Changes in fetal motility as a result of congenital disorders: an overview

Congenital hypotonia: systematic approach for prenatal detection

OBJECTIVES

Congenital hypotonic conditions are rare and heterogeneous, and some are severely debilitating or lethal. Contrary to its prominent postnatal manifestation, the prenatal presentation of hypotonia is frequently subtle, inhibiting prenatal detection. We aimed to characterize the prenatal sonographic manifestation of congenital hypotonia throughout pregnancy, evaluate the yield of diagnostic tests and propose diagnostic models to increase its prenatal detection.

METHODS

This was a retrospective observational study of singleton pregnancies with congenital hypotonia, diagnosed either prenatally or immediately after birth, at a single tertiary center between the years 2012 and 2020. Prenatally, hypotonia was diagnosed if a fetus showed sonographic or clinical signs suggestive of hypotonia and had a confirmed underlying genetic condition, or in the absence of a known genetic abnormality if the fetus exhibited multiple prominent signs suggestive of hypotonia. Postnatally, it was diagnosed in neonates displaying reduced muscle tone leading to reduced spontaneous movement, reduced swallowing or feeding difficulty. We reviewed the medical records of pregnant patients carrying fetuses subsequently diagnosed with congenital hypotonia and assessed the yield of ultrasound scans, fetal magnetic resonance imaging, computed tomography and genetic tests. The detection rate of sonographic signs suggesting fetal hypotonia was calculated. The prevalence of non-specific signs, including polyhydramnios, persistent breech presentation, intrauterine growth restriction and maternal perception of reduced fetal movement, were compared between the study group and the local liveborn singleton population. Potential detection rates of different theoretical semiotic diagnostic models, differing in the threshold for referral for a targeted scan, were assessed based on the cohort's data.

RESULTS

The study group comprised 26 cases of congenital hypotonia, of which 10 (38.5%) were diagnosed prenatally, and the controls included 95 105 singleton live births, giving a prevalence of congenital hypotonia of 1:3658. Nuchal translucency thickness and the early anomaly scan at 13-17 weeks were normal in all 22 and 23 cases, respectively, in which this was performed. The mid-trimester scan performed at 19-25 weeks was abnormal in four of 24 (16.7%) cases. The overall prenatal detection rate of congenital hypotonic conditions in our cohort was 38.5%. Only cases which underwent a targeted scan were detected and, among the 16 cases which underwent this scan, the prenatal detection rate was 62.5% compared with 0% in pregnancies that did not undergo this scan (P = 0.003). An abnormal genetic diagnosis was obtained in 21 (80.8%) cases using the following modalities: chromosomal microarray analysis (CMA) in two (9.5%), whole-exome sequencing (WES) in 14 (66.7%) and methylation analysis in five (23.8%). CMA was abnormal in 8% (2/25) of the cases and WES detected a causative genetic mutation in 87.5% (14/16) of the cases in which these were performed. Comparison of non-specific signs in the study group with those in the local singleton population showed that hypotonic fetuses had significantly more polyhydramnios (64.0% vs 3.0%, P < 0.0001), persistent breech presentation (58.3% vs 4.2%, P < 0.0001), intrauterine growth restriction (30.8% vs 3.0%, P < 0.0001) and maternal perception of reduced fetal movement (32.0% vs 4.7%, P < 0.0001). Prenatally, the most commonly detected signs supporting a diagnosis of hypotonia were structural anomaly (62.5%, 10/16), reduced fetal movement (46.7%, 7/15), joint contractures (46.7%, 7/15) and undescended testes ≥ 30 weeks (42.9%, 3/7 males). Proposed diagnostic strategies that involved performing a targeted scan for a single non-specific ultrasound sign or two such signs, and then carrying out a comprehensive genetic evaluation for any additional sign, offered theoretical detection rates in our cohort of 88.5% and 57.7%, respectively.

CONCLUSIONS

Congenital hypotonic conditions are rare and infrequently detected prenatally. Sonographic signs are visible from the late second trimester. A targeted scan increases prenatal detection significantly. Comprehensive genetic testing, especially WES, is the cornerstone of diagnosis in congenital hypotonia. Theoretical diagnostic models which may increase prenatal detection are provided. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal arthrogryposis-what do we tell the prospective parents?

Arthrogryposis, also termed arthrogryposis multiplex congenita, is a descriptive term for conditions with multiple congenital contractures (MCC). The etiology is extremely heterogeneous. More than 400 specific disorders have been identified so far, which may lead to or are associated with MCC and/or fetal hypo- and akinesia as a clinical sign. With improved sensitivity of prenatal ultrasound and expanding prenatal diagnostic options, clinicians are tasked with providing early detection in order to counsel the prospective parents regarding further prenatal diagnostic as well as management options. We summarize the most important knowledge to raise awareness for early detection in pregnancy. We review essential points for counseling when MCC is detected in order to provide answers to common questions, which, however, cannot replace interdisciplinary expert opinion in the individual case.

Eye-tracking visual patterns of sonographers with and without fetal motor assessment expertise

OBJECTIVES

Fetal motor assessment (FMA) in addition to structural anomaly scan enhances prenatal detection of arthrogryposis multiplex congenita (AMC). In the Amsterdam UMC, sonographers are trained to perform FMA. We examined the effect of motor assessment training by comparing sonographers with (SMA) and without this training (S) on their qualitative motor assessment in fetuses with normal (FNM) and abnormal motility (FAM) and their visual processing by eye-tracking.

METHODS

The study was performed from 2019 to 2020. Five SMA and five S observed five FNM and five FAM videos. Qualitative FMA consisted of six aspects of the general movement and the overall conclusion normal or abnormal. The visual processing aspects examined through eye-tracking were fixation duration, number of revisits per region of interest (ROI) and scanpaths of saccades between fixation points.

RESULTS

Quality assessment by SMA revealed more correct aspects in FNM than in FAM but overall conclusions were equally correct (92-96 %). S scored aspects of FNM better than in FAM, but overall conclusion correct only in half of FNM and three quarters of FAM. Eye-tracking of SMA and S showed fixation duration and revisits with similar distributions per ROIs for FNM and FAM, but SMA perform more trunk revisits in FNM. Scanpaths had smaller circumference, less outliers and more consistency in SMA than S.

CONCLUSION

This modest population of qualified sonographers showed that additional FMA training improved qualitative motor assessment. Eye-tracking revealed differences in visual processing and stimulates continuous education for professionals active in the detection of these rare diseases.

