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Clinical study of fetal neurobehavior by the KANET test

  • Raul Moreira Neto EMAIL logo und Selma Porovic
Veröffentlicht/Copyright: 8. Januar 2018
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Journal of Perinatal Medicine
Aus der Zeitschrift Journal of Perinatal Medicine Band 46 Heft 6

Abstract

Fetal neurology is evolving as an area of great interest in prenatal diagnosis and fetal medicine. The identification and diagnosis of brain damage prenatally has been a great challenge in obstetrics for many years. Investigations of fetal behavior in comparison with morphological studies led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of the fetal central nervous system (CNS). Four-dimensional (4D) ultrasound has greatly improved the assessment of the quality of the fetal spontaneous movements, and enabled a better evaluation of fetal behavior. The assessment of normal neurobehavioral development by 4D ultrasound provided the opportunity to investigate functional characteristics of the fetus that could predict neurological developmental dysfunction. Some studies have already been carried out to evaluate this new methodology in the observation of fetal behavior during different stages of gestation, in an attempt to better understand the relationships between the maturation of the CNS of the fetus and its implications on its behavior pattern. We present a review of literature on fetal behavior by 4D ultrasound.

Keywords: Fetal behavior; fetal neurologic screening; fetal neurology; four-dimensional ultrasound; prenatal brain impairment

Introduction

Fetal behavior can be described as any fetal action or reaction seen by ultrasound [1]. This fetal activity has been observed by two-dimensional ultrasound (2D US) and many papers on fetal behavior assessed by 2D US have been published up to now [2], [3], [4]. This method of investigation of fetal behavior has limitations, mainly because only the number of movements can be visualized, while the quality of fetal movements could not be assessed. More than this, complex facial movements could not be depicted by using only 2D US, which has been considered as a great disadvantage of 2D US [5], [6]. The development of four-dimensional ultrasound (4D US) has significantly increased the assessment of the quality of fetal movements and permitted better evaluation of fetal behavior compared with the 2D US, especially assessment of facial movements like sucking, yawning, blinking, smiling and even crying [7], [8], [9], [10]. As a result, spontaneous fetal movements, as an expression of neural activity, could be used as a marker for assessment of fetal neurological status [11], [12], [13]. The evaluation of fetal behavior could give the opportunity to recognize the difference between normal and abnormal neurological development, and even an early diagnosis of different structural or functional central nervous system (CNS) abnormalities [11]. It has been proven by many studies that most of the neurological disorders like cerebral palsy (CP) develop prenatally, while postnatal and intrapartum factors are not that important [14], [15]. Analysis of fetal behavior by 4D US should be standardized as is the case with any other clinical test [13], [16]. Kurjak et al. in the field of perinatal neurology have proposed a prenatal screening test for assessment of motor activity called the Kurjak antenatal neurodevelopmental test (KANET) [17]. This test is a continuation of 2D US assessment of fetal behavior using new 4D US techniques and introduces some postnatal signs which have been part of the postnatal neurological assessment developed by the Amiel-Tison neurological assessment at term (ATNAT) [18], [19], [20]. This was a new approach to the assessment of fetal neurological status enabling longitudinal follow-up of fetal behavior throughout gestation, making the clear distinction between neurologically normal, borderline and abnormal fetuses [19], [20], [21], [22], [23].

The aim of this review is to evaluate the contribution of 4D US in the assessment of fetal neurobehavior.

Evaluation of fetal behavior by 4D US

For a long time, the only approach for the follow-up of fetal wellbeing was the maternal sensation of fetal movements and obstetric auscultation of their heartbeats. After the appearance of real-time ultrasound, there was a revolutionary change in the assessment of fetal wellbeing [24]. Undoubtedly, one of the most amazing advancements in ultrasonography was 4D technology [25], [26]. During the last decade, 4D sonography has encouraged studies on fetal behavior with more persuasive imaging data than those obtained by 2D conventional ultrasound and even other nonultrasonic methods [9].

The first embryonic movements begin at the 7th to 8th week of gestation. Motor activity is clearly recognizable, consisting of several movement patterns between the 8th and 9th week and can be observable by 2D US [23], [25], [27], [28], [29]. Prechtl stated that these are gross movements, involving the whole body [11]. But 4D US has enhanced the investigation of the quality of spontaneous fetal movements and implementing a better evaluation of fetal behavior in comparison with 2D ultrasound [7], [9], [10], [30], [31], [32], [33], [34].

The majority of sequences of extension and flexion of the legs and arms are complex and may be better assessed with the 4D US (Figures 1–4). From 10 weeks onward, head anteflexion, retroflection and rotation could easily be observed by this new method [4], [17], as well as facial movements, swallowing, mouth opening and yawning (Figures 5 and 6). Moreover, 4D US seems to be the preferred approach for detecting sophisticated movements such as overlapped rotations and changes in direction. These components make the movements fluent and elegant and create the impression of complexity and variability, which can be shown only by 4D US [35].

Figures 1 and 2: Comparison between 3D (1) and 2D (2) images in the frontal view.
Figures 1 and 2:

Comparison between 3D (1) and 2D (2) images in the frontal view.

