Fetal Hand Research Articles

OC33.06: A longitudinal kinematical study of fetal hand movements through 4D ultrasound

OC33.06: A longitudinal kinematical study of fetal hand movements through 4D ultrasound

Influence of breech presentation on the development of fetal arm posture

Background In previous research, an age-related developmental trend towards increasing arm flexion has been found for cephalic fetuses. Aim To determine if the development of arm posture in breech fetuses is comparable to that of cephalic ones. Subjects and methods Fetal arm posture was studied longitudinally by means of real-time ultrasound in 13 healthy breech and 10 healthy cephalic fetuses. Observations started from 33 weeks gestational age until birth and were performed weekly in the breech group and every 2 weeks in the cephalic group. Results No difference could be found in arm posture between the left and the right arm in either group. Both breech and cephalic fetuses showed a clear preference for flexion in elbow and finger joints at all studied ages. After 36 weeks gestational age, the breech group showed significantly less wrist flexion when compared to the cephalic group ( p=0.037). A clear preference for location of the fetal hands near the fetal head could be observed for both groups. Conclusions As there is no evidence for an abnormal neuromotor development in healthy breech fetuses, the observed difference in wrist flexion is probably due to differences in intrauterine environment. Because of the preference for location of the hands in the vicinity of the fetal head, breech fetuses probably experience a less restricted environment (in the upper part of the uterus) than cephalic fetuses (in the lower part of the uterus).

P11.10: Use of 3D US scan and prenatal diagnosis of Weaver syndrome

Overgrowth Syndromes (OS) – Beckwith-Wiedeman (BW), Simpson-Golabi-Behmel, Perlman, Sotos, Weaver (WS), Proteus, KlippelTrenaunay and some other heterogeneous conditions – are characterized by an excessive prenatal and postnatal growth. As some of them have a poor prognosis, a correct prenatal diagnosis is essential. So far, just a few of prenatal diagnosis of OS have been reported, mostly regarding the BW one. We report the first prenatal diagnosis of Weaver syndrome, in a low risk pregnancy, detected as early as the 22 weeks’ gestation, in a G2 P1 28-year-old Caucasian woman. Parents were non related. The patient was referred to our tertiary centre because of a presumptive diagnosis of BW syndrome, that was excluded because there was neither omphalocele nor macroglossia. 2D US scan was performed with an Hitachi Logos machine (Esaote), and the images were further elaborated in a 3D freehand mode. The 2D scan showed a single living fetus with all the biometric parameters above the 99◦ centile for gestational age. The fetus showed as well: broadening of long bones epiphyses; external male genitalia with micropenis; enlarged hyperechogenic kidneys with severe hydronephrosis; camptodactyly with clinodactyly of fifth digits; enlarged liver; long, everted and broad upper lip.; large ears; enlarged plica nucalis > 9 mm; polyhydramnios. Amniocentesis showed a normal male, 46XY, karyotype. 3D surface rendering images better defined the 2D findings, especially as for the fetal profile, hands and kidneys was concerning, allowing us to postulate a prenatal diagnosis of Weaver syndrome. After extensive genetic counselling, parents opted for pregnancy termination, and a stillborn fetus weighing 788 g was delivered. Dismorphological, X-Ray and necroscopic examination confirmed the prenatal diagnosis of WS. We believe that 3D scan is helpful in making an accurate prenatal diagnosis in case of OS, permitting parents to decide in order to pregnancy termination.

Assessment of fetal behavior and general movements by four-dimensional sonography

The aim of this paper was to review the clinical applications of four-dimensional ultrasonography in the assessment of fetal behavior. With the use of a computerized database, articles on three-dimensional ultrasonography were reviewed. Several applications of dynamic three-dimensional ultrasonography have been reported, including imaging of fetal movements, facial expression and fetal hand movements. The importance of the assessment of fetal behavior by four-dimensional sonography is stressed. Four-dimensional sonography seems to be a useful imaging tool for clinical problem solving in perinatology, especially in observing the development of the central nervous system in utero.

