Assessment of fetal behavior and general movements by four-dimensional sonography

The aim of this paper was to review the clinical applications of four-dimensional ultrasonography in the assessment of fetal behavior. With the use of a computerized database, articles on three-dimensional ultrasonography were reviewed. Several applications of dynamic three-dimensional ultrasonography have been reported, including imaging of fetal movements, facial expression and fetal hand movements. The importance of the assessment of fetal behavior by four-dimensional sonography is stressed. Four-dimensional sonography seems to be a useful imaging tool for clinical problem solving in perinatology, especially in observing the development of the central nervous system in utero.     

Longitudinal study of fetal behavior by four-dimensional sonography

During the past decades, ultrasonic studies have revealed the fascinating diversity of fetal intrauterine activities. It has been shown that fetal activity occurs far earlier than a mother can register it, in fact as early as the late embryonic period. Analysis of the dynamics of fetal behavior has led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of fetal central nervous system. With 4D sonography it is possible to produce measurable parameters for the assessment of normal neurobehavioral development. There is urgent need for further multicentric studies until a sufficient degree of normative data is available and the predictive validity of specific aspects of fetal neurobehavior to child developmental outcome is better established.     

Normal standards of fetal behavior assessed by four-dimensional sonography

Objective.?In this prospective randomized study, fetal behavior was investigated in order to determine the standard parameters of fetal movements and facial expressions in all three trimesters of normal pregnancy.

Methods.?Sixty-three pregnant women with singleton pregnancies in all trimesters were included in the investigation. Four-dimensional (4D) ultrasound was performed for each patient over a 30-minute period. Variables of maternal and fetal characteristics including gestational age, eight fetal movement patterns in the first trimester, and sixteen parameters of fetal movement and fetal facial expression patterns in the second and third trimesters were recorded for the construction of fetal neurological charts.

Results.?In the first trimester, a tendency towards an increased frequency of fetal movement patterns with increasing gestational age was noticed. Only the startle movement pattern seemed to occur stagnantly during the first trimester (p > 0.05). At the beginning of the second trimester, the frequency of fetal movement patterns tended to increase. During the second and third trimester, multiple regression and polynomial regression revealed statistically significant changes in tongue expulsion (p < 0.05), smiling (p < 0.05), grimacing (p < 0.05), swallowing (p < 0.05), eye blinking (p < 0.01), head movements, and all hand to body contact movements (p < 0.01), except for head anteflexion (p > 0.05). There were no statistically significant changes during the second and third trimesters in mouthing, yawning, and sucking (p > 0.05). At the middle of the third trimester, the fetuses displayed decreasing or stagnant incidence of fetal facial expressions except for eye blinking, which showed increased frequency with increasing gestational age. A statistically significant correlation was found between all head movements and hand to body contact patterns during the second and third trimesters except for head anteflexion (r = ?0.231; p > 0.05).

Conclusions.?The full range of quantitative fetal facial expressions and fetal movement patterns can be assessed successfully by 4D sonography. It is important to be able to assess normal fetal behavior throughout gestation to identify abnormal behavior before birth.     

The potential of 4D sonography in the assessment of fetal behavior in high-risk pregnancies

Objective.?To assess differences of fetal behavior in normal and high-risk pregnancies.

Methods.?In the 1-year period (1 January 2007–31 December 2007), four-dimensional ultrasound has been used to assess Kurjak antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies after randomization in prospective longitudinal cohort study. Based on the KANET scores, the fetuses were considered as normal (≥14 points), borderline (6–13), or abnormal (0–5).

Results.?Comparison of KANET scores in low- and high-risk pregnancies were expectedly statistically significant. The largest incidence of fetuses with abnormal KANET was in the group of fetuses who had siblings with cerebral palsy. The largest incidence of the borderline KANET has been found in the group of fetuses whose mothers had fever during pregnancy. The following parameters of KANET test significantly differed between the fetuses from low- and high-risk pregnancies: overlapping cranial sutures, head circumference, isolated eye blinking, facial expressions, mouth movements, isolated hand movements, isolated leg movements, hand to face movement, finger movements, and general movements.

Conclusion.?KANET test has the potential to detect and discriminate normal from borderline and abnormal fetal behavior in normal and in high-risk pregnancies.     