Figures 3 and 4: Comparison between 3D (3) and 2D (4) images in the profile view.
Figures 3 and 4:

Comparison between 3D (3) and 2D (4) images in the profile view.

Figures 5 and 6: Mouth opening (5) and yawning (6).
Figures 5 and 6:

Mouth opening (5) and yawning (6).

The second half of pregnancy is characterized by the organization of fetal movement patterns and an increase in complexity of movements [13]. Not only the movements but the periods of rest-activity cycles become recognizable [36].

Besides, the surface rendering mode, seen only in 4D US, improves the visualization of the fetal face and opens the possibility of assessment of a full range of facial expressions, including smiling, crying, scowling and eyelid movements [37], [38], [39] (Figures 7–9). It is not possible to see these complex facial movements using real-time 2D US. Furthermore, 4D US combines the advantage of the spatial imaging of the fetal face with the addition of time, allowing detailed imaging of each fetal facial movement. Now we know that the observation of facial expression may be of scientific and diagnostic value [40] (Figures 10–16).

Figures 7–9: Crying (7), tongue expulsion (8) and smiling (9).
Figures 7–9:

Crying (7), tongue expulsion (8) and smiling (9).

Figures 10–16: Sequences of different facial expressions by 4D ultrasound.
Figures 10–16:

Sequences of different facial expressions by 4D ultrasound.

For many years, obstetricians were concentrated mostly with the number of fetal movements which was considered as an indicator of fetal wellbeing. Later studies have shown that a count of movements is an unsatisfactory indicator of brain activity, mainly due to the great intra-and inter-individual variability and the large variations between normal and abnormal, which makes this method clinically useless [41]. Instead, changes of the elegance and fluency, as well as the variability and fluctuation of intensity and speed of general movements (GMs) were shown to be the best indicator of impaired brain activity, and they are considered to be the first sign of a supra-spinal control of the motor activity [42]. It became unmistakable that the qualitative changes in GMs of both the fetus and the neonate anticipate quantitative changes when the integrity of the nervous system is damaged [43] (Figures 17–19).

Figures 17–19: Complex and sophisticated fetal movements.
Figures 17–19:

Complex and sophisticated fetal movements.

4D US emerged as a practical way for the evaluation of both brain function and structure. The analysis of fetal activity in utero by 4D US may allow early diagnosis of fetal neurological impairment [9], [44], [45]. A group of researchers from Zagreb, Croatia led by Asim Kurjak, have had a great experience using 4D US in the assessment of fetal behavior [17], [29], [46], [47]. Relying on their own experiences in the field of fetal and neonatal neurology, they suggested a new scoring system for evaluation of fetal behavior based on the prenatal assessment of fetal motor activity and call it the Kurjak antenatal neurodevelopmental test (KANET) [17]. This new test shows a relationship between fetal behavior and neurodevelopmental processes in different periods of pregnancy, making it possible to distinguish between normal and abnormal brain development [18]. KANET has a great potential because is the first test that evaluates the functional development of the fetal CNS using 4D US in a structured and systematic way [17]. This test used a pioneering idea by using 4D US to assess fetal movements and facial expressions, similar to postnatal neonatal neurological tests, such as Amiel-Tison neurological assessment at term (ATNAT) and Prechtl’s general movements [17], [21], [48], [49], [50], [51], [52]. KANET has the capacity to detect and differentiate normal, borderline and abnormal fetal behavior in high- and low-risk pregnancies and it can, consequently, become a relevant diagnostic tool for fetal neurological assessment. In order to make the test reproducible and easy to apply for fetal medicine specialists, its standardization was proposed in 2010 during the International Symposium on Fetal Neurology in Osaka, Japan, this has been widely accepted [53]. In 2014, a new consensus statement on the KANET test was created in Bucharest during the 4th International Fetal Neurology Conference, with the conclusion that KANET is ready for use in everyday clinical practice for normal and high-risk fetuses [54].

So far, KANET has proven its usefulness in a standardization of neurobehavioral assessment, with the potential for prenatal detection of fetuses with severe neurological dysfunction. Many studies using this method on fetal behavior have been conducted and published from different centers proving that the conclusions about the use of KANET in everyday clinical practice have been accurately stated [27], [43], [52], [53], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72]. However, more research is needed in order to introduce the KANET as a screening test. Components of KANET and its resulting scores are shown elsewhere [73].

Conclusion

As can be understood from this review the development of ultrasound, especially the 4D technology, has enabled a unique insight into the neurological development of the fetus with the purpose of determining whether this tool could serve as a prenatal diagnostic method to detect prenatal neurological disorders which may result in development of CP. In addition, 4D ultrasonography may become a method to assess fetal wellbeing [9], [17]. In the last three decades, there were several attempts to create a diagnostic test for the evaluation of fetal behavior. The tests were different, but none of them were implemented into daily clinical use [2], [3], [4], [74]. With a multidisciplinary approach, a prenatal neurologic screening test based on neurological 4D technology was proposed. KANET is the first prenatal neurological test based on the 4D US technique, whose preliminary results are encouraging [17], [71], [75], [76], [77], [78]. Results of numerous studies using KANET are promising and stimulating. However, all researchers involved in the estimation of fetal behavior using KANET agree that further studies in a large population with long-term follow-up are required and it is of utmost importance to continue the long-term follow-up of newborns who obtained borderline or abnormal scores after prenatal KANET assessment.