Fetal behavior during MRI changes with age and relates to network dynamics

Fetal motor behavior is an important clinical indicator of healthy development. However, our understanding of associations between fetal behavior and fetal brain development is limited. To fill this gap, this study introduced an approach to automatically and objectively classify long durations of fetal movement from a continuous four-dimensional functional magnetic resonance imaging (fMRI) data set, and paired behavior features with brain activity indicated by the fMRI time series. Twelve-minute fMRI scans were conducted in 120 normal fetuses. Postnatal motor function was evaluated at 7 and 36 months age. Fetal motor behavior was quantified by calculating the frame-wise displacement (FD) of fetal brains extracted by a deep-learning model along the whole time series. Analyzing only low motion data, we characterized the recurring coactivation patterns (CAPs) of the supplementary motor area (SMA). Results showed reduced motor activity with advancing gestational age (GA), likely due in part to loss of space (r = -.51, p < .001). Evaluation of individual variation in motor movement revealed a negative association between movement and the occurrence of coactivations within the left parietotemporal network, controlling for age and sex (p = .003). Further, we found that the occurrence of coactivations between the SMA to posterior brain regions, including visual cortex, was prospectively associated with postnatal motor function at 7 months (r = .43, p = .03). This is the first study to pair fetal movement and fMRI, highlighting potential for comparisons of fetal behavior and neural network development to enhance our understanding of fetal brain organization.

Skeletal Muscle's Role in Prenatal Inter-organ Communication: A Phenogenomic Study with Qualitative Citation Analysis

Gene targeting in mice allows for a complete elimination of skeletal (striated or voluntary) musculature in the body, from the beginning of its development, resulting in our ability to study the consequences of this ablation on other organs. Here I focus on the relationship between the muscle and lung, motor neurons, skeleton, and special senses. Since the inception of my independent laboratory, in 2000, with my team, we published more than 30 papers (and a book chapter), nearly 400 pages of data, on these specific relationships. Here I trace, using Web of Science, nearly 600 citations of this work, to understand its impact. The current report contains a summary of our work and its impact, NCBI's Gene Expression Omnibus accession numbers of all our microarray data, and three clear future directions doable by anyone using our publicly available data. Together, this effort furthers our understanding of inter-organ communication during prenatal development.

Computation of Fetal Kicking in Various Fetal Health Examinations: A Systematic Review

Fetal movement has always been considered an essential indicator to evaluate the health of the unborn fetus. Many factors affect fetal movement. The frequency of fetal kicking is an important measurement of whether fetal development is progressing and healthy. Various instruments and methods of detecting fetal movement have been used and each method has its advantages and disadvantages. Although limited by the fetal environment in utero, the finite element method and musculoskeletal model can be used to calculate fetal lower limb movement. This review aims to summarize the current detection techniques for fetal movement, especially in the lower limbs. These will be outlined by describing the different measurements of fetal movement, and the related biomechanical analyses of fetal lower limb skeletogenesis and the associated muscular development to better evaluate and calculate the movements of the fetus in the womb.

Care pathway for fetal joint contractures, Fetal Akinesia Deformation Sequence and Arthrogryposis Multiplex Congenita

Introduction The majority of arthrogryposis multiplex congenita (AMC) and lethal forms of AMC such as fetal akinesia deformation sequence (FADS) cases are missed prenatally. We have demonstrated the additional value of fetal motor assessment and evaluation in a multidisciplinary team for the period 2007-2016. An applied care pathway for fetuses presenting with joint contracture(s) in one anatomic region (e.g. talipes equinovares), more than one body part with non-progressive contractures and motility (AMC) and with deterioration over time (FADS). Methods The multidisciplinary team of Amsterdam University Medical Centre Expertise Centre FADS and AMC developed the care pathway. Additional tools are provided including a motor assessment by ultrasound examination and postmortem assessment form. Results An eight-step care pathway is presented with a proposed timing for prenatal sonographic examination, genetic examinations, multidisciplinary meetings, prenatal and postnatal counselling of the parents by specialist also treating after birth, follow-up of prenatal and postnatal findings with counselling for future pregnancies. Discussion/conclusion The scheduled serial structural and motor sonograpahic assessment together with follow-up examinations and genetic analysis, should be tailored per prenatal centre per available resources. The multidisciplinary care pathway may pave the way to increase detection rate and diagnosis of isolated contracture(s), talipes equinovares with underlying genetic causes and the rare phenotypes AMC/FADS and prompt treatment after birth within expertise teams.

Fetal movements: the origin of human behaviour

The study of the onset and ontogeny of human behaviour has made it clear that a multitude of fetal movement patterns are spontaneously generated, and that there is a close association between activity and the development of peripheral and central structures. The embryo starts moving by 7.5 week's gestation; 2 to 3 weeks later, a number of movement patterns including general movements, isolated limb and head movements, hiccup, and breathing movements, appear. Some movements (e.g. yawning, smiling, 'pointing'; we show these in eight videos in this review) precede life-long patterns; others have intrauterine functions, such as sucking/swallowing for amniotic fluid regulation, breathing movements for lung development, or eye movements for retinal cell diversity. In cases of developmental brain dysfunction, fetal general movements alter their sequence and gestalt, which suggests a dysfunction of the developing nervous system. The scarcity of longitudinal studies calls for further comprehensive research on the predictive value of prenatal functional deviations. What this paper adds Motor output can occur in the absence of sensory input. Structural development is activity-dependent. Fetal general movements are among the first movement patterns to occur. Pregnancy-related and maternal factors impact quantity and modulation of fetal general movements. Prenatal general movement assessment has not yet brought the expected breakthrough.

Evaluation of embryonic posture using four-dimensional ultrasound and virtual reality

Aim

To assess the possibility of embryonic posture evaluation (=feasibility, reproducibility, variation) at rest at 9 weeks' (+0–6 days) gestational age (GA) using four‐dimensional ultrasound and virtual reality (VR) techniques. Moreover, it is hypothesized that embryonic posture shows variation at the same time point in an uneventful pregnancy.

Methods

In this explorative prospective cohort study, 23 pregnant women were recruited from the Rotterdam periconceptional cohort. A transvaginal four‐dimensional ultrasound examination of 30 min per pregnancy was performed between 9 and 10 weeks' GA. The acquired datasets were offline evaluated longitudinally (i.e. per frame) using VR techniques.