Fetal hand movements and facial expression in normal pregnancy studied by four-dimensional sonography

AIM: To evaluate the developmental pattern of fetal hand movements and facial activity and expression during the second and third trimester of pregnancy by four-dimensional ultrasound (4D-US). SUBJECTS AND METHODS: A total of 25 fetuses in uncomplicated pregnancies were analyzed; 15 fetuses at 13 to 16 weeks and 10 fetuses at 30 to 33 weeks of gestation were studied with abdominal 4D-US. After standard assessment in two dimensional (2D) real-time B mode, a 4D mode was switched on. Further examination lasted a maximum of 15 minutes. RESULTS: Isolated hand movement and subtypes of hand movements were easily recognized by 4D-US. The sub-types of hand to head movement are: hand to head, hand to mouth, hand near mouth, hand to face, hand near face, hand to eye and hand to ear. All subtypes of hand to head movement can be seen from 13 weeks of gestation, with fluctuating incidence. Facial activities and different forms of expression are easily recognized by 4D-US. Among these, two types can be easily differentiated: smiling and scowling. CONCLUSIONS: 4D-US is superior over real-time two-dimensional ultrasound (2D-US) for qualitative, but inferior for quantitative analysis of hand movements. Thus 4D-US makes it possible to determine exactly the direction of the fetal hand, but the exact number of each type of hand movements can still not be determined. 4D-US is superior over two- and three-dimensional sonography in the evaluation of complex facial activity and expression. Among facial activities observed by 4D-US, simultaneous eyelid and mouthing movements dominate between 30 and 33 weeks of gestation. Pure mouth movements such as mouth opening, tongue expulsion, yawning and pouting are present, but at a significantly lower incidence. Facial expressions such as smiling and scowling can be precisely observed using 4D-US.     

The antenatal development of fetal behavioral patterns assessed by four-dimensional sonography

The investigation of fetal intrauterine activities has been enabled by the development of two-dimensional ultrasound. It has been shown that the earliest signs of fetal motor activity can be in the late embryonic period, and that the characteristics of fetal motor patterns change constantly throughout gestation. During the first trimester of pregnancy, the repertoire and frequency fetal movement patterns constantly expand, whereas the second and third trimesters are characterized by the progressive organization of fetal activities into complex and clearly distinct behavioral patterns. The comparison of real time ultrasonic studies of fetal behavior with the morphological studies of fetal brains has revealed that the appearance of new behavioral patterns or the transition of existing patterns directly reflect the complex neurodevelopment processes. It has been suggested that the assessment of fetal behavioral patterns could give us insight into the integrity of fetal central nervous system and enable the early detection of cerebral dysfunctions. The development of a new ultrasonic technique, four dimensional sonography, could represent a significant improvement in the assessment of fetal behavior. According to the preliminary results, this new technique could open a new perspective for the investigations of fetal behavioral patterns and contribute significantly to our better understanding of complex neurodevelopmental events. The most important neurodevelopmental events, the basic technology of 4D ultrasound and its application in the assessment of functional development of fetal central nervous system will be the subject of this review.     

Three-dimensional ultrasound in the imaging of multifetal pregnancy

The great advances in imaging techniques, such as high-resolution probes and three-dimensional ultrasound, have enabled us to image multifetal pregnancies from the time β-human chorionic gonadotropin is positive. The importance of three-dimensional sonographic evaluation of multifetal pregnancy before 12 weeks of gestation, using multiplanar sections and surface rendering, should be emphasized. In this review, we also discuss the importance of three-dimensional ultrasound imaging in second- and third-trimester multifetal pregnancy, and in the assessment of fetal weight and amniotic fluid volume. Finally, we outline the importance of novel techniques: three-dimensional power Doppler and four-dimensional ultrasound in the field of multifetal pregnancy and in performance of interventional procedures. Because three-dimensional ultrasound is still a novel sonographic modality, many of its potential utilities await studies to prove efficacy and cost-effectiveness.     

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.     

多胎妊娠早期选择性减胎术的临床研究

目的 研究多胎妊娠早期选择性减胎术的技术可靠性、安全性及其对妊娠结局的影响。方法 以超声引导下穿刺,少量氯化钾胚囊注射方法实施多胎妊娠早期选择性产硬盘减胎术患者２５例,其中１例经腹穿刺术,其中余２４例经阴穿刺术。结果 ２５例患者减胎术后,获得足月分娩者１５例,两个阶段中,初期减胎术１０例,成功率仅为３０．０％;第二阶段为临床应用期,实施１５例,分娩率达８０．０％,流产率降至６．７％。结论技术成熟的     

