The effect of intrauterine growth retardation on the quality of general movements in the human fetus

Spontaneous movements as prognostic tool of neurodevelopmental outcomes in preterm infants: a narrative review

An estimated 15 million infants are born prematurely each year. Although the survival rate of preterm infants has increased with advances in perinatal and neonatal care, many still experience various complications. Since improving the neurodevelopmental outcomes of preterm births is a crucial topic, accurate evaluations should be performed to detect infants at high risk of cerebral palsy. General movements are spontaneous movements involving the whole body as the expression of neural activity and can be an excellent biomarker of neural dysfunction caused by brain impairment in preterm infants. The predictive value of general movements with respect to cerebral palsy increases with continuous observation. Automated approaches to examining general movements based on machine learning can help overcome the limited utilization of assessment tools owing to their qualitative or semiquantitative nature and high dependence on assessor skills and experience. This review covers each of these topics by summarizing normal and abnormal general movements as well as recent advances in automatic approaches based on infantile spontaneous movements.

A markerless pipeline to analyze spontaneous movements of preterm infants

BACKGROUND AND OBJECTIVE

The analysis of spontaneous movements of preterm infants is important because anomalous motion patterns can be a sign of neurological disorders caused by lesions in the developing brain. A diagnosis in the first weeks of child's life is crucial to plan timely and appropriate rehabilitative interventions. An accurate visual assessment of infants' spontaneous movements requires highly specialized personnel, not always available, and it is operator dependent. Motion capture systems, markers and wearable sensors are commonly used for human motion analysis, but they can be cumbersome, limiting their use in the study of infants' movements.

METHODS

In this paper we propose a computer-aided pipeline to characterize and classify infants' motion from 2D video recordings. The final goal is detecting anomalous motion patterns. The implemented pipeline is based on computer vision and machine learning algorithms and includes a specific step to increase the interpretability of the results. Specifically, it can be summarized by the following steps: (i) body keypoints detection: we rely on a deep learning-based semantic features detector to localize the positions of meaningful landmark points on infants' bodies; (ii) parameters extraction: starting from the trajectories of the detected landmark points, we extract quantitative parameters describing infants motion patterns; (iii) classification: we implement different classifiers (Support Vector Machines, Random Forest, fully connected Neural Network, Long Short Term Memory) that, starting from the motion parameters, classify between normal or abnormal motion patterns.

RESULTS

We tested the proposed pipeline on a dataset, recorded at the 40th gestational week, of 142 infants, 59 with evidence of neuromotor disorders according to a medical assessment carried out a posteriori. Our procedure successfully discriminates normal and anomalous motion patterns with a maximum accuracy of 85.7%.

CONCLUSIONS

In conclusion, our pipeline has the potential to be adopted as a tool to support the early detection of abnormal motion patterns in preterm infants.

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.

Fetal akinesia deformation sequence and massive perivillous fibrin deposition resulting in fetal death in six fetuses from one consanguineous couple, including literature review

Background

Massive perivillous fibrin deposition (MPFD) is associated with adverse pregnancy outcomes and is mainly caused by maternal factors with limited involvement of fetal or genetic causes. We present one consanguineous couple with six fetuses developing Fetal Akinesia Deformation Sequence (FADS) and MPFD, with a possible underlying genetic cause. This prompted a literature review on prevalence of FADS and MPFD.

Methods

Fetal ultrasound examination, motor assessment, genetic testing, postmortem examination, and placenta histology are presented (2009–2019). Literature was reviewed for the association between congenital anomalies and MPFD.

Results

All six fetuses developed normally during the first trimester. Thereafter, growth restriction, persistent flexed position, abnormal motility, and contractures in 4/6, consistent with FADS occurred. All placentas showed histologically confirmed MPFD. Genetic analyses in the five available cases showed homozygosity for two variants of unknown significance in two genes, VARS1 (OMIM*192150) and ABCF1 (OMIM*603429). Both parents are heterozygous for these variants. From 63/1999 manuscripts, 403 fetal outcomes were mobilized. In 14/403 fetuses, congenital abnormalities in association with MPFD were seen of which two fetuses with contractures/FADS facial anomalies.

Conclusion

The low prevalence of fetal contractures/FADS facial anomalies in association with MPFD in the literature review supports the possible fetal or genetic contribution causing FADS and MPFD in our family. This study with literature review supports the finding that fetal, fetoplacental, and/or genetic components may play a role in causing a part of MPFDs.

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.

A Novel Fetal Movement Simulator for the Performance Evaluation of Vibration Sensors for Wearable Fetal Movement Monitors

Fetal movements (FM) are an important factor in the assessment of fetal health. However, there is currently no reliable way to monitor FM outside clinical environs. While extensive research has been carried out using accelerometer-based systems to monitor FM, the desired accuracy of detection is yet to be achieved. A major challenge has been the difficulty of testing and calibrating sensors at the pre-clinical stage. Little is known about fetal movement features, and clinical trials involving pregnant women can be expensive and ethically stringent. To address these issues, we introduce a novel FM simulator, which can be used to test responses of sensor arrays in a laboratory environment. The design uses a silicon-based membrane with material properties similar to that of a gravid abdomen to mimic the vibrations due to fetal kicks. The simulator incorporates mechanisms to pre-stretch the membrane and to produce kicks similar to that of a fetus. As a case study, we present results from a comparative study of an acoustic sensor, an accelerometer, and a piezoelectric diaphragm as candidate vibration sensors for a wearable FM monitor. We find that the acoustic sensor and the piezoelectric diaphragm are better equipped than the accelerometer to determine durations, intensities, and locations of kicks, as they have a significantly greater response to changes in these conditions than the accelerometer. Additionally, we demonstrate that the acoustic sensor and the piezoelectric diaphragm can detect weaker fetal movements (threshold wall displacements are less than 0.5 mm) compared to the accelerometer (threshold wall displacement is 1.5 mm) with a trade-off of higher power signal artefacts. Finally, we find that the piezoelectric diaphragm produces better signal-to-noise ratios compared to the other two sensors in most of the cases, making it a promising new candidate sensor for wearable FM monitors. We believe that the FM simulator represents a key development towards enabling the eventual translation of wearable FM monitoring garments.

