Many infants prenatally exposed to high levels of alcohol show one particular anomaly of the corpus callosum

INTRODUCTION

Effects of prenatal alcohol exposure on the brain are seen at every age. The earlier they can be quantified, the better the prognosis for the affected child. Here we show measurable alcohol effects at birth on a structure currently used for nosology only much later in life.

METHODS

Midline shape of the corpus callosum was imaged in infants via averaged unwarped transfontanelle ultrasound. We compared measures of these shapes among 23 infants prenatally exposed to high levels of alcohol and 21 infants unexposed to alcohol or only lightly exposed.

RESULTS

A particular feature of the corpus callosum, the appearance of a "hook" (obtuse angle) between the splenium and the long diameter of the arch in this plane, is strongly associated with prenatal alcohol exposure. In half of the high-exposed infants, the splenium angle is larger than in any of the unexposed brains. Simply characterizing this angle as less than or greater than 90 degrees detects 12 of the 23 exposed infants as anomalous with only 1 false positive among the unexposed. This apparently direct effect of prenatal ethanol exposure on the details of the callosum in about half the at-risk subjects cannot be attributed to any of several plausible competing exposures or other confounding factors applying during or after gestation.

CONCLUSION

An average of the images for the unexposed subjects has the geometry of textbook images of normal babies; but the average for the subgroup of high-angle subjects may serve as a template or guide to this regional damage parallel to the familiar photographic exemplars that help to assess facial signs.

Intérêt de l’échographie 3D-4D en échographie fœtale et gynécologique : principes et indications

Three-dimensional ultrasound has become an essential tool for visualization of fetal structures in the past few years. The recent improvements in transducers and signal processing provide new information, particularly in obstetrics and gynecology sonography. The present paper will present the most recent advances in volume acquisition and presentation modes followed by results of fetal organ visualization in normal and abnormal cases as well as applications in gynecology.

Foetal alcohol syndrome: a dental and skeletal age analysis of patients and controls

Foetal alcohol syndrome (FAS) consists of multisystem abnormalities and is caused by the excessive intake of alcohol during pregnancy. The teratogenic effect of alcohol on the human foetus has now been established beyond reasonable doubt and FAS is one of the most important human teratogenic conditions known today. The purpose of this study was to assess the dental age (DA) and skeletal age (SA) of children with FAS and compare them with matched controls. The samples of 90 children diagnosed with FAS and 90 controls were matched for age, gender, and social class. The mean chronological age (CA) of the FAS subjects was 8.95 years, with the controls slightly older at 9.04 years. This difference was not significant. Dental maturity was determined by assessing the stage of tooth formation and SA assessment was made from hand-wrist radiographs for the patients and controls by assigning a SA and comparing it with standard plates. The means and standard deviations of CA and DA for the stages of calcification were calculated and the Pearson ranked order correlation coefficient was applied to measure the associations between skeletal maturity indicators and DA. t-tests were used to test for group differences between independent groups, and paired t-tests to determine paired group differences. This study provided evidence of a positive association between DA and SA in both the FAS children and the controls. The data suggest that both DA and SA may be a reflection of general somatic growth. It must be acknowledged that growth of individuals is often irregular, when any norms of development based on central tendencies and variabilities of healthy children are applied. Some aspects of growth and development for healthy children may show a variable pattern of growth. Therefore, correlation of these aspects of growth and development will often not show the degree of correlation that theoretically exists between different areas of growth and development. A more complete appraisal of the entire skeleton and an evaluation of the entire dentition, rather than just the mandibular teeth, might improve the correlation between the variables.

Foetal alcohol syndrome: a cephalometric analysis of patients and controls

Foetal alcohol syndrome (FAS) consists of multi-system abnormalities and is caused by the excessive intake of alcohol during pregnancy. The teratogenic effect of alcohol on the human foetus has now been established beyond reasonable doubt and FAS is the most important human teratogenic condition known today. The purpose of this study was to analyse the craniofacial parameters of children with FAS and compare them with matched controls. Ninety children diagnosed with FAS (45 males, 45 females) and 90 controls were matched for age, gender, and social class. The mean age of the FAS children was 8.9 years with the controls slightly older at 9.1 years. This age difference was not significant (P = 0.34). A standard lateral cephalometric radiograph of each subject was taken. The radiographs were digitized for 20 linear and 17 angular measurements. These 37 variables were formulated to assess the size, shape, and relative position of three craniofacial complexes: (1) the cranial base, (2) midface, and (3) mandible. In addition, nine variables were computed to compare the soft tissue profiles. The study showed that measurements related to face height and mandibular size appear to be the most important features when distinguishing FAS children. Overall, the FAS children in the present study presented with vertically and horizontally underdeveloped maxillae, together with features of long face syndrome with large gonial angles and a short ramus in relation to total face height. There was also a tendency for the development of an anterior open bite, which appears to be compensated for by an increase in the vertical dimension of the anterior alveolar process to bring the incisor teeth into occlusion. The latter adaptation occurred mainly in the mandible.

