Fetal Facial Expressions: Demonstration of the Smiling, the Sad and the Scowling Fetus with 4D-Ultrasound

Fetuses exhibit different movement patterns during their intrauterine development. The earliest spontaneous movements can be seen in the embryo at 7 weeks of gestation [Einspieler C, Prechtl HFR. In: Prayer D (ed.) Fetal MRI, Medical Radiology 2010, 177-187, Lebit FD, Vladareanu R. Maedica 2011; 6: 120-127]. In the first trimester, fetal movements increase rapidly in frequency and complexity [Lebit FD, Vladareanu R. Maedica 2011; 6: 120-127, Yigiter AB, Kavak ZN. J Matern Fetal Neonatal Med 2006; 19: 707-721]. With progressing gestational age, general movements, head movements, isolated limb movements, finger movements, breathing movements, hiccups and different facial expressions can be seen by ultrasound [Einspieler C, Prechtl HFR. Fetal movements. Though they might be spontaneous, yet there is method in them. In: Prayer D (ed.) Fetal MRI, Medical Radiology 2010, 177-187, Lebit FD, Vladareanu R. Maedica 2011; 6: 120-127, Yigiter AB, Kavak ZN. J Matern Fetal Neonatal Med 2006; 19: 707-721]. In particular, facial movements show a maximum frequency at the end of the second trimester and a decline in the third trimester [Lebit FD, Vladareanu R. Maedica 2011; 6: 120-127, Yigiter AB, Kavak ZN. J Matern Fetal Neonatal Med 2006; 19: 707-721]. Different facial movements can be observed during pregnancy: mouthing, yawning, sucking, tongue protrusion, eye blinking, eye movements, smiling, cry movements and scowling. Most fetal movements can be easily recognized with conventional 2D ultrasound. However, some facial movements, such as smiling, cry movements and scowling, are more readily discernible with 4D ultrasound [Yigiter AB, Kavak ZN. J Matern Fetal Neonatal Med 2006; 19: 707–721, Kawakami F, Yanaihara T. Infant Behav Dev. 2012; 35: 466–471, Kanenishi K, Hanaoka U, Noguchi , et al. Int J Gynaecol Obstet. 2013; 121: 257–260, Merz E, Pashaj S. Donald School J Ultrasound Obstet Gynecol. 2013; 7: 400–408]. This is particularly true with 4D HDlive rendering ([Fig. 1]-[3]) [Merz E. Ultraschall in Med 2012; 33: 211–212, Hata T, Hanaoka U, Mashima M, et al. J. Med Ultrasonics 2013; 40: 437–441], a technique in which the human skin-based color spectrum and the movable virtual light source allow virtually photographic imaging of fetuses [Merz E. Ultraschall in Med 2012; 33: 211–212]. Depending on the position of the virtual light source, the different anatomical facial structures and in particular minor movements are visualized in a more accentuated manner.

There is more and more evidence that fetal movements may be a key to predicting healthy brain function of the fetus [Kurjak A, Miskovic B, Stanojevic M, et al. J Perinat Med. 2008; 36: 73–81, Stanojevic M, Kurjak A, Salihagic-Kadic A, et al. J Perinat Med 2011; 39: 171–177]. Precise observation of fetal facial expression using this 4D technique may provide new and/or additional information to facilitate improved understanding of fetal neurological development and fetal brain function in utero [Hata T, Sato M, Kanenishi K, et al. Donald School J Ultrasound Obstet Gynecol. 2012; 6: 121–131]. However, expressions, such as smiling, cry movements and scowling, should not be misunderstood as emotional qualities of the fetus. These involuntary movements surely demonstrate more endogenously generated physiologic reflex patterns.