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Weissbach T, Hausman-Kedem M, Yanay Z, Meyer R, Bar-Yosef O, Leibovitch L, Berkenstadt M, Chorin O, Shani H, Massarwa A, Achiron R, Weisz B, Sharon R, Mazaki-Tovi S, Kassif E. Congenital hypotonia: systematic approach for prenatal detection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:94-105. [PMID: 36779229 DOI: 10.1002/uog.26178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Congenital hypotonic conditions are rare and heterogeneous, and some are severely debilitating or lethal. Contrary to its prominent postnatal manifestation, the prenatal presentation of hypotonia is frequently subtle, inhibiting prenatal detection. We aimed to characterize the prenatal sonographic manifestation of congenital hypotonia throughout pregnancy, evaluate the yield of diagnostic tests and propose diagnostic models to increase its prenatal detection. METHODS This was a retrospective observational study of singleton pregnancies with congenital hypotonia, diagnosed either prenatally or immediately after birth, at a single tertiary center between the years 2012 and 2020. Prenatally, hypotonia was diagnosed if a fetus showed sonographic or clinical signs suggestive of hypotonia and had a confirmed underlying genetic condition, or in the absence of a known genetic abnormality if the fetus exhibited multiple prominent signs suggestive of hypotonia. Postnatally, it was diagnosed in neonates displaying reduced muscle tone leading to reduced spontaneous movement, reduced swallowing or feeding difficulty. We reviewed the medical records of pregnant patients carrying fetuses subsequently diagnosed with congenital hypotonia and assessed the yield of ultrasound scans, fetal magnetic resonance imaging, computed tomography and genetic tests. The detection rate of sonographic signs suggesting fetal hypotonia was calculated. The prevalence of non-specific signs, including polyhydramnios, persistent breech presentation, intrauterine growth restriction and maternal perception of reduced fetal movement, were compared between the study group and the local liveborn singleton population. Potential detection rates of different theoretical semiotic diagnostic models, differing in the threshold for referral for a targeted scan, were assessed based on the cohort's data. RESULTS The study group comprised 26 cases of congenital hypotonia, of which 10 (38.5%) were diagnosed prenatally, and the controls included 95 105 singleton live births, giving a prevalence of congenital hypotonia of 1:3658. Nuchal translucency thickness and the early anomaly scan at 13-17 weeks were normal in all 22 and 23 cases, respectively, in which this was performed. The mid-trimester scan performed at 19-25 weeks was abnormal in four of 24 (16.7%) cases. The overall prenatal detection rate of congenital hypotonic conditions in our cohort was 38.5%. Only cases which underwent a targeted scan were detected and, among the 16 cases which underwent this scan, the prenatal detection rate was 62.5% compared with 0% in pregnancies that did not undergo this scan (P = 0.003). An abnormal genetic diagnosis was obtained in 21 (80.8%) cases using the following modalities: chromosomal microarray analysis (CMA) in two (9.5%), whole-exome sequencing (WES) in 14 (66.7%) and methylation analysis in five (23.8%). CMA was abnormal in 8% (2/25) of the cases and WES detected a causative genetic mutation in 87.5% (14/16) of the cases in which these were performed. Comparison of non-specific signs in the study group with those in the local singleton population showed that hypotonic fetuses had significantly more polyhydramnios (64.0% vs 3.0%, P < 0.0001), persistent breech presentation (58.3% vs 4.2%, P < 0.0001), intrauterine growth restriction (30.8% vs 3.0%, P < 0.0001) and maternal perception of reduced fetal movement (32.0% vs 4.7%, P < 0.0001). Prenatally, the most commonly detected signs supporting a diagnosis of hypotonia were structural anomaly (62.5%, 10/16), reduced fetal movement (46.7%, 7/15), joint contractures (46.7%, 7/15) and undescended testes ≥ 30 weeks (42.9%, 3/7 males). Proposed diagnostic strategies that involved performing a targeted scan for a single non-specific ultrasound sign or two such signs, and then carrying out a comprehensive genetic evaluation for any additional sign, offered theoretical detection rates in our cohort of 88.5% and 57.7%, respectively. CONCLUSIONS Congenital hypotonic conditions are rare and infrequently detected prenatally. Sonographic signs are visible from the late second trimester. A targeted scan increases prenatal detection significantly. Comprehensive genetic testing, especially WES, is the cornerstone of diagnosis in congenital hypotonia. Theoretical diagnostic models which may increase prenatal detection are provided. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Weissbach
- Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Hausman-Kedem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Z Yanay
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Schneider Children's Medical Center, Petach Tikva, Israel
| | - R Meyer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - O Bar-Yosef
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Neurology, Safra Children's Hospital, Sheba, Tel Hashomer, Israel
| | - L Leibovitch
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Neonatal Intensive Care Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - M Berkenstadt
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Danek Institute of Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - O Chorin
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Danek Institute of Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - H Shani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Danek Institute of Genetics, Sheba Medical Center, Tel Hashomer, Israel
| | - A Massarwa
- Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Achiron
- Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Sharon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurology, Sheba Medical Center, Tel Hashomer, Israel
| | - S Mazaki-Tovi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - E Kassif
- Institute of Obstetrical and Gynecological Imaging, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Morita M, Ryo E, Kamata H, Seto M, Yatsuki K. Counting fetal movements of small-for-gestational infants using a fetal movement acceleration measurement recorder. J Matern Fetal Neonatal Med 2019; 33:3699-3705. [PMID: 30835606 DOI: 10.1080/14767058.2019.1583732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Our purpose was to clarify whether small-for-gestational (SGA) infants is associated with a decrease in fetal movements (FMs) even in the absence of hypoxia. We used a fetal movement acceleration measurement (FMAM) recorder, which enabled counting gross FMs for hours at a time.Methods: (1) Parameters of FMs for 13 women who delivered SGA infants were plotted over normal reference value curves made from 64 normal pregnant women in another study. (2) Linear regression analysis was conducted for the women with SGA infants and the normal pregnant women.Results: Thirty-eight data recordings were available in the SGA group. (1) For the ratio of movement positive 10-s epoch, 14 recordings (36.8%) were below 10% of the normal values. For an average number of movements, 13 (34.2%) were below 10%. Regarding average number, average duration, and longest duration of non-movement period, 12 (31.6%), 13 (34.2%), and 15 records (39.4%) were above 90% of the normal values, respectively. (2) SGA was a factor that decreased the positive epoch ratio and the average movements number, and increased the average number and duration, and the longest duration of non-movement period.Conclusions: SGA is associated with decreased movements even in the absence of hypoxia.
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Affiliation(s)
- Masayoshi Morita
- Department of Obstetrics and Gynecology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Eiji Ryo
- Department of Obstetrics and Gynecology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Hideo Kamata
- Department of Obstetrics and Gynecology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Michiharu Seto
- Department of Obstetrics and Gynecology, School of Medicine, Teikyo University, Tokyo, Japan
| | - Keita Yatsuki
- Department of Obstetrics and Gynecology, School of Medicine, Teikyo University, Tokyo, Japan
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