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Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (2): 220-227    DOI: 10.31083/j.ceog.2020.02.5434
Original Research Previous articles | Next articles
Forehead and facial heights in Down syndrome and normal fetuses in the midtrimester of pregnancy
I. H. Kalelioglu1, *(), S. G. Erzincan2, R. Has1, A. Yuksel1
1Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey
2Department of Obstetrics and Gynecology, Trabzon Kanuni Research and Teaching Hospital, Trabzon, Turkey
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Abstract  Objectives: To compare forehead height (FH), facial heights (FaHs) and the ratios of biparietal diameter (BPD) and femur length (FL) to these heights in midtrimester normal and Down syndrome (DS) fetuses. Methods: 150 normal and 26 DS fetuses were scanned at 15-25 weeks of gestation. At the mid-sagittal image of the fetal profile, FH, FaH, upper facial height (UFaH) and lower facial height (LFaH) were measured in millimeters with “two line distance” tool. The results were expressed as multiples of the gestation-specific normal median (MoMs) using the regression of the equation derived from normal fetuses. The ratios of BPD/UFaH, BPD/LFaH, BPD/FaH, BPD/FH, FL/UFaH, FL/LFaH, FL/FaH, FL/FH were also assessed. Results: In normal fetuses, FH and FaHs increased linearly with gestational age (GA). UFaH increased linearly from 5.2 mm at 15 weeks to 15.7 mm at 25 weeks. LFaH increased from 9.3 mm at 15 weeks to 32 mm at 25.2 weeks. FaH increased from 16 mm at 15 weeks to 39 mm at 25 weeks. FH increased from 17.7 mm at 15 weeks to 42.8 mm at 25 weeks. Only UFaH was found to be significantly smaller in DS fetuses (with a mean of 0.91 MoM, 95% CI, 0.7-1.1, p = 0.003), than in normal fetuses (1 MoM, 95% CI, 0.6-1.3). Concomitantly, none of the ratios changed with gestation and all were found to be statistically higher in DS fetuses (p < 0.05). Conclusions: UFaH, is smaller in DS fetuses compared with normal fetuses in the midtrimester of pregnancy. The ratios of BPD and FL to all heights are higher in fetuses with DS than in normal fetuses.
Key words:  Down syndrome      Facial height      Fetal face      Ultrasound     
Published:  15 April 2020     
*Corresponding Author(s):  I. H. Kalelioglu     E-mail:  dr.ikalelioglu@gmail.com

Cite this article: 

I. H. Kalelioglu, S. G. Erzincan, R. Has, A. Yuksel. Forehead and facial heights in Down syndrome and normal fetuses in the midtrimester of pregnancy. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(2): 220-227.

URL: 

https://ceog.imrpress.com/EN/10.31083/j.ceog.2020.02.5434     OR     https://ceog.imrpress.com/EN/Y2020/V47/I2/220

Figure 1.  — Ultrasound images of a normal fetus (A, B, C) and a fetus with Down syndrome (D, E, F) showing the forehead and facial height measurements at 20 weeks of gestation. Figures 1A and 1D, show the two lines passing through the most prominent border of the cranial vault and the upper margin of the maxilla, respectively in a normal fetus and a fetus with Down syndrome. Figures 1B and 1E, show the two lines delineating the upper facial height (UFaH), respectively in a normal fetus and a fetus with Down syndrome. Figures 1C and 1F, show the two lines delineating the lower facial height (LFaH), respectively in a normal fetus and a fetus with Down syndrome.

Figure 2.  — Relationship of (a) upper facial height (UFaH), (b) lower facial height (LFaH), (c) facial height (FaH) and (d) forehead height (FH) to gestational age in 150 normal fetuses between 15 and 25 weeks of gestation (GW: gestational age in weeks).