Congenital Cystic Adenomatoid Malformation in the Fetus: A Hypothesis of Its Development

We present a case of congenital cystic adenomatoid malformation of the lung diagnosed at 34 weeks of gestation in the setting of polyhydramnios. The fetus had CCAM in the L lung, with mediastinal shift to the right and ascites. The neonate underwent drainage of cysts and subsequent left lung lobar resection with improvement in respiratory function. The pathology of CCAM is reviewed in detail. We speculate the role of alcohol as a teratogen through retinoic acid at 8-10 weeks of gestation when fetal lungs are actively developing.

Preliminary evidence that prenatal alcohol damage may be visible in averaged ultrasound images of the neonatal human corpus callosum

Brain damage consequent to prenatal alcohol exposure can be detected by measurements of the corpus callosum in the midline magnetic resonance (MR) brain image in adolescents and adults. The present article extends this finding into the neonatal period, when the power of detection to ameliorate the quality of the child's future life is greatest. The midline corpus callosum of the very young infant can be located reliably in multiple frames of clinical transfontanelle ultrasound. We studied a sample of 18 children aged 17 weeks or less, 7 of whom were exposed to high levels of alcohol prenatally and 11 of whom were not exposed or only minimally exposed. The midline callosum of each child was imaged up to 50 times by a standard clinical device, and coplanar subsets of these series were averaged with reference to fiducial image structures. On each average image four semilandmark points were set and their configuration quantified by standard landmark methods. The angle between the terminal bulb of splenium and the long axis of the callosal outline classifies four of the seven exposed infants as different from all 11 of the unexposed infants. This simple angle measurement upon averaged ultrasound images of the human neonatal midline corpus callosum, perhaps a version of the long-sought "biomarker of prenatal alcohol damage," may be able to discriminate baby brains affected by prenatal alcohol exposure from those that were unaffected.

Deep serotonergic and dopaminergic structures in fetal alcoholic syndrome: a study with nor-beta-CIT-single-photon emission computed tomography and magnetic resonance imaging volumetry

BACKGROUND

In prenatally alcohol exposed children, the relationship between brain structure and function is highlighted to be important to study.

METHODS

We studied 12 children with fetal alcoholic syndrome (FAS) and fetal alcoholic effects (FAE) by magnetic resonance imaging volumetry and by single-photon emission computed tomography with iodine-123 labeled 2beta-carbomethoxy-3beta-(4-iodophenyl) ([123I]nor-beta-CIT) and related these findings to those from neuropsychological and psychiatric tests.

RESULTS

The absolute volumes of studied nuclei, including the brain volume, were significantly smaller in FAS/FAE children than in control patients. After normalization of volumes, significant differences were not found. Left hippocampus was smaller than the right (p<.003) but did not significantly differ from the control subjects. The children with FAS/FAE showed reduced serotonin (p=.02) in the medial frontal cortex and slightly increased striatal dopamine transporter binding. All FAS/FAE children had attention-deficit/hyperkinetic disorder (ADHD). None had depression. The internalization scores correlated with dopamine transporter binding (r=-.65; p=.03).

CONCLUSIONS

The results indicate that the serotonin (5-HT) system may be vulnerable to the effects of ethanol in utero. The high dopamine transporter levels may correlate with the ADHD findings. Reduced serotonin and increased binding of dopamine transporter are also seen in type 2 alcoholism. Some behavioral problems of FAS/FAE might be preventable by early intervention and treatment.

Midaortic syndrome associated with fetal alcohol syndrome

Midaortic syndrome (MAS) is an uncommon condition characterized by progressive narrowing of the abdominal aorta and its branches and impressive formation of collateral circulation. It affects children and young adults and presents predominantly as untreatable hypertension. Fetal alcohol syndrome (FAS) refers to a constellation of physical, behavioral, and cognitive abnormalities secondary to alcohol exposure in utero. The authors present an unusual association between a hypoplastic abdominal aorta and fetal alcohol syndrome. The patient discussed in this article presented with severe hypertension that was successfully treated with renal angioplasty.

