4D ultrasound study of fetal facial expressions at 20–24 weeks of gestation

Miki Sato, Kenji Kanenishi, Uiko Hanaoka, Junko Noguchi, Genzo Marumo,
Toshiyuki Hata

PII: S0020-7292(14)00251-3
DOI: doi: 10.1016/j.ijgo.2014.03.036
Reference: IJG 7985

To appear in: International Journal of Gynecology and Obstetrics

Received date: 24 November 2013

Revised date: 28 March 2014
Accepted date: 14 May 2014

Please cite this article as: Sato Miki, Kanenishi Kenji, Hanaoka Uiko, Noguchi Junko,
Marumo Genzo, Hata Toshiyuki, 4D ultrasound study of fetal facial expressions at
20–24 weeks of gestation, International Journal of Gynecology and Obstetrics (2014), doi:
10.1016/j.ijgo.2014.03.036

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CLINICAL ARTICLE

4D ultrasound study of fetal facial expressions at 20–24 weeks of gestation

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Miki Sato a, Kenji Kanenishi a, Uiko Hanaoka a, Junko Noguchi b, Genzo Marumo c,

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Toshiyuki Hata a,*

a
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Department of Perinatology and Gynecology, Kagawa University School of
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Medicine, Miki, Kagawa, Japan

b
Department of Nursing, Kagawa Prefectural College of Health Sciences, Takamatsu,
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Kagawa, Japan
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c
Department of Obstetrics and Gynecology, Marumo Ladies Clinic, Minato-ku, Tokyo,
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Japan
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* Corresponding author: Toshiyuki Hata

Department of Perinatology and Gynecology, Kagawa University School of Medicine,

1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan. Tel.: +81 87 891 2174; fax: +81 87

891 2175.

E-mail address: toshi28@med.kagawa-u.ac.jp

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Keywords: 4D ultrasound; Fetal brain function; Fetal facial expression; Fetal

neurophysiology; Second trimester; Third trimester

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Synopsis: Frequencies of complicated facial expressions may increase with

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advancing gestation owing to the development and maturation of the fetal brain and

central nervous system.

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ABSTRACT

Objective: To assess the frequency of fetal facial expressions at 20–24 weeks of

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gestation using four-dimensional (4D) ultrasonography and to determine whether

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there was any correlation between facial expression and gestational age (20–34

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weeks).

Methods: The facial expressions of 23 healthy fetuses were examined using 4D

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ultrasound at 20–24 weeks. Each fetus was recorded continuously for 15 minutes.
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The frequencies of mouthing, yawning, smiling, tongue expulsion, scowling, sucking,

and blinking were assessed and the data combined with those expressions observed
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at 25–34 weeks of gestation in two previous studies (n=34) to determine the

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correlation between gestational age and each of the facial expressions.

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Results: Mouthing was significantly more frequent than the other six facial
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expressions at 20–24 weeks (P<0.05). Yawning was significantly more frequent than

smiling, scowling, and blinking (P<0.05), and sucking was significantly more frequent

than smiling, scowling, and blinking (P<0.05). The frequency of yawning, smiling,

tongue expulsion, scowling, and blinking increased with gestational age (P<0.05).

Mouthing movement and sucking frequencies remained constant between 20 and 34

weeks.

Conclusion: Frequencies of complicated facial expressions such as smiling and

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scowling may increase with advancing gestation owing to the development of the fetal

brain and central nervous system.

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1. Introduction

Prenatal facial expressions are thought to reflect fetal well-being and neurologic

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development [1–3]. Therefore, the evaluation of such facial expressions may be used

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to indicate a normal fetal brain and central nervous system [4,5]. Kurjak et al. [6]

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developed the Kurjak Antenatal Neurological Test (KANET) for evaluating the fetal

neurologic condition using four-dimensional (4D) ultrasonography. This test has been

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used extensively for assessing facial expressions. After 16 weeks of gestation,
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muscles involved in fetal facial expressions have fully formed, and there is a gradual

deposition of fetal facial adipose tissue between 24 and 36 weeks of gestation [7].
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Several studies have assessed the frequencies of fetal facial expressions observed
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using 4D ultrasound devices in the later stages of the second trimester and in the
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third trimester of pregnancy [4–15]. However, the observations reported are

inconsistent because of the subjective judgments of the examiners, interobserver

variability, the different devices used in the studies, the small study populations

examined, and variations in the examination time among the studies [14]. The aim of

the present study was to evaluate the frequencies of fetal facial expressions at 20–24

weeks of gestation using 4D ultrasound, and to combine these facial expression data

with data obtained at 25–27 weeks and at 28–34 weeks in two previous investigations
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[4,14] to determine whether there was any correlation between gestational age and

the expression of each facial expression.