AI Approaches Towards Prechtl's Assessment of General Movements: A Systematic Literature Review

General movements (GMs) are spontaneous movements of infants up to five months post-term involving the whole body varying in sequence, speed, and amplitude. The assessment of GMs has shown its importance for identifying infants at risk for neuromotor deficits, especially for the detection of cerebral palsy. As the assessment is based on videos of the infant that are rated by trained professionals, the method is time-consuming and expensive. Therefore, approaches based on Artificial Intelligence have gained significantly increased attention in the last years. In this article, we systematically analyze and discuss the main design features of all existing technological approaches seeking to transfer the Prechtl's assessment of general movements from an individual visual perception to computer-based analysis. After identifying their shared shortcomings, we explain the methodological reasons for their limited practical performance and classification rates. As a conclusion of our literature study, we conceptually propose a methodological solution to the defined problem based on the groundbreaking innovation in the area of Deep Learning.

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.

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.

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 response to maternal hunger and satiation - novel finding from a qualitative descriptive study of maternal perception of fetal movements

Background

Maternal perception of decreased fetal movements is a specific indicator of fetal compromise, notably in the context of poor fetal growth. There is currently no agreed numerical definition of decreased fetal movements, with the subjective perception of a decrease on the part of the mother being the most significant definition clinically. Both qualitative and quantitative aspects of fetal activity may be important in identifying the compromised fetus. Yet, how pregnant women perceive and describe fetal activity is under-investigated by qualitative means. The aim of this study was to explore normal fetal activity, through first-hand descriptive accounts by pregnant women.

Methods

Using qualitative descriptive methodology, interviews were conducted with 19 low-risk women experiencing their first pregnancy, at two timepoints in their third trimester. Interview transcripts were later analysed using qualitative content analysis and patterns of fetal activity identified were then considered along-side the characteristics of the women and their birth outcomes.

Results

This paper focuses on a novel finding; the description by pregnant women of fetal behaviour indicative of hunger and satiation. Full findings will be presented in later papers. Most participants (74% 14 of 19) indicated mealtimes were a time of increased fetal activity. Eight participants provided detailed descriptions of increased activity around meals, with seven (37% 7 of 19) of these specifying increased fetal activity prior to meals or in the context of their own hunger. These movements were interpreted as a fetal demand for food often prompting the mother to eat. Interestingly, the women who described increased fetal activity in the context of hunger subsequently gave birth to smaller infants (mean difference 364 gm) than those who did not describe a fetal response to hunger.

Conclusions

Food seeking behaviour may have a pre-birth origin. Maternal-fetal interaction around mealtimes could constitute an endocrine mediated communication, in the interests of maintaining optimal intrauterine conditions. Further research is warranted to explore this phenomenon and the potential influence of feeding on the temporal organisation of fetal activity in relation to growth.

General movements in healthy full term infants during the first week after birth

BACKGROUND

The quality of general movements (GMs) is a widely used criterion to assess neurological dysfunction in young infants. It is unknown, however, whether the birth process influences the motor repertoire of healthy full term infants during the first week after birth.

AIMS

To assess the quality of GMs and to determine the motor optimality score (OS) in healthy full term infants during the first week after birth and to evaluate the influence of the mode of delivery on GM quality.

STUDY DESIGN

Thirty-three healthy full term infants born either vaginally or after caesarean section (CS) under spinal anaesthesia were video recorded in the first week after birth in order to assess GM quality and to determine OS with Prechtl's method.

RESULTS

Abnormal GMs were observed mainly on the early recordings: 86% on the day of birth (day 0), 94% on day 1, and 68% on day 2. On days 5 to 7 (day 5-7) all GMs were normal (P<.001). The OSs increased significantly from median 12 on day 0 to 18 on day 5-7 (P<.001). Monotonously slow movements were frequently seen during the first days but not on day 5-7 (P<.001). GM quality and OS did not differ between infants born by vaginal delivery or after CS under spinal anaesthesia.

CONCLUSIONS

Healthy full term infants often showed abnormal GM quality and lower OSs during the first week after birth, irrespective of the mode of delivery. GM quality normalised during subsequent days and was normal on day 5-7.

Placental pathology in pregnancies with maternally perceived decreased fetal movement--a population-based nested case-cohort study

Background

Decreased fetal movements (DFM) are associated with fetal growth restriction and stillbirth, presumably linked through an underlying placental dysfunction. Yet, the role of placental pathology has received limited attention in DFM studies. Our main objective was to explore whether maternal perceptions of DFM were associated with placental pathology in pregnancies recruited from a low-risk total population.

Methods/Principal Findings

Placentas from 129 DFM and 191 non-DFM pregnancies were examined according to standardized macro- and microscopic protocols. DFM was defined as any maternal complaint of DFM leading to a hospital examination. Morphological findings were timed and graded according to their estimated onset and clinical importance, and classified in line with a newly constructed Norwegian classification system for reporting placental pathology. With our population-based approach we were unable to link DFM to an overall measure of all forms of placental pathology (OR 1.3, 95% CI 0.8–2.2, p = 0.249). However, placental pathology leading to imminent delivery could be a competing risk for DFM, making separate subgroup analyses more appropriate. Our study suggests a link between DFM and macroscopic placental pathology related to maternal, uteroplacental vessels, i.e. infarctions, placental lesions (intraplacental hematomas) and abruptions. Although not statistically significant separately, a compound measure showed a significant association with DFM (OR 2.4, 95%CI 1.1–5.0, p = 0.023). This association was strengthened when we accounted for relevant temporal aspects. More subtle microscopic materno-placental ischemic changes outside the areas of localized pathology showed no association with DFM (OR 0.5, 95%CI 0.2–1.4, p = 0.203). There was a strong association between placental pathology and neonatal complications (OR 2.9, 95% CI 1.6–5.1, p<0.001).

