New scoring system for fetal neurobehavior assessed by three- and four-dimensional sonography

Artificial intelligence as a new answer to old challenges in maternal-fetal medicine and obstetrics

BACKGROUND

Following the latest trends in the development of artificial intelligence (AI), the possibility of processing an immense amount of data has created a breakthrough in the medical field. Practitioners can now utilize AI tools to advance diagnostic protocols and improve patient care.

OBJECTIVE

The aim of this article is to present the importance and modalities of AI in maternal-fetal medicine and obstetrics and its usefulness in daily clinical work and decision-making process.

METHODS

A comprehensive literature review was performed by searching PubMed for articles published from inception up until August 2023, including the search terms "artificial intelligence in obstetrics", "maternal-fetal medicine", and "machine learning" combined through Boolean operators. In addition, references lists of identified articles were further reviewed for inclusion.

RESULTS

According to recent research, AI has demonstrated remarkable potential in improving the accuracy and timeliness of diagnoses in maternal-fetal medicine and obstetrics, e.g., advancing perinatal ultrasound technique, monitoring fetal heart rate during labor, or predicting mode of delivery. The combination of AI and obstetric ultrasound can help optimize fetal ultrasound assessment by reducing examination time and improving diagnostic accuracy while reducing physician workload.

CONCLUSION

The integration of AI in maternal-fetal medicine and obstetrics has the potential to significantly improve patient outcomes, enhance healthcare efficiency, and individualized care plans. As technology evolves, AI algorithms are likely to become even more sophisticated. However, the successful implementation of AI in maternal-fetal medicine and obstetrics needs to address challenges related to interpretability and reliability.

The Lower Limb Movements of the Fetus in Uterus: A Narrative Review

The fetus movements play an important role in fetal well-being. With the continuous advancement of real-time scanning machines, it is feasible to observe the fetus movement in detail. The characteristics of fetal lower limb movements in prenatal examination have not been systematically investigated. This review proposes the patterns of fetal lower limb movements, the maternal influence on fetal lower limb movements, and the application of fetal lower limb movements for the diagnosis of prenatal diseases. A systematic search of literature on the lower limb movements of the fetus in uterus was performed in the databases, namely, Web of Science and Scopus. Thirty-four publications were selected. This review demonstrates that isolated fetal lower limb movements are rare and always accompanied with the movements of other body segments. Detection of the presence of fetal leg movements seems to be of no diagnostic value for fetuses with prenatal diseases. The isolated lower limb movement was statistically significant different between fetuses of low- and high-risk pregnant women. The coordinated movements of the fetal lower limbs and other parts should be considered when analyzing fetal movements in the future study.

Artificial intelligence to understand fluctuation of fetal brain activity by recognizing facial expressions

OBJECTIVE

To examine whether artificial intelligence can achieve discoveries regarding fetal brain activity.

METHODS

In this observational study, the authors collected images of fetal faces using a four-dimensional ultrasound technique obtained from singleton pregnancies of outpatients in routine practice at 27 to 37 weeks of gestation between February 1 and December 31, 2021. The authors developed an artificial intelligence classifier to recognize seven facial expressions of fetuses, then applied it to video files of fetal facial images to generate the probabilities, as confidence scores, of each expression category. Discrete Fourier transform and chaotic analysis were used to investigate the scores. Mann-Whitney test, t test, variance test, and one-way analysis of variance were used for statistical analysis.

RESULTS

Facial expression changes were observed in cycles averaging 66 to 73 s. The power spectrum showed that mouthing and neutral expressions were the most prevalent. There was a difference between categories for the spectrum (p = 0.004). Two different states--dense and sparse--of confidence scores were discovered. The correlation dimension was 1.19 ± 0.22 and 1.33 ± 0.27 for dense and sparse, respectively (p = 0.047).

CONCLUSION

This method objectively and quantitatively demonstrated fetal brain activity and may provide insight into how the fetus spends its time in utero.

Factors affecting yawning frequencies in preterm neonates

Yawning is a long neglected behavioral pattern, but it has recently gained an increasing interdisciplinary attention for its theoretical implications as well as for its potential use as a clinical marker, with particular regard to perinatal neurobehavioral assessment. The present study investigated the factors affecting yawning frequencies in hospitalized preterm neonates (N = 58), in order to distinguish the effects of hunger and sleep-related modulations and to examine the possible impact of demographic and clinical variables on yawning frequencies. Results showed that preterm neonates yawned more often before than after feeding, and this modulation was not explained by the amount of time spent in quiet sleep in the two conditions. Moreover, second born twins, known to be more prone to neonatal mortality and morbidity, showed increased yawning rates compared to first born twins. Overall, our results are consistent with the hypothesis that yawning frequencies in preterm neonates are modulated by separate mechanisms, related e.g. to hunger, vigilance and stress. These findings, although preliminary and based only on behavioral data, might indicate that several distinct neuropharmacological pathways that have been found to be involved in yawn modulation in adults are already observable in preterm neonates.

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.

Foetal mouth movements: Effects of nicotine

AIM

To assess whether foetal mouth movement frequency changes across gestation and whether there are differences between cigarette and e-cigarette exposure conditions in comparison to a non-exposed group of foetuses.

METHOD

Pregnant women underwent 4-dimensional (4D) foetal ultrasound scans at 32 weeks (106 scans) and 36 weeks of gestational age (87 scans) at James Cook University Hospital, UK. The 4D scans were coded using the Fetal Observable Movement System (FOMS). Measures of maternal smoking status, stress, depression, anxiety, attachment and time of scan were also collected. There were four exposure groups: non-smokers, light smokers (<10 per day), heavy smokers (11-20 per day) and e-cigarette users.

