The relationship between the quantity and quality of prenatal movements in pregnancies complicated by intra-uterine growth retardation and premature rupture of the membranes

Intrauterine twin environment and genetic factors subliminally affecting general movements in preterm infants

BACKGROUND

Understanding background factors is beneficial for interpreting general movements (GMs). This study examines the factors involved in preterm-writhing GMs by comparing twins and singletons.

METHOD

The subjects were 107 infants cared for at Oita University. The cohort consisted of very-low-birth-weight infants, including twins with a birth weight < 2000 g. The median gestational age (GA) was 29 weeks 1 day. The subjects consisted of 75 singletons, 32 twins (16 pairs), 20 monochorionic twins (M-twins), and 12 dichorionic twins (D-twins). GMs were scored according to the GMs optimality score (GMOS) and integrated into 6 items: the quality, neck-trunk and space, amplitude-speed, rotation, onset-offset and cramped, and tremulous score at 32-34 weeks, 35-36 weeks, and 37-42 weeks' GA. A hierarchical cluster analysis was performed using integrated GMOS, and the characteristics of clusters were examined according to clinical backgrounds.

RESULTS

Three clusters were identified. Cluster 1 was characterized by good-quality GMs, cluster 2 by a poor repertoire but optimal space and rotatory components, and cluster 3 by overall poor-quality GMs, respectively. The mean GMOSs were 36.6, 31.8 and 24.3 in clusters 1, 2, and 3, respectively. There were no marked differences in proportions within clusters with respect to sex and twins. Small-for-gestational age (SGA) was significantly more frequent in cluster 3 at 32-34 weeks' GA than in other clusters. Perinatal brain injury had a significantly lower proportion in cluster 1 and a higher proportion in cluster 3 at 35-36 weeks' GA and 37-42 weeks' GA. M-twin pairs tended to belong to the same clusters at 35-36 weeks' GA.

CONCLUSION

Preterm writhing GMs are associated with SGA and perinatal brain injury. Cluster matching in M-twins suggests that certain genetic factors may substantially influence GMs.

Fetal akinesia deformation sequence and massive perivillous fibrin deposition resulting in fetal death in six fetuses from one consanguineous couple, including literature review

Background

Massive perivillous fibrin deposition (MPFD) is associated with adverse pregnancy outcomes and is mainly caused by maternal factors with limited involvement of fetal or genetic causes. We present one consanguineous couple with six fetuses developing Fetal Akinesia Deformation Sequence (FADS) and MPFD, with a possible underlying genetic cause. This prompted a literature review on prevalence of FADS and MPFD.

Methods

Fetal ultrasound examination, motor assessment, genetic testing, postmortem examination, and placenta histology are presented (2009–2019). Literature was reviewed for the association between congenital anomalies and MPFD.

Results

All six fetuses developed normally during the first trimester. Thereafter, growth restriction, persistent flexed position, abnormal motility, and contractures in 4/6, consistent with FADS occurred. All placentas showed histologically confirmed MPFD. Genetic analyses in the five available cases showed homozygosity for two variants of unknown significance in two genes, VARS1 (OMIM*192150) and ABCF1 (OMIM*603429). Both parents are heterozygous for these variants. From 63/1999 manuscripts, 403 fetal outcomes were mobilized. In 14/403 fetuses, congenital abnormalities in association with MPFD were seen of which two fetuses with contractures/FADS facial anomalies.

Conclusion

The low prevalence of fetal contractures/FADS facial anomalies in association with MPFD in the literature review supports the possible fetal or genetic contribution causing FADS and MPFD in our family. This study with literature review supports the finding that fetal, fetoplacental, and/or genetic components may play a role in causing a part of MPFDs.

Reduced fetal movements at term, low-risk pregnancies: is it associated with adverse pregnancy outcomes? Ten years of experience from a single tertiary center

OBJECTIVE

We aimed to assess the outcomes of low-risk pregnancies complicated by isolated reduced fetal movements (RFM) at term.

STUDY DESIGN

The study population were patients at term, with singleton, low-risk, pregnancies who presented to our obstetric-triage and delivered during the subsequent 2 weeks. The study group included patients with an isolated complaint of RFM (RFM group). The control group included patients without history of RFM (control group). The pregnancy, delivery, and neonatal outcomes were compared between the groups. Severe and mild composites of adverse neonatal outcomes were defined. Multivariate regression analyses were performed to identify independent association with adverse neonatal outcomes.