Conclusions

In our population-based study we were generally unable to link maternally perceived DFM to placental pathology. Some associations were seen for subgroups.

Intrauterine growth restriction and cerebral palsy

Intrauterine growth restriction (IUGR) can be described as condition in which fetus fails to reach his potential growth. It is common diagnosis in obstetrics, and carries an increased risk of perinatal mortality and morbidity. Moreover, IUGR has lifelong implications on health, especially on neurological outcome. There is a need for additional neurological assessment during monitoring of fetal well-being, in order to better predict antenatally which fetuses are at risk for adverse neurological outcome. Studies have revealed that the behavior of the fetus reflects the maturational processes of the central nervous system (CNS). Hence, ultrasound investigation of the fetal behavior can give us insight into the integrity and functioning of the fetal CNS. Furthermore, investigations carried out using modern method, four-dimensional (4D) sonography, have produced invaluable details of fetal behavior and its development, opening the door to a better understanding of the prenatal functional development of the CNS. Based on previous observations and several years of investigation, our reaserch group has proposed a new scoring system for the assessment of fetal neurological status by 4D sonography named Kurjak antenatal neurodevelopmental test (KANET). The value of KANET in distinguishing fetal brain and neurodevelopmental alterations due to the early brain impairment in utero is yet to be assessed in large population studies. However, preliminary results are very encouraging.

Optimization and initial experience of a multisection balanced steady-state free precession cine sequence for the assessment of fetal behavior in utero

BACKGROUND AND PURPOSE

The assessment of motor function is an essential component of neurologic examinations, which imaging studies have extended to the fetus. US assessment is hampered by a limited FOV, whereas MR imaging has the potential to be an alternative. Our objectives were to optimize a cine MR imaging sequence for capturing fetal movements and to perform a pilot analysis of the relationship between the frequency of movements and uterine spatial constrictions in healthy fetuses.

MATERIALS AND METHODS

Initially, a bSSFP cine sequence was selected for optimization, and various compromises were explored in all acquisition parameters to achieve an effective balance between anatomic coverage of the fetus and the temporal resolution of cine data, with the aim of maximizing both. Subsequently, cross-sectional qualitative and quantitative analyses of fetal movements were performed prospectively by using a cohort of 37 healthy fetuses (median GA, 29 weeks; range, 20-37 weeks) with the optimized cine protocol. Two smaller subgroups were selected for representative sampling of overall behavior patterns by using cine data of longer duration and for volumetric quantification of free intrauterine space.

RESULTS

The optimized cine sequence, with TR/TE of 3.21/1.59 ms, coupled with parallel imaging and partial-Fourier imaging, resulted in a section-acquisition time of 0.303 seconds. Anatomic coverage was enhanced by using a combination of thick sagittal sections (30-40 mm) and multisection acquisitions to display movements in all fetal limbs, head, and trunk simultaneously. All expected motor patterns were observed throughout this gestational period, and a significant decreasing trend in overall movement frequency with age was demonstrated (r = -0.514, P = .0011). Also a significant negative correlation was found between overall movement frequency and the total intrauterine free space (r = -0.703, P = .0001). Furthermore, a significant decrease in the frequency of leg movements was shown in fetuses older then 30 weeks' GA compared with those younger than that (P = .015).

CONCLUSIONS

Cine MR imaging is effective for observing fetal movements from midgestation with near full-body coverage. Also, reductions in free space with increasing GA appear to be a factor in the gradual reductions in overall levels of fetal activity as well as in restrictions in movement within specific regions of the fetal anatomy.

Fetal general movements and brain sonography in a population at risk for preterm birth

BACKGROUND

General movements (GMs) assessed three months post term are related to brain injury and neurological outcome.

AIMS

To study GMs in fetuses and their predictive value for echogenicity changes in the fetal brain.

STUDY DESIGN

Prospective study of fetal GMs (classified as normal or abnormal) and echogenicity changes in the periventricular, basal ganglia/thalami area, and ventricular system (classified as absent, mild or moderate).

SUBJECTS

121 fetuses from pregnancies affected by hypertensive disorders and/or preterm labour, at risk for preterm birth (26-34weeks gestational age).

OUTCOME MEASURES

Prevalence of abnormal GMs, GM parameters (amplitude, speed and complexity), and moderate echogenicity changes in the fetal brain (periventricular >or=IB, intraventricular grade II/III, and basal ganglia/thalamus locally increased). Predictive values of GMs for clinical parameters and moderate echogenicity changes.

RESULTS

GMs were abnormal in 58%, with amplitude affected in 96%, and speed and complexity in 59%. Abnormal GMs correlated with oligohydramnios (p=0.002) and hypertensive disorders (p=0.015). Echogenicity changes of the brain were absent, mild and moderate in 27%, 39% and 31%, respectively. The sensitivity of GMs for moderate echogenicity changes in the three areas combined was 0.65, and the periventricular area 0.85, specificity both 0.44, negative predictive values 0.73 and 0.96 respectively.

CONCLUSIONS

Qualitative abnormal GMs are frequent in fetuses of compromised pregnancies, and correlate with hypertensive disorders and oligohydramnios. The amplitude of GMs was most frequently affected. Abnormal GMs relate to moderate echogenicity changes especially in the periventricular area of the fetal brain, while normal GMs predict absence of moderate echogenicity changes.

General movements in the perinatal period and its relation to echogenicity changes in the brain

BACKGROUND

In preterm born infants abnormal general movements (GMs) generally normalize before three months post term, but may persist when perinatal brain injury is present.

AIMS

To assess the continuity of GM quality from fetal to early neonatal period and its relation to brain echogenicity changes.

STUDY DESIGN

Prospective study examining GMs and three vulnerable brain areas before and 7days after birth. The quality of GMs was classified as normal or abnormal by Gestalt-perception. The brain was examined for moderate echogenicity changes (periventricular: brighter than choroid plexus, intraventricular: filling equal or more than 50% of the ventricle, and locally increased basal ganglia/thalami).