Results

The ultrasound data of 16 (70%) out of 23 pregnancies were eligible for evaluation. At rest the analysis of the embryonic posture was feasible and showed a strong (>80%) intraobserver and interobserver reproducibility for most body parts. The majority of the body parts were in similar anatomic positions at rest. However, variations in anatomic positions (e.g. 6% rotated head, 9% laterally bent spine), within and between embryos, were seen at 9 weeks' GA.

Conclusion

In this unique study, we showed for the first time that embryonic posture measurements at rest can be performed in a reliable way using state‐of‐the‐art four‐dimensional ultrasound and VR techniques. Already early in prenatal life there are differences regarding posture within and between embryos.

Ultrasonographic evidence of persistent hyperextension of the fetal neck: is it a true sign? A diagnostic and prognostic challenge

OBJECTIVE

The purpose of this study was to evaluate the clinical evolution, structural anomalies associated and neonatal outcomes of fetal neck hyperextension in two cases with prenatal ultrasound diagnosis in two different gestational ages.

METHODS

In 2019, two cases of fetal hyperextension came to our attention. Follow-up information was obtained from hospital medical records and obstetrical care providers.

RESULTS

Two woman were investigated in our institution for the presence of fetal abnormalities in the II and III trimester, respectively. In both cases, fetal attitude presented persistent fetal neck hyperextension. One of the two fetuses had a mild ventriculomegaly and suspected for micrognathia. Both had an amniotic fluid increase. One of two had no movement in the lower and upper limbs in ultrasound scans associated with club foot and suspected scoliosis. Both were born by cesarean section with pretty different prognosis: one healthy baby had a retarded psychomotor development and the other one died after 6 months. A precise diagnosis was possible only in one case.

CONCLUSION

The early identification of a fetus with persistent hyperextension of the fetal head should require a detailed ultrasound exam for structural abnormalities and a careful prenatal counseling due to possible postnatal outcome.

Recognizing the unique prenatal phenotype of Prader-Willi Syndrome (PWS) indicates the need for a diagnostic methylation test

OBJECTIVES

Prader-Willi syndrome (PWS) is a neurogenetic disorder characterized by mental retardation, morbid obesity, and endocrine and behavior disorders. We previously showed in a small group of patients that PWS may have a unique prenatal phenotype. We aimed to characterize clinical and ultrasonic features in a larger series of pregnancies with a PWS fetus.

METHODS

We retrospectively interviewed all mothers of children with PWS followed in the Israel national multidisciplinary PWS clinic. We compared details of the PWS pregnancy with the pregnancies of healthy siblings and with data from the general population. Medical records including ultrasound reports, obstetric records, and genetic results were analyzed.

RESULTS

Distinct prenatal features of PWS pregnancies included abnormal fetal growth [fetal growth restriction (FGR) (37.3%), increased head to abdominal circumference ratio (44.8%), decreased abdominal circumference (49.2%)], markedly decreased fetal movements (DFM) (80.4%), and polyhydramnios (42.0%) (P < 0.001 for all). The combination of abnormal growth accompanied by polyhydramnios or DFM was highly suggestive for PWS.

CONCLUSIONS

Recognition of the unique PWS phenotype should alert obstetricians to consider the possibility of PWS, perform the diagnostic methylation test, provide appropriate counseling, and plan optimal management of the affected pregnancy.

Decreased fetal movements: Perinatal and long-term neurological outcomes

BACKGROUND

While maternal perception of decreased fetal movements during advanced stages of pregnancy may be an indicator for adverse perinatal outcome, the long-term neurological outcome of offspring of affected pregnancies remains largely unknown.

OBJECTIVE

To examine whether maternal complaint of decreased fetal movements is associated with adverse perinatal outcomes, and to assess the implications of decreased fetal movements on long-term neurological morbidity of the offspring.

STUDY DESIGN

A single center cohort analysis including deliveries between the years 1991-2014 was conducted. The association between decreased fetal movements and adverse perinatal outcome was evaluated using a general estimation equation (GEE) multivariable analyses. Incidence of hospitalizations (up to age 18 years) due to various neurological conditions was compared between offspring of affected pregnancies, and those who were not, using a Kaplan-Meyer survival curve. A Cox proportional hazards model was used to control for confounders.

RESULTS

439 (0.18%) of 242,342 deliveries included in this study were accompanied by maternal complaint of decreased fetal movements. Perinatal outcome was comparable between the groups, with no cases of perinatal mortality observed among the exposed group. Total neurological-related hospitalization rate of the offspring, as well as hospitalizations due to movement disorders, were higher among the exposed group (Kaplan-Meyer log-rank test P < 0.05). This association between decreased fetal movements and increased long-term neurological hospitalization proved to be independent of potential confounders with an adjusted hazard ratio of 1.54 (95% CI 1.0-2.37).

CONCLUSION

Maternal complaint of decreased fetal movements does not predict adverse perinatal outcome but is associated with an elevated risk for long-term neurological morbidity of the offspring.

Sonographic Detection of Seizure-Like Activity in Fetuses with Congenital Infection: Report of Three Cases and Review of the Literature

Fetal seizure is a very rare prenatal finding and associated with an almost invariably poor outcome, the most common causes being hypoxic-ischemic encephalopathy, congenital anomalies of either the central nervous system (CNS) or musculoskeletal system, and metabolic disorders. The prenatal detection of seizure-like activity in fetuses with congenital infection has not been previously reported. In this report, we describe 3 cases of seizures in fetuses with congenital infection including Zika virus (n = 2) and toxoplasmosis (n = 1). All 3 fetuses had associated CNS abnormalities and the perinatal outcome was uniformly poor. This report suggests that for fetuses with proven congenital infections an extended and targeted sonographic examination may be helpful in -detecting associated fetal seizures that may even worsen the neonatal outcome.

Fetal arthrogryposis: Challenges and perspectives for prenatal detection and management

Antenatal identification of fetuses with multiple congenital contractures or arthrogryposis multiplex congenita (AMC) may be challenging. The first clinical sign is often reduced fetal movement and/or contractures, as seen on prenatal ultrasounds. This can be apparent at any point, from early to late pregnancy, may range from mild to severe involvement, with or without associated other structural anomalies. Possible etiologies and their prognosis need to be interpreted with respect to developmental timing. The etiology of AMC is highly heterogeneous and making the specific diagnosis will guide prognosis, counseling and prenatal and perinatal management. Current ultrasound practice identifies only approximately 25% of individuals with arthrogryposis prenatally before 24 weeks of pregnancy in a general obstetrics care population. There are currently no studies and guidelines that address the question of when and how to assess for fetal contractures and movements during pregnancy. The failure to identify fetuses with arthrogryposis before 24 weeks of pregnancy means that physicians and families are denied reproductive options and interventions that may improve outcome. We review current practice and recommend adjusting the current prenatal imaging and genetic diagnostic strategies to achieve early prenatal detection and etiologic diagnosis. We suggest exploring options for in utero therapy to increase fetal movement for ongoing pregnancies.