RESULTS

Among the 13,338 pregnant women, 2762 (20.7%) were included in the RFM group and 10,576 (79.3%) in the control group. The RFM group had higher rates of nulliparity (p < 0.001), and smoking (p < 0.001). At admission, the RFM group had higher rates of IUFD (p < 0.001). The RFM group had higher rates of Cesarean delivery due to non-reassuring fetal monitor (p < 0.001), and mild adverse neonatal outcomes (p = 0.001). RFM was associated with mild adverse outcome independent of background confounders (aOR = 1.4, 95% CI 1.2-2.6, p < 0.001).

CONCLUSION

Patients presented with isolated RFM at term had higher rates of IUFD at presentation and significant adverse outcomes at delivery.

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.

Fetal general movements and brain sonography in a population at risk for preterm birth

BACKGROUND

General movements (GMs) assessed three months post term are related to brain injury and neurological outcome.

AIMS

To study GMs in fetuses and their predictive value for echogenicity changes in the fetal brain.

STUDY DESIGN

Prospective study of fetal GMs (classified as normal or abnormal) and echogenicity changes in the periventricular, basal ganglia/thalami area, and ventricular system (classified as absent, mild or moderate).

SUBJECTS

121 fetuses from pregnancies affected by hypertensive disorders and/or preterm labour, at risk for preterm birth (26-34weeks gestational age).

OUTCOME MEASURES

Prevalence of abnormal GMs, GM parameters (amplitude, speed and complexity), and moderate echogenicity changes in the fetal brain (periventricular >or=IB, intraventricular grade II/III, and basal ganglia/thalamus locally increased). Predictive values of GMs for clinical parameters and moderate echogenicity changes.

RESULTS

GMs were abnormal in 58%, with amplitude affected in 96%, and speed and complexity in 59%. Abnormal GMs correlated with oligohydramnios (p=0.002) and hypertensive disorders (p=0.015). Echogenicity changes of the brain were absent, mild and moderate in 27%, 39% and 31%, respectively. The sensitivity of GMs for moderate echogenicity changes in the three areas combined was 0.65, and the periventricular area 0.85, specificity both 0.44, negative predictive values 0.73 and 0.96 respectively.

CONCLUSIONS

Qualitative abnormal GMs are frequent in fetuses of compromised pregnancies, and correlate with hypertensive disorders and oligohydramnios. The amplitude of GMs was most frequently affected. Abnormal GMs relate to moderate echogenicity changes especially in the periventricular area of the fetal brain, while normal GMs predict absence of moderate echogenicity changes.

Movement analysis in neonates with spina bifida aperta

INTRODUCTION

In neonates with spina bifida aperta (SBA), leg movements by myotomes caudal to the meningomyelocele (MMC) are transiently observed. It is unclear whether these leg movements relate to functional neural conduction through the MMC. For optimal therapeutical intervention, pathophysiological insight in these transient leg movements seems relevant. If leg movements by myotomes caudal to the MMC concur with the execution of general movements (GMs), functional neural conduction through the MMC is implicated.

OBJECTIVE

In neonates with SBA, we aimed to determine whether the transiently present leg movements caudal to the MMC indicate functional neural conduction through the MMC.

METHODS

During the perinatal period, fetuses and neonates with SBA (n = 7 and n = 13, respectively) were longitudinally analysed for concurrency between leg movements caudal to the MMC and GMs. To address the integrity of the reflex arc in spinal segments (at, or) caudal to the MMC, tendon leg reflexes were assessed during the first postnatal week.

RESULTS

At postnatal day 1, leg movements caudal to the MMC concurred with GMs in 12 of 13 infants. Isolated leg movements were observed in only 3 of these 12 infants (isolated vs. concurrent; p < 0.005). Leg movements concurring with GMs lasted longer than isolated leg movements (median duration = 11 s vs. 2 s; p < 0.05). Between days 1 and 7, tendon leg reflexes (at, or) caudal to the MMC had disappeared in all but 1 neonate. However, leg movements caudal to the MMC remained concurrently present with GMs in all five neonates available for follow-up after day 7. Comparing these leg movements between days 1 and 7 indicated a decreased duration (-44%, p < 0.05).