Brain function in fetal alcohol syndrome assessed by single photon emission computed tomography

This case series reports results of single photon emission computed tomography (SPECT) studies in three patients with fetal alcohol syndrome (FAS), who had previously undergone structural magnetic resonance imaging (MR). The MR studies revealed several brain anomalies, including microcephaly, agenesis or hypoplasia of corpus callosum and agenesis of hippocampal commissure. The SPECT data revealed that the CBF was reduced by at least 25% in the temporal region relative to the cerebellum in all three patients. By contrast, the temporal-cerebellar differences were between 4% and 7% in two controls. The functional abnormalities in FAS, like neuroanatomical abnormalities, are likely to be multiple and varied because of heterogeneity of this syndrome. Our findings suggest the need for a larger study to test the hypothesis that temporal lobe abnormalities are a notable occurrence in FAS. Discovery of specific regional brain dysfunctions (such as temporal lobe dysfunction) that are particularly vulnerable to alcohol's teratogenic effect may allow clinicians and researchers to look for markers useful in FAS screening and may have implications for prevention and treatment of FAS.

[Fetal alcohol syndrome]

Fetal alcohol syndrome is frequently observed. It is estimated that 0.2% of newborns in France have fetal alcohol syndrome, a rate which reaches 1% in certain studies. Ultrasound diagnosis is straightforward, based on: - intrauterine growth retardation, predominantly involving the limbs and occurring early without oligoamnios; - specific facial dysmorphism with two essential signs, frontal rounding of the philtrum, suppression of the Cupidon arch; - several malformations involving the corpus callosum, ocular and renal tissue; - markedly higher incidence in multiple parity women over thirty who gain little weight during pregnancy. We report seven cases observed between 1994 and 1999 and discuss the growth curve and the facial dysmorphism.

Brain perfusion SPECT and MRI in foetal alcohol syndrome

Six boys and five girls with a mean age of 8.6 (range 3 to 13) years with foetal alcohol syndrome (FAS) were studied by MRI and single photon emission computed tomography (SPECT) to find specific areas of vulnerability. Morphological anomalies shown in six of 11 patients by MRI were situated both cortically and subcortically: cortical atrophy (N = 2), dilated ventricle (N = 1), corpus callosum hypoplasia (N = 1), cerebellar atrophy (N = 2), one of the latter with Arnold-Chiari malformation (N = 1). Delayed myelination of the white matter was seen in two patients. Volumetric studies of the hippocampus showed morphological left-right asymmetry in five of eight patients. However, SPECT showed mild hypoperfusion of the left hemisphere in all 10 subjects. The negative left-right index was located especially in the left parietooccipital region, i.e. in the brain areas implicated in arithmetical and logical-grammatical functions, which are known to be affected in FAS. Normal left-right dominance was also lacking in the frontal area, i.e. the brain area affected in attention-deficit-hyperactivity disorder (ADHD). Detection of these abnormalities, although they are not unique to FAS, may be helpful in the diagnosis and any attempts at rehabilitation. Diverse morphological and functional abnormalities are more frequent than has usually been believed even in less impaired children with FAS.

Vanished twin and fetal alcohol syndrome in the surviving twin. A case report

BACKGROUND

The diagnosis of twin pregnancy can be made early in pregnancy by ultrasonography (US). Follow-up examination occasionally demonstrates the disappearance of one of the twins.

CASE

A twin disappeared on US examination; the surviving twin exhibited signs of fetal alcohol syndrome and other congenital anomalies, accompanied by a placental form of fetus papyraceus.

CONCLUSION

Early US examination is useful for diagnosing multiple gestation. However, a follow-up examination is required to alert the clinician to the disappearance of one twin. Careful examination of the placenta may document fetal remnants. In this case a small, atretic nodule on the placental surface was evidence of the vanished twin.

Eye size in healthy Swedish children and in children with fetal alcohol syndrome

PURPOSE

This study set out to collect reference data for normal ocular growth and to study the teratological effects of alcohol on eye development.

METHODS

Eye size was studied in 92 healthy Swedish children (age 1 month to 16 years) as reference and in 13 children (age 1.4 months to 17 years) with fetal alcohol syndrome (FAS) using ultrasonographic axial length measurements. Another three children with FAS were evaluated by clinical examination only.

