The prognostic role of CRL discordance in first trimester ultrasound.

OBJECTIVES: In the first trimester, intertwin crown-rump length (CRL) discordance has emerged as a notable factor linked to adverse perinatal health effects. It is frequently employed as a basis for counseling parents regarding potential adverse pregnancy outcomes. Despite its established association with adverse outcomes, the significance of CRL discordance in substantially predicting pregnancy problems and its efficacy in pregnancy screening remain subjects of ongoing discussion. The aim of this manuscript is to present current knowledge on CRL discordance. METHODS: PubMed was searched for related articles with terms "Crown-Rump length", "Prenatal Screening", "Twin pregnancy", "Discordance". RESULTS: Twenty-two studies were included in our study with six reporting data on monochorionic and 16 assessing the correlation between CRL discordance and adverse pregnancy outcomes. Fetal loss at the 20th and 24th week of the pregnancy, SGA neonates, pre-term delivery (32 weeks), perinatal death (24 weeks) are all reported adverse outcomes associated with CRL discordance. The reported cut-off for increased risk of adverse perinatal outcomes is a discordance of at least 10% or more. CONCLUSIONS: Increased CRL (>10 %) discordance is linked to a higher risk of sFGR in both monochorionic and dichorionic pregnancies, fetal loss, and preterm delivery.

Left atrial strain in fetal echocardiography - could it be introduced to everyday clinical practice?

OBJECTIVES: Prenatal cardiology is a part of preventive cardiology based on fetal echocardiography and fetal interventional cardiology, which facilitates treatment of congenital heart defects (CHD) in pediatric patients and consequently in adults. Timely prenatal detection of CHD plays a pivotal role in facilitating the appropriate referral of pregnant women to facilities equipped to provide thorough perinatal care within the framework of a well-structured healthcare system. The aim of this paper is to highlight the role of left atrial strain (LAS) in prenatal evaluation of fetal heart and prediction of structural and functional disorders. METHODS: We conducted a comprehensive literature review searching PubMed for articles published from inception up until August 2023, including the search terms "left atrial strain", "fetal echocardiography", and "prenatal cardiology" combined through Boolean operators. In addition, references lists of identified articles were further reviewed for inclusion. RESULTS: Our review underscores the significance of LAS parameters in fetal echocardiography as a screening tool during specific gestational windows (starting from 11 to 14 weeks of gestation, followed by better visualization between 18 and 22 weeks of gestation). The left atrial strain technique and its parameters serve as valuable indicators, not only for identifying cardiac complications but also for predicting and guiding therapeutic interventions in cases of both cardiac and noncardiac pregnancy complications in fetuses. Evidence suggests establishment of second-trimester reference strain and strain rate values by speckle-tracking echocardiography in the healthy fetal cohort is essential for the evaluation of myocardial pathologies during pregnancy. CONCLUSIONS: Finding of LAS of fetal heart is feasible and probably can have potential for clinical and prognostic implications.

Why maternal mortality in the world remains tragedy in low-income countries and shame for high-income ones: will sustainable development goals (SDG) help?

Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal mortality (MM) and morbidity are a public health issue, with scarce knowledge on their levels and causes in low-income (LIC) countries. The data on MM and morbidity should rely on population-based studies which are non-existent. Therefore, maternal mortality ratio (MMR) estimates are based mostly on the mathematical models. MMR declined from 430 per 100,000 live births (LB) in 1990 to 211 in 2017. Absolute numbers of maternal deaths were 585,000 in 1990, 514,500 in 1995 and less than 300,000 nowadays. Regardless of reduction, MM remains neglected tragedy especially in LIC. Millennium Development Goals (MDGs) declared reduction MMR by three quarters between 2000 and 2015, which failed. Target of Sustainable Development Goals (SDGs) was to decrease MMR to 70 per 100,000 LB. Based on the data from the country report on SDGs in 10 countries with the highest absolute number of maternal deaths it can be concluded that the progress has not been made in reaching the targeted MMR. To reduce MMR, inequalities in access to and quality of reproductive, maternal, and newborn health care services should be addressed, together with strengthening health systems to respond to the needs and priorities of women and girls, ensuring accountability to improve quality of care and equity.