CONCLUSIONS

In neonates with SBA, leg movements caudal to the MMC concur with GMs, indicative of functional neural conduction through the MMC. The disappearance of these leg movements is caused by lower motor neuron dysfunction at the reflex arc, whereas neural conduction through the MMC is still functional.

Acid-base status at birth, spontaneous motor behaviour at term and 3 months and neurodevelopmental outcome at age 4 years in full-term infants

OBJECTIVE

The aim of the study was to assess the relationship between acid-base status and quality and quantity of General Movements (GMs) at birth and quality of GMs at age 3 months and motor, cognitive and behavioural functioning at the age of 4 years.

METHODS

From a cohort of 84 term children with different umbilical artery pH without severe neonatal neurological abnormalities, GMs were assessed at term and at 3 months. At the age of 4 years, 44 children were assessed by means of the Movement Assessment Battery for Children (Movement-ABC), Neurological Examination for Toddlers of Hempel, Kaufman Assessment Battery for Children information processing (Kaufman ABC), Visuomotor Integration (VMI), the Child Behaviour Checklist (CBCL) and Precursors ADHD Questionnaire (PAQ).

RESULTS

We found no relationship between pH or GM-quality and quantity at term or GM-quality at 3 months and scores on most of the items of the Movement-ABC, cognitive and behavioural outcome. However, neonatal pH value and GM-quality at 3 months were related to some extent to the presence of subtle signs of neuromotor dysfunction as measured by the Hempel test.

CONCLUSIONS

In a sample of infants with a large variation in umbilical artery pH and without severe neonatal neurological abnormalities, acid-base status at birth and quality of GMs at 3 months of age is not predictive for motor milestone achievement, cognitive and behavioural functioning at 4 years, but these parameters are related to a less optimal condition of the nervous system. The latter finding has, however, limited clinical significance.

Role of motility in embryonic development I: Embryo movements and amnion contractions in the chick and the influence of illumination

This study provides a quantitative analysis of the active movements of the chick embryo and of the contractions of the amnion over the entire developmental period of 21 days. Four types of embryo movements are distinguished. The motor activity of the embryo shows two characteristic peaks, with maximum contraction frequencies on the 12th and on the 16th day. In contrast, the amnion activity is higher at earlier stages and decreases as the body activity increases. The amnion activity is largely independent of the body activity. Illumination has a strong influence on embryo movements. It is shown that increases of light intensity affect the patterns of activity of both the embryo and the amnion. While the effect of light on the embryo can be interpreted as being transmitted via the optic system, the mechanism of the amniotic response is unclear. The results suggest that the amnion itself may be sensitive to light. J. Exp. Zool. (Mol. Dev. Evol.) 291:186-194, 2001.

The compromised intra-uterine environment: implications for future lung health

1. Epidemiological studies of infants, children and adults indicate that prenatal compromises that restrict fetal growth and cause low birthweight increase the risk of respiratory deficiencies after birth. 2. It is apparent that the lung has a limited ability to recover from early developmental compromises and that altered development can permanently impair lung architecture. 3. Lung development in utero can be adversely affected by factors associated with fetal growth restriction, namely fetal hypoxaemia, reduced substrate supply and hypercortisolaemia. 4. We have conducted a series of studies of respiratory development in chronically catheterized ovine fetuses and postnatal lambs in which growth restriction was induced during late gestation by embolizing the umbilico-placental vascular bed, a technique that replicates key aspects of human placental insufficiency. 5. During late gestation, restricting the growth of the ovine fetus did not alter lung weight or lung liquid secretion or volume when each factor was related to bodyweight, but it did lead to increased lung DNA concentrations and an increased thickness of the air-blood barrier. Expression of pulmonary surfactant proteins A, B and C were not altered and, hence, it was unlikely that surfactant protein synthesis had been impaired by growth restriction. 6. When growth restriction continued to term, lambs were born with a low birthweight and remained small compared with controls for 8 weeks after birth. Low-birthweight lambs were mildy hypoxaemic and compliances of their lungs and chest wall were, respectively, decreased and increased relative to controls. Pulmonary surfactant proteins A, B and C were not deficient, indicating that decreased lung compliance most likely had a structural basis.