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2. Materials and methods

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Between November 1, 2010 and April 30, 2013, women who were at 20 to 24 weeks

of gestation and were scheduled to undergo routine ultrasound examinations were

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asked to take part in a 15-minute examination of fetal facial expression. The study
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was approved by the Ethics Committee of Kagawa University School of Medicine,

Miki, Japan, and standardized informed consent was obtained from each woman.
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The exclusion criterion was multiple gestations. Gestational age was estimated based
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on the first day of the last menstrual period and confirmed by first-trimester or early
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second-trimester ultrasound examinations. All 4D ultrasound examinations were

performed using a Voluson E8 (GE Medical Systems, Milwaukee, WI, USA)

ultrasound system and a 1–4-MHz transabdominal transducer (RAB2-5-D: GE,

Medical Systems, Milwaukee, WI, USA) [4,14]. After a two-dimensional (2D)

ultrasound examination had been performed, the ultrasound device was switched to

4D mode. The transducer was set so that sagittal sections of the fetal face involving

the forehead, nose, and mouth could be obtained. The images were acquired in the
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region of interest (ROI): a volume box, with parameters determined by the examiner,

was superimposed over the 2D image, and a 3D image corresponding to it was

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subsequently reconstructed. The crystal array of the transducer was automatically

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passed over the ROI at a rate of 40 times per second (maximum), and the 4D images

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generated by this process were shown on a monitor. Each of the 15-minute

examinations was recorded on DVD-R. One fetus was examined twice because it

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was inactive during the first examination. All examinations were performed in the
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afternoon in a quiet, temperature-controlled room. Fetuses were not stimulated by

mechanical or acoustic devices during image acquisition.

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As previously reported [4,14], the DVD recordings were examined to assess the
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frequency of seven types of facial expression: blinking, mouthing (Supplementary

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Material S1), yawning (Supplementary Material S2), smiling (Supplementary Material

S3), tongue expulsion, scowling (Supplementary Material S4), and sucking. Each

facial expression has been described in detail in previous studies [4,14,16]. The

category of “mouthing movement” did not include other mouth movements such as

yawning, smiling, tongue expulsion, scowling, or sucking. All sonographic scans were

performed by the same researcher (GM). The frequency of each fetal facial

expression was assessed by the same researcher (MS), who has considerable
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experience in this area. The results are presented as median and range values.

Facial expression frequencies at 20–24 weeks of gestation were compared using the

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Kruskal–Wallis one-way analysis of variance by ranks test. The Spearman rank

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correlation coefficient was used to determine if there was any correlation between

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gestational age and each of the seven facial expressions using the combined data

obtained from 4D ultrasound examinations at 20–24 weeks of gestation in the present

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study and data obtained from examinations of 34 fetuses at 25–34 weeks of gestation
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in two previous studies [4,14]. Data were analyzed using SPSS, version 16 (SPSS Inc,

Chicago, IL, USA). P<0.05 was considered statistically significant.

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3. Results
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Twenty-six women agreed to participate in the study. None of the participants smoked
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or had complicating diseases. Three of the 26 participants were excluded from the

study because the recording for one fetus was unsatisfactory, and two of the

recordings were only 12 and 13 minutes rather than 15 minutes. Twenty-three fetuses

were enrolled in the study to compare the frequencies of facial expressions at 20–24

weeks of gestation. The median gestational age at the time of the 4D ultrasound

examination was 22 weeks and 5 days (range, 20 weeks and 2 days to 24 weeks).

The growth of all fetuses was within the expected range for gestational age and the
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4D ultrasound examination did not reveal any developmental abnormalities. No

congenital malformations or genetic disorders were observed in the neonates.

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As described in two previous studies [4,14], observing the fetal face was difficult when

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fetal extremities or the umbilical cord were in front of the face, or the fetal face was

facing the uterine wall or the placenta. When possible, the uterine wall and placenta

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were excluded from the ROI. In the present study, there was no maternal obesity. By
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moving the probe or asking the mother to change her position, a favorable view of the

face was obtained for all fetuses.

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The frequency of each of the seven facial expressions was determined for each fetus
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by examining the 15-minute recording (Table 1). At 20–24 weeks of gestation the
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most common facial expression was mouthing (median frequency was 6; range,

2–13) and was significantly more frequent than the other six facial expressions

(P<0.05) (Fig. 1). Yawning was significantly more frequent (median, 0; range, 0–3)

than smiling (median, 0; range, 0–2), scowling (median, 0; range, 0–1), and blinking

(median, 0; range, 0–0) (P<0.05) (Fig. 1). Sucking (median, 0; range, 0–3) was

significantly more frequent than smiling, scowling, and blinking (P<0.05) (Fig. 1). The

median of tongue expulsion was 0 (range, 0–2). None of the fetuses blinked during
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the 15-minute examination at 20–24 weeks.