Use and misuse of ultrasound in obstetrics with reference to developing countries.

Maternal and neonatal health is one of the main global health challenges. Every day, approximately 800 women and 7,000 newborns die due to complications during pregnancy, delivery, and neonatal period. The leading causes of maternal death in sub-Saharan Africa are obstetric hemorrhage (28.8%), hypertensive disorders in pregnancy (22.1%), non-obstetric complications (18.8%), and pregnancy-related infections (11.5%). Diagnostic ultrasound examinations can be used in a variety of specific circumstances during pregnancy. Because adverse outcomes may also arise in low-risk pregnancies, it is assumed that routine ultrasound in all pregnancies will enable earlier detection and improved management of pregnancy complications. The World Health Organization (WHO) estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken. Unfortunately, besides all the exceptional benefits of ultrasound in obstetrics, its inappropriate use and abuse are reported. Using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication can be considered ethically unjustifiable. Ultrasound assessment when indicated should be every woman's right in the new era. However, it is still only a privilege in some parts of the world. Investment in both equipment and human resources has been clearly shown to be cost-effective and should be an obligatory step in the improvement of health care. Well-developed health systems should guide developing countries, creating principles for the organization of the health system with an accent on the correct, legal, and ethical use of diagnostic ultrasound in pregnancy to avoid its misuse. The aim of the article is to present the importance of correct and appropriate use of ultrasound in obstetrics and gynecology with reference to developing countries.

Pre-eclampsia and maternal health through the prism of low-income countries.

Hypertensive syndrome in pregnancy complicates up to 15% of pregnancies, and preeclampsia (PE) occurs in about 3-10% of pregnant women. Inadequate prenatal care is associated with higher mortality from PE, possibly due to reduced monitoring, detection, and missed opportunities for early intervention. The imperative of the clinician's work is to monitor the symptoms and clinical signs of PE, and stratification of patients in relation to the risk of PE is essential. PE represents a multisystem inflammatory response, and the consequences can be expected in all organs. The question of the effect of PE on long-term maternal health is raised. The aim of the paper is to present the effect of PE on the patient's health through the prism of low-income countries.

Facts and doubts on the beginning of human life - scientific, legal, philosophical and religious controversies.

It is very complicated to give correct answer to the question "How to define human life?" Nowadays dilemmas consider the respect of human life from the birth to death involve not just biology but also other sciences like philosophy, theology, sociology, psychology, law and politics. These sciences evaluate the topic from different points of view. Integration of all of these perspectives could result with a proper definition. The principal purpose of this paper is to try to determine when a human individual begins. If this proves to be too difficult, we might have to settle for a specific stage in the reproductive process before which it would be impossible to say with any plausibility that a human individual exists. It is necessary to return the moral dimension of observation to the science of life. The point is to reconcile the universal ethical principles concerning the absolute value of life with the everyday challenges and dilemmas. It is our deepest conviction that life has an absolute value and that there always remains something indestructible and substantial in life, which may neither be evaluated by anything final, nor completely reduced to the material biological equivalent and the genetic substratum.

Association between maternal thyroid function and risk of gestational hypertension and preeclampsia.

OBJECTIVES: To investigate the influence of maternal level of thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and free thyroxine (FT4) one by one or in combination on incidence of gestational hypertension and preeclampsia. METHODS: The study included pregnant women (n=107) hospitalized in the period from July 1, 2020 to October 10, 2021 at the Department of Pathology of Pregnancy of the University Clinic of Obstetrics and Gynecology, University Clinical Center Sarajevo (UCCS) (Bosnia and Herzegovina), due to hypertensive disorder in pregnancy without symptoms of impaired thyroid function. In all patients fulfilling inclusion criteria TSH, FT3, and FT4 using electrochemiluminescence immunoassay (ECLIA, Roche Diagnostics, Basel, Switzerland) were checked. There were two groups of patients: one with gestational hypertension (G1) and the other with preeclampsia (G2). The programs SPSS for Windows 25.0, SPSS Inc, Chicago, IL, USA and Microsoft Excel 11, Microsoft Corporation, Redmond, WA, USA were used for statistical analysis using nonparametric Mann-Whitney U test because the distribution of the data was not normal. The result was considered statistically significant if p<0.05. RESULTS: Gestational age at delivery (G2 36.86 ± 3.79 vs. G1 38.94 ± 2.15; p=0.002) and birth weight (G2 2,841.36 ± 1,006.39 vs. G2 3,290.73 ± 745.6; p=0,032) were significantly different between the investigated groups. The difference between the peak systolic (p=0.002), peak diastolic blood pressure (p=0.007), TSH (p=0.044), and FT3 (p=0.045) were statistically significant. Impaired thyroid function was observed more often in G2 than in G1. CONCLUSIONS: Thyroid function was more often affected adversely in pregnancies complicated with preeclampsia than with gestational hypertension. Based on the results of our study it might be prudent to check thyroid hormones in all asymptomatic pregnancies with preeclampsia or gestational hypertension. These findings need confirmation in larger better designed prospective studies.