Developmental trajectories of general and breathing movements in fetal twins

This study examined the developmental trajectories of general and breathing movements in fetal twins. Fetal movement patterns were assessed from real-time ultrasound recordings performed at 12-15, 20-23, and 28-32 weeks of gestation in 42 twin pairs. Results indicated that both general movements and breathing movements followed a curvilinear, inverted U-shaped curve. Developmental trajectories were unrelated within pairs of twins and were not associated with gestational age at birth and birth weight. However, sex differences were found for general movements with males displaying more time making general movements at 21 weeks and a steeper decline in time spent making general movements during the second half of pregnancy than females. These age-related changes in fetal movements may reflect CNS development. These findings also suggest that twins' behavioral development is largely independent of co-twin development, gestational age at birth, and birth weight, but not of fetal sex.

Fetal akinesia deformation sequence, arthrogryposis multiplex congenita, and bilateral clubfeet: Is motor assessment of additional value for in utero diagnosis? A 10-year cohort study

Objective

The diagnosis of fetal akinesia deformation sequence (FADS) is a challenge. Motor assessment is of additional value to advanced ultrasound examinations (AUE) for in utero FADS diagnosis before 24 weeks of gestation.

Methods

All consecutive fetuses with greater than or equal to two contractures on the 20 week structural anomaly scan (2007–2016) were included. Findings at AUE, including motor assessment were analysed and related to outcome.

Results

Sixty‐six fetuses fulfilled the inclusion criteria. On the basis of the first AUE, FADS was suspected in 13 of 66, arthrogryposis multiplex congenita (AMC) in 12 of 66, bilateral pes equinovares (BPEV) in 40 of 66, and Holt‐Oram syndrome in one of 66. On the basis of the first motor assessment, the suspected diagnosis changed in 19 of 66, in 13 of 66 worsening to FADS, six of 66 amelioration from FADS, and confirmed FADS in seven of 13. The result was 20 FADS, seven AMC, and 38 BPEV. Second AUE in 44 fetuses showed additional contractures in two of eight FADS, and one intrauterine fetal death (IUFD). The second motor assessment changed the diagnosis in three of 43, one worsening from BPEV into FADS, two ameliorations from FADS, and confirmed FADS in seven by deterioration of motility. The result was nine FADS, six AMC, and 29 BPEV.

Conclusion

The results suggest that motor assessment has additional value to distinguish between FADS, AMC, and BPEV.

Systematic motor assessment for differentiation, quality, and quantity of the movements has been performed in a high risk population for FADS.¹

This analysis revealed abnormal quality in all fetuses with deterioration in a 2‐week period, reduced differentiation in the majority and only half showed abnormal quantity.

This study evaluates whether motor assessment in addition to advanced ultrasound examination in case of multiple contractures, supports the timely diagnosis of FADS.

Neuroimaging perspectives on fetal motor behavior

We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.

Neurodevelopmental Correlates of Fetal Motor Behavior Assessed Using Cine MR Imaging

BACKGROUND AND PURPOSE

Fetal motor behavior is widely used as a clinical indicator for healthy development; however, our understanding of its potential as a marker for neurologic integrity is underdeveloped. MR imaging allows complete views of the whole fetus, which, combined with brain imaging, may improve the characterization of this relationship. This study aimed to combine an analysis of fetal motor behavior, brain MR imaging, and postnatal outcome, to provide insight into neurodevelopmental correlates of motor behavior.

MATERIALS AND METHODS

Cine MR imaging was used to acquire sequences of fetal motor behavior in subjects with normal and abnormal findings on conventional brain MR imaging between 18 weeks' gestation and term. General movement sequences were analyzed using established criteria. Brain MR imaging was reported by an expert fetal neuroradiologist. Subjects were followed for up to 4 years postnatally with standard postnatal assessments.

RESULTS

Nineteen of 21 fetuses with normal brain MR imaging findings showed normal general movements, compared with 14 of 22 of the fetuses with abnormal brain MR imaging findings, which, when classified by severity of the malformation, showed a significant relationship with postnatal outcome (P = .021). There was a significant relationship among neurodevelopmental outcome, general movement quality, and MR imaging of the brain (P = .020).

CONCLUSIONS

The findings from this study demonstrate that a combined structural and functional imaging approach to the fetus will improve the characterization of early neurologic integrity, with the potential to inform postnatal outcome. This also lays the groundwork for further in vivo research as advanced imaging techniques are developed to study fetal neurologic development.

4D assessment of fetal brain function in diabetic patients

OBJECTIVE

To assess whether there is a difference in the behavior of fetuses of pregnant women with diabetes under treatment with insulin, compared to fetuses of pregnant women without diabetes.

MATERIALS AND METHODS

Kurjak's antenatal neurodevelopmental test (KANET) - a method that, by application of four-dimensional (4D) ultrasound, assesses fetal behavior in a similar way that neonatologists perform a neurological assessment in newborns - was applied from 28 to 38 weeks of gestation to 40 pregnancies with pre-existing diabetes mellitus or gestational diabetes mellitus (GDM) requiring insulin (diabetic group) and to 40 non-diabetic cases, with otherwise low-risk pregnancies (non-diabetic group).

RESULTS

There were no statistically significant differences regarding maternal age (30.5±5.1 years for diabetic group vs. 29.8±6.2 years for non-diabetic group) and gestational age (32±1.6 weeks for the diabetic group compared to 33±1.2 weeks for the non-diabetic group). After analysis of the results obtained from application of KANET to each group, results of KANET had higher scores in the non-diabetic group.

CONCLUSION

It appears that there are differences in the fetal behavior between diabetic and non-diabetic fetuses, and also the specific parameters - movements that were different between the two groups were identified.

Visualization and quantitation of fetal movements by real-time three-dimensional ultrasound with live xPlane imaging in the first trimester of pregnancy

Aim

To prove whether real-time three-dimensional (3D) ultrasound with live xPlane imaging is better in observing fetal movements than standard ultrasound imaging.

