4D ultrasound study of fetal facial expressions in the third trimester of pregnancy

Objective: To evaluate the frequencies of fetal facial expressions in the third trimester of pregnancy, when fetal brain maturation and development are progressing in normal healthy fetuses.

Methods: Four-dimensional (4?D) ultrasound was used to examine the facial expressions of 111 healthy fetuses between 30 and 40?weeks of gestation. The frequencies of seven facial expressions (mouthing, yawning, smiling, tongue expulsion, scowling, sucking, and blinking) during 15-minute recordings were assessed. The fetuses were further divided into three gestational age groups (25 fetuses at 30–31?weeks, 43 at 32–35?weeks, and 43 at ≥36?weeks). Comparison of facial expressions among the three gestational age groups was performed to determine their changes with advancing gestation.

Results: Mouthing was the most frequent facial expression at 30–40?weeks of gestation, followed by blinking. Both facial expressions were significantly more frequent than the other expressions (p?p?=?.031). Other facial expressions did not change between 30 and 40?weeks. The frequency of yawning at 30–31?weeks was significantly higher than that at 36–40?weeks (p?Conclusions: Our results suggest that 4D ultrasound assessment of fetal facial expressions may be a useful modality for evaluating fetal brain maturation and development. The decreasing frequency of fetal yawning after 30?weeks of gestation may explain the emergence of distinct states of arousal.     

Fetal behavioral and structural abnormalities in high risk fetuses assessed by 4D sonography

We have realized that the way we are looking at the motoric activity influenced the way we assessed the motoric activity. Throughout the years of these investigations, it has been influenced by those who thought that all motility was caused by generation of CNS or matured CNS. However, there remains an incomplete view of the neurological development of fetuses over the course of the life span, with methods of assessment remaining grounded in newborn models of the CNS. It is through this review hat we attempt to develop a continuous line of understanding of fetal behavior assessment in abnormal fetuses after ascertaining the normal standard behavioral pattern parameters.     

Nitric oxide and peroxynitrite platelet levels in women with small-for-gestational-age fetuses

Objective  The placenta produces reactive oxygen species (ROS) including nitric oxide (NO) and peroxynitrite (ONOO⁻) that have pronounced effects on placental function. Excessive ROS production may occur in pathological pregnancies, such as those complicated by small-for-gestational-age (SGA) fetuses.
Design  The aim of the present work was to study NO and ONOO⁻ levels in platelets of pregnant women with SGA fetuses compared with a control group.
Setting and population  The study was performed on 30 pregnant women with SGA fetuses (SGA group) and on 30 healthy pregnant women (appropriate-for-gestational-age [AGA] group) matched for maternal and gestational age. All women included in this study were in the third trimester of pregnancy.
Methods  Platelets were isolated by differential centrifugation. NO metabolites, after enzymatic conversion followed by the Griess reaction, were measured as nitrite by spectrophotometric detection. Peroxynitrite (ONOO⁻) levels were evaluated using the fluorescence probe 2,7-dichlorofluorescein diacetate (DCFDA).
Main outcome measures  The following determinations were made: platelet nitric oxide and peroxynitrite levels in the SGA group and controls; inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS) and nitrotyrosine (N-Tyr) expression in the same groups.
Results  Our results show that both platelet NO and ONOO⁻ levels were significantly higher in the SGA group than in the controls.
Conclusion  Increased platelets levels of nitric oxide and peroxynitrite might play a role in the pathophysiology of intrauterine growth restriction. Further investigations are in progress to clarify if these molecules are pathogenetic factors, an epiphenomenon or a pathophysiological marker.     