Doppler ultrasonography of the uterine artery in correlation with KANET.

OBJECTIVES: The aim of this prospective study was to correlate the Doppler ultrasonography of the uterine arteries with the Kurjak Antenatal Neurodevelopmental Test (KANET), to investigate the effect of uterine artery flow assessed by the Doppler on fetal behavior. METHODS: A population of 80 pregnant women in the second trimester of pregnancy was included for uterine artery Doppler (UAD) assessment. The investigation group consisted of 40 women with abnormal UAD, while the control group consisted of 40 women with normal UAD. The inclusion criteria for the investigated group were: gestation above 20 weeks, and an abnormal finding of Doppler ultrasonography of the uterine arteries. All patients underwent a KANET test and were followed up to the end of their pregnancy. RESULTS: There was a statistically significant difference in the average score of KANET tests between the two groups (9.20±3.32 vs. 13.55±2.21; p=0.001). In the first group, an abnormal flow on the side of the placenta affected the score of the KANET test (B=11.948; p=0.005), while abnormal flow on the opposite side did not affect the score of the KANET test (p>0.05). Physiological flow had no effect on the KANET test in the control group (p>0.05). CONCLUSIONS: Abnormal flow affects the value of the KANET score, and can be used as one of the parameters in evaluation of probable fetal neurodevelopmental disorders.

CONTROVERSIES ON THE BEGINNING OF HUMAN LIFE - SCIENCE AND RELIGION CLOSER AND CLOSER.

One of the most controversial topics in modern bioethics, science, and philosophy is the beginning of individual human life. In the seemingly endless debate, strongly stimulated by recent technologic advances in human reproduction, a synthesis between scientific data and hypothesis, philosophical thought, and issues of humanities has become a necessity to deal with ethical, juridical, and social problems. Furthermore, in this field there is a temptation to ask science to choose between opinions and beliefs, which neutralize one another. The question of when human life begins requires the essential aid of different forms of knowledge. Here we become involved in the juncture between science and religion, which needs to be carefully explored. Modern bioethics and science are strongly concerned for the respect of human life at both ends of its existence (birth and death), but other sciences (eg. Philosophy, technology, psychology, sociology, law, and politics) consider the beginning of human life according to different points of view. However, bioethical topics like this one cannot be treated from only one perspective (eg. Biological, philosophical, or religious) because conclusions might be not good enough or reductive. This reality should be regarded in all its richness: An embryo gives a biologist and a geneticist substance for consideration, but because we are talking about the beginning of human life, it requires philosophical-anthropological consideration and confrontation with theology; in its protection we have to include ethics and law. In experiencing and investigating social behavior, other disciplines, such as the history of medicine and sociology, have to be included. It is hard to answer the question when human life should be legally protected. At the time of conception? At the time of implantation? At the time of birth? In all countries (except Ireland and Liechtenstein) juridical considerations are based on Roman law. Roman civil law says that the fetus has right when it is born or if it is born-nasciterus. Few countries agree with definition of beginning of human personality at the time of conception. The majority does not grant legal status to the human embryo in vitro (i.e., during the 14 days after fertilization). Thus, even in the absence of legal rights, there is no denying that the embryo constitutes the beginning of human life, a member of the human family. Therefore, whatever the attitude, every country has to examine which practices are compatible with the respect of that dignity and the security of human genetic material.The question when a human life begins and how to define it, could be answered only through the inner-connecting pathways of history, philosophy, medical science and religion. It has not been easy to determine where to draw the fine line between the competence of science and methaphysics in this delicate philosophical field. To a large extent the drawing of this line depends on one's fundamental philosophical outlook. The point at which human life begins will always be seen differently by different individuals, groups, cultures, and religious faiths. In democracy there are always at least two sides, and the center holds only when the majority realizes that without a minority democracy itself is lost. The minority in turn must realize its best chance lies in persuasion by reason and thoughtfulness rather than fanaticism.