Quantitative analysis of fetal general movements: methodological considerations

OBJECTIVES

We studied the effects of gestational age and various smoothing procedures on four incidence parameters of fetal general movement, to evaluate reported variation in previous studies and to establish the optimal way of smoothing.

SUBJECTS AND METHODS

General movements were studied longitudinally between 24 and 40 weeks of gestation in 29 healthy fetuses. The number of movement bursts per hour, burst duration, onset-onset interval between successive bursts (OOI) and the percentage incidence were analysed in detail.

RESULTS

Advancing gestation was characterised by a proportional increase in OOI's lasting > 60 s and a decreased number of bursts, whereas burst duration remained relatively stable (unsmoothed data). Smoothing resulted in an exaggerated decrease in the number of bursts and in increases in burst duration, OOI and percentage incidence. These changes occurred in a gestational age specific manner and could largely explain the variation in results between previous studies.

CONCLUSIONS

The temporal patterning of fetal general movements undergoes developmental change, as shown by differential effects of smoothing between mid and late pregnancy. A smoothing procedure is to be preferred which includes short intervals (1-3 s) between the elements composing a burst, since small changes in movement generation can still be recognised this way.

Spontaneous motor activity in the perinatal infant before and after birth: stability in individual differences

This study was undertaken to determine if a relationship existed between the duration of spontaneous general movements before and after birth. Twenty-two infants were examined three times as fetuses between 38 and 40 weeks gestational age and three times as neonates between 2 and 4 weeks postnatal age. Motor activity level during active sleep periods was quantified by direct sonographic visualization for fetuses and by videotaped images of trunk movement for neonates. We found that both fetuses and neonates exhibited stable individual differences in motor activity level. In addition, infants who moved at a certain rate as fetuses generally moved at the same relative rate as neonates up to 4-weeks postnatal age. Our findings suggested that individual differences in motor activity level in the 1st month following birth probably arise during fetal life.

Computer-assisted analysis of fetal movements in intrauterine growth retardation (IUGR)

A quantitative analysis of various fetal activities (mouth, eye and gross body movements) was made in 10 IUGR human fetuses. The aim of the study was to see whether IUGR fetuses move differently to normal fetuses. Each real-time ultrasound recording lasted 1 h and the analysis of various activities was carried out during replay of video recordings by means of a specially designed computer program. The following aspects have been investigated: (1) incidence, duration and interval for each of the fetal activities described; (2) the relationship between incidence, duration and interval for each single activity; (3) the correlations between the different activities. The results were compared with a group of 10 fetuses from normal pregnancies. On quantitative evaluation no clear effects due to uncomplicated IUGR could be detected except for median duration of eye movements, which turned out to be longer in the IUGR group. The evaluation of correlations between the characteristics (incidence, duration and interval) of each activity showed a positive correlation between incidence and duration of mouthing movements in the IUGR group, not found in the normal group. The study of the correlation between different fetal activities has shown an inverse correlation between mouthing and other activities in the normal fetuses, not found in the IUGR group. We conclude that in mildly affected fetuses with no evidence of hypoxia, there are no quantitative differences compared to normal fetuses in terms of the motility studied. The only differences found were in relation to the performance of such activities and they could reflect a dysfunction of the central nervous system resulting from a metabolic disturbance.

Is neurological assessment of the fetus possible?

The possibility to assess the functional condition of the fetal nervous system is of great importance to the obstetrician, since a considerable part of early brain damage is of prenatal origin. Several attempts to develop such a technique are reviewed. In addition, a new method, the qualitative assessment of fetal general movements, is described as a successful tool to obtain reliable data on the fetal brain dysfunction. This new method is robust, non-intrusive and cost-effective. There is also the advantage that the same criteria for the diagnostic assessment can be used for the fetus as well as for the young infant.

Assessment of the quality of general movements in fetuses and infants of women with type-I diabetes mellitus

The effect of type-I diabetes on the quality of general movements (GMs) was studied longitudinally in 12 human fetuses. GMs were analysed at two-weekly intervals from 16 weeks until delivery. A pregnancy optimality-score and a diabetes optimality-score were used to cover the course of the pregnancy and delivery and the severity of diabetes. GMs of infants were analysed 1, 4-6, and 12-18 weeks after birth and the Bayley developmental test was performed at 10 months. All fetuses showed normal GMs at 16 weeks. From 20 weeks onwards until delivery five fetuses developed abnormal GMs. The diabetes optimality-score was significantly lower in the group with abnormal GMs (P = 0.018) whereas the pregnancy optimality-score did not differ between fetuses with normal and abnormal GMs. Our results indicate that type-I diabetes can have a negative impact on prenatally observed GMs. Consistently normal GMs indicate normal neurodevelopmental outcome at 10 months whereas in the group with abnormal GMs reduced Bayley-scores may occur.