RESULTS

The control group demonstrated a marked increase in total axial length during the first 2 years of life. Girls with FAS had a shorter total axial length (p = 0.045) than their controls. Both boys and girls with FAS demonstrated a relatively smaller vitreous body than the controls, p = 0.015 and 0.068, respectively. Three children with FAS had severe structural anomalies.

CONCLUSION

The observations support previous studies indicating that alcohol has an adverse effect on growth and configuration of the eye.

Isolated hyperechoic fetal bowel: significance and implications for management

OBJECTIVE

The objective of this study was to determine the significance of isolated hyperechoic fetal bowel.

STUDY DESIGN

Forty-five cases with prospective, ultrasonographic diagnosis of isolated hyperechoic fetal bowel were reviewed. Fetal variables, including aneuploidy, deoxyribonucleic acid studies for cystic fibrosis, congenital infection, growth retardation, and intrauterine death were reported.

RESULTS

Thirty-four of the 45 cases (76%) resulted in live-born infants without detected abnormalities. However, hyperechoic bowel was associated with cystic fibrosis in two cases (4%), congenital infection in two cases (4%), and fetal alcohol syndrome in one case. Termination of pregnancy was elected in three cases and intrauterine fetal death occurred in three cases (7%). Growth retardation was observed in five of 39 (13%) live-born infants.

CONCLUSION

Isolated hyperechoic fetal bowel is associated with significant pathologic disorders. Women whose fetuses are diagnosed as having isolated hyperechoic bowel should be offered additional prenatal diagnostic options, including maternal serologic studies for congenital infection, fetal karyotype, and deoxyribonucleic acid testing for cystic fibrosis. In addition, continuing ultrasonographic evaluation of fetal growth and antenatal biophysical assessment should be considered.

Incidence of renal anomalies in children prenatally exposed to ethanol

OBJECTIVE

Based on a number of studies involving animals as well as human case reports indicating an association between prenatal ethanol exposure and renal malformations, it has been suggested that children with fetal alcohol syndrome (FAS) should be screened for renal anomalies. The purpose of this study was to evaluate a group of children prenatally exposed to alcohol to determine the incidence of renal anomalies and to evaluate the need for such a screening procedure.

METHODS

Renal ultrasounds were performed on a total of 84 patients (68 children, 13 adolescents, and three adults). In addition to screening for malformations, renal size was studied. Data were analyzed using both chronologic and height-age as determinants of kidney size.

PATIENTS

Of these 84 patients, 51 (61%) had FAS, and 33 (39%) had a history of prenatal ethanol exposure but did not have FAS.

RESULTS

Three (3.6%) patients (one with FAS, two with prenatal ethanol exposure who did not have FAS) had significant renal abnormalities. This incidence was not significantly different from that found in ultrasound screening of newborns. The kidneys of children with both FAS and prenatal ethanol exposure who did not have FAS were significantly smaller than normal for both chronologic and height-age. When children were compared across chronologic ages, those with FAS had significantly smaller kidneys than those who had no evidence of FAS. After adjusting for height, the difference between these two groups was no longer significant.

CONCLUSIONS

Based on these data, children prenatally exposed to ethanol do not need to be screened for renal anomalies.

Quantitation of craniofacial anomalies in utero: fetal alcohol and Crouzon syndromes and thanatophoric dysplasia

The study of fetal growth and development by ultrasound has been greatly facilitated in the past few years by the availability of anthropometric standards for the fetal body. Thus, the obstetrician is able to discern between normal and grossly abnormal, and even to quantitate certain fine fetal structures such as the face. This paper presents results obtained from a group of 5 patients referred to the Medical Center from private practices in Indianapolis, Indiana. Prenatal cephalometric analyses by ultrasound suggested the presence of craniofacial anomalies in all 5 cases. However, such defects were not detectable by routine ultrasonographic examination. A clinical examination after birth of each of these 5 patients suggested the following diagnoses: Fetal Alcohol Syndrome (FAS) in 2 individuals, Fetal Alcohol Effects (FAE) in one individual, Crouzon Syndrome (CS) in one patient, and Thanatophoric Dysplasia (TD) in one patient. In order to compare the craniofacial measurement values for each patient to normal standards, we developed Z-Score profiles and Pattern Variability Indexes (PVI) as described by Garn et al. [1984, 1985]. The values presented here support the idea that even mildly abnormal fetal craniofacial patterns are detectable by this relatively new application of ultrasound. At the present time, no conclusions can be made regarding the diagnostic accuracy of these patterns and profiles. However, the potential value of fetal cephalometry for documenting craniofacial dysmorphology is clearly indicated.