胚胎体内注射生理盐水在减胎术中的应用

目的探讨胚胎体内注射生理盐水减胎的可行性。方法将2000年1月至2004年12月因2胎或2胎以上孕8~10周的多胎妊娠在广州市第二人民医院接受减胎的孕妇32例,分成两组,一组采用胚胎体内注射生理盐水减胎,为注射组;另一组采用机械破坏法减胎,为机械组。比较两组的手术时间、感染率、流产率、早产率、足月产率、平均孕周。结果两组病例均1次减胎手术成功。注射组减灭1个胎儿所需的时间为(5.8±1.8)min,非常显著地少于机械组的(18.6±10.2)min(P<0.01)。注射组术后无感染发生,机械组有1例发生感染。注射组的流产率、早产率分别为5.6%(1/18)和27.8%(5/18),低于机械组的21.4%(3/14)和28.6%(4/14),但无统计学意义。注射组的足月产率为66.7%(12/18),高于机械组的50.0%(7/14),无统计学差异。注射组平均孕周为(35.2±3.6)周,显著长于机械组的(32.1±4.1)周(P<0.05)。结论与机械破坏法比较,胚胎体内注射生理盐水是一种安全、有效、可行的减胎方法,适用于妊娠8~10周需要减胎的多胎妊娠孕妇。     

Two-dimensional real-time ultrasound in the assessment of fetal activity in single and multiple pregnancy

One of the central issues in developmental neurology is the need to formulate concepts helping to understand human behavior, which reflects the central nervous system from early intrauterine age to the young infant and even up to adulthood. Real-time ultrasound observations have been used from the early 1980s onwards to witness the origin, occurrence and developmental course of specific fetal movement patterns emerging during early prenatal life. A large variety of movement patterns has been observed: startles; general movements; breathing movements; head, trunk and extremity movements; jaw openings; yawning; sucking; swallowing; hiccups; and hand/face contacts. In combination with fetal heart rate monitoring, two-dimensional ultrasound has been used in the third trimester to document the development of fetal behavioral states continuing from pre- to postnatal life. In the early 1990s we started to perform longitudinal examinations in twin pregnancies observing similar movement patterns to those in singletons. In multiple pregnancies, the inter-twin variance of different subsets and the possible impact of internal and external parameters can be studied. In addition, we have studied inter-twin reactions towards touch, reflecting the development of both initiative and sensitivity towards touch and finally the first inter-human contacts. Here we describe some essential issues of the documentation of fetal behavior in singleton and twin pregnancy.     

Fetal heart rate patterns in pregnancies complicated by maternal diabetes

Objective: To compare the fetal heart rate (FHR) pattern between fetuses of well controlled diabetic and non diabetic mothers using a computerized analysis of FHR. Study design: Weekly fetal surveillance was performed in 99 fetuses of mothers with diabetes class A, 21 fetuses of mothers with diabetes class B-R, and 55 fetuses of non-diabetic women, starting at 30 weeks' gestation. All diabetic patients were well controlled. Fetal surveillance included a computerized analysis of the FHR, umbilical and uterine Doppler velocimetry, and a biophysical profile. Changes of FHR variation, frequency of FHR accelerations, and umbilical and uterine Doppler velocimetry were calculated using a regression analysis for each patient. The average slopes and the intercept at 30, 34, and 38 weeks' gestation of these variables were compared among the three groups. Results: The slope of FHR variation and the frequency of accelerations had a lower rate of increase during the third trimester in fetuses of mothers with diabetes class A (0.84 ± 0.25 ms/week and 0.06 ± 0.02/20 min/week, respectively) compared with fetuses of non-diabetic mothers (1.34 ± 0.55 ms/week and 0.5 ± 0.1/20 min/week, respectively). In fetuses of mothers with diabetes class B-R, FHR variation did not change with gestation (−0.011 ± 0.2 ms/week) with a small increase in the frequency of accelerations (0.02 ± 0.004/20 min/week. While no differences were observed at 30 weeks' gestation, FHR variation and the frequency of accelerations were significantly reduced at 34 weeks' gestation in fetuses of mothers with diabetes class B-R compared with fetuses of non-diabetic mothers (P < 0.01). At 38 weeks' gestation, fetuses of mothers with diabetes class B-R and diabetes class A had both significantly reduced FHR variation as well as frequency of accelerations compared with fetuses of non-diabetic mothers (P < 0.01). The rate of decrease of the umbilical and uterine artery S/D ratios were similar among the three groups. Conclusions: The FHR pattern appears to be different in fetuses of well controlled diabetic mothers when related to fetuses of non-diabetic mothers. Disease specific standards should be considered for interpretation of FHR patterns in diabetic pregnancies.     