RESULTS

No significant differences in relative frequency of mouth movements between the exposure groups at 32- and 36 weeks of gestational age were found. Foetal mouth movements declined from 32 to 36 weeks of gestation for non-exposed and e-cigarette-exposed foetuses.

CONCLUSION

Due to variability in foetal behaviour, examining mouth movements alone may not be the most appropriate method for assessing group differences. However, in line with other research, mouth movement frequency declined between 32- and 36 weeks of gestational age. A combination of foetal behavioural assessments is needed to assess the effects of cigarette and e-cigarette exposure on foetal neurobehavioural development.

Recognition of facial expression of fetuses by artificial intelligence (AI)

OBJECTIVES

The development of the artificial intelligence (AI) classifier to recognize fetal facial expressions that are considered as being related to the brain development of fetuses as a retrospective, non-interventional pilot study.

METHODS

Images of fetal faces with sonography obtained from outpatient pregnant women with a singleton fetus were enrolled in routine conventional practice from 19 to 38 weeks of gestation from January 1, 2020, to September 30, 2020, with completely de-identified data. The images were classified into seven categories, such as eye blinking, mouthing, face without any expression, scowling, smiling, tongue expulsion, and yawning. The category in which the number of fetuses was less than 10 was eliminated before preparation. Next, we created a deep learning AI classifier with the data. Statistical values such as accuracy for the test dataset and the AI confidence score profiles for each category per image for all data were obtained.

RESULTS

The number of fetuses/images in the rated categories were 14/147, 23/302, 33/320, 8/55, and 10/72 for eye blinking, mouthing, face without any expression, scowling, and yawning, respectively. The accuracy of the AI fetal facial expression for the entire test data set was 0.985. The accuracy/sensitivity/specificity values were 0.996/0.993/1.000, 0.992/0.986/1.000, 0.985/1.000/0.979, 0.996/0.888/1.000, and 1.000/1.000/1.000 for the eye blinking, mouthing, face without any expression, scowling categories, and yawning, respectively.

CONCLUSIONS

The AI classifier has the potential to objectively classify fetal facial expressions. AI can advance fetal brain development research using ultrasound.

Pregnant Agencies: Movement and Participation in Maternal-Fetal Interactions

Pregnancy presents some interesting challenges for the philosophy of embodied cognition. Mother and fetus are generally considered to be passive during pregnancy, both individually and in their relation. In this paper, we use the enactive operational concepts of autonomy, agency, individuation, and participation to examine the relation between mother and fetus in utero. Based on biological, physiological, and phenomenological research, we explore the emergence of agentive capacities in embryo and fetus, as well as how maternal agency changes as pregnancy advances. We show that qualitatively different kinds of agency have their beginnings already in utero, and to what extent fetal and maternal movement modulate affectivity and individuation in pregnancy. We thus propose that mother and fetus are both agents who participate in pregnancy. Pregnancy then emerges as a relational developmental organization that anchors and holds its developing participants. We end the paper with reflections on ethical implications of this proposal, and suggestions for future research.

Effect of psychotropic drugs on fetal behavior in the third trimester of pregnancy

AIM

To assess the effect of psychotropic drugs on fetal behavior using four-dimensional (4D) ultrasound in the third trimester of pregnancy.

METHODS

Fetal behavior was assessed using Kurjak's antenatal neurodevelopmental test (KANET) using 4D ultrasound between 28 and 36 weeks of gestation. Thirty healthy (control group) and 10 psychotropic-drug-administered pregnant (case group) women were studied. The total value of the KANET score and values of each parameter (eight parameters) were compared between the two groups.

RESULTS

The total KANET score was normal (except for one fetus in the case group: total score of 9) in both groups, and there was no significant difference in the total KANET score. When individual KANET parameters were compared, no significant differences were noted in any of the eight parameters.

CONCLUSION

Our results showed that there is no difference in fetal behavior between fetuses of normal pregnant women and those of psychotropic-drug-administered pregnant women in the third trimester of pregnancy. These results suggest that psychotropic drugs may not affect fetal behavioral development in utero. However, the data and their interpretation in the present study should be taken with some degree of caution because of the small number of subjects studied. Further studies involving a larger sample size are needed to assess the effect of psychotropic drugs on fetal neurobehavior during pregnancy.

Prediction of postnatal developmental disabilities using the antenatal fetal neurodevelopmental test: KANET assessment

Objective To assess the usefulness of the antenatal fetal neurodevelopmental test for the prediction of postnatal developmental disabilities. Methods Fetal behavior was assessed with Kurjak's antenatal neurodevelopmental test (KANET) using four-dimensional ultrasound between 28 and 38 weeks of gestation. A score range of 0-5 was characterized as abnormal, from 6 to 9 was considered borderline, and 10-16 was normal. After birth, follow-up was conducted for at least 2 years in all fetuses. Results There were 337 normal (95.47%) and 16 borderline (4.53%) cases among the 353 cases studied, whereas there was no abnormal case. Five cases with postnatal developmental disabilities (one case of Werdig-Hoffmann disease diagnosed just after delivery, one case of autism spectrum disorder diagnosed at 24 months, one case of Ullrich congenital muscular dystrophy diagnosed at 9 months and two cases of developmental disorders diagnosed at age 3 and 18 months) were noted among the 337 normal cases (1.48%), whereas three cases with developmental disabilities (one case of motor development delay diagnosed at 6 months, one case of Duchenne muscular dystrophy diagnosed at 18 months and one case of autism spectrum disorder diagnosed at age 30 months) were found among the 16 borderline cases (18.75%). There was a significant difference in the prevalence of postnatal developmental disabilities between the normal and borderline KANET groups (P<0.001). Conclusion Our results suggest that the KANET assessment may be a useful diagnostic modality for the prediction of postnatal developmental disabilities.

Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases

Introduction

The term multiple primary tumor (MPT) is used to describe cases where two or more primary tumors show no histopathological similarities in between. Multiple primary tumor cases have begun to increase in recent years as a result of the increase in life expectancy because of the increase in life standards and progress in diagnostic methods. In this study, MPT cases with periampullary tumors that underwent Whipple procedure were discussed in the light of literature data.

Materials and methods

The patient files of 223 cases with periampullary tumors that underwent Whipple procedure in our hospital during the last 6 years were examined retrospectively. More than one primary tumor was detected in 21 patients.

Results

Periampullary carcinomas were detected as a second primary tumor in 18 patients. First primary tumor was periampullary carcinoma in 3 patients that underwent Whipple procedure. After the Whipple procedure, 5 patients died due to early complications in the first 30 days and 6 patients died due to metastases and additional problems that developed during follow-up.

Discussion

The incidence of MPT has been reported as 0.7 to 14.5% in the literature. Most of them are multiple primary case presentations. In patient management, it is recommended that each tumor should be evaluated independently of its own characteristics, and treatment and follow-up should be planned accordingly.

Conclusion

The MPT cases are increasing. The possibility of MPT as well as metastasis should be kept in mind during the evaluation of tumor foci seen during diagnosis and follow-up of patients. The characteristics of each tumor, survival, and prognosis should be evaluated separately and the most appropriate treatment should be offered to the patient. It is recommended that synchronic primary tumors which are considered to be surgically resectable without metastasis should be removed in the same session.How to cite this article: Dilek ON, Ozsay O, Karaisli S, Gür EÖ, Er A, Haciyanli SG, Kar H, Dilek FH. Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases. Euroasian J Hepato-Gastroenterol 2018;8(1):1-5.

The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia

Introduction

Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy.

Materials and methods

All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively.

Results

A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy.

Conclusion

Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia.

How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.

Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System

Aim

This research focused on the results of the cross-validation program related with the performance of a Cuban novel low-cost real-time quantitative polymerase chain reaction (qPCR) assay for hepatitis B virus (HBV) quantification developed by the Therapeutic Vaccine against Hepatitis B Department, Vaccines Division, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba.

Materials and methods

Dilution series with the plasmid standard at concentrations of 900,000 to 0.09 copies/reaction (c/r) were made for each PCR instrument. The mean cycles threshold (Ct) values and PCR efficiency were compared among the cyclers. Hepatitis B virus-positive serum samples were used for the calculation of reproducibility of the HBV assay. Biotecon Diagnostics (BCD) also ordered the oligo sequences from a second supplier and compared the PCR performance to those provided from the CIGB.

Results

All PCR cyclers were able to detect concentrations up to 0.09 c/r. However, below the concentration of 9 c/r, the variation of results increased within and between the cyclers. The PCR efficiency showed satisfying results. The overall coefficient of variation (CV) cycler values were 1.29 and 0.91% for M6 and M19 respectively. No significance was observed between the different primer suppliers.

Conclusion

The HBV assay was performed with a good concordance between the five real-time instruments from different suppliers. The HBV assay was also performed with a high reproducibility for samples with a high and a low viral load. The HBV assay is robust against different primer suppliers.

How to cite this article: Aguiar J, Silva JA, García G, Guillén G, Aguilar JC. Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System. Euroasian J Hepato-Gastroenterol 2018;8(1):38-41.

Reference values for a fetal movement acceleration measurement recorder to count fetal movements

BackgroundA newly developed fetal movement acceleration measurement recorder has made it possible to count gross movements for hours. The purpose of this study was to determine the normal reference values for such movements.MethodsOne hundred and six pregnant women recorded fetal movements by themselves when they slept at home weekly from 28 weeks to term. The normal reference values were determined based on the data that could be recorded for more than 4 h per night.ResultsA total of 2,458 h of data from 385 recordings from 64 women was available. The median ratio of 10-s periods in which fetal movements occurred to the total time interval was 17% at 28 gestational weeks, decreasing to ∼6% at term. The number of fetal movements was 74 times/h, decreasing to 29 times at term. The number, the mean, and the longest durations of periods with no fetal movement, meaning no fetal movements were found for more than 5 min, were 1.56 times/h, 7.95 and 14.25 min, respectively, at 28 weeks, and increasing to 2.54 times, and 9.63 and 19.67 min, respectively, at term.ConclusionsThis study provides normal reference values for gross fetal movement count using the fetal movement acceleration measurement recorder.

Primary Gastric Lymphoma: Clinicopathological Profile

Introduction

Gastrointestinal tract (GIT) is the most common site of involvement of extranodal non-Hodgkin’s lymphoma (NHL). There is regional variation in anatomical distribution of extranodal NHL, stomach being the most common site followed by small intestine. Primary gastric lymphoma (PGL) predominantly involves the antrum and corpus of the stomach. It arises from mucosa-associated lymphoid tissue (MALT) and is of B-cell lineage and often associated with Helicobacter pylori infection. Primary gastric lymphoma often presents with nonspecific symptoms. The present study was undertaken to ascertain the clinicopathological characteristics of PGL at a tertiary care center in South India.

Materials and methods

It is a retrospective study from 2006 to 2016. Patient’s data were obtained from institutional medical records. The histopathology slides were reviewed. The relevant immunohistochemistry (IHC) markers done were leukocyte common antigen (LCA), CD3, CD20, CD79a, CD10, Bcl-2, Bcl-6, CD5, Cyclin D1, CD138, and Ki-67. Correlating with the immunoprofile, further subtyping was done.

Results

A total of 405 patients of NHL were seen during the study period, out of which 43 patients were PGL. There were 32 males and 11 females, with M:F of 2.9:1. The mean age at diagnosis was 58 years. Abdominal pain and new-onset dyspepsia were the commonly observed presenting symptoms. The common site of involvement was antrum (20). Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype. Helicobacter pylori infection was seen in 18 (41%) patients. Majority of the patients were in stages II and III.