Craniofacial and oral manifestations of fetal alcohol syndrome

Six representative patients with fetal alcohol syndrome (FAS) were studied for craniofacial and oral anomalies, dental development, and long-term bodily growth patterns. The craniofacial features observed were reduction of total head size, increased head-body ratio, the existence of upper and middle craniofacial asymmetry and telecanthus in some instances, and the features of a long face syndrome with a large gonial angle. Dental development was mildly to moderately delayed, and enamel anomalies were present. Analysis of growth patterns demonstrated compensatory growth in stature, weight, or head circumference and a delayed bone age in some instances. It is suggested that the semiquantitative score system for fetal alcohol syndrome study may fail to diagnose individual cases and that craniofacial features are more important in diagnosis than seems to have been appreciated in the past.

Stippled epiphyses in fetal alcohol syndrome

We report on punctate epiphyseal calcifications (stippled epiphyses) in the fetal alcohol syndrome and present the differential diagnosis of chondrodysplasia punctata. A literature survey shows that epiphyseal calcifications accompanying alcoholic embryopathy are regularly located in the lower limbs and rarely found in the upper extremities.

[Chondrodysplasia punctata and maternal alcohol intoxication. Apropos of 7 cases]

The authors report 7 cases of chondrodysplasia punctata in whom maternal alcohol intoxication was found. Most often, it consisted of chronic and confirmed alcoholism, except for the last case, in which an acute intoxication had occurred at about the 4th or 5th week of pregnancy. Clinically, the appearance of the children was evocative of fetal alcohol syndrome, except in the last case when, in contrast, the facial dysmorphy was very typical of chondrodysplasia punctata. The skeletal anomalies preferentially involve the lower limbs, sometimes the sacrum, and in one single case, the dorsal spine. Upper limbs are always spared. The maternal hepatic lesions may be responsible for the skeletal impairment, due to their repercussion on the metabolism of vitamin K. This skeletal impairment would then be close to that induced by treatments with warfarin during pregnancy. Whatever, it is absolutely necessary to X-ray the lower limbs in cases with fetal alcohol syndrome, in order to not overlook associated bone lesions.

A cephalometric study of fetal alcohol syndrome

Analysis of cephalometric radiographs of 12 children with fetal alcohol syndrome corroborated the clinical observation of midfacial deficiency described in patients with this disorder. Contrary to previous reports, however, our data show that this abnormality is not caused by true maxillary hypoplasia but by retrusion of the maxilla. We postulate that this abnormal position is secondary to restricted forward growth of the face, resulting from abnormal brain growth and subsequent shortening of the anterior cranial base.

Cervical spine anomalies in fetal alcohol syndrome

Fifty cases of well-documented fetal alcohol syndrome were reviewed with the intent of describing the cervical vertebral anomalies. Thirty-eight cases had adequately detailed x-ray examination to be included in this study. Of these, 19 or 53% showed congenital fusion of two or more cervical vertebrae. The associated findings were minor anomalies on the intravenous pyelogram (IVP) in three of 18 IVPs done, mild to moderate microcephaly in 53%, and significant congenital heart anomalies in 41%. Although the vertebral anomalies bear a resemblance to the Klippel Feil syndrome, it is thought that the two syndromes are separate. The patterns of occurrence of the vertebral anomalies are different in the two groups, and the visceral expression of the disorder is also different. The major visceral anomaly in the Klippel Feil syndrome being in the genitourinary system and in the fetal alcohol syndrome being in the cardiovascular system. The patterns, however, are close enough to imply teratogenic event as the etiology in the Klippel Feil group. The occurrence of neck fusion in the fetal alcohol syndrome is common enough for it to be used in making the diagnosis.

Bone fusion in the foetal alcohol syndrome

Clinical examinations and radiographic skeletal surveys have been carried out in 15 patients with foetal alcohol syndrome. Fusion of the capitate and hamate bones in the carpus was bilateral in one patient and unilateral in two. All three had accessory ossification centres at the proximal ends of both second metacarpals. Two of these patients also had radio-ulnar synostosis. Digital shortening, which was demonstrated by pattern profile analysis, was very variable in degree and anatomical distribution. Other skeletal changes of uncertain significance were a "beaten copper" appearance of the calvarium in four patients, and coxa valga in one other. Diagnosis of the foetal alcohol syndrome warrants consideration in any individual presenting with carpal fusion or with radio-ulnar synostosis.