The development of 4D US has significantly improved the assessment of the quality of fetal movements and enabled a better evaluation of fetal behavior in comparison with 2D US. It is our belief that recent data obtained by 4D sonography are stimulating and might result in a more effective strategy to assess neurodevelopment before birth.

  1. Author’s statement

  2. Conflict of interest: Authors state no conflict of interest.

  3. Material and methods: Informed consent: Informed consent has been obtained from all individuals included in this study.

  4. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

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Received: 2016-12-16
Accepted: 2017-07-14
Published Online: 2018-01-08
Published in Print: 2018-08-28

©2018 Walter de Gruyter GmbH, Berlin/Boston

Artikel in diesem Heft

  1. Frontmatter
  2. Editorial
  3. A tribute to Ingrid Gruenberg, Managing Editor of the Journal of Perinatal Medicine and Case Reports in Perinatal Medicine
  4. Highlight: Intrapartum Care
  5. Editorial
  6. Intrapartum care
  7. Highlight articles
  8. Trends in characteristics of women choosing contraindicated home births
  9. Impact factors on fetal descent rates in the active phase of labor: a retrospective cohort study
  10. Fetal cardiac time intervals in healthy pregnancies – an observational study by fetal ECG (Monica Healthcare System)
  11. Hypercoiling of the umbilical cord in uncomplicated singleton pregnancies
  12. Validation of a new algorithm for the short-term variation of the fetal heart rate: an antepartum prospective study
  13. Relationship between various maternal conditions and lactic acid dehydrogenase activity in umbilical cord blood at birth
  14. The frequency and type of placental histologic lesions in term pregnancies with normal outcome
  15. Review article
  16. Clinical study of fetal neurobehavior by the KANET test
  17. Regular articles
  18. Maternal demographic factors associated with emergency caesarean section for non-reassuring foetal status
  19. Early usage of Bakri postpartum balloon in the management of postpartum hemorrhage: a large prospective, observational multicenter clinical study in South China
  20. Efficacy of inhaled nitric oxide in neonates with hypoxic respiratory failure and pulmonary hypertension: the Japanese experience
  21. Transfusion-associated necrotizing enterocolitis re-evaluated: a systematic review and meta-analysis
  22. Transfusion-associated necrotizing enterocolitis in preterm infants: an updated meta-analysis of observational data
  23. Commentary
  24. Watch out for congenital Zika syndrome in non-endemic regions
  25. Letters to the Editor
  26. Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is the evidence sufficient?
  27. Reply to: Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is evidence sufficient?
  28. Obituary
  29. Klaus Riegel (1926–2018)
https://doi.org/10.1515/jpm-2016-0414
Schlagwörter für diesen Artikel
Fetal behavior; fetal neurologic screening; fetal neurology; four-dimensional ultrasound; prenatal brain impairment

Artikel in diesem Heft

  1. Frontmatter
  2. Editorial
  3. A tribute to Ingrid Gruenberg, Managing Editor of the Journal of Perinatal Medicine and Case Reports in Perinatal Medicine
  4. Highlight: Intrapartum Care
  5. Editorial
  6. Intrapartum care
  7. Highlight articles
  8. Trends in characteristics of women choosing contraindicated home births
  9. Impact factors on fetal descent rates in the active phase of labor: a retrospective cohort study
  10. Fetal cardiac time intervals in healthy pregnancies – an observational study by fetal ECG (Monica Healthcare System)
  11. Hypercoiling of the umbilical cord in uncomplicated singleton pregnancies
  12. Validation of a new algorithm for the short-term variation of the fetal heart rate: an antepartum prospective study
  13. Relationship between various maternal conditions and lactic acid dehydrogenase activity in umbilical cord blood at birth
  14. The frequency and type of placental histologic lesions in term pregnancies with normal outcome
  15. Review article
  16. Clinical study of fetal neurobehavior by the KANET test
  17. Regular articles
  18. Maternal demographic factors associated with emergency caesarean section for non-reassuring foetal status
  19. Early usage of Bakri postpartum balloon in the management of postpartum hemorrhage: a large prospective, observational multicenter clinical study in South China
  20. Efficacy of inhaled nitric oxide in neonates with hypoxic respiratory failure and pulmonary hypertension: the Japanese experience
  21. Transfusion-associated necrotizing enterocolitis re-evaluated: a systematic review and meta-analysis
  22. Transfusion-associated necrotizing enterocolitis in preterm infants: an updated meta-analysis of observational data
  23. Commentary
  24. Watch out for congenital Zika syndrome in non-endemic regions
  25. Letters to the Editor
  26. Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is the evidence sufficient?
  27. Reply to: Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is evidence sufficient?
  28. Obituary
  29. Klaus Riegel (1926–2018)
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