Methods

50 healthy women with singleton pregnancies (22-43 years old) at 11 to 14 weeks of gestation underwent real-time 3D ultrasound examination with live xPlane imaging from July 2014 to February 2015. The incidence and frequency of 10 fetal movement patterns in 10 minutes were evaluated, including general movements (GMs), isolated arm movements, isolated leg movements, hiccup, stretching, breathing, startle, jaw opening, isolated head retroflexion, and isolated head anteflexion. The correlation between gestational age and frequency of each fetal movement pattern was analyzed.

Results

GM had the highest incidence (100%), followed by startle (84%) and isolated arm movements (68%). Their median frequency was 5 (IQR 3-6), 5 (IQR 1.75-11.5), and 1 (IQR 0-2), respectively. GM (Z = 5.875, P < 0.001) and startle (Z = 5.302, P < 0.001) had significantly higher frequency than isolated arm movements. The other 7 fetal movement patterns had much lower incidence and frequency. The frequency of GM was positively correlated with gestational age (r = 0.360, P = 0.010).

Conclusion

Real-time 3D ultrasound with live x Plane imaging was shown to be a feasible tool for observing fetal movements.

Fetal Neurology: Past, Present and Future

Neurological failure is the most apprehension complication of pregnancy, labor and the neonatal period. The origin and outcome correlation is frequently doubtful. The arrival of four-dimensional ultrasonography (4D US) and its function to study fetal behavior patterns have initiated to offer insight into the structural and functional fetal brain development. Although many fetal behavioral studies have been conducted, it is still questionable whether the assessment of continuity from fetal to neonatal behavior could improve our ability of early detection of brain pathology. Neurological assessment of fetus in utero is extremely difficult even having such sophisticated equipment like 4D ultrasound. As it is well known that quantity of GMs is not so informative and predictive for neurological impairment, their quality should be assessed. Gestalt perception of premature GMs we are dealing with in utero and several weeks postnatally are not as predictive for the detection of neurologically abnormal fetuses or newborns as fidgety GMs. Therefore, some additional parameters should be added to the prenatal neurological examination in order to improve our ability to make the distinction between normal and abnormal fetuses.

How to cite this article

Kurjak A, Antsaklis P, Stanojevic M. Fetal Neurology: Past, Present and Future. Donald School J Ultrasound Obstet Gynecol 2015;9(1):6-29.

Prader-Willi syndrome can be diagnosed prenatally

The aim of this study was to characterize the fetal phenotype of a cohort of individuals with confirmed diagnoses of Prader-Willi syndrome (PWS), a severe multi-system genetic disorder, diagnosed by a specific methylation test. We interviewed mothers of 106 individuals with PWS to obtain information about the pregnancy of their affected child. For 47 pregnancies of children younger than 10 years, we also reviewed the obstetric ultrasound and detailed obstetric history from medical records. We compared the PWS pregnancies with those of the sibling closest in age and with the general population. McNemars, Chi-square and Fisher exact tests were used for statistical analyses. Decreased fetal movements, small for gestational age (SGA), asymmetrical intrauterine growth (increased head/abdomen circumferences ratio) and polyhydramnios were found in 88%, 65%, 43%, and 34%, respectively (P < 0.001 vs. siblings and P < 0.0001 vs. the general population for all measurements). No severe morphological abnormalities were found. A combination of 2, 3, and 4 abnormalities was found in 27%, 29%, and 24% of pregnancies, respectively. Fourteen out of 15 umbilical artery Doppler studies were within the normal range (93%). The rare combination of asymmetrical intrauterine growth and polyhydramnios was found in 34% of PWS pregnancies (P < 0.0001 vs. the general population). Prenatal genetic screening for PWS by methylation testing is indicated when any combination of polyhydramnios, SGA or asymmetric intrauterine growth, with normal Doppler studies is present, particularly when asymmetrical intrauterine growth and polyhydramnios coexist.

Fetal Behavior and Heart Rate in Twin Pregnancy: A Review

Fetal movements and fetal heart rate (FHR) are well-established markers of fetal well-being and maturation of the fetal central nervous system. The purpose of this paper is to review and discuss the available knowledge on fetal movements and heart rate patterns in twin pregnancies. There is some evidence for an association or similarity in fetal movement incidences or FHR patterns between both members of twin pairs. However, the temporal occurrence of these patterns seems to be for the most part asynchronous, especially when stricter criteria are used to define synchrony. The available data suggest that fetal behavior is largely independent of sex combination, fetal position, and presentation. Conversely, chorionicity appears to have some influence on fetal behavior, mainly before 30 weeks of gestation. There is preliminary evidence for the continuity of inter-individual differences in fetal activity and FHR patterns over pregnancy. Comparisons between studies are limited by large methodological differences and absence of uniform concepts and definitions. Future studies with high methodological quality are needed to provide a more comprehensive knowledge of normal fetal behavior in twin pregnancy.

Clubfeet and associated abnormalities on fetal magnetic resonance imaging

OBJECTIVE

Clubfoot, or talipes equinovarus (TEV), is commonly diagnosed on prenatal ultrasound. This study sought to visualize TEV and associated abnormalities on fetal magnetic resonance imaging (MRI) compared with ultrasound.

METHODS

This retrospective study included the MRI scans of 44 fetuses with TEV using postnatal assessment and autopsy as standard of reference. Isolated TEV was differentiated from complex TEV with associated abnormalities. MRI findings and previous ultrasound diagnoses were compared.

RESULTS

Isolated TEV was found in 19/44 (43.2%) fetuses and complex TEV in 25/44 (56.8%). Associated abnormalities consisted of the following: central nervous system/spinal abnormalities in 13/25 (52.0%) fetuses; musculoskeletal abnormalities in 7/25 (28.0%); thoracic abnormalities in 3/25 (12.0%); a tumor in one case; and hydrops fetalis in one. Of the 44 cases, 35 (79.5%) pregnancies were delivered, and nine (20.5%) pregnancies, which were terminated, all had complex TEV. Of the 42 available ultrasound reports, additional MRI findings were made in 8/42 (19.0%) cases. MRI did not add findings in isolated TEV on ultrasound. In 4/44 (9.1%) cases, autopsy revealed additional findings compared with prenatal imaging.

CONCLUSION

Fetal MRI enables differentiation between isolated and complex TEV. Isolated TEV on ultrasound may not be an MRI indication, whereas MRI may be useful in cases of complex TEV.