Normal and abnormal fetal hand positioning and movement in early pregnancy detected by three- and four-dimensional ultrasound

The recent advance of three-dimensional/four-dimensional ultrasound has clearly demonstrated details of fetal movement. Many musculoskeletal tissues and their innervation are associated with hand/finger positions and movements. This article focuses on details of fetal hand/finger positioning and movement in early pregnancy in vivo. From our data, mild adduction of the thumb and atonic fingers were observed from 11 weeks of gestation and the appearance of the palm was clearly different from that at 9 and 10 weeks. Fetuses start to clench and unclench their fists from 12 weeks and independent movement of each finger is occasionally seen from 13 or 14 weeks. In our series of fetuses with congenital central nervous system diseases, fetuses had normal hand/finger positioning and movements. We present two cases with congenital hand/finger malpositioning – one had an overlapping finger which was conspicuous after 13 weeks; the other had contractural malpositioning of the wrist demonstrated from 11 weeks. There may be different mechanisms associated with muscular and tendon variation between abnormal palmar/wrist flexion and abnormal digital flexion. Three- and four-dimensional ultrasound may reveal further details of fetal behaviors in utero.

Normal and abnormal fetal hand positioning and movement in early pregnancy detected by three- and four-dimensional ultrasound

Normal and abnormal fetal hand positioning and movement in early pregnancy detected by three- and four-dimensional ultrasound

Mucosally-derived HPV-40 can infect both human genital foreskin and cutaneous hand skin tissues grafted into athymic mice

HPV-40 is a rare HPV type that has been detected only in genital mucosal tissues. This HPV type is very closely related to HPV-7, which has a predominantly cutaneous tissue tropism. We have shown, previously, that an isolate of HPV-40 (described here as HPV-40 Hershey or HPV-40 H) productively infected genital tissues. In this study, HPV-40 H was tested for productive infection of cutaneous tissue. Fetal hand skin fragments were incubated with infectious HPV-40 H and implanted subrenally into athymic mice. After 120 days, xenografts showed morphological changes consistent with HPV-40 H infection and were HPV-40 DNA in situ positive and capsid antigen positive. The results demonstrated that hand skin can support HPV-40 H infection thereby indicating that this viral type has the capacity to infect both genital mucosal and cutaneous tissues.

Fetal hand movements and facial expression in normal pregnancy studied by four-dimensional sonography.

To evaluate the developmental pattern of fetal hand movements and facial activity and expression during the second and third trimester of pregnancy by four-dimensional ultrasound (4D-US). A total of 25 fetuses in uncomplicated pregnancies were analyzed; 15 fetuses at 13 to 16 weeks and 10 fetuses at 30 to 33 weeks of gestation were studied with abdominal 4D-US. After standard assessment in two dimensional (2D) real-time B mode, a 4D mode was switched on. Further examination lasted a maximum of 15 minutes. Isolated hand movement and subtypes of hand movements were easily recognized by 4D-US. The sub-types of hand to head movement are: hand to head, hand to mouth, hand near mouth, hand to face, hand near face, hand to eye and hand to ear. All subtypes of hand to head movement can be seen from 13 weeks of gestation, with fluctuating incidence. Facial activities and different forms of expression are easily recognized by 4D-US. Among these, two types can be easily differentiated: smiling and scowling. 4D-US is superior over real-time two-dimensional ultrasound (2D-US) for qualitative, but inferior for quantitative analysis of hand movements. Thus 4D-US makes it possible to determine exactly the direction of the fetal hand, but the exact number of each type of hand movements can still not be determined. 4D-US is superior over two- and three-dimensional sonography in the evaluation of complex facial activity and expression. Among facial activities observed by 4D-US, simultaneous eyelid and mouthing movements dominate between 30 and 33 weeks of gestation. Pure mouth movements such as mouth opening, tongue expulsion, yawning and pouting are present, but at a significantly lower incidence. Facial expressions such as smiling and scowling can be precisely observed using 4D-US.

The 'sacral hand wedge': a cause of arrest of descent of the fetal head during vacuum assisted delivery.