Conclusion

In our study, the initial presentation of PGL was with nonspecific symptoms like abdominal pain and new-onset dyspepsia. High degree of suspicion of such symptoms and biopsy of all suspicious lesions is essential for early detection. Diffuse large B-cell lymphoma was the most common histological subtype seen in our study.

How to cite this article: Malipatel R, Patil M, Rout P, Correa M, Devarbhavi H. Primary Gastric Lymphoma: Clinicopathological Profile. Euroasian J Hepato-Gastroenterol 2018;8(1):6-10.

Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy

Hepatitis B virus (HBV) infections represent one of the major public health problems in global context. More than 2 billion people in the world have been infected with this virus at some point of time in their life and millions are chronically infected, indicating that chronic HBV-infected subjects remain as a living source of HBV transmission. The public health impact of this is tremendous. Considerable numbers of chronic HBV-infected individuals would eventually develop progressive liver diseases and their complications like hepatic failure, liver cirrhosis (LC), and hepatocellular carcinoma (HCC). Epidemiological studies have suggested that about 0.6 to 1.2 million people die annually from HBV-related liver diseases. These figures about death due to HBV and sufferings from HBV-related diseases indicate a notion of medical emergencies about HBV. In addition to these, the impact of HBV on health care delivery system moves beyond these numbers of HBV-related patients and HB-related deaths. This is because significant insights have already been developed about epidemiology, virology, and pathogenesis of HBV. Also, an effective and widely used preventive vaccine is available against HBV. In addition to these, antiviral drugs against HBV have been developed from early 1980s and several such drugs are now available commercially in the open market around the worldwide. Unfortunately, the ongoing therapeutic regimens could not stand the test of time and new insights about HBV pathogenesis are required for the development of new, novel, and evidence-based therapies for chronic HBV infections.

How to cite this article: Akbar SMF, Al-Mahtab M, Khan SI. Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy. Euroasian J Hepato-Gastroenterol 2018;8(1):42-46.

Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis

Aim

Alpha-fetoprotein (AFP) is still the most commonly used and the single most recommended marker in the diagnosis of hepatocellular carcinoma (HCC). Interleukin (IL)-6 is a circular cytokine and its role on carcinogenesis in various hematological and solid tumors is clearly documented. A combination of serum IL-6 and AFP may provide beneficial information regarding early diagnosis of HCC. In this study, the effect of plasma IL-6 level in the diagnosis of HCC was investigated.

Materials and methods

A total of 130 patients with liver cirrhosis, together with 30 control cases were enrolled in the trial. A diagnosis of HCC was present in 75 patients (57.6%) in the liver cirrhosis group. Blood samples were obtained from the enrolled study and control cases. Alpha-fetoprotein was quantified by chemiluminescent method. Plasma IL-6 levels of samples obtained at -80°C were quantified by human IL-6 BMS213/2 BMS213/2TEN kit.

Results

The HCC patients were older than the patients in the cirrhosis group (p = 0.016). On comparison of the HCC patients with the control group, AFP (p < 0.001) and IL-6 (p < 0.001) were significantly higher among the HCC patients. Comparison of HCC patients with liver cirrhosis cases with no diagnosis of HCC revealed significantly high AFP (p < 0.001) and IL-6 levels (p < 0.001) in HCC group. Cutoff value for IL-6 was calculated as 5.73 (pg/mL). No difference was detected in AFP (p = 0.600) and IL-6 (0.344) in all three subgroups. A total of 17 patients died during a mean follow-up period of 32.9 months. No correlation was found between mean AFP values and IL-6 values and survival rates.

Conclusion

Plasma IL-6 level was found to be significant in the diagnosis of HCC. Alpha-fetoprotein and IL-6 provided no advantage in terms of early diagnosis of HCC and no correlation was observed between these markers and survival.

How to cite this article: Yakut M, Özkan H, Karakaya MF, Erdal H. Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis. Euroasian J Hepato-Gastroenterol 2018;8(1):23-30.

Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis

INTRODUCTION

We aimed to investigate the effects of intake of yogurt containing Bifidobacterium longum (BB536-y) and fructo-oligosaccharides (FOS) in preventing colorectal carcinogenesis in healthy subjects, and the preventive effects of short-chain fatty acids (SCFA), whose production was enhanced by the intake of BB536-y and FOS, in human colon cancer cell lines.

MATERIALS AND METHODS

The subjects were 27 healthy persons who were divided into a group taking yogurt containing BB536 (BB536-y group; n = 14) and a group taking yogurt containing BB536 and FOS (BB536-y with FOS group; n = 13) once a day for 5 weeks. The feces were sampled before and after the intake to analyze the amount of SCFA in the feces and the profile of intestinal flora, such as putrefactive bacteria and Bacteroides fragilis enterotoxin (ETBF). Subsequently, human colon cancer cell lines (DLD-1 cells, WirDr cells) were cultured in the presence of SCFA (butyric acid, isobutyric acid, acetic acid) in order to evaluate the cell growth-inhibitory activity of SCFA (WST-8 assay) by calculating the IC50 value from the dose-response curve.

RESULTS

Intake of BB536-y increased the total amount of SCFA in the feces and significantly suppressed the detection rate of ETBF and growth of putrefactive bacteria. Intake of BB536-y with FOS was associated with a higher Bifidobacterium detection rate than that of BB536-y alone. The contents of butyric acid, isobutyric acid, and acetic acid, namely, of SCFA, were also decreased. Analysis of the results of culture of DLD-1 cells and WirDr cells in the presence of butyric acid, isobutyric acid, and acetic acid revealed that each of the substances showed significant cell growth-inhibitory activity, with the activity being the highest for butyric acid, followed by that for isobutyric acid and acetic acid.