Table 1  — Characteristics of study groups and distribution of ultrasound parameters. (DS: Down syndrome, UFaH: upper facial height, LFaH: lower facial height, FaH: facial height, FH: forehead height, GA: gestational age in weeks. MWU: Mann-Whitney U test).
DS fetuses (n = 26)Normal fetuses (n = 150)p Value
Maternal age (years)(MWU)
Median (min-max)35.5 (22-43)29 (18-41)0.001
GA (weeks)
Median (min-max)20 (15-25)19 (15-25)0.8
mmMOMmmMOM
UFaH
Median (min-max) Correlation with GA LFaH9.9 (5.9-13.5)
0.918(P < 0.001)
0.91 (0.7-1.1)10.6 (5.2-15.7)
0.899 (P < 0.001)
1(0.6-1.3)< 0.001
Median (min-max)17.8 (10.1-25.1)1.05 (0.8-1.3)15.6 (9.3-25.2)1(0.7-1.3)0.09
Correlation with GA
FaH
0.870(P < 0.001)0.814(P < 0.001)
Median (min-max)28.7 (16-39)1.01 (0.8-1.1)25.9 (16-39)1(0.8-1.2)0.2
Correlation with GA
FH
0.937(P < 0.001)0.934(P < 0.001)
Median (min-max)28.7(15.8-39.1)0.98 (0.7-1.1)28 (17.7-42.8)1(0.7-1.2)0.2
Correlation with GA0.844(P < 0.001)0.870 (P < 0.001)
Table 2  — Median UFaH, LFaH, FaH and FH in normal fetuses, together with regressed values* (*UFaH = (0.755 x GA) - 3.868, LFaH = (1.2 x GA) - 7.18, FaH = (1.9 x GA) - 11.1, and FH = (1.8 x GA) - 7.1 UFaH: upper facial height, LFaH: lower facial height, FaH: facial height, FH: forehead height, GA: gestational age in weeks).
GAnUFaHLFaHFaHFH
MedianRegressedMedianRegressedMedianRegressedMedianRegressed
1597.117.511.410.919.617.420.119.9
16128.28.212.112.120.219.323.221.7
17278.98.913.913.322.421.224.623.5
18219.79.714.314.523.723.125.725.3
191710.910.515.815.7272528.827.1
20811.311.217.116.828.926.929.528.9
211211.611.918.1183028.832.530.7
221413.312.720.519.232.430.733.732.5
231614.113.520.820.434.732.636.534.3
241113.214.321.821.635.734.536.336.1
25314.31522.722.836.936.435.437.9
Table 3  — Individual UFaH, LFaH, FaH and FH all in MoM values in 26 Down syndrome fetuses (GA: gestational age in weeks, UFaH: upper facial height, LFaH: lower facial height, FaH: facial height, FH: forehead height).
GAUFaHLFaHFaHFH
15.000.961.040.981.03
15.000.881.070.961.01
15.000.830.870.830.78
15.000.800.880.820.89
16.001.090.941.001.04
16.001.051.151.110.99
16.000.731.331.090.85
17.000.840.900.890.99
18.000.931.061.020.89
19.000.931.121.031.14
19.000.840.930.891.07
19.000.840.760.791.01
20.001.061.051.041.02
20.000.951.341.171.06
20.000.701.281.030.93
21.000.991.041.000.79
21.000.951.161.061.07
21.000.831.040.940.71
22.000.950.810.910.96
22.000.951.131.100.86
23.000.890.860.880.78
23.000.870.960.941.07
23.000.871.081.011.03
24.001.011.081.040.94
24.000.871.151.020.95
25.000.971.071.030.98
Figure 3.  — Relationship of (a) biparietal diameter to upper facial height ratio (BPD/UFaH), (b) biparietal diameter to lower facial height ratio (BPD/LFaH), (c) biparietal diameter to facial height ratio (BPD/FaH) and (d) biparietal diameter to forehead height ratio (BPD/FH) to gestational age in 150 normal fetuses between 15 and 25 weeks of gestation (GW: gestational age in weeks).

Figure 4.  — Relationship of (a) femur length to upper facial height ratio (FL/UFaH), (b) femur length to lower facial height ratio (FL/LFaH), femur length to facial height ratio (FL/FaH) and (d) femur length to forehead height ratio (FL/FH) to gestational age in 150 normal fetuses between 15 and 25 weeks of gestation (GW: gestational age in weeks).

Table 4  — Comparison of ratios between normal fetuses and fetuses with Down syndrome (BPD: Biparietal diameter, FL: femur length, UFaH: upper facial height, LFaH: lower facial height, FaH: facial height, FH: forehead height, MWU: Mann-Whitney U test).
RatiosKaryotypenMeanStd. DeviationP (MWU)
BPD/UFaHDown syndrome266.35761.5395
Normal fetuses1504.07620.55805< 0.001
BPD/ LFaHDown syndrome263.67571.00191
Normal fetuses1502.70680.4072< 0.001
BPD/FaHDown syndrome262.3130.58131
Normal fetuses1501.61870.2012< 0.001
BPD/FHDown syndrome262.24570.513
Normal fetuses1501.53190.20361< 0.001
FL/UFaHDown syndrome264.71321.22548
Normal fetuses1502.60650.42603< 0.001
FL/LFaHDown syndrome262.70340.69898
Normal fetuses1501.72780.29053< 0.001
FL/FaHDown syndrome261.70460.41254
Normal fetuses1501.03410.15502< 0.001
FL/FHDown syndrome261.65720.36406
Normal fetuses1500.9810.16933< 0.001
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