Abstract
Aim: The aim of the study was to observe different expressions and movements of a fetal face during investigation of fetal behavior in the second and the third trimester of normal pregnancies, as a probable manifestation of fetal awareness.
Subjects and methods: Over a 6-month period a study was conducted in three centers in Zagreb, Croatia and in Barcelona and Malaga, Spain. Women with singleton pregnancies (16–33 weeks) who were referred for ultrasound check-up for determination of gestational age, suspicious fetal malformations, polyhydramnios, and/or the assessment of biophysical profile or other possible pathology, were assigned to the study. After regular two-dimensional (2D) ultrasound assessment at an antenatal clinic, pregnant women were offered the possibility of undergoing 4D ultrasound examination if the fetus and the mother were considered “normal”, i.e., if ultrasound and clinical assessment were uneventful. If the newborn delivered at term had 1- and 5-min Apgar scores of 7 and 10, respectively, and if the newborn was considered “term and normal” (normal spontaneous activity, normal posture and tone, and presence of some primitive reflexes) at the first and subsequent regular check-ups, the inclusion criteria were deemed to have been met. Out of 119 patients, 99 fulfilled the inclusion criteria, 40 of whom were in the second, and 59 in the third trimester of pregnancy. A Voluson 730 Expert system with a transabdominal 5-MHz transducer was used for 4D ultra- sonography. After regular 2D scanning, the 4D mode was switched on, and a live 3D image was reconstructed by selecting ideal 2D mid-sagittal images of the face (the region of interest). The volume was automatically scanned every 2 s while the surface-rendered mode was switched on, and 4D images were displayed on the screen and recorded on videotape during a 30-min observation period. Movements of the following fetal face structures were analyzed: forehead, brows, nasal soft tissue and nasolabial folds, upper lip, oral cavity and tongue, lower lip and chin, eyelids and eyes, mouth and mouth angles, and facial expression. 4D ultrasonography allowed in utero observations of fetal facial expressions such as smiling, yawning, and swallowing.
Results: The quality of 4D depiction of fetal facial expressions increased with gestational age. The frequency of fetal facial expressions such as yawning ranged from 1 and 6 with a median of 1.5 per 30-min observation period; smiling ranged from 2 and 8 with the median of 2; tongue expulsion ranged from 2 to 6, median 3; mouth and eye squeezing ranged from 5 to 10, median 6; scowling ranged from 1 to 3, median 0.5; and isolated eye blinking ranged from 4 to 12 with a median of 5.
Conclusions: Our study shows the ability of 4D sonography to depict different facial expressions and movements, which might represent fetal awareness. Never-theless, long, precise and thorough observation of fetal faces by 4D sonography was hampered as the images were only near real-time. Thus, we were only able to study the quality and not the quantity of facial movement patterns.
References
1 Arabin B: Two-dimensional real-time ultrasound in the assessment of fetal activity in single and multiple pregnancies. Ultrasound Rev Obstet Gynecol4 (2004) 3710.3109/14722240410001700258Search in Google Scholar
2 Azumendi G, A Kurjak: Three-dimensional and four-dimensional sonography in the study of the fetal face. Ultrasound Rev Obstet Gynecol3 (2003) 160Search in Google Scholar
3 Benacerraf B: The future of ultrasound: viewing the dark side of moon?Ultrasound Obstet Gynecol23 (2004) 21110.1002/uog.993Search in Google Scholar
4 Blin O, JP Azulay, G Masson, G Serratrice: Le bâillement. Physiopathologie et neuropharmacologie. Therapie46 (1991) 37Search in Google Scholar
5 Chambers D, IM McGonnel: Neural crest: facing the facts of head development. Trends Genet18 (2002) 381Search in Google Scholar
6 Cioni G, HFR Prechtl: Preterm and early postterm motor behaviour in low-risk premature infants. Early Hum Dev23 (1990) 159Search in Google Scholar
7 De Meyer V, W Zemen, CG Palmer: The face predicts the brain: diagnostic significance of medial facial anomalies for holoprosencephaly (arhinencephaly). Pediatrics34 (1964) 256Search in Google Scholar