CONCLUSION

These findings suggest that intake of both BB536-y and BB536-y with FOS prevents colorectal carcinogenesis.How to cite this article: Ohara T, Suzutani T. Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis. Euroasian J Hepato-Gastroenterol 2018;8(1):11-17.

Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease

Introduction

Noninvasive assessment of esophageal varices (EV) decreases the medical and financial burden related to screening and helps in the management of patients with chronic liver diseases (CLDs). In this study, our aim was to assess the utility of the platelet count/spleen diameter index for the noninvasive evaluation of EV.

Materials and methods

In this cross-sectional observational study, a total of 100 CLD patients underwent screening endoscopy for EV in Medicine and Gastroenterology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. Platelet count/spleen diameter ratio was assessed in all patients and its diagnostic implication was calculated.

Results

Upper gastrointestinal endoscopy revealed that 45 (45.0%) patients had medium EV followed by 27 (27.0%) that had small EV and 19 (19.0%) patients had large EV. Receiver operator characteristic (ROC) curve was constructed using platelet count/spleen index, which gave a cut-off value of >905. The validity of platelet count/spleen index evaluation of CLD was: Sensitivity 92.3%, specificity 66.7%, accuracy 90.0%, positive predictive value (PPV) and negative predictive value (NPV) were 96.6 and 46.2% respectively. True positive was 84 cases, false positive 3 cases, false negative 7 cases, and true negative 6 cases. If we consider cut-off value as 909 in the evaluation of EV in CLD, then true positive was 85 cases, false positive 3 cases, false negative 6 cases, and true negative 6 cases. From this, by calculation, sensitivity was 93.4%, specificity 66.7%, accuracy 91%, PPV 96.6%, and NPV 50%.

Conclusion

The platelet count/spleen index may be proposed to be a safe and reliable mean of screening of EV in CLD patients; however, case-control study would be required to validate this.

How to cite this article: Hossain E, Ahammed F, Saha SK, Foez SA, Rahim MA, Noor-e-Alam SM, Abdullah AS. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2018;8(1):18-22.

4D assessment of motoric function in a singleton acephalous fetus: the role of the KANET test

Acephalous fetus in a singleton pregnancy is an extremely rare case. In twin pregnancy, it could be presumed as one type of twin reverse arterial perfusion sequence (TRAPS). In this particular case report, the situation was different. An acephalous fetus developed in a singleton pregnancy and may have been a complication of an amniotic band in the very early weeks of gestation. Nevertheless proving it is still a constraint. Despite that, motor findings in utero by using four-dimensional (4D) ultrasound were very interesting to study. Movement of the acephalous fetus is challenging thought on fetal behavior theory, as brain development and function play the central role. The Kurjak antenatal neurodevelopmental tests (KANET) was used to measure the fetal behavior of this acephalous fetus. A comparison with post natal movement findings was also done to provide a better understanding.

Current status of fetal neurodevelopmental assessment: Four-dimensional ultrasound study

With the latest advent of four-dimensional (4-D) ultrasound, fetal neurobehavioral or neurodevelopmental assessment can be easily and readily performed. Using this technique, typical fetal movements and behavioral patterns have become apparent in all three trimesters of pregnancy. In twin pregnancy, 4-D ultrasound facilitates the precise evaluation of inter-twin contact and intra-pair stimulation. New fetal neurobehavioral assessment tests, such as Kurjak's Antenatal Neurodevelopmental Test and the Fetal Observable Movement System, may reflect the normal and abnormal neurological development of the fetus, and will facilitate more precise assessments of fetal neurobehavior or neurodevelopment, and fetal brain and central nervous system functions. In this review article, I also discuss interesting topics regarding maternal and fetal stress, fetal pain, and fetal consciousness. Four-dimensional ultrasound has opened the door to new scientific fields, such as 'fetal neurology' and 'fetal psychology,' and fetal neurobehavioral science is at the dawn of a new era. Knowledge on fetal neurobehavior and neurodevelopment will be advanced through fetal behavioral research using this technique.

Three-dimensional Ultrasound in Detection of Fetal Anomalies

In the history of 3D/4D ultrasound technology, the great achievement was high definition (HD) live technology. This technology is a novel ultrasound technique that improves the 3D/4D images. HDlive ultrasound has resulted in remarkable progress in visualization of early embryos and fetuses and in the development of sonoembryology. HDlive uses an adjustable light source and software that calculates the propagation of light through surface structures in relation to the light direction. The virtual light source produces selective illumination, and the respective shadows are created by the structures where the light is reflected. This combination of light and shadows increases depth perception and produces remarkable images that are more natural than those obtained with classic three-dimensional (3D) ultrasound. The virtual light can be placed in the front, back, or lateral sides, where viewing is desired until the best image is achieved. A great advantage is that the soft can be applied to all images stored in the machine's memory. With HDlive ultrasound, both structural and functional developments can be assessed from early pregnancy more objectively and reliably and, indeed, the new technology has moved embryology from postmortem studies to the in vivo environment. Practically, in obstetrical ultrasound, HDlive could be used during all three trimesters of pregnancy.

How to cite this article

Pooh RK, Kurjak A. Three-dimensional Ultrasound in Detection of Fetal Anomalies. Donald School J Ultrasound Obstet Gynecol 2016;10(3):214-234.

