Abnormal behavioral patterns in the human fetus at term: correlation with lesion sites in the central nervous system after birth

Intrapartum fetal heart rate patterns of trisomy 21 fetuses: A case-control study

BACKGROUND/AIM

To determine whether there are specific characteristic intrapartum heart rate patterns for fetuses with trisomy 21(T21).

BACKGROUND STUDY DESIGN/PATIENTS

Intrapartum fetal heart rate (FHR) tracings of T21 fetuses were compared to those of euploid fetuses in a retrospective, observational, matched, case-control study. The study group consisted of 42 fetuses with T21 and 42 matched euploid controls. Matching was designed to accommodate possible confounders. The sign test and McNemar's test were used for categorical variables. The paired t test was used for comparison between quantitative variables.

RESULTS

Intrapartum baseline FHR of fetuses with T21 was found to be slightly decreased compared to controls (122.5 vs 129.05 beats per minute, p=0.028). No differences were detected in the presence of periodic changes, or FHR variability between the groups.

CONCLUSION

When evaluating intrapartum FHR of fetuses with T21, decreased baseline FHR can be expected.

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.

Comparison of fetal heart rate patterns using nonlinear dynamics in breech versus cephalic presentation at term

BACKGROUND

It has been reported that breech fetuses have inferior neurological outcomes regardless of mode of delivery, raising the possibility that in utero neurological impairment is more frequent in breech fetuses, possibly contributing to malpresentation.

AIMS

To assess differences between the cardiovascular autonomic nervous systems (ANSs) of breech and cephalic fetuses using nonlinear dynamic indices of fetal heart rate (FHR) variability.

STUDY DESIGN AND SUBJECTS

This study included 86 fetuses with breech presentation and 173 fetuses with cephalic presentation, with no other maternal or fetal problems. We analyzed FHR variability and spectral indices as markers of ANS behavior. We used nonlinear dynamic indices to represent the complexity of heart rate regulation, as well as correlation dimension as a chaotic index of the cardiovascular control system.

RESULTS

One of FHR parameters (Mean minute range) was significantly lower in breech than cephalic fetuses (p=0.0294). However, there were no other significant differences in any linear or nonlinear indices, nor in clinical outcomes, between breech and cephalic fetuses.

CONCLUSION

Our data suggest that breech fetuses have neither more active ANS nor less active complexity control systems than do cephalic fetuses. This indicates that the neurologic maturation of breech fetuses is not inferior to cephalic ones. The practical implication of these findings is that the nervous system integrity of breech fetuses may not result directly in neonatal complications.

Prenatal stroke

The main focus of this chapter is the comprehensive description of the neuropathology, the imaging correlates and underlying mechanisms of prenatal stroke. We describe established prenatal stroke in subgroups similar to postnatal stroke: arterial (forebrain or hindbrain) infarction, venous thrombosis, primary lobar haemorrhage. This longitudinal classification should facilitate the study of risk factors and mechanisms. Forebrain lesions of arterial type present as porencephaly, (hemi)hydranencephaly, multicystic encephalopathy or schizencephaly. Venous prenatal forebrain stroke presents as simple porencephaly (in some of genetic nature) and sinus thrombosis. A list of rare porencephaly-like conditions is added for differentiation from arterial and venous porencephaly. Hindbrain infarctions (so far the only reported variants seem to be of arterial nature) present as brainstem disconnection, focal brainstem destruction, uni- or bilateral cerebellar destruction and focal spinal cord ischaemia. Prenatal intracranial haemorrhage and congenital brain infection should be considered in the differential diagnosis of prenatal stroke.

Brain function in utero unique to the developing fetus

Behaviour originally depends on precise and specific interconnections between nerve cells. The nervous system itself develops in a series of appropriately timed steps with a temporal sequence characteristic of each neural structure.