Real-time 3-D sonographic observation of fetal facial expression

AIM: There have been a few reports about 3-D sonographic observation of fetal movements using dynamic 3-D sonography. However, dynamic 3-D sonography is not real-time, the frame rate being in the region of 4-6 frames per second depending on the size of the region of interest and the number of lines employed. Recently, a new faster 3-D sonography, which acquires up to 28 frames per second, has become available. Using this system, we studied a full range of fetal facial expressions during pregnancy. METHODS: A total of 17 normal fetuses in 16 pregnancies (15 singletons and one twin) at 20-38 weeks' gestation was studied using a transabdominal real-time 3-D ultrasound machine. This 3-D ultrasound machine proved capable of providing continuous 3-D sonographic images every 0.05 and 0.035 s. The fetal face was monitored for 15 min for each subject. RESULTS: Fetal eyelid movement (fetal blinking) was observed in three of 17 fetuses (17.6%). Double blinking was identified in one fetus at 38 weeks. Various types of mouth movement (yawning, a little opening, chewing, and subtle lip movement) could be observed in nine of 17 fetuses (52.9%). In the course of yawn-like opening of the mouth, tongue movements such as tongue thrust and tongue click were clearly shown in three fetuses (17.6%). A lingula movement was also identified in the course of tongue movement. CONCLUSION: Real-time 3-D sonography provides a novel means for evaluation of fetal movement, particularly fetal facial expression, in the second and third trimesters. Real-time 3-D sonography might be an important modality in future fetal behavior research and in evaluation of fetal well-being.     

Growth restriction: identifying fetuses at risk

Purpose: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10–20th%, and compare outcomes using umbilical artery Doppler (UAD).

Materials and methods: Retrospective, cohort evaluating ultrasound (US) EFW 10–20th%, between 2002 and 2012. Cases were identified with EFW % 10–20. Controls, EFW?>20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes.

Results: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10–20th% (GA 33.6?±?3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2–68.7], p?p?p?p?p?Conclusions: Pregnancies with EFW 10–20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.     

Fetal biophysical profile and cerebro-umbilical ratio in assessment of perinatal outcome in growth-restricted fetuses

AIM: To examine the value of the fetal biophysical profile (FBP) and the Doppler cerebro-umbilical ratio (C/U) in the assessment of perinatal outcome in growth-restricted and hypoxic fetuses. STUDY DESIGN: The prospective clinical study included 87 pregnant women with singleton pregnancies at 28-42 weeks of gestation with clinically verified intrauterine growth restriction (IUGR). After assessment of FBP, flow velocity waveforms from the umbilical and middle cerebral arteries were recorded and the C/U ratio was calculated. The C/U ratio and FBP were assessed twice a week. At delivery, umbilical arterial pH, the occurrence of meconium-stained amniotic fluid (MAF), Apgar score at 5 min and the incidence of cesarean sections were used as outcome parameters. RESULTS: The mean FBP value was 5.5 +/- 0.96 in cases with MAF, and 6.88 +/- 0.26 in cases without MAF. Also, there was no statistical significance in the relation between the C/U ratio and the appearance of MAF. At pH >7.2, the mean FBP value was 7.11 +/- 0.23, while it was 2.83 +/- 0.79 in newborns with acidosis. Both FBP and C/U values were statistically correlated with pH (p < 0.01). The mean umbilical arterial pH was 7.31 +/- 0.0 at a C/U ratio of >/=1 and 7.21 +/- 0.03 at a C/U ratio of <1. In cases with Apgar scores of 8-10, the mean FBP value was 7.28 +/- 0.23, at Apgar scores of 5-7 it was 3.9 +/- 0.52, while at Apgar scores of 0-4 the mean FBP value was 1.5 +/- 0.5. The mean Apgar score at 5 min was 9.54 +/- 0.09 at a C/U ratio of >/=1, and 8.12 +/- 0.49 at a C/U ratio of <1. The mean FBP value in cases of vaginal delivery was 7.55 +/- 0.31. In cesarean section deliveries, the mean FBP value was 5.97 +/- 0.37. Also, there was a high frequency of cesarean sections in growth-restricted fetuses with a C/U ratio of <1 (p < 0.05), i.e. slightly less than FBP. CONCLUSIONS: FBP and C/U ratio were associated with low arterial pH, low Apgar score and the rate of cesarean sections (p < 0.05), but there was no association between FBP or C/U ratio and the appearance of MAF (p > 0.5). Due to their good predictive value the FBP and C/U ratio could be used in the prenatal monitoring of growth-retarded and hypoxic fetuses. These two methods can be used as important parameters in the decision to end pregnancies with IUGR, when pathological values occur. Thus a reduction in perinatal morbidity, mortality and the incidence of infants with poor neurologic outcome can be expected.     