During a study of 108 vacuum assisted deliveries, a fetal hand was detected in the pelvic space between the head and maternal sacrum in seven of the procedures. The larger presenting diameters resulting from the compound fetal presentations were reflected in a greater number of pulls and higher traction forces recorded during the deliveries. In all cases, extraction of the hand facilitated the completion of birth without causing serious injury to the fetus or maternal perineum. It is recommended that a digital examination to detect the presence of a fetal hand in the sacral space should become a part of standard vacuum delivery practice.

The ‘sacral hand wedge’: a cause of arrest of descent of the fetal head during vacuum assisted delivery

During a study of 108 vacuum assisted deliveries, a fetal hand was detected in the pelvic space between the head and maternal sacrum in seven of the procedures. The larger presenting diameters resulting from the compound fetal presentations were reflected in a greater number of pulls and higher traction forces recorded during the deliveries. In all cases, extraction of the hand facilitated the completion of birth without causing serious injury to the fetus or maternal perineum. It is recommended that a digital examination to detect the presence of a fetal hand in the sacral space should become a part of standard vacuum delivery practice.

Prenatal age-specific reference intervals for measuring all five digits of the fetal hand.

To construct prenatal age-specific reference intervals for measurement of five digits in normal fetuses. Prospective cross-sectional study of fetuses assessed at an antenatal ultrasound unit in a university-affiliated general hospital. The study cohort comprised 302 pregnant women attending our clinic for routine fetal biometry or anomaly scan between December 1997 and June 2000. They all fulfilled the study inclusion criteria: singleton fetuses with normal anatomy, accurate gestational age and no medical complications of pregnancy. Each fetus was scanned once only and the finger measurements of one hand were obtained. Electronic calipers were placed on the outer margin of the proximal phalanx to the outer margin of the distal phalanx level. Those measurements and the relevant gestational age were registered in a computerized database. The linear increase of size of each of the five fingers was plotted across the evaluated range of gestation (P < 0.001; r2 between 0.85 and 0.86 for fingers I to V). Tables showing the 5th, 50th and 95th centiles of finger lengths between 14 and 27 weeks' gestation were created based on the reference interval charts. Second-trimester measurement of all five digits of the fetal hand is feasible. This may assist in the evaluation of fetuses that are primarily suspected of having genetic abnormalities that might be expressed by deviation in finger length.

The Architecture of the Fibrous Complex between the Palmar Aponeurosis and the Flexor Retinaculum

Summary. During cadaver dissections of 34 adult human hands (fixed in formaldehyd solution), we examined a fibrous complex at the distal end of the flexor retinaculum. This fibrous complex was first mentioned by Legueu and Juvara (1892). It is located always ulno-dorsally to the attachment of the palmaris longus tendon into the palmar aponeurosis. Measurements of this special connective tissue show a mean length of 18.6 mm, a mean height of 4.3 mm and a mean width of 3.1 mm.Also, we looked for the fibrous complex in six adult plastinated transverse sections and in 12 fetal hands where it occurred in a constant way. We also found a very close topographic relationship between these oblique criss-crossed fibers and the palmar cutaneous branch of the median nerve. This nerve regularly gives some ulnar branches to the fibrous complex. The clinical relevance of the fibrous complex is discussed in relationship to a carpal tunnel syndrome. The described transverse fibers of the connective tissue complex are in danger as well as the ulnar branches of the palmar cutaneous nerve when releasing the flexor retinaculum during operation.

The Use of Ultrasound to Identify Fetuses with Down Syndrome

Karyotyping by invasive prenatal testing such as amniocentesis or chorionic villi sampling is the only definitive method of determining Down syndrome. However, both methods are associated with procedure-related risks. The combination of two noninvasive tools, the maternal serum triple screen and the ultrasound examination, provides a way of identifying fetuses at higher risk for Down syndrome. Ultrasound markers are sonographic findings that may exist as structural malformations or normal variants that are more prevalent in Down syndrome. Depending on the particular marker, either a single marker or a cluster may indicate an increased risk of an affected fetus. Sonographic markers include duodenal atresia, cardiac defects, brachycephaly, mild ventriculomegaly, flattened facial profile, thickened nuchal skin fold, fetal hydrops, hyperechoic bowel, choroid plexus cysts, pyelectasis, shortened extremities, echogenic intracardiac foci, greater iliac wing angle, and specific findings in the fetal hand and foot.