Fetal facial expression in response to intravaginal music emission

This study compared fetal response to musical stimuli applied intravaginally (intravaginal music [IVM]) with application via emitters placed on the mother’s abdomen (abdominal music [ABM]). Responses were quantified by recording facial movements identified on 3D/4D ultrasound. One hundred and six normal pregnancies between 14 and 39 weeks of gestation were randomized to 3D/4D ultrasound with: (a) ABM with standard headphones (flute monody at 98.6 dB); (b) IVM with a specially designed device emitting the same monody at 53.7 dB; or (c) intravaginal vibration (IVV; 125 Hz) at 68 dB with the same device. Facial movements were quantified at baseline, during stimulation, and for 5 minutes after stimulation was discontinued. In fetuses at a gestational age of >16 weeks, IVM-elicited mouthing (MT) and tongue expulsion (TE) in 86.7% and 46.6% of fetuses, respectively, with significant differences when compared with ABM and IVV (p = 0.002 and p = 0.004, respectively). There were no changes from baseline in ABM and IVV. TE occurred ≥5 times in 5 minutes in 13.3% with IVM. IVM was related with higher occurrence of MT (odds ratio = 10.980; 95% confidence interval = 3.105–47.546) and TE (odds ratio = 10.943; 95% confidence interval = 2.568–77.037). The frequency of TE with IVM increased significantly with gestational age (p = 0.024). Fetuses at 16–39 weeks of gestation respond to intravaginally emitted music with repetitive MT and TE movements not observed with ABM or IVV. Our findings suggest that neural pathways participating in the auditory–motor system are developed as early as gestational week 16. These findings might contribute to diagnostic methods for prenatal hearing screening, and research into fetal neurological stimulation.

Fetal Neurology: The Role of Fetal Stress

Fetal development and growth, as well as the timing of birth is influenced by the intrauterine environment. Many environmental factors causing the fetal stress can interfere with fetal development and leave long-term and profound consequences on health. Fetal glucocorticoid overexposure has primarily significant consequences for the development of the central nervous system. In response to an adverse intrauterine conditions, the fetus is able to adapt its physiology to promote survival. However, these adaptations can result in permanent changes in tissue and organ structure and function that directly ‘program’ predisposition to disease. Cardiometabolic disorders, behavioral alterations and neuropsychiatric impairments in adulthood and/ or childhood may have their roots in the fetal period of life. Fetal response to stress and its prenatal and lifelong consequences are discussed in this review.

How to cite this article

Kadić AS. Fetal Neurology: The Role of Fetal Stress. Donald School J Ultrasound Obstet Gynecol 2015;9(1):30-39.

Antenatal and Postnatal Assessment of Neurobehavior: Which One should be used?

It is obvious that this environment is quite different from one man is experiencing after birth, but, although different, intrauterine environment is ideal at that stage of human development. There is a question of the environmental discontinuity between intrauterine conditions characterized by existence of microgravity (baby astronaut hypothesis), and extrauterine life with gravity as developmental condition sine qua non. The human brain is one of the organs which is very sensitive to environmental changes affecting its growth and development. The brain of very tiny prematurely born babies is unable to follow the genetically determined growth pattern in extrauterine environment, even when postnatal nutrition and nurturing of the babies according to our best knowledge are appropriate. Is this fact of any significance to make distinction between normal and abnormal neurodevelopment pre- and postnatally is still unclear?

Kurjak antenatal neurodevelopmental test (KANET) using four-dimensional ultrasound (4D US) has been introduced using ten parameters and after attempt of standardization only eight parameters remained for neurodevelopmental assessment of low- and high-risk fetuses. We believe that at present level of knowledge, KANET test could be considered as a good test for the detection of fetuses with high neurological risk, without the possibility to define reliable long-term neurodevelopmental outcome. This is also hardly possible based on postnatal neurological assessment with 27 different postnatal tests. They were primarily neurobehavioral or neuromotor assessments that were suitable for use with preterm infants, and were discriminative, predictive or evaluative.

There was a high willingness of clinician to find postnatal neurodevelopmental test which could be predictive for short- term and long-term outcome of low and high-risk infants.

Although, there are many tests available for prenatal and postnatal assessment of neurodevelopment, none of them is reliable in the prediction of neurodevelopmental outcome in low-risk population, while many could be used with fairly acceptable predictivity in high-risk population. Although, many studies have been conducted in order to solve this problem, still there is a space for improvement. In postnatal period we are dealing with infant in front of the clinician with direct observation, while pretnatally we are dealing with quite different environment and less mature brain.

How to cite this article

Stanojevic M. Antenatal and Postnatal Assessment of Neurobehavior: Which One should be used? Donald School J Ultrasound Obstet Gynecol 2015;9(1):67-74.

KANET in Brazil: First Experience

Objective

The goal of this pilot test is to compare Kurjak's antenatal neurological test (KANET) results between high and low-risk pregnancies and see the feasibility of using this test on a larger scale in Brazil.

Methods

We applied KANET test in high-risk (n = 17) and low-risk (n = 34) pregnancies and compared the results.

Results

There was a significant difference between groups of high-risk and low-risk pregnancies for all parameters in KANET score 2. For KANET score 0, 5 out of 8 parameters where significant different: isolated head anteflexion, cranial sutures and head circumference, isolated hand movement or hand to face movements, isolated leg movement and fingers movements. All abnormal KANET result came from high-risk pregnancies (17.6%). No low-risk pregnancies presented KANET score 0. Efficacy and effectiveness were not evaluated due to the imprecision inherent in data from small samples.

Conclusion

This successful preliminary study of KANET in Brazil showed important differences in fetal behavior between the low and high-risk pregnancies, and can be used as information of feasibility and identify modifications needed in the design of a larger testing study.

How to cite this article

Neto RM. KANET in Brazil: First Experience. Donald School J Ultrasound Obstet Gynecol 2015;9(1):1-5.