SUBJECTS

94 fetuses from pregnancies complicated by preterm hypertensive disorders or labour at a gestational age between 26 and 34weeks.

OUTCOMES MEASURES

Correlations of fetal GMs, echogenicity changes, and clinical parameters (e.g. gestational age, parity, hypertensive disorders or preterm labour, oligohydramnios and fetal growth restriction) with neonatal GMs.

RESULTS

Fetal GMs were abnormal in 64%, normalizing in 68% within 7days after birth. Fetal GMs were significantly related to postnatal GMs (p=0.045). Moderate fetal brain echogenicity changes and clinical parameters were not significantly related to neonatal GM.

CONCLUSIONS

In this population of pregnancies compromised by hypertensive disorders or preterm labour fetal GMs correlated with neonatal GMs. Presence of moderate echogenicity changes in the fetal brain was not related to neonatal GMs.

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.

General movements in infants born from mothers with early-onset hypertensive disorders of pregnancy in relation to one year's neurodevelopmental outcome

BACKGROUND

Assessment of general movements (GMs) at three months is considered useful for prediction of adverse neurological outcome in high risk infants.

AIMS

To study the prevalence of abnormal GMs in infants born from women with early-onset hypertensive disorders of pregnancy and the association of GMs with neurodevelopmental outcome at one year.

STUDY DESIGN

Prospective study, part of a randomised controlled trial of pre-birth management strategies.

SUBJECTS

Infants born from women with early-onset hypertensive disorders of pregnancy.

OUTCOME MEASURES

GMs observation and neurological examination at term and three months corrected age; at one year neurological examination and Bayley Scales of Infant Development.

RESULTS

From 216 women included, 175 of 178 surviving infants (mean gestational age 31.6 weeks [SD 2.3], mean birth weight 1346 grams [SD 458]), were examined at three months. At term age normal, mildly abnormal and definitely abnormal GMs were observed in 54%, 36% and 10% respectively; and at three months in 47%, 40% and 13%. Mildly or definitely abnormal GMs at three months were not associated with abnormal neurological examination at one year, however, they were associated with delayed psychomotor development at one year (p = 0.01).

CONCLUSIONS

In this prospective study, including small for gestational age, preterm infants about half of them did not have normal GMs at term and three months. There was no association of GMs at term nor three months with neurological outcome at one year, but there was a significant association of GMs at three months with one year psychomotor development.

Management of decreased fetal movements

Maternal perception of decreased fetal activity is a common complaint, and one of the most frequent causes of unplanned visits in pregnancy. No proposed definitions of decreased fetal movements have ever been proven to be superior to a subjective maternal perception in terms of identifying a population at risk. Women presenting with decreased fetal movements do have higher risk of stillbirth, fetal growth restriction, fetal distress, preterm birth, and other associated outcomes. Yet, little research has been conducted to identify optimal management, and no randomized controlled trials have been performed. The strong associations with adverse outcome suggest that adequate management should include the exclusion of both acute and chronic conditions associated with decreased fetal movements. We propose guidelines for management of decreased fetal movements that include both a nonstress test and an ultrasound scan and report findings in 3014 cases of decreased fetal movements.

Fetal onset of general movements

Perinatal qualitative assessment of general movements (GMs) is a tool to evaluate the integrity of the young nervous system. The aim of this investigation was to study the emergence of GMs. Fetal onset of GMs was studied sonographically in 18 fetuses during the first trimester of uncomplicated in vitro fertilization (IVF) pregnancies in weekly assessments. The earliest motility consisting of small and simple sideways bending (SB) of head and/or rump starts at 7 wk, lasting about 1 s. Between 7 and 8.5 wk, motility differentiates further into movements in which also one or two arms or legs become active; movements are still slow, small, and in one direction, but the duration increases to a few seconds. The transition into GMs at 9-10 wk is characterized by variation in participating body parts and amplitude, speed, and direction during longer periods of time. Between 9 and 13 wk, simple and stereotyped SBs and GMs may coexist. At 9 wk, the incidence of SBs decreases (p = 0.01) and that of GMs increases (p = 0.006). The data suggest that initial simple fetal motility is generated by spinal and brainstem circuitries, and the emergence of complex and variable GMs denotes the onset of supraspinal modulation of this spinal and brainstem activity.

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

After 35 years of real-time two-dimensional sonography, can we now identify changes in fetal motility indicative of malfunction of the central nervous system in high-risk pregnancies? A literature search on motor assessment procedures (movements specified for body part (SMP), quantity, quality and behavioral state), and motor milestones obtained per fetus (with various congenital disorders) yielded 48 articles describing motility of 104 fetuses. In 67%, SMPs (especially isolated arm or leg movements, breathing and general movements) were assessed. Quantitative aspects were examined in 76%, qualitative aspects in 62% and behavioral states in two fetuses. Abnormal motility can be divided into two main subcategories: hypo- and hyperkinetic, demonstrating decreased variation in qualitative performance (reduced or increased, respectively, amplitude, speed and number of participating body parts, abnormal quantity (reduced or increased, respectively) and reduced differentiation into SMPs. Posture was affected in 40/60 hypokinetic and 4/44 hyperkinetic moving fetuses. The majority of the disorders resulted in an adverse outcome. Fourteen percent survived with a handicap, depending on the underlying disorder. The 16 disorders with hypokinetic motility had mainly an autosomal recessive etiology with no possibility of invasive prenatal diagnosis or conclusive sonographic structural anomalies, in contrast to the 17 disorders with hyperkinetic motility. Within the limitations of the studies, a deeper understanding of affected milestones in motor development can be obtained. Broadening motor assessment procedures from quantitative only to include qualitative aspects, differentiation of SMPs and behavioral states and emphasizing onset and continuity of motility before and after birth will enhance the reliability and predictive value of motility as a parameter in the assessment of fetal condition.

The assessment of fetal behavior of growth restricted fetuses by 4D sonography

AIM

To find out whether the quantity of fetal facial expression and quality of body movements can be used as an additional diagnostic criterion for prenatal brain impairment in fetuses with growth restriction.