胎儿医学框架下的氯化钾减胎术应用于早中孕期多胎妊娠的经验——来自单一中心的临床研究

目的:总结我院在胎儿医学框架下建立的氯化钾减胎术在早中孕期应用于多胎妊娠的临床经验。方法:回顾研究2011年1月至2013年12月在上海市第一妇婴保健院于孕11~16周行氯化钾减胎的32例患者的临床资料,记录围手术期母胎并发症及分娩28天后围产儿结局,总结单一中心采用该技术积累的相关经验。结果:患者的平均减胎手术孕周(13.81±0.84)周,平均分娩孕周(34.52±5.78)周,平均新生儿出生体重(2541±665.9)g。围产儿存活率为92.8%,母体并发症包括妊娠期高血压1例,重度子痫前期1例,未发生严重的分娩并发症。结论:在胎儿医学框架下进行的氯化钾减胎技术用于早中孕期减胎安全有效,改善了多胎妊娠的围产儿结局。     

Normal standards of fetal behavior assessed by four-dimensional sonography.

OBJECTIVE: In this prospective randomized study, fetal behavior was investigated in order to determine the standard parameters of fetal movements and facial expressions in all three trimesters of normal pregnancy. METHODS: Sixty-three pregnant women with singleton pregnancies in all trimesters were included in the investigation. Four-dimensional (4D) ultrasound was performed for each patient over a 30-minute period. Variables of maternal and fetal characteristics including gestational age, eight fetal movement patterns in the first trimester, and sixteen parameters of fetal movement and fetal facial expression patterns in the second and third trimesters were recorded for the construction of fetal neurological charts. RESULTS: In the first trimester, a tendency towards an increased frequency of fetal movement patterns with increasing gestational age was noticed. Only the startle movement pattern seemed to occur stagnantly during the first trimester (p > 0.05). At the beginning of the second trimester, the frequency of fetal movement patterns tended to increase. During the second and third trimester, multiple regression and polynomial regression revealed statistically significant changes in tongue expulsion (p < 0.05), smiling (p < 0.05), grimacing (p < 0.05), swallowing (p < 0.05), eye blinking (p < 0.01), head movements, and all hand to body contact movements (p < 0.01), except for head anteflexion (p > 0.05). There were no statistically significant changes during the second and third trimesters in mouthing, yawning, and sucking (p > 0.05). At the middle of the third trimester, the fetuses displayed decreasing or stagnant incidence of fetal facial expressions except for eye blinking, which showed increased frequency with increasing gestational age. A statistically significant correlation was found between all head movements and hand to body contact patterns during the second and third trimesters except for head anteflexion (r = -0.231; p > 0.05). CONCLUSIONS: The full range of quantitative fetal facial expressions and fetal movement patterns can be assessed successfully by 4D sonography. It is important to be able to assess normal fetal behavior throughout gestation to identify abnormal behavior before birth.     

Down syndrome screening in multiple pregnancies by nuchal translucency measurement

Various non-invasive screening methods for Down syndrome have been introduced in clinical practice during the last two decades. Specific problems were encountered when these methods were applied for multiple pregnancies (twins and high-order multiples). The aim of the current review is to explore these issues and propose an adjusted methodological approach for this highly selected population. Overall, more women with twin pregnancies (mainly those who conceived via assisted reproduction) are found to be false-positive for Down syndrome. This is because the standard screening algorithms include maternal age. In addition, mid-trimester maternal serum screening is associated with a higher false-positive rate, secondary to changes in the fetoplacental endocrinologic metabolism in assisted reproduction pregnancies. Therefore, in multiple pregnancies, mid-trimester maternal serum screening is of limited clinical value. In those pregnancies, screening for Down syndrome by means of nuchal translucency measurements at 10-14 weeks is associated with a lower false-positive rate than mid-trimester serum screening. Nuchal translucency measurement is among the best available and most efficient screening methods for multiple pregnancies. This method for screening enables us to specifically identify those fetuses at high risk of Down syndrome and other anomalies and thus contribute for a better outcome. In addition, it should be systematically performed before any fetal reduction in high-order multiples is planned.     