First Experience in Clinical Application of KANET

Introduction of three- and four-dimensional ultrasound into clinical practice enabled qualitative and quantitative assessment of fetal movements, including the analysis of fetal face expression which is considered to be the mirror of the maturational processes of upper motor neuron. Since, prenatal fetal behavioral patterns are reflections of developmental and maturational processes within the fetal central nervous system, the findings about changes in fetal movements and behavior could leed to the prenatal diagnosis of neurological impairment. Kurjak's antenatal neurodevelopment test (KANET) is the first prenatal test based on the three- and four-dimensional ultrasound examination of the fetus that could be used for the evaluation and prediction of the fetal neurologic status.

How to cite this article

Luetic AT. First Experience in Clinical Application of KANET. Donald School J Ultrasound Obstet Gynecol 2015;9(1):96-99.

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.

Is in utero Fetal Neurological Assessment Comparable to Postnatal Neurological Assessment?

The traditional concept that brain damage is caused during birth or early neonatal period has been challenged. This is supported by the fact that the incidence of cerebral palsy stayed unchanged despite the global increase of cesarean sections. Consequently, the medicolegal importance of fetal neurological research is essential and needed. Years of research have provided us with important knowledge about association of fetal movements with brain development. The basic studies were done by two-dimensional ultrasound. The implementation of four-dimensional ultrasound in evaluation of fetal behavior has opened new and unexplored possibilities of evaluating the quality of fetal movements and a detailed assessment of fetal facial expressions. It is known that early postnatal neurological assessment, regarding future prediction of neurological optimality, has great limitations do to wonderful brain plasticity. Taking this very important limitation in to the account we could conclude that the preliminary studies comparing prenatal and postnatal neurological assessment are comparable. More importantly they emphasize the fact that the study of fetal behavior is most probably the right path in the study of fetal neurological development.

How to cite this article

Vasilj O. Is in utero Fetal Neurological Assessment Comparable to Postnatal Neurological Assessment? Donald School J Ultrasound Obstet Gynecol 2015; 9(1):91-95.

HDlive and 4D Ultrasound in the Assessment of Fetal Facial Expressions

Four-dimensional (4D) sonographic assessment of fetal facial expressions is considered to reflect normal and abnormal fetal neurological developments, and may be an important clue to predict the fetal brain function and well-being before and after birth. HDlive is a new surface-rendering mode, which uses an adjustable light source that facilitates the ability to create lighting and shadowing effects, thereby increasing depth perception. This technique facilitates extraordinarily realistic imaging of the fetal face, making it almost impossible to differentiate between actual photographs and HDlive images. In this article, we discuss recent topics regarding fetal facial expressions assessed by 4D ultrasound and HDlive, focusing on mouthing, sucking, yawning, blinking, tongue expulsion, scowling (pain/distress), and smiling. Moreover, we consider possibility of the existence of fetal emotion or awareness.

How to cite this article

Hata T, Kanenishi K, Hanaoka U, Marumo G. HDlive and 4D Ultrasound in the Assessment of Fetal Facial Expressions. Donald School J Ultrasound Obstet Gynecol 2015;9(1):44-50.

Recent Results of the Clinical Application of Kanet Test

Many investigations led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of fetal central nervous system (CNS), and may make possible to distinguish between normal and abnormal brain development as well as prenatal diagnosis of neurological impairment. The arrival of three- and four-dimensional ultrasound (3D/4D US) made possible to study fetal behavioral patterns. Kurjak's antenatal neurodevelopmental test (KANET) is the first prenatal test based on 3D/4D ultrasound examination of the fetus, that could be used for the evaluation and prediction of fetal neurological status. Here, we present our review of literature on KANET around the world and summarized results of this promising prenatal neurological screening test.

How to cite this article

Neto RM, Kurjak A. Recent Results of the Clinical Application of Kanet Test. Donald School J Ultrasound Obstet Gynecol 2015;9(4):420-425.

Assessment of fetal behavior using four-dimensional ultrasonography: current knowledge and perspectives

In the last decades, the development of real-time ultrasonography has allowed the direct view of the fetus in the uterus, as well as assessing its activity. The advent of three-dimensional ultrasonography (3D) at the end of the 80s initiated a new era in diagnostic imaging for Obstetrics, dramatically increasing the possibility of studying the fetus. Recently, a new technique allowing the 3D image to be transformed into real-time was introduced: the four-dimensional (4D) ultrasonography. It allows the continuous monitoring of fetal face and other surface areas, such as the extremities. Some studies have already assessed this new methodology for fetal behavior observation during different stages of pregnancy, trying to understand better the relationship between fetal central nervous system maturation and the implications for its behavior. In this article, the authors review the current use of 4D ultrasonography in the assessment of fetal behavior, and discuss the possibilities of the technique to show the neurological development of the fetus, by means of watching movement and facial expressions. They also highlight the potential applicability of this new method in this new research area of fetal medicine.

4D Ultrasound - Medical Devices for Recent Advances on the Etiology of Cerebral Palsy

Children cerebral palsy (CCP) encompasses a group of nonprogessive and noninfectious conditions, which cause light, moderate, and severe deviations in neurological development. Diagnosis of CCP is set mostly by the age of 3 years. The fact that a large number of cerebral damage occurs prenatally and the fact that early intervention in cases of neurological damage is successful, prompted some researchers to explore the possibility of detecting neurologically damaged fetus in the uterus. This research was made possible thanks to the development of two-dimensional ultrasound technology in a real time, which enabled the display of the mobility of the fetus. Advancement of the ultrasound technology has enabled the development of 4D ultrasound where a spontaneous fetal movement can be observed almost in a real time. Estimate of the number and quality of spontaneous fetal movements and stitches on the head, the neurology thumb and a high palate were included in the prenatal neurological screening of the fetus. This raises the question, as to does the fetal behavior reflect, (which was revealed in 2D or 4D ultrasound), fetal neurological development in a manner that will allow the detection of the brain damage.