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Yawning, smiling, tongue expulsion, scowling, and blinking were significantly more

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frequent after 24 weeks of gestation [4,14] than at 20–24 weeks of gestation (P<0.05)

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(Figs 2–6), whereas the mouthing movement frequency (median, 6; range, 1–19) and

sucking frequency (median, 0; range, 0–3) remained constant between 20 and 34

weeks of gestation.
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4. Discussion
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Mouthing movement was the most common facial expression at 20–34 weeks of
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gestation (P<0.05) and the frequency of mouthing remained constant throughout this
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period [4,14]. These findings support similar findings by Yigiter and Kavak [10] who
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reported that there was no significant change in mouthing movement during the

second and third trimesters of pregnancy. However, there was a significant difference

in yawning frequencies with gestational age (P<0.05): yawning was most frequent at

24 weeks and least frequent at 34 weeks of gestation, which supports findings by

Reissland et al. [12] for yawning and mouth stretching between 24 and 36 weeks of

gestation.
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In the present study, the frequency of sucking remained unchanged between 20 and

34 weeks of gestation, which supports findings reported by Yigiter and Kavak [10].

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Furthermore, Reissland et al. [13] reported that the frequency of lip pucker did not

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differ significantly with gestational age. Nonnutritive sucking is used in a diverse

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manner, mainly with premature infants to facilitate nutritive sucking, and it can

contribute to the management of an infant’s feeding development [17]. These findings

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suggest that in the second and third trimesters fetuses may start to prepare for
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feeding after delivery.
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Data from the present study and the two previous investigations [4,14] showed that
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the frequency of scowling (or grimacing) increased with advancing gestational age
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(P<0.05), which supports similar findings in other studies [10,15]. Reissland et al. [15]
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suggested that healthy fetuses progress toward an increasingly complete pain or

distress (scowling or grimacing) expression as they mature. Fetuses are thought to

react to painful stimuli from 24 weeks of gestation and this may be possible from 16

weeks of gestation [18,19]. These findings suggest that the increasing frequency of

fetal scowling with advancing gestation may be an adaptive process that is beneficial

to the neonate after delivery [15].

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Yigiter and Kavak [10] reported that fetal smiling frequency peaked between 24 and

32 weeks of gestation. Data from the present study and previous investigations [4,14]

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showed that the frequency of smiling increased with advancing gestational age

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between 20 and 34 weeks of gestation (P<0.05). The complexity of fetal facial

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movements such as laughter-face gestalt and cry-face gestalt has been reported to

increase with gestational age [7]. Increasing frequencies of more complicated facial

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expressions, such as smiling and scowling, with advancing gestation may indicate the
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development and maturation of the fetal brain and central nervous system.
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No changes in the frequency of fetal yawning between 20 and 36 weeks of gestation

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have been observed using conventional 2D ultrasound [20]. Yigiter and Kavak [10]
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observed a gradual increase in yawning between 20 and 34 weeks of gestation using

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4D ultrasound, but there was no significant change. Data from the present study and

previous investigations [4,14] showed that there was a significant positive correlation

between the frequency of fetal yawning and gestational age at 20–34 weeks of

gestation (P<0.05). However, Reissland et al. [12] reported a decline in the frequency

of fetal yawning with age from 28 weeks of gestation. Nevertheless, the recognition of

fetal yawning indicates healthy brainstem maturation and should facilitate

understanding of the neural underpinnings of sleep and arousal systems [21].

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Kurjak et al. [9] noted that fetal blinking shows a peak frequency at approximately 28

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weeks of gestation. However, in the present study and in previous investigations

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[4,14], the frequency of fetal blinking rose with increasing gestational age during the

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second and third trimesters of pregnancy (P<0.05), which is supported by the findings

of Yigiter and Kavak [10].

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There are several possible reasons for the discrepancies among investigations

performed by different research groups regarding the frequencies of fetal yawning

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and blinking observed in the second and third trimesters, including differences in the
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ultrasound devices used in the different studies. Furthermore, the subjective

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judgment methods used by the examiners to assess the fetal facial expressions
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observed using 4D ultrasound devices could result in interobserver variability. Further

studies are needed to investigate intra- and interobserver reproducibility for 4D

sonographic assessment of fetal facial expression. One possible explanation for the

discrepancy in fetal blinking between studies [4,9,10,14] is the relatively small size of

the study population involved in the present study and in the investigation conducted

by Yigiter and Kavak [10]. The duration of the examination period may also account

for some of the variation between studies: the examination period in the present and
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previous studies [4,14] and in the study performed by Lebit and Vladareanu [11] was