SUBJECT AND METHODS

A prospective study was conducted in 50 uncomplicated healthy women as control group with reliably dated pregnancies and 50 pregnant women with a growth restricted fetus as study group in the third trimester of pregnancy. 4D ultrasound observation is specially designed to assess whether functional brain impairment and fetal growth restriction had prenatally occurred by the utilization of several behavioral patterns.

RESULTS

The median value of all movement patterns in the normal fetuses differed from fetuses with intrauterine growth restriction (IUGR). Statistical evaluation revealed significant differences in the distribution of the movements between these groups (P<0.05). We noted a tendency that IUGR fetuses have less behavioral activity than normal fetuses in all observed movement patterns. Correlation reached statistical significance between normal and IUGR fetuses in the third trimester in hand to head, hand to face and head retroflexion. Statistically significant differences could be shown in the distribution of the median values of observation over the five qualitative categories of head and hand movements (P<0.05).

CONCLUSIONS

Recent data on IUGR fetuses obtained by 4D sonography are stimulating and might result in a more effective strategy to assess development before birth. The results of this study may encourage future use of 4D ultrasound for quantitative and qualitative assessment of fetal behavior as possible indicators of the neurological condition in IUGR fetuses.

Evidence of early development of action planning in the human foetus: a kinematic study

The aim of the present study was to investigate whether foetal hand movements are planned and how they are executed. We performed a kinematic analysis of hand movements directed towards the mouth and the eyes in the foetuses of eight women with normally evolving pregnancies. At 14, 18 and 22 weeks of gestation, eight foetuses underwent a 20-min four-dimensional-ultrasound session. The video recordings for these movements were then imported into in-house software developed to perform kinematic analysis. We found that spatial and temporal characteristics of foetal movements are by no means uncoordinated or unpatterned. By 22 weeks of gestation the movements seem to show the recognizable form of intentional actions, with kinematic patterns that depend on the goal of the action, suggesting a surprisingly advanced level of motor planning.

Normal fetal motility: an overview

After 35 years of real-time two-dimensional sonography, and now that 4D sonography is within our grasp, this article presents an overview of present-day knowledge of normal fetal motility. A literature search was carried out on articles from 1970, using the keywords: 'fetal', 'movements', 'motility', 'movement patterns', 'ultrasound' and 'sonography'. Inclusion criteria were human studies and use of real-time sonography. Articles were screened for type of motor assessment procedure, in terms of whether they: specified movements for participating body parts (specific movement pattern, SMP), were qualitative (performance in terms of speed and amplitude), were quantitative, identified behavioral states, stated the duration of observation, and specified gestational age. We noted developmental milestones obtained for each study aim. One of four aims was identified for each article, depending on whether it focused on emergence, development, or continuity after birth of the movement patterns, or on the relationship of various motor aspects to other parameters that evaluate fetal condition, such as blood flow and fetal heart rate. A total of 109 relevant articles was identified, examining 9862 fetuses. Assessment was performed primarily with analysis of SMPs (89%); 52% also included non-SMPs (NSMPs), 78% included quantification, 24% assessment of quality, and 32% behavioral states. The duration of observation was 1 h or longer in 50% of the studies. The focus in 28 studies was on emergence, in 44 it was on development, in five it was on continuity and in 32 it was on relationship of the movements with other parameters of fetal well-being. A few milestones identified were determination of the strictly age-related emergence of SMPs and behavioral states, the highly reproducible quality of SMPs throughout gestation, the age-related trends in quantified SMPs, the continuity in quality and quantity after birth, and the close relationship between motility and heart-rate variability, flow parameters, and behavioral states. Periods of longest inactivity recorded before 20 weeks were 13 min; after 30 weeks they were 45 min. Much insight was obtained into the development of motility and its relationship to other parameters from those articles applying comparable assessment procedures. An assessment procedure with well-defined SMPs, qualitative and quantitative aspects of SMPs and NSMPs, and an observation period dependent on age are advocated for future research.

Movement analysis in neonates with spina bifida aperta

INTRODUCTION

In neonates with spina bifida aperta (SBA), leg movements by myotomes caudal to the meningomyelocele (MMC) are transiently observed. It is unclear whether these leg movements relate to functional neural conduction through the MMC. For optimal therapeutical intervention, pathophysiological insight in these transient leg movements seems relevant. If leg movements by myotomes caudal to the MMC concur with the execution of general movements (GMs), functional neural conduction through the MMC is implicated.

OBJECTIVE

In neonates with SBA, we aimed to determine whether the transiently present leg movements caudal to the MMC indicate functional neural conduction through the MMC.

METHODS

During the perinatal period, fetuses and neonates with SBA (n = 7 and n = 13, respectively) were longitudinally analysed for concurrency between leg movements caudal to the MMC and GMs. To address the integrity of the reflex arc in spinal segments (at, or) caudal to the MMC, tendon leg reflexes were assessed during the first postnatal week.

RESULTS

At postnatal day 1, leg movements caudal to the MMC concurred with GMs in 12 of 13 infants. Isolated leg movements were observed in only 3 of these 12 infants (isolated vs. concurrent; p < 0.005). Leg movements concurring with GMs lasted longer than isolated leg movements (median duration = 11 s vs. 2 s; p < 0.05). Between days 1 and 7, tendon leg reflexes (at, or) caudal to the MMC had disappeared in all but 1 neonate. However, leg movements caudal to the MMC remained concurrently present with GMs in all five neonates available for follow-up after day 7. Comparing these leg movements between days 1 and 7 indicated a decreased duration (-44%, p < 0.05).

CONCLUSIONS

In neonates with SBA, leg movements caudal to the MMC concur with GMs, indicative of functional neural conduction through the MMC. The disappearance of these leg movements is caused by lower motor neuron dysfunction at the reflex arc, whereas neural conduction through the MMC is still functional.