Assessment of the blood flow in kidneys of growth-restricted fetuses using quantitative three-dimensional power Doppler ultrasound

Objective

Fetuses with fetal growth restrictions have higher perinatal mortality rates than fetuses without fetal growth restrictions. Vascularization of the fetal kidney is crucial to fetal growth. Hence, we assessed blood flow and vascularization of fetal kidneys in non-growth-restricted as well as growth-restricted fetuses using quantitative three-dimensional power Doppler ultrasound.

Maternal blood pressures during pregnancy and the risk of delivering a small-for-gestational-age neonate

Objective: To determine the relationship between maternal blood pressures throughout pregnancy and the risk of delivering a small-for-gestational-age (SGA) neonate. Methods: Women were prospectively enrolled at 9–14 weeks and had serial blood pressure measurements throughout pregnancy. SGA prevalence was compared to maternal blood pressure at enrollment, average blood pressure during each trimester, and blood pressure trends throughout gestation. Blood pressure was categorized as normotension, prehypertension, or hypertension using Joint National Committee on Hypertension-7 (JNC-7) definitions. Information on preeclampsia prevalence was also obtained due to its frequent concurrence with SGA. Results: A total of 758 women had 8438 blood pressure measurements taken (average 11.1, range 3–14) and 65 (8.6%) delivered an SGA neonate. Forty-two of 514 (8.2%) normotensive women at enrollment and 23/244 (9.4%) women with enrollment prehypertension or hypertension delivered an SGA neonate. Women with persistent hypertensive range blood pressures had an SGA rate 2–3 times higher than other women (p = 0.272) as well as a significantly higher preeclampsia rate (p < 0.001). Women with elevated enrollment blood pressures did not have an increased SGA rate if their blood pressures improved throughout pregnancy. Logistic regression identified enrollment uterine artery Doppler, pregnancy-associated plasma protein-A levels, and ethnicity as primary contributors to SGA. Conclusion: Blood pressure improvement throughout pregnancy decreases the preeclampsia rate without increasing SGA frequency. Theoretical risks of fetal growth delay should not prevent investigations into improved maternal blood pressure control, possibly at thresholds lower than commonly used in obstetric practice, beginning in the first trimester of pregnancy.     

Predictiveness of antenatal umbilical artery Doppler for adverse pregnancy outcome in small-for-gestational-age babies according to customised birthweight centiles: population-based study

Objective  To examine the relationship between smallness at birth and the predictive value of umbilical artery Doppler.
Design  Retrospective cohort.
Setting  Tertiary referral university hospital, Barcelona.
Population  A total of 7645 singleton pregnancies delivered between January 2002 and June 2004.
Methods  The associations with adverse outcome were assessed for small-for-gestational-age (SGA) babies according to customised standards who had normal and abnormal umbilical artery Doppler.
Main outcome measures  Neonatal morbidity and perinatal mortality.
Results  Of the 369 SGA fetuses that had been identified antenatally, 70 (19%) had an abnormal umbilical artery Doppler and the babies from these pregnancies had a higher risk for neonatal morbidity when compared with babies with normal birthweight (OR 3.99, 95% CI 1.04–11.03). However, the remaining 299 (81%) fetuses with normal umbilical artery Doppler also had an elevated risk of neonatal morbidity (OR 2.26, 95% CI 1.04–4.39). Overall, many of the instances of adverse outcome associated with smallness for gestational age were attributable to the group with normal Doppler than to the group with abnormal Doppler.
Conclusion  Normal antenatal umbilical artery Doppler cannot be taken as an indicator of low risk in pregnancies where the fetus is SGA according to customised percentiles.