Fetal and Neonatal Hand Movement

Fetal movement occurs early in human gestation and can be observed by ultrasound imaging. This was a descriptive study of fetal hand movements from 14 weeks of gestation to postnatal day 1. The purpose of the study was to identify specific hand movements and their developmental trends in order to better understand low-risk human development. Twenty-one women with low-risk pregnancies were identified from a university obstetrics clinic. Their fetuses or neonates were the focus of this study. Ultrasound imaging was used at 14, 20, 26, 32, and 37 weeks of gestation, and videotaping was used at 1 day after birth. Between 12 and 16 minutes of usable imaging was obtained at each fetal age, and 24 minutes of videotape was collected neonatally. The duration and frequency of 7 hand movements were determined and reliably scored. Nonparametric analyses were used. Fetal and neonatal movements did not appear to be random, and they appeared to be directed or aimed at specific targets. Fetal movement was variable throughout gestation. Differences occurred between fetal and neonatal data. Durations of certain hand movements provided data that exhibited some developmental trends, such as decreasing linear trends and regression-type U curves. Fetal movements to or at the head and face and the observations scored at 32 weeks of gestation were the best predictors of neonatal movement. Results suggest the potential for fetal movement to be observed and scored reliably, with scores used to further our understanding of the development of human movement.

Ultrasonographic diagnosis of trisomy 18: is it practical in the early second trimester?

The objective of this paper was to determine the rate of prenatal detection of ultrasonographic abnormalities in fetuses with trisomy 18 during the early second trimester. Our prenatal diagnosis database (encompassing January 1987 to June 1996) was searched for all patients referred for prenatal genetic evaluation between 14 and 22 weeks of gestation and who were found to have a fetus with a trisomy 18 karyotype. The sonographic reports and films were evaluated for the presence or absence of fetal anatomic abnormalities. Thirty-five fetuses were identified with a mean age of 17.3+/-2.0 (standard deviation) weeks. Thirty of the 35 (86%) had at least one detected abnormality. Most fetuses had more than one abnormality, with the mean number of abnormalities per fetus being three (range, 0 to 6). The most common abnormalities noted were persistent abnormal position of fetal fingers (89%); choroid plexus cysts (43%); abnormally shaped fetal head (strawberry or lemon) (43%); two-vessel umbilical cord (40%); cardiac defects (37%); intrauterine growth restriction (29%); omphalocele (20%); neural tube defects (9%); and cystic hygroma or lymphangiectasia (14%). Abnormalities of amniotic fluid volume (12%) and renal defects (9%) were seen less frequently. These data suggest that in the early second trimester, the time of most routine screening ultrasonographic examinations, most but not all fetuses with trisomy 18 have sonographically detectable anatomic abnormalities. The fetal hand appears to be abnormal in most early second trimester fetuses with trisomy 18, but the abnormality may be subtle and or unilateral.

Human fetal hand size and hand maturity in the first half of the prenatal period

The purpose of the present study has been to establish radiographic standards of hand length and finger bone size in the first half of the prenatal period, and to relate these measurements to general fetal size (CRL) and foot length (FL), as well as to the skeletal maturity assessed from a Composite Number of Ossified bones in hand and foot radiographs (CNO). The right hand and foot of each of 251 normal human fetuses (CRL 47–194 mm) were radiographed. From each hand radiograph hand length (DM), third proximal phalangeal bone length (PP) and third metacarpal bone length (MC) were measured. The study showed that third proximal phalangeal and metacarpal bone lengths both provide a valuable basis for estimating hand length. Both hand length and the length of the third metacarpal bone were found to be good predictors of general fetal size (CRL). The study provides standards for the relationships between hand and finger bone sizes, general fetal length and foot length. By combining third metacarpal bone size and skeletal maturity of the hand and foot general fetal development (age and crown-rump length) can be estimated. Insight into normal hand size and finger bone size at different stages of normal development including skeletal maturation is useful in future evaluation of handsize under pathological conditions.