Movement analysis in the early detection of newborns at risk for developing spasticity due to infantile cerebral palsy

In order to limit the consequences of infantile cerebral palsy (ICP), physiotherapy should start as early as possible. This requires that infants at risk are detected at the earliest age possible. Today, diagnosis is based on visual observation by physicians and as such is influenced by subjective impressions. Objective methods, quantifying the pathological deviation from normal spontaneous motor activity would be preferable as they, for example, allow an inter- and intra-individual comparison of movement. In this paper we have developed a methodology that allows the 3-dimensional acquisition of unconstrained movement in newborn babies, using a motion analysis system. From the recorded movement data we have extracted 53 quantitative parameters that describe the differences between healthy and affected participants. Considered individually, each of these parameters does not permit a conclusive statement to be made as to whether or not the patient is at risk. Cluster analysis based on Euclidian distances therefore has been used to find an optimal combination of eight parameters. The optimal combination has been subsequently applied to organize the participants' movement into preferably homogeneous classes labelled "healthy" or "at risk". Classification was performed utilising quadratic discriminant analysis. The methodology presented allows a reliable discrimination between healthy and affected participants. Overall detection rate reached 73%. This value is expected to rise with increasing patient and norm collective database size.

Neonatal general movements: an early predictor for neurodevelopmental outcome in infants with intrauterine growth retardation

Intrauterine growth retardation plays a significant role in neurodevelopmental outcome. The assessment of general movements during the first 20 weeks is a new method for early detection of brain dysfunction. General movements in 31 infants with asymmetric intrauterine growth retardation and their appropriate for gestational age-matched controls were examined. General movements were scored as normal or abnormal by sequential videotape recordings in the writhing (term to 2 weeks), early fidgety (9-11 weeks), and late fidgety (14-16 weeks) periods. Scores were compared between the groups and correlated with neurodevelopmental outcome at 2 years. The incidence of normal general movements was lower in the intrauterine growth retarded infants than in the controls (P < .001). Significant correlations were found between general movement quality and neurodevelopmental scores in the intrauterine growth retarded group. The fidgety movements were the most sensitive and specific for prediction of neurologic outcome. The general movement assessment can, therefore, serve as an additional tool for examining the neurologic status of the preterm and term intrauterine growth retarded infant.

Role of motility in embryonic development I: Embryo movements and amnion contractions in the chick and the influence of illumination

This study provides a quantitative analysis of the active movements of the chick embryo and of the contractions of the amnion over the entire developmental period of 21 days. Four types of embryo movements are distinguished. The motor activity of the embryo shows two characteristic peaks, with maximum contraction frequencies on the 12th and on the 16th day. In contrast, the amnion activity is higher at earlier stages and decreases as the body activity increases. The amnion activity is largely independent of the body activity. Illumination has a strong influence on embryo movements. It is shown that increases of light intensity affect the patterns of activity of both the embryo and the amnion. While the effect of light on the embryo can be interpreted as being transmitted via the optic system, the mechanism of the amniotic response is unclear. The results suggest that the amnion itself may be sensitive to light. J. Exp. Zool. (Mol. Dev. Evol.) 291:186-194, 2001.

Human fetal and neonatal movement patterns: Gender differences and fetal-to-neonatal continuity

Longitudinal quantification of leg movements per minute for human subjects during both fetal and neonatal periods was accomplished from videotapings conducted antenatally (ultrasonography 30, 34, and 37 weeks gestational age) and postnatally (birth and 6 weeks of age). Fetal/neonatal subjects displayed decreasing numbers of leg movements per minute during antenatal development (30 to 37 weeks), followed by increasing numbers of leg movements per minute during postnatal development (birth to 6 weeks of age). Male subjects displayed greater numbers of leg movements per minute than female subjects during both antenatal and postnatal development. Fetal-to-neonatal continuity for numbers of leg movements per minute was found for comparisons between fetal (37 weeks gestational age) and neonatal (during sleep states at birth) measures, and females displayed a stronger and different movement continuity pattern than males. These results indicate a differential time course for neurobehavioral development of male and female fetuses/neonates, and the findings have implications for the clinical assessment of fetal neurobehavioral development and well-being.

Implications of a neural network model of early sensori-motor development for the field of developmental neurology

This paper reports on a neural network model for early sensori-motor development and on the possible implications of this research for our understanding and, eventually, treatment of motor disorders like cerebral palsy. We recapitulate the results we published in detail in a series of papers [1-4]. The neural circuits in the model self-organize on the basis of rhythmic activity spontaneously generated in the model. This indicates the importance of endogenously generated activity in the developing brain. We also show that afferent feed-back from the mechanical part of the model is easily incorporated in the neural part of the model. In this way the model acquires reflex-related properties which have long been demonstrated in man. In the discussion we relate these experimental findings to the variability concept from developmental neurology and show how variable motor performance is important for motor learning. We also discuss possible implications of our modelling effort for movement disorders, specifically spastic cerebral palsy.

Computer-assisted analysis of fetal movements in intrauterine growth retardation (IUGR)

A quantitative analysis of various fetal activities (mouth, eye and gross body movements) was made in 10 IUGR human fetuses. The aim of the study was to see whether IUGR fetuses move differently to normal fetuses. Each real-time ultrasound recording lasted 1 h and the analysis of various activities was carried out during replay of video recordings by means of a specially designed computer program. The following aspects have been investigated: (1) incidence, duration and interval for each of the fetal activities described; (2) the relationship between incidence, duration and interval for each single activity; (3) the correlations between the different activities. The results were compared with a group of 10 fetuses from normal pregnancies. On quantitative evaluation no clear effects due to uncomplicated IUGR could be detected except for median duration of eye movements, which turned out to be longer in the IUGR group. The evaluation of correlations between the characteristics (incidence, duration and interval) of each activity showed a positive correlation between incidence and duration of mouthing movements in the IUGR group, not found in the normal group. The study of the correlation between different fetal activities has shown an inverse correlation between mouthing and other activities in the normal fetuses, not found in the IUGR group. We conclude that in mildly affected fetuses with no evidence of hypoxia, there are no quantitative differences compared to normal fetuses in terms of the motility studied. The only differences found were in relation to the performance of such activities and they could reflect a dysfunction of the central nervous system resulting from a metabolic disturbance.