Fetal DNA in maternal plasma in preeclamptic pregnancies

Cell-free fetal DNA present in maternal circulation has revolutionized non-invasive prenatal diagnosis of genetic diseases. In preeclampsia, the quantity of fetal DNA in maternal plasma has been studied and found to be higher in comparison to healthy pregnant women. Whether the quantity of fetal DNA can be used as a reliable predictive biomarker of preeclampsia is currently uncertain. This is a systematic review on studies quantifying fetal DNA in preeclamptic pregnancies. Using a PubMed search 22 studies were identified. In all of them, elevated levels of fetal DNA in maternal plasma in preeclampsia were found. In some of the studies, the higher concentration of fetal DNA was observed before the onset of clinical symptoms. This shows that fetal DNA levels might have a potential informative value as an early diagnostic biomarker of preeclampsia. However, in most of the studies important data are missing and there is an enormous variability in the reported results between the studies. From the available data it is currently not possible to perform a meta-analysis due to the variation between studies. If once fetal DNA should be used as a marker for determining preeclampsia at early stage, it is necessary to reduce these variations via standardized protocols for the quantification of cell-free fetal DNA as well as its reporting in the publications.     

173例多胎妊娠选择性减胎术后的围生结局

目的:分析多胎妊娠选择性减胎术后的围生结局。方法:回顾性分析2012年1月至2015年9月间173例多胎妊娠孕妇在广州医科大学附属第三医院胎儿医学中心通过经腹胎儿心内注射氯化钾(KCL)减胎术或射频消融(RFA)减胎术将多胎妊娠减至单胎或双胎的临床资料,分析减胎术后的围生结局。结果:KCL减胎术121例,术后流产率为10.0%,围生儿存活率89.2%。孕早期的流产率、≤34周早产率与孕中期比较,差异无统计学意义(P0.05);保留单胎的分娩孕周较保留双胎的延长约2周(37.96±2.65周vs 35.93±2.19周)且新生儿体质量更重(2.91±0.55 kg vs 2.51±0.44kg),差异有统计学意义(P0.05)。RFA减胎术52例,术后围生儿存活率为71.2%。双胎输血综合征(TTTS)、选择性胎儿生长受限(s FGR)、双胎反向灌注序列综合征(TRAPs)、双胎之一结构或遗传异常术后的存活率分别为68.2%、83.3%、100.0%、53.8%。结论:KCL减胎术可在孕早中期进行,减至单胎可能更有益于围生结局。RFA减胎术中s FGR和TRAPs术后的存活率较高。选择性减胎术对改善多胎妊娠的围生结局有益。     

Four-dimensional sonographic assessment of fetal movement in the late first trimester

Objective

To evaluate, using four-dimensional (4D) sonography, the frequency of fetal movements during the late first trimester of normal singleton pregnancies.

Methods

Singleton pregnancies were studied—using transvaginal 4D sonography—for 10 minutes at 10-11 and 12-13 weeks of gestation. The frequencies of 5 fetal movements (isolated arm, isolated leg, short trunk, long trunk, and jumping movements) were evaluated.

Results

In the 17 pregnancies studied, the most frequent fetal movements were isolated arm movement at 10-11 weeks and jumping movement at 12-13 weeks. There was a significant difference in the frequency of jumping movement between 10-11 and 12-13 weeks (P < 0.05).

Conclusion

The difference in frequency of 5 fetal movements at 10-11 and 12-13 weeks of gestation may be caused by early neuromuscular development and differentiation of the neuromuscular system.     

Fetal heart rate patterns in normal and ritodrine-treated pregnancies,detected by magnetocardiography

Objective: The aim of the present study was to test the validity of magnetocardiography in the diagnosis of fetal heart rate arrhythmias in normal pregnancies, as compared to the number of arrhythmias reported in other series, which were detected by use of other diagnostic techniques. We also evaluated the influence of ritodrine on the fetal heart rhythm in pregnancies treated for the risk of preterm labor by means of magnetocardiography, in order to provide preliminary results that could be utilized in the future establishment of magnetocardiography as a screening procedure in the diagnosis and management of fetal arrhythmias. Methods: We performed a prospective study on two subgroups of pregnant women: one of 84 women with normal healthy singleton pregnancies and one of 68 pregnant women treated with ritodrine for the risk of preterm labor. Results: The prevalence of fetal arrhythmias in the first subgroup was 3.5% (3/84), while in the second subgroup the prevalence was 16% (11/68). Conclusions: The incidence of fetal arrhythmias detected in our population of normal pregnancies was comparable to that reported in previous studies by use of other techniques. Results gained from the second subgroup, although not comparable to others, owing to lack of similar reports, led us to believe that magnetocardiography's advantages over conventional methods of fetal cardiac surveillance could highlight the technique as a useful screening procedure for the detection of preterm fetuses, which should be submitted to closer investigation, because of the arrhythmias caused by ritodrine infusion.