Spontaneous motility in preterm, small-for-gestational age infants. I. Quantitative aspects

The developmental course of the quantitative aspects of early spontaneous motility was studied longitudinally in fourteen intrauterine growth-retarded infants, with a birth weight below the 5th percentile, in relation to perinatal variables, brain ultrasound findings and neurological outcome. Quantitative motility was studied during the preterm period until term age, from 1 h videotape recordings, using Prechtl's classification of different spontaneous movement patterns. Comparison to a low-risk reference group, consisting of preterm, appropriate-for-gestational age infants, showed that significant differences were inconsistent and obviously by chance, with the possible exception of a decreased rate of startles from the 2nd to the 6th postnatal weeks. A trend of increasing duration of GMs was present with increasing postnatal age. There were hardly any correlations between perinatal variables and quantitative motility, and if present the correlations were weak. Such correlations were found between the reduction of heart-rate variability on cardiotocography and the rate of startles and twitches during the first week and furthermore between the neonatal blood glucose level and the rate of isolated arm movements and total motility during the first week. This study demonstrates that intrauterine growth retardation has little or no influence on the quantitative aspects of spontaneous motility postnatally during the preterm period.

State of the art of a new functional assessment of the young nervous system. An early predictor of cerebral palsy

The paper provides a survey of the state of the art of a new neurological diagnostic procedure in fetuses, preterm and term infant as well as in young infants. This method consists of a judgement of the movement quality of a particular type of spontaneous movements, the so-called general movements. At a very early age normal and abnormal general movement quality predicts the neurological outcome over 2 years, in particular cerebral palsy. The reliability of this method turned out to be very robust. Recent animal experiments on isolated parts of the central nervous system provide convincing evidence of endogenously generated neural activity. Similar neural mechanisms must provide the basis for spontaneous movements seen in the human at early ages. Those neural defects leading to qualitative changes of general movements are described in detail.

Pulmonary hypoplasia and fetal breathing in preterm premature rupture of membranes

Forty-eight patients with premature rupture of membranes prior to 24 weeks gestation (PPROM) were studied to investigate whether there was any difference in fetal breathing movements in those fetuses that did or did not develop pulmonary hypoplasia. The diagnosis of pulmonary hypoplasia was made on the basis of ultrasound measurement of fetal lung length. A control group of fetuses with intact membranes and normal pregnancies at the same gestation was also studied. The group that developed pulmonary hypoplasia had significantly less breathing movements than those that did not develop pulmonary hypoplasia and controls. This reduction in breathing movements may contribute to the development of pulmonary hypoplasia.

Studies on fetal motor behaviour in normal and complicated pregnancies

The possibility of studying fetal motor behaviour by ultrasound techniques has provoked research on its potential application for assessment of prenatal neurological conditions. The characteristics ('quality') of one particular movement pattern, the 'general movement', has been shown to be discriminative between uncomplicated pregnancy and major pathology of the developing central nervous system. Some recent studies have investigated whether the quality and/or the quantity of fetal movements correlated with other clinical variables during complicated pregnancies, and whether they provided prognostic information for the neurological outcome. Longitudinal research encompassing the pre- and postnatal periods was performed on uncomplicated pregnancies and on pregnancies complicated by intrauterine growth retardation, oligohydramnios (due to premature rupture of the amniotic membranes), or fetal breech position. Although the quantity of both fetal general movements and fetal breathing movements were found to be related to clinical variables of the fetal condition (such as heart rate variability, heart rate decelerations), clinical application seems limited due to large inter- and intra-individual variabilities. In contrast, the quality of fetal general movements appeared highly correlated with parameters of fetal clinical condition in individual cases and fulfilled several prerequisites for serving as a reliable diagnostic tool for prediction of the fetal condition and for assessment of the integrity of the central nervous system.