Is neurological assessment of the fetus possible?

The possibility to assess the functional condition of the fetal nervous system is of great importance to the obstetrician, since a considerable part of early brain damage is of prenatal origin. Several attempts to develop such a technique are reviewed. In addition, a new method, the qualitative assessment of fetal general movements, is described as a successful tool to obtain reliable data on the fetal brain dysfunction. This new method is robust, non-intrusive and cost-effective. There is also the advantage that the same criteria for the diagnostic assessment can be used for the fetus as well as for the young infant.

Computerised analysis of behaviour in normal and growth-retarded fetuses

Fetal behaviour [fetal heart rate (FHR) variation and movements (FA)] was studied in 27 normally grown fetuses and in 18 fetuses with intrauterine growth restriction (IUGR). FHR and FA were recorded using a single 1.5 MHz ultrasound transducer and analyzed by computer. The IUGR fetuses had significantly lower FA rates than the normally grown fetuses at all gestation times. They also spent a significantly lower proportion of time exhibiting high FHR variation at 28-31 weeks. Only two of the eighteen IUGR fetuses had abnormal biophysical profile scores (BPS) at the time of recording and yet all but one of them had either FHR or FA patterns that were outside the 10-90th centile range for the normally grown fetuses, suggesting that FHR and FA abnormalities predated BPS changes. More of the IUGR fetuses had abnormalities of FA than FHR. Finally, within the IUGR fetuses, those with small head circumferences (less than 3rd centile) had lower FA rates during periods of both low and high FHR variation, though this was only statistically significant for periods of low FHR variation (P < 0.05). This preliminary study offers the possibility that such objective evaluation of fetal behaviour could be used in a clinical setting and provide a more sensitive method of fetal assessment than the BPS.

Spontaneous motility in preterm, small-for-gestational age infants. II. Qualitative aspects

In order to document in detail the developmental course of qualitative aspects of early spontaneous motility in intrauterine growth-retarded infants, sequential videotape recordings were made in 19 preterm infants with a birth weight below the 5th percentile. The quality of general movements (GMs) was studied longitudinally during the preterm and postterm period until approximately 20 weeks corrected age, using Prechtl's method of quality assessment. An abnormal quality of GMs was present in 15 out of 19 infants. Compared to a low-risk group, consisting of appropriate-for-gestational age preterm infants, the proportion of infants with normal findings on brain scans who had an abnormal quality of GMs was high. The presence of 'abrupt chaotic' GMs was related to late fetal heart-rate decelerations and ischaemic alterations of the placenta. The quality of GMs normalized before or during the third month postterm in most infants with abnormal GMs. In four infants, the GMs did not normalize during the study period. The quality of fidgety movements was, in particular, a marker for neurological outcome at 24 months. This study demonstrates that intrauterine growth retardation may cause prolonged, but in most cases transient brain dysfunction; the qualitative assessment of GMs may help to identify infants at increased risk for neurodevelopmental abnormalities.

Spontaneous motility in preterm, small-for-gestational age infants. I. Quantitative aspects

The developmental course of the quantitative aspects of early spontaneous motility was studied longitudinally in fourteen intrauterine growth-retarded infants, with a birth weight below the 5th percentile, in relation to perinatal variables, brain ultrasound findings and neurological outcome. Quantitative motility was studied during the preterm period until term age, from 1 h videotape recordings, using Prechtl's classification of different spontaneous movement patterns. Comparison to a low-risk reference group, consisting of preterm, appropriate-for-gestational age infants, showed that significant differences were inconsistent and obviously by chance, with the possible exception of a decreased rate of startles from the 2nd to the 6th postnatal weeks. A trend of increasing duration of GMs was present with increasing postnatal age. There were hardly any correlations between perinatal variables and quantitative motility, and if present the correlations were weak. Such correlations were found between the reduction of heart-rate variability on cardiotocography and the rate of startles and twitches during the first week and furthermore between the neonatal blood glucose level and the rate of isolated arm movements and total motility during the first week. This study demonstrates that intrauterine growth retardation has little or no influence on the quantitative aspects of spontaneous motility postnatally during the preterm period.

State of the art of a new functional assessment of the young nervous system. An early predictor of cerebral palsy

The paper provides a survey of the state of the art of a new neurological diagnostic procedure in fetuses, preterm and term infant as well as in young infants. This method consists of a judgement of the movement quality of a particular type of spontaneous movements, the so-called general movements. At a very early age normal and abnormal general movement quality predicts the neurological outcome over 2 years, in particular cerebral palsy. The reliability of this method turned out to be very robust. Recent animal experiments on isolated parts of the central nervous system provide convincing evidence of endogenously generated neural activity. Similar neural mechanisms must provide the basis for spontaneous movements seen in the human at early ages. Those neural defects leading to qualitative changes of general movements are described in detail.

Posture, spontaneous movements, and behavioural state organisation in infants affected by brain malformations

Posture, quantity of spontaneous movement patterns, quality of general movements (GMs), and behavioural state organisation were studied in nine infants affected by documented brain malformations. A single 1 h video recording of five infants and two or more serial video recordings of another four infants were performed after birth. The graphic representation of single movement patterns (actogram) and of behavioural states of one video recording was performed in eight out of nine infants. The quality of GMs was assessed according to Prechtl's method in all video recordings. All nine infants showed a less variable posture than normal newborn infants and an unusual resting posture was detected in seven infants. Poor behavioural state organisation without sleep cycles was common to the nine infants and excessive wakefulness was observed in six infants. As for the quantity of single movement patterns, six infants lacked one or two movement patterns normally present in healthy newborn infants. An abnormal quality of GMs was noted in all nine infants and distinct motor abnormalities were observed in single infants. A monotonous and sometimes stereotyped sequence of different body parts involved in the movement (i.e. poor repertoire GMs) was common to all infants. In the four infants of whom two or more video recordings were available, initial poor repertoire GMs were followed by a further deterioration in movement quality. No relationship was found between the quantity of defective brain tissue, lack of a specific part of the brain, type and severity of GM and posture abnormalities.