Simplified ultrasound screening for fetal brain function based on behavioral pattern

Despite the longstanding conclusion that behavior can reveal aspects of underlying anatomy and function, no generalized antenatal behavior screening has been developed to identify fetuses that may have central nervous system defects requiring further evaluation. We devised a brief ultrasound examination to distinguish fetuses with compromised central nervous system function from the general population and evaluated it with this study. The study design compared behavioral findings obtained by retrospectively reviewing the ultrasound examinations of 5 fetuses that had abnormal behavior with prospectively obtained findings of 29 normal fetuses. Median time for brief examination criteria was 50 min (range, 30-60 min). The only case undetectable by this brief ultrasound examination has an eye-movement period significantly longer than the normal upper limit. Using this method as a screening test may make it possible to include assessment of fetal brain function as part of routine antenatal care.

The relationship between the response to external light stimulation and behavioral states in the human fetus: how it differs from vibroacoustic stimulation

OBJECTIVE

To determine the effects of external light stimulation on fetal behavioral states and know the difference from those of vibroacoustic stimulation.

METHODS

A flashlight and a vibroacoustic stimulator was applied directly on the maternal abdomen to determine the response of 56 normal fetuses at 36-40 weeks gestation. Fetal heart rate (FHR) and body movements were recorded using an actocardiograph, and fetal eye movements were observed using real-time ultrasonography. Using Nijhuis's criteria, the fetal behavioral states (1F-4F) were determined. FHR acceleration was considered a fetal response to the stimulations.

RESULTS

The lag time between stimulation and fetal response was within 4 s. A positive response rate to the light stimulation was higher at behavioral states 2F (82%) and 3F (83%) than at state 1F (4%). Light stimulation changed the behavioral state of two of the six 3F fetuses (33%) from 3F to 4F. No change of state was observed in fetuses that were in states 1F and 2F. For vibroacoustic stimulation, fetal response was 100% positive and changes of states were observed frequently irrespective of the behavioral state before the stimulation.

CONCLUSION

Fetal response to light stimulation is closely connected to fetal behavioral states and may reflect some distinct stages of the sleep-wakefulness cycle.

Dependence of aortic pulse wave assessments on behavioural state in normal term fetus

To investigate any influence of behavioural states on the pulse waves in the descending aorta, 21 human fetuses were studied in utero in uncomplicated gestation at the age of 36-41 weeks. The fetal behavioural states were identified using two real-time scanners and one cardiotocograph. The aortic waveform data and pulse wave velocity (PWV) were recorded by means of two double phase-locking echo-trackers. The PWV of the fetal aorta was significantly lower in fetal behavioural state (FBS) 2F than in FBS 1F, when the fetus was apnoeic, and was also reduced in both states during fetal breathing. The calculated pulse pressure showed the same trend as the PWV. The fetal aortic end diastolic diameter and the pulse amplitude did not alter, when the two states changed. Our data suggest that the central haemodynamics in term fetuses are independently influenced by their behavioural state as well as by fetal breathing. The study of pulse waves in the fetal aorta should preferably be performed during apnoea in state 1F, when neither gross body movements nor breathing movements disturb the recording.

The function of fetal/neonatal rapid eye movement sleep

The hypothesis is put forward that rapid eye movement (REM) sleep in early life serves as (1) an indicator for the degree of brain maturation and (2) the promoter of further brain development. This hypothesis, although not exclusive, differs (a) from the theory of Roffwarg et al. that REM sleep substitutes for 'wakefulness' during the period (early life) in which wakefulness is limited, (b) from the theory of Crick and Mitchson, i.e., the 'unlearning' hypothesis of REM sleep, (c) from the theory of Jouvet, i.e., that REM sleep is a time for genetic read-out and (d) from the theory of Freud, i.e., that dreams fulfil our wishes (in other words, activation of neuronal systems that were disproportionally activated during wakefulness).

Breech presentation: is there a difference in eye movement patterns compared with cephalic presentation in the human fetus at term?

OBJECTIVE

Our purpose was to characterize eye movement patterns in the human fetus at term persisting in breech presentation.

STUDY DESIGN

Studied were 11 fetuses in breech presentation and 12 in cephalic presentation at 36 to 41 weeks' gestation, of which the presentation remained unchanged from 32 weeks' gestation until delivery. With real-time ultrasonography we analyzed three measurements by means of the Mann-Whitney rank-sum test: (1) duration of eye-movement and no-eye-movement periods, (2) frequency of eye movements, and (3) proportion of horizontal, vertical, and oblique eye movements.

