Maja Predojević

The potential of 4D sonography in the assessment of fetal behavior in high-risk pregnancies

Objective. To assess differences of fetal behavior in normal and high-risk pregnancies. Methods. In the 1-year period (1 January 2007–31 December 2007), four-dimensional ultrasound has been used to assess Kurjak antenatal neurodevelopmental test (KANET) in low- and high-risk pregnancies after randomization in prospective longitudinal cohort study. Based on the KANET scores, the fetuses were considered as normal (≥14 points), borderline (6–13), or abnormal (0–5). Results. Comparison of KANET scores in low- and high-risk pregnancies were expectedly statistically significant. The largest incidence of fetuses with abnormal KANET was in the group of fetuses who had siblings with cerebral palsy. The largest incidence of the borderline KANET has been found in the group of fetuses whose mothers had fever during pregnancy. The following parameters of KANET test significantly differed between the fetuses from low- and high-risk pregnancies: overlapping cranial sutures, head circumference, isolated eye blinking, facial expressions, mouth movements, isolated hand movements, isolated leg movements, hand to face movement, finger movements, and general movements. Conclusion. KANET test has the potential to detect and discriminate normal from borderline and abnormal fetal behavior in normal and in high-risk pregnancies.

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.

Assessment of motoric and hemodynamic parameters in growth restricted fetuses – case study

Abstract Objective: In order to more accurately assess fetal neurological status in five fetuses with severe intrauterine growth restriction (IUGR), combined assessment of their hemodynamics and motor activity was undertaken in this study. Method: Hemodynamic changes in the placental and fetal cerebral vessels were evaluated using the umbilical artery resistance index (URI), and the middle cerebral artery resistance index (CRI). The blood flow redistribution towards the fetal brain in response to fetal hypoxia was detected by the C/U (cerebro – umbilical) ratio, expressed as CRI/URI. Motoric parameters were assessed by new antenatal neurologic scoring test named Kurjak Antenatal Neurodevelopmental Test (KANET), based on evaluation of spontaneous motor activity using four-dimensional (4D) ultrasound. Results: KANET has potential in recognizing pathologic and borderline behavior in IUGR fetuses with or without blood flow redistribution towards the fetal brain. Very low values of C/U ratio and abnormal KANET score have indicated adverse pregnancy outcome. Conclusion: In some pregnancies complicated with IUGR, estimation of the risk of hypoxia versus prematurity can be extremely puzzling. Combined assessment of hemodynamic and motoric parameters in IUGR fetuses could allow construction of an algorithm, which would be helpful in the decision making process of pregnancy termination.

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.

Prenatal and postnatal neurological evaluation of a fetus and newborn from pregnancy complicated with IUGR and fetal hypoxemia

In this case report, we present prenatal and postnatal neurological evaluation of a fetus and newborn from pregnancy complicated with intrauterine growth restriction, fetal hypoxemia, and preterm labor. Despite unfavorable intrauterine conditions, this premature infant showed normal early neurological development that was verified not only by postnatal tests but also with a new prenatal neurological screening test.

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.

Early functional and morphological brain disturbances in late-onset intrauterine growth restriction.

AIMS To determine whether the brain disturbances develop in late-onset intrauterine growth restriction (IUGR) before blood flow redistribution towards the fetal brain (detected by Doppler measurements in the middle cerebral artery and umbilical artery). Further, to evaluate predictive values of Doppler arterial indices and umbilical cord blood gases and pH for early functional and/or morphological brain disturbances in late-onset IUGR. STUDY DESIGN This cohort study included 60 singleton term pregnancies with placental insufficiency caused late-onset IUGR (IUGR occurring after 34 gestational weeks). Umbilical artery resistance index (URI), middle cerebral artery resistance index (CRI), and cerebroumbilical (C/U) ratio (CRI/URI) were monitored once weekly. Umbilical blood cord samples (arterial and venous) were collected for the analysis of pO2, pCO2 and pH. Morphological neurological outcome was evaluated by cranial ultrasound (cUS), whereas functional neurological outcome by Amiel-Tison Neurological Assessment at Term (ATNAT). RESULTS 50 fetuses had C/U ratio>1, and 10 had C/U ratio≤1; among these 10 fetuses, 9 had abnormal neonatal cUS findings and all 10 had non-optimal ATNAT. However, the total number of abnormal neurological findings was much higher. 32 neonates had abnormal cUS (53.37%), and 42 (70.00%) had non-optimal ATNAT. Furthermore, Doppler indices had higher predictive validity for early brain disturbances than umbilical cord blood gases and pH. C/U ratio had the highest predictive validity with threshold for adverse neurological outcome at value 1.13 (ROC analysis), i.e., 1.18 (party machine learning algorithm). CONCLUSION Adverse neurological outcome at average values of C/U ratios>1 confirmed that early functional and/or structural brain disturbances in late-onset IUGR develop even before activation of fetal cardiovascular compensatory mechanisms, i.e., before Doppler signs of blood flow redistribution between the fetal brain and the placenta.

Fetal neurophysiology according to gestational age

More than 99% of the human neocortex is fashioned during intrauterine life, resulting in the fascinating diversity of fetal functions and activities. The objective of this review is to present the most significant neurodevelopmental events, as well as new findings about prenatal motor and sensory development.

Assessment of the Fetal Neuromotor Development with the New KANET Test

Development of ultrasound technology, especially four-dimensional (4D) ultrasound, enabled insight into the fetal neuromotor development that is reflected by the repertoire of fetal activities or fetal behavior. Based on that new technology, the Zagreb group proposed a screening test called the Kurjak Antenatal Neurodevelopmental Test (KANET). Over several years, the KANET has been used to assess almost 2000 fetuses. Results are promising, and the test has demonstrated an ability to recognize normal, borderline, and abnormal behavior in fetuses from normal and pathological pregnancies. However, further studies are necessary as well as long-term postnatal monitoring of children who were prenatally evaluated with the KANET in order to determine its clinical value in identification of children with neurological risk.

Neurologic parameters in the perinatal period in children with neurodevelopmental disorders

Cerebral palsy (CP) is a term encompassing a group of nonprogressive, noncontagious conditions causing mild, moderate or severe disorders of neurodevelopment. Objective: Objective of this study was to analyze the possible prenatal etiological factors for the emergence of neurodevelopmental disorders (NDs) and CP from the medical records of 100 children with neuromotor disabilities who were treated in Special Hospital for Children with Neuro-developmental and Movement Disorders, Goljak, Croatia. Results: ND and CP were more often diagnosed in children with birth weight below 2500 g which was statistically proved at the level of significance reaching 0.05, although significant correlation was low for both parameters reaching 0.21. There are both statistically significant differences and the statistically significant correlation between the three gestational age categories within ND and CP. There were more children with the birth weight below 2500 g in the CP than in the ND group and the difference was statistically significant. In the CP group, there were more children with the lower gestational age than in the ND group, which was statistically highly significant. This difference, together with correlation is significant at the level of 0.01. Conclusion: Further studies on the etiology of NDs are needed, with particular focus on the intrauterine risk factors.