15 minutes, whereas other studies have reported using examination periods of 10

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minutes [7,12,13,15] and 30 minutes [8–10]. Fifteen minutes may be too short an

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interval to register all facial activities given that the examiners did not observe most of

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the chosen facial activities during the 15-minute observation period of each fetus at

20–24 weeks of gestation. Further studies involving a larger study population and an

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extended examination period are required to assess the precise frequencies of fetal
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facial expressions between 20 and 34 weeks of gestation.
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HDlive, the latest ultrasound technology, facilitates the creation of clearer images of
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fetal faces and facial expressions than those obtained using conventional 4D
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ultrasound owing to better depth perception and the depiction of skin-like colors,
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which gives the fetal images a more realistic appearance [21–24]. The precise

observation of fetal facial expression with this technique may generate additional

information to advance understanding of fetal neurobehavioral development and fetal

brain function in utero [25]. HDlive may also facilitate a better understanding and

evaluation of fetal facial expressions in the second trimester of pregnancy given that it

was difficult to observe facial expressions at 20–24 weeks of gestation in the present

study. Moreover, novel fetal neurobehavioral functions and ontogenic changes in

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various facial movements may be uncovered through observation with HDlive [23].

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In conclusion, the present study offered a distinct methodological description of fetal

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facial expressions from 20 weeks onward. However, this technology does not provide

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specific information regarding which nervous centers are developed or undergoing

development, and correlations between the described facial expressions and the fetal

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condition or even later neonatal neurodevelopment are not yet clear. Moreover, the
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significance of the description of fetal facial expressions for future research or clinical

importance remains unclear.

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Acknowledgments
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The study was supported by a Grant-in-Aid for Scientific Research on Innovative

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Areas “Constructive Developmental Science” (No. 24119004), and a Research Grant

(No. 25462561) from The Ministry of Education, Culture, Sports, Science and

Technology, Japan.

Conflict of interest

The authors have no conflicts of interest.

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Figure legends

Figure 1 Comparison of the frequencies of fetal facial expressions at 20–24 weeks of

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gestation.

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Figure 2 Frequency of yawning in relation to gestational age. Data regarding

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frequency of yawning at 25–27 and 28–34 weeks of gestation were obtained from

previous studies [4,14].

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Figure 3 Frequency of smiling in relation to gestational age. Data regarding
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frequency of smiling at 25–27 and 28–34 weeks of gestation were obtained from

previous studies [4,14].

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Figure 4 Frequency of tongue expulsion in relation to gestational age. Data regarding

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frequency of tongue expulsion at 25–27 and 28–34 weeks of gestation were obtained
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from previous studies [4,14].

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Figure 5 Frequency of scowling in relation to gestational age. Data regarding

frequency of scowling at 25–27 and 28–34 weeks of gestation were obtained from

previous studies [4,14].

Figure 6 Frequency of blinking in relation to gestational age. Data regarding

frequency of blinking at 25–27 and 28–34 weeks of gestation were obtained from

previous studies [4,14].

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Table 1 Frequencies of mouthing, yawning, smiling, tongue expulsion, scowling, sucking, and blinking
in each fetus.

Gestational age at Tongue

Fetus Mouthing Yawning Smiling Scowling Sucking Blinking
examination expulsion

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1 23 wk 5 d 8 0 0 0 0 0 0

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2 22 wk 5 d 6 1 1 0 0 0 0

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3 22 wk 6 d 2 1 0 0 0 0 0

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4 22 wk 5 d 8 0 0 0 0 0 0

5 24 wk 4 1 0 0 0 0 0

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6 24 wk 10 0 0 0 1 0 0

7 22 wk 6 d 6 0 0 0 0 0 0
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8 21 wk 4 d 8 1 0 0 0 3 0

9 23 wk 3d 3 0 0 0 0 0 0

10 21 wk 6 d 6 0 1 0 0 0 0
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11 23 wk 5 d 13 3 0 2 0 0 0

12 21 wk 3 d 3 0 0 0 0 0 0
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13 23 wk 4 d 3 2 0 0 0 1 0

14 20 wk 2 d 8 0 0 1 0 1 0
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15 23 wk 4 d 3 1 0 0 0 0 0

16 21 wk 1 d 6 0 0 2 0 0 0
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17 23 wk 1 d 4 0 0 0 1 1 0

18 21 wk 3 d 3 2 2 0 0 1 0

19 20 wk 2 d 11 2 0 0 0 2 0

20 23 wk 5 d 7 0 0 0 0 0 0

21 21 wk 6 d 9 1 0 0 0 1 0

22 22 wk 5 d 4 0 0 0 0 2 0

23 20 wk 4 d 6 0 0 0 0 2 0
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