Motion-compensation techniques in neonatal and fetal MR imaging

SUMMARY

Fetal and neonatal MR imaging is increasingly used as a complementary diagnostic tool to sonography. MR imaging is an ideal technique for imaging fetuses and neonates because of the absence of ionizing radiation, the superior contrast of soft tissues compared with sonography, the availability of different contrast options, and the increased FOV. Motion in the normally mobile fetus and the unsettled, sleeping, or sedated neonate during a long acquisition will decrease image quality in the form of motion artifacts, hamper image interpretation, and often necessitate a repeat MR imaging to establish a diagnosis. This article reviews current techniques of motion compensation in fetal and neonatal MR imaging, including the following: 1) motion-prevention strategies (such as adequate patient preparation, patient coaching, and sedation, when required), 2) motion-artifacts minimization methods (such as fast imaging protocols, data undersampling, and motion-resistant sequences), and 3) motion-detection/correction schemes (such as navigators and self-navigated sequences, external motion-tracking devices, and postprocessing approaches) and their application in fetal and neonatal brain MR imaging. Additionally some background on the repertoire of motion of the fetal and neonatal patient and the resulting artifacts will be presented, as well as insights into future developments and emerging techniques of motion compensation.

4D Sonography in Assessment of Fetal Neurobehavior

‘Observation of fetal behavior reflects the functioning of the central nervous system, and behavioral assessment of the fetus enables the function of the brain to be examined’.1 The introduction of four-dimensional (4D) sonography techniques would facilitate fetal behavioral assessment in three dimensions in real time during pregnancy. We describe the latest 4D sonographic studies on fetal neurobehavior in all three trimesters of pregnancy. 4D sonography also facilitated the evaluation of interhuman contact and intrapair stimulation in twin pregnancies in utero. This novel technique may assist in the evaluation of fetal neurobehavior and intertwin contact and intrapair stimulation and offer potential advantages relative to conventional two-dimensional sonography. 4D sonography may become an important modality in future research on fetal neurobehavioral development and the prenatal identification of severely brain-damaged infants.

How to cite this article

Hata T, Sato M, Kanenishi K, Hanaoka U, Tanaka H. 4D Sonography in Assessment of Fetal Neurobehavior. Donald School J Ultrasound Obstet Gynecol 2012;6(2):121-131.

Ultrasound Assessment of Fetal Neurobehavior in High-risk Pregnancies

Objectives

Assessment of the fetal behavior in normal and high-risk pregnancy during second and third trimesters.

Materials and methods

The study group included 61 healthy pregnant women and 135 pregnant women with high-risk pregnancy between 24 and 38 weeks of gestation for a period of 3 years (January 2009-May 2011). After 4D ultrasound examination we applied antenatal neurological score KANET 1. Score is considered normal between 14 and 20, borderline between 6 and 13 and abnormal between 0 and 5.

Results

The Kurjak antenatal neurological test (KANET) scores have significant differences, when applied on the two groups of pregnant women. Most fetuses who obtained normal KANET score were found in normal pregnancies, those who obtained borderline score were fetuses with intrauterine growth restriction (IUGR) with increased resistance index (RI) of middle cerebral artery (ACM) and the most fetuses with abnormal KANET score came from pregnancies complicated by threatened preterm delivery with PPROM.

Conclusion

Dynamic evaluation of fetal behavior reflects directly the processes of maturation and development of the central nervous system. This can make the difference between normal and abnormal brain development and may be used for early diagnosis of neurological disorders that become manifest in perinatal and postnatal periods.

How to cite this article

Vladareanu R, Lebit D, Constantinescu S. Ultrasound Assessment of Fetal Neurobehavior in High-risk Pregnancies. Donald School J Ultrasound Obstet Gynecol 2012;6(2):132-147.

Abnormalities of the upper extremities on fetal magnetic resonance imaging

OBJECTIVE

In view of the increasing use of fetal magnetic resonance imaging (MRI) as an adjunct to prenatal ultrasonography, we sought to demonstrate the visualization of upper extremity abnormalities and associated defects on MRI, with regard to fetal outcomes and compared with ultrasound imaging.

METHODS

This retrospective study included 29 fetuses with upper extremity abnormalities visualized with fetal MRI following suspicious ultrasound findings and confirmed by postnatal assessment or autopsy. On a 1.5-Tesla unit, dedicated sequences were applied to image the extremities. Central nervous system (CNS) and extra-CNS anomalies were assessed to define extremity abnormalities as isolated or as complex, with associated defects. Fetal outcome was identified from medical records. MRI and ultrasound findings, when available, were compared.

RESULTS

Isolated upper extremity abnormalities were found in three (10.3%) fetuses. In 26 (89.7%) fetuses complex abnormalities, including postural extremity disorders (21/26) and structural extremity abnormalities (15/26), were demonstrated. Associated defects involved: face (15/26); musculoskeletal system (14/26); thorax and cardio/pulmonary system (12/26); lower extremities (12/26); brain and skull (10/26); and abdomen (8/26). Of the 29 cases, 18 (62.1%) pregnancies were delivered and 11 (37.9%) were terminated. MRI and US findings were compared in 27/29 cases: the diagnosis was concordant in 14 (51.9%) of these cases, and additional findings were made on MRI in 13/27 (48.1%) cases.

CONCLUSIONS

Visualization of upper extremity abnormalities on fetal MRI enables differentiation between isolated defects and complex ones, which may be related to poor fetal prognosis. MRI generally confirms the ultrasound diagnosis, and may provide additional findings in certain cases.

The role of 4-D ultrasonography in prenatal assessment of fetal neurobehaviour and prediction of neurological outcome

OBJECTIVE

To determine the role of 4-D ultrasonography in prenatal assessment of fetal neurobehavior and in prediction of adverse neurological outcome.

DESIGN

Prospective cohort study.

SETTING

Women Hospital, Hamad Medical Corporation, Qatar.

POPULATION

Forty pregnant women between 20 and 38 weeks of gestation with high risk for neurological abnormalities and 40 low risk cases were included.

METHODS

Prenatal fetal neurological assessment using Kurjak antenatal neurodevelopmental test (KANET). Postnatal neurological assessment was performed using Amiel-Tison's neurological assessment at term (ATNAT) for all live-borns.

MAIN OUTCOME MEASURES

Prediction of fetuses at neurological risk.