Prospective evaluation of the relationship between gestational age and fetal hand posture in trisomy

Prospective evaluation of the relationship between gestational age and fetal hand posture in trisomy

The significance of ultrasonographically diagnosed fetal wrist position anomalies

OBJECTIVE: Our purpose was to determine the clinical significance of ultrasonographically diagnosed fetal wrist position anomalies. STUDY DESIGN: The relationship of the fetal hand to the forearm was prospectively evaluated in all second- and third-trimester scans over a 5-year period. If an abnormal wrist position was detected, a targeted scan, including echocardiography, was performed. The outcomes of abnormal pregnancies were obtained. RESULTS: An abnormal relationship of the hand to the forearm was found in 22 fetuses in 27,467 scans. Nine had a normal karyotype, and 13 had an abnormal karyotype. Among the nine with normal chromosomes, three had evidence of a movement disorder. Three with normal karyotypes are alive; two of these are the only normally functioning survivors. They had no other major anomalies and were shown prenatally to have normal movement of the limbs. CONCLUSIONS: An abnormal fetal wrist position is associated with a high incidence of karyotype and movement abnormalities. (Am J Obstet Gynecol 1996;174:1834-9.)

Development of the human wrist joint ligaments.

Many studies have been published on the development of the human wrist joint, but scant attention has been given to the development of the wrist joint ligaments. Moreover, traditional description of wrist anatomy usually depict only the superficial capsular fibers of the wrist joint. The only ligamentous structure to receive much attention is the articular disc of the wrist joint, which has been described as a fibrocartilaginous structure extending from the medial edge of the lower end of the radius to the ulnar styloid process. In the present report, we synthesize our observations in the wrist joint ligaments in 35 serially sectioned human embryonic and fetal hands (16 embryos and 19 fetuses). The interosseous intercarpal ligaments are organized from the mesenchyme, which, until O'Rahilly's stage 23, fills the intercarpal spaces. These ligaments are not individually distinguishable until the 9th week of development. The collateral ligaments begin to form in O'Rahillys's stage 22 and are completely formed by the end of week 10. The palmar radiocarpal and ulnocarpal ligaments (beginning with the palmar radiocarpal ligament) begin to form in O'Rahilly's stage 23 and are fully developed by the end of week 10. At this time, development of the dorsal radiocarpal ligament begins; this process is completed by the end of week 13. The articular disc which is initially formed of a single element, first appears in O'Rahilly's stage 23 and its organization is completed at week 10 of development. We establish the morphogenetic time-table of the wrist joint ligaments. Our descriptive findings may help explain carpal motion and the origin of wrist injuries.

Evaluation of Fetal Hands With Ultrasound During a Routine Obstetric Examination

In this prospective study, 100 second trimester fetuses were assessed to determine the frequency of visualization of the open fetal hands and the three phalanges of the fifth digit during a routine ultrasound examination. Open right hands were seen in 82 (82%) fetuses, and the three phalanges of the right fifth digit were seen in 71 (71%) fetuses. Open left hands were visualized in 80 (80%) fetuses, and the three phalanges of the left fifth digit were seen in 70 (70%) fetuses. Both open hands were seen in 73 (73%) fetuses, and only one open hand was seen in 17 (17%) fetuses. Fetal abnormalities, such as clenched hands with or without overriding fingers, hypoplasia of the middle phalanx of the fifth digit, or clinodactyly of the fifth finger, have been reported to be associated findings of certain fetal chromosomal disorders (e.g., trisomies 13, 18, and 21) and may initiate further genetic evaluation. The present study shows that it is feasible to include the assessment and documentation of fetal hands in the routine obstetric ultrasound examination without significantly increasing the scanning time.