Creative Person-Centered Psychopharmacotherapy in the Context of Prenatal Psychiatry - Dilemmas and Challenges.

The authors presented a psychopharmacotherapeutic approach to the treatment of women in the prenatal period that requires a personalized, person-centered treatment plan. Treatment should include care for the mental health of women of childbearing age, pregnancy planning, during the prenatal period, and then during the postpartum period. The authors highlighted creative psychopharmacotherapy which is the foundation of holistic and integrative treatment of mental disorders. They emphasize the significant role of the mother in the emotional development of the child, which begins while the child is still in the womb. Mothers who stop taking psychotropic drugs during pregnancy have an increased risk of recurrence of the mental disorder after childbirth because the mother's psychiatric illness is not a benign event and can cause significant morbidity for both the mother and her child, therefore, discontinuation or denial of medication during pregnancy is not always the safest option. For more serious disorders, such as schizophrenia, bipolar disorder, and severe depression, medications may be needed during pregnancy and lactation, despite complex evidence based on the effects of psychotropic medications on the fetus and newborn. Perinatal mental health has become a significant focus of interest in recent years. The randomized controlled examinations provide evidence of the effectiveness of psychological and psychosocial interventions at the individual level. It is necessary to make a new conceptual shift in the approach to maintaining the mental health of pregnant women and newborns, and that is to optimize the mental health of pregnant women, and not simply reduce the symptoms of mental disorders from which they suffer before conception, during pregnancy and after childbirth. Dilemmas and challenges of psychopharmacotherapeutic treatment in the prenatal period are intensified by the knowledge that the psychological difficulties of mothers can significantly affect the integrity of the safe relationship between mother and child, which is essential for the emotional, cognitive, and behavioral development of the child. Often, these problems existed before pregnancy or occurred during pregnancy, and they are often the deterioration of the mental state due to discontinuation of pharmacotherapy during this period. The quality of the biopsychosocial milieu in the fetal period and childhood during the early neuroplastic development phase is one of the determinants of risk for diseases during the life cycle. For this reason, the mental health of pregnant women and mothers must be optimized. For many of these women, health is optimized with pharmacotherapy.

Professionally responsible advocacy for women and children first during the COVID-19 pandemic: guidance from World Association of Perinatal Medicine and International Academy of Perinatal Medicine.

The goal of perinatal medicine is to provide professionally responsible clinical management of the conditions and diagnoses of pregnant, fetal, and neonatal patients. The New York Declaration of the International Academy of Perinatal Medicine, "Women and children First - or Last?" was directed toward the ethical challenges of perinatal medicine in middle-income and low-income countries. The global COVID-19 pandemic presents common ethical challenges in all countries, independent of their national wealth. In this paper the World Association of Perinatal Medicine provides ethics-based guidance for professionally responsible advocacy for women and children first during the COVID-19 pandemic. We first present an ethical framework that explains ethical reasoning, clinically relevant ethical principles and professional virtues, and decision making with pregnant patients and parents. We then apply this ethical framework to evidence-based treatment and its improvement, planned home birth, ring-fencing obstetric services, attendance of spouse or partner at birth, and the responsible management of organizational resources. Perinatal physicians should focus on the mission of perinatal medicine to put women and children first and frame-shifting when necessary to put the lives and health of the population of patients served by a hospital first.

Maternal obesity influences the endocrine cord blood profile of their offspring.

