Assessment of fetal behavior and general movements by four-dimensional sonography

Maternal perception of fetal movements in the third trimester: A qualitative description

PROBLEM

Decreased fetal movements is a common reason for unscheduled antenatal assessment and is associated with adverse pregnancy outcome.

BACKGROUND

Fetal movement counting has not been proven to reduce stillbirths in high-quality studies.

AIMS

The aim was to explore a qualitative account of fetal movements in the third trimester as perceived by pregnant women themselves.

METHODS

Using qualitative descriptive methodology, interviews were conducted with 19 women experiencing an uncomplicated first pregnancy, at two timepoints in their third trimester. Interview transcripts were later analysed using qualitative content analysis.

FINDINGS

Pregnant women described a sustained increase in strength, frequency and variation in types of fetal movements from quickening until 28-32 weeks. Patterns of fetal movement were consistently described as involving increased movement later in the day and as having an inverse relationship to the women's own activity and rest. At term, the most notable feature was increased strength. Kicking and jolting movements decreased whilst pushing and rolling movements increased.

DISCUSSION

Maternal descriptions of fetal activity in this study were consistent with other qualitative studies and with ultrasound studies of fetal development.

CONCLUSION

Pregnant women observe a complex range of fetal movement patterns, actions and responses that are likely to be consistent with normal development. Maternal perception of a qualitative change in fetal movements may be clinically important and should take precedence over any numeric definition of decreased fetal movement. Midwives may inform women that it is normal to perceive more fetal movement in the evening and increasingly strong movements as pregnancy advances.

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.

What We have Learned from Fetal Neurophysiology?

The nervous system is one of the earliest emerging systems in fetal development. Due to progress of modern imaging technologies, such as ultrasound, a growing pool of information on the development of the central nervous system (CNS) and fetal behavioral patterns has been made available. The major events in the development of the CNS, fetal motor and sensory development as well as fetal response to stress are discussed in this review. The fetus is not entirely protected from harmful influence of the external factors. Postnatal follow-up studies have showed that many environmental influences causing the fetal stress can interfere with the fetal neurodevelopment and leave long-term and profound consequences on brain structure and function.

How to cite this article

SalihagićKadić A, Predojevic M. What We have Learned from Fetal Neurophysiology? Donald School J Ultrasound Obstet Gynecol 2012;6(2):179-188.

4D Sonography in Assessment of Fetal Neurobehavior

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

How to cite this article

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

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.

Four-dimensional Ultrasound Evaluation of Fetal Neurobehavioral Development

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

Further Experience in the Clinical Assessment of Fetal Neurobehavior

Recent development of three-dimensional (3D) and four-dimensional ultrasound (4D) provided us with new possibilities to study fetal movements and behavior. Many studies have been conducted in order to provide information on specific movement pattern appearance in normal and high-risk fetus. This was the base for multicenter study on use of new scoring system for fetal neurobehavior which purpose is to recognize fetuses with increased risk for poor neurological outcome. The purpose of this paper is to give brief review on the use of 3D and 4D ultrasound in the assessment of fetal behavior.

Objectives

Define possibilities to study fetal movements and behavior by 3D and 4D ultrasound

Decribe new scoring system for neurobehavior in fetuses with increased risk for poor neurological outcome

Summarize behavioral perinatology research and potential clinical applications

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

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

Structural and functional early human development assessed by three-dimensional and four-dimensional sonography

OBJECTIVE

To summarize the role of three-dimensional and four-dimensional ultrasound in the assessment of early human development.

DESIGN

Review of literature.

SETTING

Ultrasound research center and obstetrics and gynecology department in a tertiary care facility.

RESULT(S)

The introduction of high-frequency transvaginal tranducers has resulted in remarkable progress in ultrasonographic visualization of early embryos and fetuses and the development of sonoembryology. Furthermore, recent introduction of three-dimensional and four-dimensional ultrasounds combined with the transvaginal approach has produced more objective and accurate information on embryonal and early fetal development. For the first time parallel analyses of structural and functional parameters in the first 12 weeks of gestation become possible.

CONCLUSION(S)

The anatomy and physiology of placental and embryonic development is a field where medicine exerts its greatest impact on early pregnancy at present time, and it opens fascinating aspects of embryonic differentiation. Clinical assessment of those stages of growth rely heavily on three-dimensional and four-dimensional sonography, one of the most promising forms of noninvasive diagnostics today and embryological phenomenon, once matters for textbooks are now routinely recorded with outstanding clarity.