8 De Vries MP, GHA Visser, HFR Prechtl: The emergence of fetal behavior. Early Hum Dev7 (1982) 301Search in Google Scholar
9 Diewert VM: Development of human craniofacial morphology during late embryonic and early fetal periods. Am J Orthod88 (1985) 6410.1016/0002-9416(85)90107-1Search in Google Scholar
10 England MA: Anatomical development of the CNS. In: Levene MI, FA Chervenak, M Whittle (eds): Fetal and neonatal neurology and neurosurgery, 3rd Ed. Churchill Livingstone, London 2001, p 21Search in Google Scholar
11 Hadders-Algra M, WJ Klip-Van den Niewcendijk, A Martijn, L van Eyken. Assessment of general movements: towards a better understanding of a sensitive method to evaluate brain function in young infants. Dev Med Child Neurol39 (1997) 89Search in Google Scholar
12 Humphrey T: Some correlations between the appearance of human fetal reflexes and the development of the nervous system. Prog Brain Res4 (1964) 9310.1016/S0079-6123(08)61273-XSearch in Google Scholar
13 Kostovic I, M Judas, Z Petanjek, G Šimić: Ontogenesis of goal-directed behavior: anatomo-functional considerations. Int J Psychophysiol19 (1995) 85Search in Google Scholar
14 Kuma A, M Akiyama, C Yamashiro, H Tanaka, T Yanagihara, T Hata: Three-dimensional sonographic assessment of fetal behavior in the early second trimester of pregnancy. J Ultrasound Med20 (2001) 1271Search in Google Scholar
15 Kurjak A: The beginning of human life and its modern scientific assessment. Clin Perinatol30 (2003) 2710.1016/S0095-5108(02)00087-8Search in Google Scholar
16 Kurjak A, G Azumendi, N Veček, S Kupešić, M Solak, D Varga, F Chervenak: Fetal hand movements and facial expression in normal pregnancy studied by four-dimensional sonography. J Perinat Med31 (2003) 496Search in Google Scholar
17 Kurjak A, M Stanojevic, W Andonotopo, A Salihagic-Kadic, JM Carrera, G Azumendi: Behavioral pattern continuity from prenatal to postnatal life – a study by four-dimensional (4D) ultrasonography. J Perinat Med32 (2004) 346Search in Google Scholar
18 Legercrantz H, T Ringstedt: Epigenetic and functional organization of the neuronal circuits in the CNS during development. In: Levene MI, FA Chervenak, M Whittle (eds): Fetal and neonatal neurology and neurosurgery, 3rd Ed. Churchill Livingstone, London 2001, p 3Search in Google Scholar
19 McManus B, RD Brandstetter: A fetal yawn. New Engl J Med336 (1997) 1329Search in Google Scholar
20 Nijhuis IJM, JG Nijhuis: Functional assessment of the fetal CNS. In: Levene MI, FA Chervenak, M Whittle (eds): Fetal and neonatal neurology and neurosurgery, 3rd Ed. Churchill Livingstone, London 2001, p 89Search in Google Scholar
21 Petrikovsky BM, GP Kaplan, H Pestrak: The application of color Doppler technology to the study of fetal swallowing. Obstet Gynecol86 (1995) 605Search in Google Scholar
22 Prechtl FHR: Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Hum Dev23 (1990) 15110.1016/0378-3782(90)90011-7Search in Google Scholar
23 Prechtl HFR: State of the art of a new functional assessment of the young nervous system. An early predictor of cerebral palsy. Early Hum Dev50 (1997) 110.1016/S0378-3782(97)00088-1Search in Google Scholar
24 Rotten D, JM Levaillant: Two- and three-dimensional sonographic assessment of the fetal face. 1. A systematic analysis of the normal face. Ultrasound Obstet Gynecol23 (2004) 224Search in Google Scholar
25 Salihagić-Kadić A, M Medić, A Kurjak: Neurophysiology of fetal behavior. Ultrasound Rev Obstet Gynecol4 (2004) 2Search in Google Scholar
26 Sepulveda W, M Mangiamarchi: Fetal yawning. Ultrasound Obstet Gynecol5 (1995) 57Search in Google Scholar
27 Sherer DM, J Smith, JS Abramowicz: Fetal yawning in utero at 20 weeks gestation (letter). J Ultrasound Med10 (1991) 68Search in Google Scholar
28 The Royal College of Obstetricians and Gynaecologists: Fetal awareness: report of a working party. RCOG Press, London 1997Search in Google Scholar
29 Timor-Tritsch IE, LD Platt: Three-dimensional ultrasound experience in obstetrics. Curr Opin Obstet Gynecol14 (2002) 569Search in Google Scholar
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