Current Role of 3D/4D Sonography in Obstetrics and Gynecology

Modern 3D/4D sonography provides a routine method not only for storing single image planes as in 2D ultrasound but also for storing complete sets of volume data in the computer memory. Once acquisition is completed, all volumes can be accessed from the memory and normal and abnormal findings in both obstetrics and gynecology can be demonstrated in different display modes. Furthermore digital storage of volumes permits virtual examinations by reloading of volumes and navigating through them in the absence of the patient.

This review article would like to give an illustration of the latest technologies in 3D/4D ultrasound in obstetrics and gynecology.

How to cite this article

Merz E, Pashaj S. Current Role of 3D/ 4D Sonography in Obstetrics and Gynecology. Donald School J Ultrasound Obstet Gynecol 2013;7(4):400-408.

Neurobehavior in fetal life

Assessment fetal behavior gave a promising opportunity to understand the hidden function of the developmental pathway of the fetal central nervous system. After the assessment of normal neurobehavioral development by four-dimensional (4D) ultrasound, attempts have been made to identify functional characteristics of the fetus that predict a range of subsequent developmental dysfunction. These attempts resulted in producing the Kurjak Antenatal Neurodevelopmental Test (KANET). Assessment of fetal behavior by 4D ultrasound and application of KANET scoring test has been recently published in several journals and summarized results are presented in this review.

Continuity between fetal and neonatal neurobehavior

The human brain is very sensitive to environmental changes affecting its growth and development. Environmental changes influence neonatal behavior after birth, enabling continuity between prenatal and postnatal behavior, but postnatal adaptation could be considered as discontinuity. Thus there is the question of environmental discontinuity between intrauterine conditions characterized by existence of microgravity and extrauterine life with gravity as a developmental condition sine qua non. Four-dimensional ultrasound is currently being assessed as a functional prenatal screening test for detection of neurological impairment in utero. The Kurjak Antenatal Neurodevelopmental Test (KANET) combines the assessment of fetal behavior, general movements, and three out of four signs that have been postnatally considered as symptoms of possible neurodevelopmental impairment (neurological thumb, overlapping sutures and small head circumference). Although the KANET has been tested on normal and high-risk pregnancies, the significance of the test for detection and prevention of neurodevelopmental disability is still questionable.

Alcohol delays the emergence of the fetal elicited startle response, but only transiently

Prenatal exposure to alcohol may exert a significant detrimental effect on the functioning of the individual's brain, however few studies have examined this before birth. This longitudinal study examined the effect of maternal alcohol consumption on the elicited startle response of the fetus. Two groups of fetuses were examined: one whose mothers drank alcohol (approximately 10 units per week); the other whose mothers did not drink alcohol. Fetuses were examined at 29, 32 and 35 weeks gestation and their startle response observed using ultrasound in response to 2 presentations of a pink noise (70-250Hz) at 90dB(A) separated by 30s. Fetuses exposed to alcohol exhibited a weaker startle response at 29 weeks gestation than did fetuses not exposed to alcohol. There was no difference in the response at 32 and 35 weeks gestation. To ensure that the effects were not due to a more general effect of alcohol on fetal movement, a second experiment compared the spontaneous movements (observed on ultrasound for 45 min) of fetuses whose mothers drank alcohol and fetuses of mothers who didn't drink alcohol. There were no differences in movements exhibited by the fetuses. The results suggest that exposure to alcohol delays the emergence of the elicited startle response at 29 weeks gestation but this delay has disappeared by 32 weeks gestation. The possible role of altered neural development, acute exposure to alcohol and disruptions to the fetus's behavioural repertoire, in mediating these effects are discussed.

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.

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.

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.

3D and 4D sonography and magnetic resonance in the assessment of normal and abnormal CNS development: alternative or complementary

Advanced transvaginal neurosonography has revealed normal and abnormal intracranial morphology. Transvaginal three-dimensional (3D) sonography demonstrates bony structure, multiplanar analysis of inside detailed morphology, tomographic ultrasound imaging in any cutting sections, 3D sonoangiography and volume calculation of ventricles and/or intracranial lesions. Longitudinal assessment of normal and abnormal central nervous system (CNS) development is done by serial scanning. However, the transvaginal high-frequency approach has several limitations due to lack of penetration and cranial bone ossification with advanced gestational age. Magnetic resonance neuroimaging enabled observation of the whole intracranial cavity, brainstem and cortical gyral/sulcal development. On the other hand, neuro-sonography has advantages in detecting intracranial calcification, vascular abnormalities, intratumoral vascularity and bone dysplasia. Moreover, 3D ultrasound demonstrates extra CNS abnormalities, strongly associated with CNS abnormalities. Any less-invasive modalities can be used for a CNS anomaly screening scan and ultrasound is no doubt the first choice. Once CNS abnormality is suspected, it is suggested to use the different technologies according to what is looked for in each abnormal CNS case. Of course, MR and 3D ultrasound imaging should be complementary as well as alternative.

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.

Contribution of Transvaginal High-Resolution Ultrasound in Fetal Neurology

Transvaginal high-resolution ultrasound and three-dimensional (3D) ultrasound have been establishing sonoembryology as well as neurosonography in the first trimester. Fetal brain is rapidly developing and changing its appearance week by week during pregnancy. The most important organ, but it is quite hard to observe detailed structure of this organ by conventional transabdominal sonography. It is possible to observe the whole brain structure by magnetic resonance imaging in the post half of pregnancy, but it is difficult in the first half gestation, and transvaginal high-resolution 3D ultrasound is the most powerful modality. As for brain vascularization, main arteries and veins have been demonstrated and evaluated in various CNS conditions. Transvaginal high-resolution 3D ultrasound can demonstrate cerebral fine vascular anatomy, such as medullary vessels and it is greatly expected to estimate neurological prognosis relating with vascular development during fetal period.

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.