Perinatal motor behaviour and neurological outcome in spina bifida aperta

AIM OF THE STUDY

In the present longitudinal study we investigated the relationship between prenatal motor behaviour and the postnatal neurological sequelae of infants with spina bifida aperta.

METHODS AND PATIENTS

Prenatal isolated leg movements and general movements of 13 fetuses/infants with spina bifida aperta were assessed by means of ultrasound recordings, and were compared with: 1. the spinal level of morphological defect (meningo-myelocele), 2. the postnatal motor behaviour, 3. the postnatal sensory function, and 4. the final motor outcome.

RESULTS

In all 13 cases studied, the spinal defect was either at thoracic (n = 8) or at lumbal (n = 5) level. All fetuses displayed active leg movements corresponding to the functioning of low lumbal myelum segments (L4-5 in two cases or L5-S1 in 11 cases), despite vertebral defects at high localisation. These leg movements were of normal quality (normal in appearance) and endogenously generated, since no external stimulus was exerted to elicit them. This implies that in fetuses with spina bifida aperta active leg movements can be generated at spinal segments which are located at (n = 1), or under (n = 12) the meningo-myelelocele. Postnatally, for a short period of time (mostly during the first few hours), leg movements related to myelum function at (n = 1) or lower than (n = 7) the spinal defect were detected. However, only in two infants these early leg movements were of normal quality and corresponded with the final motor outcome. In contrast to these early neonatal leg movements, early sensory function was strongly related to the spinal defect (r = 0.76; P = 0.005) and to the final motor outcome (sensory function predicted outcome in all infants of whom follow-up was performed).

CONCLUSION

These data on fetuses/infants with spina bifida aperta strongly indicate that a discrepancy exists between the occurrence of prenatal leg movements and the spinal localisation of the meningo-myelocele on the one hand, and between the occurrence of pre- and postnatal leg movements on the other hand (quantity and quality).

Which better predicts later outcome in full-term infants: quality of general movements or neurological examination?

The qualitative assessment of general movements (GMs) has been shown to be a better predictor of neurological outcome than the traditional neurological examination in brain-damaged preterm infants. The aim of this study was to compare the results of the two techniques in term infants. Off-line assessment of GMs from videorecordings and neurological examinations were carried out, from birth till about 6 months of postterm age, in a group of 58 term infants, the majority of which were affected by mild to severe hypoxic-ischaemic encephalopathy. The agreement between the two techniques and their predictive power, with respect to the neurological outcome at 2 years, were evaluated for four age groups. The range of agreement between neurological and GM findings was between 78 and 83%. At all ages the results of GM observation correlated highly with the neurological outcome; their sensitivity and specificity with respect to outcome were consistently slightly superior to those of neurological examination. In infants normalize after an initial period of transient abnormalities, GMs normalize earlier than the neurological results.

Comparison between observation of spontaneous movements and neurologic examination in preterm infants

OBJECTIVE

The Prechtl method of qualitative assessment of general movements (GMs) has been shown to be a good predictor of neurologic outcome in fetuses, preterm infants, and term infants. The aim of this study was to compare the results of this new technique with those of traditional neurologic examination and of cranial ultrasonography in preterm infants.

METHODS

Serial videotape recordings (with off-line assessment of GMs), ultrasound examination of the brain, and neurologic examinations were performed from birth until about 6 months of corrected age, on a group of 66 preterm infants whose gestational age ranged from 26 to 36 weeks (mean 30.7 weeks). The agreement between the two techniques and their predictive power, with respect to the neurologic outcome at 2 years of corrected age, were evaluated for five different age groups from preterm age to 65 weeks of postmenstrual age.

RESULTS

Overall agreement of the neurologic and GM findings was 80.3% and strongly age related (lower during the preterm and term periods and higher thereafter). At all ages the results of GM observation correlated highly with neurologic outcome; they showed higher sensitivity and specificity than the neurologic examination. This held true in particular before term age, when poor neurologic responses might be related to transient complications, and at term age, mainly because of infants with normal neurologic examination results but unfavorable outcome. During the preterm period the ultrasound results showed a better specificity and a lower sensitivity to outcome than GM findings.

CONCLUSIONS

The results of this study indicate that quality assessment of GMs should be added to traditional neurologic assessment, neuroimaging, and other tests of preterm infants for diagnostic and prognostic purposes.

Assessment of general movements: towards a better understanding of a sensitive method to evaluate brain function in young infants

The consistent presence of an abnormal quality of general movements (GMs) during the first postnatal months points to a high risk for the development of a neurological disability. To elucidate the significance of abnormal GMs during a single assessment, a classification system for abnormal GMs was developed. To this end six term and ten preterm infants with abnormal GMs were studied longitudinally with video and electromyographic (EMG) recordings till 59 weeks postmenstrual age (PMA). Two basic categories of abnormal GMs were distinguished: (1) mildly abnormal GMs (two types), which lacked fluency while conserving pattern complexity, and (2) definitely abnormal GMs (four types), which lacked fluency and complexity altogether. GM type before 39 weeks PMA correlated with findings on neonatal ultrasound brain scans. GM quality after 47 weeks PMA was strongly related to neurodevelopmental outcome at 1 1/2 years of age, suggesting that the absence of the age-specific 'fidgety' character of GMs could be a herald of disability.

The assessment of general movements is a valuable technique for the detection of brain dysfunction in young infants. A review

Recently, a new assessment technique by which to evaluate brain function in the fetus and newborn infant has been developed. The method is based on the assessment of the quality of General Movements (GMs). GMs are complex movements involving all parts of the body. They are present throughout fetal life and postnatally until about 3-4 months post-term. The persistent presence of abnormal GMs during the neonatal period and the absence of age-specific characteristics ("fidgety" movements) around 3 months-post term are both powerful predictors of the development of handicap.