RESULTS

The difference in the range of KANET score was significant. A significant difference was shown for isolated head anteflexion, isolated eye blinking, facial expressions, mouth movements, isolated hand movements, hand to face movement, finger movements, and general movements. For isolated leg movement and cranial sutures, the difference was not significant. All cases with abnormal KANET proved to be abnormal postnatally.

CONCLUSION

4-D ultrasonography may have an important role in prenatal assessment of fetal neurobehavior and prediction of adverse neurological outcome. However, further large studies are recommended before the test could be recommended for wider clinical practice.

Fetal akinesia and associated abnormalities on prenatal MRI

OBJECTIVE

In view of the increasing role of magnetic resonance imaging (MRI) as an adjunct to prenatal ultrasonography (US), this study sought to demonstrate the visualization of fetal akinesia and associated abnormalities on MRI.

METHODS

This retrospective study included six fetuses with akinesia and associated abnormalities, depicted on fetal MRI after suspicious prenatal US. The whole fetus was assessed for musculoskeletal abnormalities and associated pathological conditions elsewhere. Fetal outcome data were compared with prenatal imaging. US and MRI findings were also compared.

RESULTS

Akinesia resulting in arthrogryposis was seen in 6/6 fetuses, with abnormal musculature in 5/6 fetuses. Associated brain abnormalities were found in 2/6 fetuses; facial abnormalities in 3/6; lung hypoplasia in 3/6; and polyhydramnios in 2/6. There were 5/6 pregnancies that were terminated and one individual died neonatally. MRI and brain autopsy were concordant in 4/6 cases. MRI and body autopsy were concordant in 1/6 cases and in 5/6 cases, autopsy revealed additional abnormalities. In addition to US, MRI correctly identified central nervous system findings in four cases and lung hypoplasia in three cases.

CONCLUSION

Our MRI results demonstrate fetal akinesia and associated abnormalities, which may have an impact on perinatal management, as an adjunct to prenatal US.

An Attempt to Standardize Kurjak's Antenatal Neurodevelopmental Test: Osaka Consensus Statement

Analysis of the dynamics of fetal behavior in comparison with morphological studies has led to the conclusion that fetal behavioral patterns are directly reflecting developmental and maturational processes of fetal central nervous system (CNS). Four-dimensional ultrasound (4D US) offers a practical means for assessment of both the brain function and structure. The visualization of fetal activity in utero by 4D US could allow distinction between normal and abnormal behavioral patterns which might make possible the early recognition of fetal brain impairment. That new technology enabled introduction of Kurjak's antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies. In order to make the test reproducible, the standardization of the test was proposed in Osaka, Japan, during the International Symposium on Fetal Neurology of International Academy of Perinatal Medicine.

The KANET should be performed in the 3rd trimester from 28th to 38th week of gestation. The assessment should last from 15 to 20 minutes, and the fetuses should be examined when awake. If the fetus is sleeping, the assessment should be postponed for 30 minutes or for the next day between 14 and 16 hours. In cases of definitely abnormal or borderline score, the test should be repeated every two weeks till delivery. New modified KANET test should be used with eight instead of 10 parameters: Facial and mouth movements are combined in one category, isolated hand movements and hand to face movements are combined in one category. The score should be the same for abnormal fetuses 0 to 5, borderline score is from 6 to 13 and normal score is 14 or above.

After 4D US assessment of behavioral patterns in the fetuses from high-risk pregnancies, it is very important to continue with follow-up after delivery in infants who were borderline or abnormal as fetuses. Postnatal assessment of neonates includes initial neurological assessment according to Amiel-Tison's methodology (Amiel-Tison Neurological Assessment at Term, ATNAT) in the early neonatal period and every two weeks in preterm infants till discharge and at the postmenstrual age (PMA) between 37 and 40 weeks. If ATNAT is borderline or abnormal, initial assessment of general movements at the age of 36 to 38 weeks of PMA should be performed, than at writhing age (between 46 and 52 weeks), and at the fidgety age after 54 weeks of PMA. If the finding of fidgety movements is mildly abnormal or definitely abnormal, then one more assessment should be done in 2 to 4 weeks till PMA of 58 weeks. Brain ultrasonography should be performed in the first week of life and every 2 weeks afterward till discharge. In severely affected infants with grade 3 and above intraventricular hemorrhage, and those highly suspicious of hypoxic ischemic brain damage, magnetic resonance (MR) should be done if available. Infants should be followed until the age of at least 24 months when diagnosis of disabling or nondisabling cerebral palsy can be ultimately made. Infants with CP should be reassessed at the age of 6 years.

Mother's anxiety and depression and associated risk factors during early pregnancy: effects on fetal growth and activity at 20-22 weeks of gestation

To examine effects of mother's anxiety and depression and associated risk factors during early pregnancy on fetal growth and activity. Repeated measures of mother's anxiety (State-Anxiety Inventory (STAI-S)) and depression (Edinburgh Postnatal Depression Scale (EPDS)) and related socio demographics and substance consumption were obtained at the 1st and 2nd pregnancy trimesters, and fetus' (N = 147) biometric data and behavior was recorded during ultrasound examination at 20-22 weeks of gestation. Higher anxiety symptoms were associated to both lower fetal growth and higher fetal activity. While lower education, primiparity, adolescent motherhood, and tobacco consumption predicted lower fetal growth, coffee intake predicted lower fetal activity. Vulnerability of fetal development to mother's psychological symptoms as well as to other sociodemographic and substance consumption risk factors during early and mid pregnancy is suggested.

The potential of 4D sonography in the assessment of fetal neurobehavior--multicentric study in high-risk pregnancies

OBJECTIVE

An evolving challenge for obstetrician is to better define normal and abnormal fetal neurological function in utero in order to better predict antenatally which fetuses are at risk for adverse neurological outcome.

PATIENTS AND METHODS

Prenatal neurological assessment in high-risk fetuses using four-dimensional ultrasound applying the recently developed Kurjak antenatal neurodevelopmental test (KANET). Postnatal neurological assessment was performed using Amiel Tison's neurological assessment at term (ATNAT) for all live-borns and general movement (GM) assessment for those with borderline and abnormal ATNAT.