Objective To compare the endocrine cord blood characteristics of offspring from obese mothers with those of offspring from healthy controls. Methods Cross-sectional case control study. SETTING: University medical centers. PATIENT(S): Offspring from obese mothers (n = 41) and healthy controls (n = 31). INTERVENTION(S): Cord blood withdrawal from neonates. MAIN OUTCOME MEASURE(S): Cord blood total cholesterol (TC), triglycerides (TGs), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), blood glucose (GL) and insulin (Ins). Result(s) Fetal GL and TGs were reduced in the offspring of obese women when compared to those in the offspring of the controls. The mean cord blood GL level was 47.8 mg/dL standard deviation (SD 33.1) in the offspring of the obese group vs. 57.9 mg/dL (SD 12.5) in the offspring of the control group, and the mean cord blood TG level was 26.5 (SD 33.6) in the offspring of the obese group vs. 34.6 (SD 12.3) in the offspring of the control group. Maternal obesity was also associated with reduced levels of TC and HDL-C in the pregnant women. Conclusion The observed results suggest that GL and TGs in the cord blood of the offspring of obese mothers were significantly lower than those in the offspring of the control group.

Clinical management of coronavirus disease 2019 (COVID-19) in pregnancy: recommendations of WAPM-World Association of Perinatal Medicine.

These guidelines follow the mission of the World Association of Perinatal Medicine, which brings together groups and individuals throughout the world with the goal of improving outcomes of maternal, fetal and neonatal (perinatal) patients. Guidelines for auditing, evaluation, and clinical care in perinatal medicine enable physicians diagnose, treat and follow-up of COVID-19-exposed pregnant women. These guidelines are based on quality evidence in the peer review literature as well as the experience of perinatal expert throughout the world. Physicians are advised to apply these guidelines to the local realities which they face. We plan to update these guidelines as new evidence become available.

Risk factors associated with adverse fetal outcomes in pregnancies affected by Coronavirus disease 2019 (COVID-19): a secondary analysis of the WAPM study on COVID-19.

Objectives To evaluate the strength of association between maternal and pregnancy characteristics and the risk of adverse perinatal outcomes in pregnancies with laboratory confirmed COVID-19. Methods Secondary analysis of a multinational, cohort study on all consecutive pregnant women with laboratory-confirmed COVID-19 from February 1, 2020 to April 30, 2020 from 73 centers from 22 different countries. A confirmed case of COVID-19 was defined as a positive result on real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens. The primary outcome was a composite adverse fetal outcome, defined as the presence of either abortion (pregnancy loss before 22 weeks of gestations), stillbirth (intrauterine fetal death after 22 weeks of gestation), neonatal death (death of a live-born infant within the first 28 days of life), and perinatal death (either stillbirth or neonatal death). Logistic regression analysis was performed to evaluate parameters independently associated with the primary outcome. Logistic regression was reported as odds ratio (OR) with 95% confidence interval (CI). Results Mean gestational age at diagnosis was 30.6±9.5 weeks, with 8.0% of women being diagnosed in the first, 22.2% in the second and 69.8% in the third trimester of pregnancy. There were six miscarriage (2.3%), six intrauterine device (IUD) (2.3) and 5 (2.0%) neonatal deaths, with an overall rate of perinatal death of 4.2% (11/265), thus resulting into 17 cases experiencing and 226 not experiencing composite adverse fetal outcome. Neither stillbirths nor neonatal deaths had congenital anomalies found at antenatal or postnatal evaluation. Furthermore, none of the cases experiencing IUD had signs of impending demise at arterial or venous Doppler. Neonatal deaths were all considered as prematurity-related adverse events. Of the 250 live-born neonates, one (0.4%) was found positive at RT-PCR pharyngeal swabs performed after delivery. The mother was tested positive during the third trimester of pregnancy. The newborn was asymptomatic and had negative RT-PCR test after 14 days of life. At logistic regression analysis, gestational age at diagnosis (OR: 0.85, 95% CI 0.8-0.9 per week increase; p<0.001), birthweight (OR: 1.17, 95% CI 1.09-1.12.7 per 100 g decrease; p=0.012) and maternal ventilatory support, including either need for oxygen or CPAP (OR: 4.12, 95% CI 2.3-7.9; p=0.001) were independently associated with composite adverse fetal outcome. Conclusions Early gestational age at infection, maternal ventilatory supports and low birthweight are the main determinants of adverse perinatal outcomes in fetuses with maternal COVID-19 infection. Conversely, the risk of vertical transmission seems negligible.

