.2 28 13.1
College 149 45.7 45 40.2 104 48.6
Degree 98 30.1 37 33 61 28.5
Postgraduate 34 10.4 13 11.6 21 9.8
Marital status (n/%)
Single 18 5.5 5 4.5 13 6.1 .630†
Cohabitant 138 42.3 44 39.2 94 43.9
Married 164 50.3 60 53.6 104 48.6
Divorced 6 1.8 3 2.7 3 1.4
First pregnancy (n/%)
Yes 176 54.0 61 54.6 115 53.7 .901†
No 150 46.0 51 45.5 99 46.3
Number of offspring (mean ± S.D.) 1.35 0.66 1.33 .51 1.36 .72 .815*
H SCALE
I score 9.77 3.12 10.06 2.98 9.61 3.18 .216*
R score 3.65 1.83 3.97 1.77 3.49 1.85 .022*
Extreme 2.49 3.68 2.73 3.91 2.36 3.56 .387*
Total score 35.02 9.54 36.06 9.47 34.48 9.56 .155*
PSS Total score 20.1 8.37 18.22 2.76 21.07 10 .003*
*Student t-test ; † Chi-square test
TABLE I. Descriptive statistics and groups differences.
H-Scale
Introspectiveness Reactivity Extreme Responses HSUM
PSS Total score .124 -.077 .112 .081
TABLE II. Partial correlational analysis (Pearson correlation) controlled for age and number of offsprings between hyperarousal (H-Scale) and perceived stress (PSS) in total sample.
(Dependent Variable) Predictors Unstandardized coefficients Standardized coefficients
B S.E. Beta t p
PSS Total score a(Model 1: Complicated pregnancy) (Costante) 19,557 1,385 14,125 ,000
INTROSPECTIVENESS ,098 ,178 ,105 ,548 ,585
REACTIVITY ,565 ,239 ,361 2,361 ,020
EXTREME RESPONSES ,085 ,101 ,120 ,834 ,406
HSUM -,133 ,076 -,455 -1,748 ,083
             
PSS Total score b(Model 2: Uncomplicated pregnancy) (Costante) 16,201 3,224 5,026 ,000
INTROSPECTIVENESS ,534 ,447 ,170 1,196 ,233
REACTIVITY -1,097 ,599 -,203 -1,832 ,068
EXTREME RESPONSES -,038 ,256 -,014 -,149 ,882
HSUM ,106 ,198 ,101 ,535 ,593
a R = .233; F = 1.540; p = .196 ; b R = .183; F = 1.804; p = .129
TABLE III. Linear regression analysis.

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Authors

Maria Rosaria Anna Muscatello - Psychiatry Unit, University Hospital of Messina, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

Maria Catena Silvestri - Psychiatry Unit, University Hospital of Messina, Italy

Fabrizio Turiaco - Psychiatry Unit, University Hospital of Messina, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

Fiammetta Iannuzzo - Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

Giovanni Genovese - Psychiatry Unit, University Hospital of Messina, Italy

Clara Lombardo - Department “Scienze della Salute”, University “Magna Graecia”, Catanzaro, Italy

Roberta Granese - Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy; Gynecology and Obstetrics Unit, University Hospital of Messina, Italy

Giulia Fangano - Psychiatry Unit, University Hospital of Messina, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

Antonio Bruno - Psychiatry Unit, University Hospital of Messina, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

Gianluca Pandolfo - Psychiatry Unit, University Hospital of Messina, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy

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How to Cite
Muscatello, M. R. A., Silvestri, M. C., Turiaco, F., Iannuzzo, F., Genovese, G., Lombardo, C., Granese, R., Fangano, G., Bruno, A., & Pandolfo, G. (2025). Perceived stress and hyperarousal in women with uncomplicated and complicated pregnancy: a cross-sectional, correlation study . Italian Journal of Psychiatry, 11(2). https://doi.org/10.36180/2421-4469-2025-586
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