RESULTS

There were significant differences in the eye movement directions between breech and cephalic fetuses: horizontal (median 70.3% vs 80.2%), vertical (17.4% vs 11.0%), and oblique (13.1% vs 9.1%), respectively. No differences were noted in the duration of eye-movement and no-eye-movement periods or in the frequency of eye movements.

CONCLUSION

Eye movement pattern, in direction, of term fetuses persisting in breech presentation run on a different in-utero developmental course of neural control from those in cephalic fetuses.

The relationship between age-related heart rate changes and developing brain function: a model of anencephalic human fetuses in utero

We attempted to identify the brain segment which controls heart rate changes in human fetuses with advancing gestation. Twelve anencephalic and 165 normal fetuses (control-group fetuses) between 25-32 weeks' gestation were studied. The instantaneous fetal heart rate (FHR) data were obtained from each fetus for a continuous 90-120 min period, using an external cardiotocograph. Calculations included the 'individual probability distribution matrices' in which the FHRs at 1 beat/min intervals between 110 and 180 beats/min, the beat-to-beat differences (DFHRs) between +/- 5 beats/min and the probability values were arranged in rows, columns and the corresponding elements, respectively. Using 2-gestational-week intervals probability distribution matrices (age-group probability distribution matrices) obtained from 335 normal fetuses in our previous study as a reference, the difference between a given 'individual probability distribution matrix' and the corresponding age-group probability distribution matrix' was quantified as the 'difference rate' according to the formula in the text. From 25-26 to 27-28 weeks' gestation, the 'difference rates' in four anencephalic fetuses, with only the spinal cord preserved, were significantly higher in value than those of control-group fetuses, whereas the rates in four fetuses with both the spinal cord and medulla oblongata preserved, indicated no significant differences. From 29-30 to 31-32 weeks' gestation, the rates of the four fetuses with the spinal cord and medulla oblongata preserved, showed significant differences from the control-group fetuses. These findings suggest that there is a critical period between 27-28 and 29-30 weeks' gestation with regard to the developing brain function pertaining to FHR changes. In the early stage, the medulla oblongata plays a role in FHR changes, whereas, in the latter stage, the brain cephalad to the medulla also appears to take on the role of FHR regulator.

Symposium: Normal and abnormal REM sleep regulation: The importance of REM sleep for brain maturation

A number of studies, some done by us, are reviewed concerning the function of foetal/neonatal REM sleep. The hypothesis is put forward that REM sleep in early life serves as an indicator for: (1) the degree of brain maturation, and (2) the promotion of further brain development. This hypothesis, although not exclusive, differs from: the original theory of Roffwarg et al. (1966) that REM sleep serves as "wakefulness" during the period in which wakefulness is limited; and also from the theory of Crick and Mitchson (1983-the "unlearning" hypothesis of REM sleep). As the functions of sleep in general, and REM sleep in particular, are still unclear, we hope this review will suggest new possibilities for future research.

Can brain impairment be detected by in utero behavioural patterns?

Fetal behavioural patterns were examined to test whether they could be used to localise sites of brain damage antenatally. Decreased fetal movement, persistent nonreactive fetal heart rate (FHR) pattern, and/or central nervous system malformation were used as indicators of possible neurological impairment. Ten fetuses tested in this way underwent further ultrasound examination observing movement of the extremities, chest wall (breathing), and eye and mouth, and active/quiet FHR patterns. Eight of these 10 fetuses were found on postnatal examination to have a brain impairment. The fetuses having potential in utero brain impairment were divided into four groups: those with (1) lesion sites at, or caudal to, the pons-medulla that were specifically identified by fetal behaviour, (2) diffuse lesions in the brain which, although resulting in abnormal behaviour, could not be localised by this behaviour, (3) lesions localised in the cerebral hemisphere(s) but with no abnormal behaviour and (4) temporally abnormal behaviour in utero, finally changing over to a normal pattern with no neonatal neurological abnormality. A screening system for the antenatal assessment of brain impairment is thus proposed.