RESULTS

Inclusion criteria were met by 288 pregnant women in four centers of whom 266 gave birth to a live-born baby. It was revealed that 234 fetuses were neurologically normal, 7 abnormal and 25 borderline. Out of 7 abnormal fetuses ATNAT was borderline in 5 and abnormal in 2, whereas GM assessment was abnormal in 5 and definitely abnormal in 2. Out of 25 KANET borderline fetuses, ATNAT was normal in 7, borderline in 17 and abnormal in 1, whereas the GM assessment was as follows: normal optimal in 4, normal suboptimal in 20, and abnormal in 1. In summary, out of 32 borderline and abnormal fetuses ATNAT was normal in 7, borderline in 22 and abnormal in 3; GM assessment was normal optimal in 4, normal suboptimal in 20, abnormal in 6 and definitely abnormal in 2.

CONCLUSION

The sonographic test requires further studies before being recommended for wider clinical practice.

Four-dimensional Ultrasound Evaluation of Fetal Neurobehavioral Development

The introduction of four-dimensional (4D) ultrasound techniques would facilitate fetal behavioral assessment in three-dimensions in realtime during pregnancy. We describe the latest 4D sonographic studies on fetal behavior, especially fetal whole-body movements and facial expressions in all three trimesters of pregnancy and the continuation of behavior from the fetal to neonatal period. Moreover, we introduce a new scoring system (KANET, Kurjak Antenatal Neurological Test) for assessment of the fetal neurological status using 4D ultrasound. 4D ultrasound also facilitated the evaluation of inter-human contact in twin pregnancies in utero. This novel technique may assist in the evaluation of fetal behavior and inter-twin contact, and offer potential advantages relative to conventional two-dimensional ultrasound. 4D ultrasound should become an important modality in future research on fetal neurobehavioral development and the prenatal identification of severely brain-damaged infants. Further studies involving a larger sample size are needed to ascertain the role of 4D ultrasound in the evaluation of fetal neurobehavioral development.

Serial postural and motor assessment of Fetal Akinesia Deformation Sequence (FADS)

BACKGROUND

Fetal Akinesia Deformation Sequence (FADS) is a rare, in most cases autosomal recessive, disorder. Its heterogeneous origin results in variable onset and expression of motor and postural anomalies. DNA-diagnostic possibilities are limited, thus prenatal diagnosis is chiefly dependent on sonographic examinations.

AIM

To explore postural and motor development from a systematic sonographic protocol for fetuses at high risk for FADS. Specific questions are: which motor (i.e., specific movement patterns, quality and quantity of general movements) and postural aspects are most informative about emerging FADS and is the gestational age of onset range of FADS more limited for siblings?

METHODS

Ten families underwent 45, 15-minute sonographic assessments for motility and posture for ten index fetuses with FADS and nine subsequent pregnancies from five families.

RESULTS

FADS was diagnosed between 18 and 33 weeks gestation in ten index pregnancies and between 11 and 18 weeks gestation in 4/9 subsequent pregnancies, 1-12 weeks earlier than their index pregnancies. From the four assessment aspects, posture and movement quality were always abnormal, movement quantity in 7/14 and differentiation into specific movement patterns were reduced in comparison with healthy siblings (p<0.01). Deterioration occurred in a 2 week period.

CONCLUSIONS

Serial postural and qualitative assessments were most informative diagnosing FADS. Quantity and differentiation into specific movement patterns contributed substantially. Onset range of FADS within siblings was suggested to be more limited than between families.

The current state and future of fetal imaging

Fetal magnetic resonance imaging (MRI) may add important diagnostic information to prenatal sonography and has the power to confirm or change decisions at critical points in clinical care. Recent studies have shown MRI to be a critical clinical adjunct in the evaluation of the developing central nervous system (CNS), especially at early gestational ages, and MRI has been used in three significant ways: (1) for the quantification of brain growth and structural abnormalities using biometry, (2) for the qualitative evaluation of CNS microstructure, and (3) for the qualitative assessment of dynamic fetal movements in utero.

The assessment of fetal neurobehavior by three-dimensional and four-dimensional ultrasound

The development of three-dimensional (3D) and four-dimensional ultrasound (4D) has provided new opportunities to study fetal and even embryonic behavior. These techniques enable simultaneous spatial imaging of the entire fetus and its movements. Recently, multicenter studies of fetal brain function have been carried out, the aim of which is to establish the standards of embryonic and fetal peripheral and body movements and facial expression as additional diagnostic criteria for prenatal brain development. Additional studies have been conducted in order to provide more information on specific movement patterns and quality of movement in the high-risk fetus. The purpose of this paper is to review and analyze the published literature on the use of 3D and 4D ultrasound in the assessment of fetal behavior.

Neonatal hypertonia: I. Classification and structural-functional correlates

Neonatal hypertonic states can be encountered as expressions of abnormal tone and posture. It would be useful for the neonatal neurointensivist to more precisely describe the various presentations of neonatal hypertonia, taking into consideration a classification scheme adopted for hypertonia in children at older ages. An understanding of the ontogeny of muscle tone and posture during fetal and postnatal preterm time periods with maturation to full-term ages will help conceptualize the developmental structural-functional correlates that subserve the evolving expression of this abnormal clinical sign. In the future, a more accurate description of neonatal hypertonic states should be part of the complete clinical examination to help integrate etiology, timing of injury, and neurologic localization before choosing the appropriate therapeutic intervention.

An Attempt to Introduce Neurological Test for Fetus Based on 3D and 4D Sonography

Fetal neurology is a new challenging field. Brain damage often originates in fetal life. Early identification of this damage has implications for perinatal management; moreover documentation of such lesions is essential in case of litigation. In the last two decades, fetal imaging with 2-dimensional ultrasounds and conventional magnetic resonance imaging have made a major contribution in the identification of classic brain lesions and malformations. However, it is only recently with diffusion weight imaging that the whole spectrum of perinatal white matter injuries has been described in the neonate. The recent advances of 3DUS and 4DUS in exploring fetal motor behavior should support a better clinical description of the full spectrum of fetal damage. New neurological test (KANET) of the fetus recently suggested by us (Kurjak et al 2008) might be helpful in the assessment of fetal neurobehavior.

Early sonographic prenatal diagnosis of seizures

Fetal seizures are an unusual phenomenon. When diagnosed by ultrasonography, they are frequently associated with malformations and carry a poor prognosis. We describe first trimester seizures in two siblings with arthrogryposis multiplex congenita. In both cases, convulsions appeared before other sonographic signs of the disease. Review of the literature revealed 11 other cases of fetal seizures diagnosed by ultrasound, all later in gestation. Fetal seizures may be the first manifestation of defective neural and motor development. Therefore, in pregnancies at high risk for neuromuscular disease, early sonographic evaluation of fetal motility, in addition to the anatomical survey, is advised.