Multi-center results on the clinical use of KANET.

An extensive review of the literature on the diagnostic and clinical accuracy of Kurjak's antenatal neurodevelopmental test (KANET) and the summarized results of the multi-center study involving 10 centers revealed that four-dimensional ultrasonography (4D US) has become a powerful tool and KANET a valuable test that empowers the clinicians worldwide to evaluate the fetal behavior in a systematic way and contribute to the detection of fetuses that might be at high risk for neurological impairments and in particular cerebral palsy (CP). After 10 years of clinical use, many published papers and multi-center studies, hundreds of trained physicians and numerous tests performed all over the world, KANET has proven its value and has been showing encouraging results so far. The aim of this paper is to show the results from the studies done so far and to reveal the clinical value of the KANET. We expect that data from the larger ongoing collaborative study, the short- and long-term postnatal follow-up will continue to improve our knowledge. Ultimately, we all strive to prevent the CP disorders, autism spectrum disorder (ASD) and other neurological impairments and we are convinced that KANET might be helpful in the realization of this important aim.

Spirituality, Religiosity and Nationalism from the Perspective of Public and Global Mental Health.

Despite the intensive globalization and an attractive idea of human cosmopolitism the world is still divided into rival nations and religions, with confronting ethics and many war conflicts across the globe producing and perpetuating huge mental health problems. Radicalism, malignant nationalism, pathological religiosity and violent extremism and terrorism are important issues from the public and global mental health perspective. Public and global mental health research can inform preventive strategies and interventions against malignant nationalism, pathological religiosity and violent extremism. Healthy spirituality, sound religiosity and normal nationalism may contribute significantly to public and global mental health and promotion of empathic civilization. The aim of this paper is to address, stress and support mutual understanding and creative cooperation between religions and nations in promotion of public and global mental health, research, patient care and education.

Is Four-Dimensional (4D) Ultrasound Entering a New Field of Fetal Psychiatry?

The aim of is to explore whether by observing the fetus by 4D US it is possible to enter fetal behavior, emotions, mental status, consciousness, awareness and other states connected with fetal mind and ability of self-regulation. It is well known that fetal motoric activity is enabling the development of central and peripheral nervous system and the muscles. It is 4D US which enabled to investigate fetal movement patterns from the first trimester of pregnancy throughout the whole pregnancy. Based on the evaluation of fetal spontaneous motor activity by 4D US, a prenatal neurologic scoring test named Kurjak Antenatal Neurodevelopmental Test (KANET) was created. This test has been used to assess almost 2000 fetuses and our results have indicated that KANET has an ability to recognize normal, borderline, and abnormal behavior in fetuses from normal and abnormal pregnancies. The fetus is able to process tactile, vestibular, taste, olfactory, auditory and visual sensations. The fetus responds to painful stimuli with a wide spectrum of reactions. Important external signs of emotion are facial expressions. The existence of a wide range of facial expressions, including grimacing, smiling, crying, similar to emotional expressions in adults, has been revealed by 4D sonography in the 2nd and 3rd trimesters of pregnancy. It is questionable if mental, emotional and behavioral conditions of the fetus were covered in this paper and whether we are able to perceive the fetus as the patient who may develop communication or some other psychiatric disorders which we will be hopefully able to recognize prenatally. Although it seems as the speculation from the point of view of our recent diagnostic possibilities, it is apparent that the day when this will be a reality is rapidly approaching.

Cognitive Functions of the Fetus.

The human brain is intricately designed to execute cognitive functions, such as perception, attention, action, memory and learning. The complete nervous system is active during prenatal development and the aim of this review is to present data on fetal cognitive functions. The fetus processes sensory stimuli at a cortical level, including painful stimulus, from about 25 weeks of gestation onwards. At gestational week 34, the fetus is able not only to perceive complex acoustic external sounds but also to discriminate between different sounds. Fetal action planning is established by 22 weeks and investigations using four-dimensional ultrasound reveal that complexity of fetal motor action and behavior increases as pregnancy progresses. The capacity of the fetus to learn and memory are prodigious. At term, subcortical structures of the brain are well developed. There is high activity in primary cortical areas and low activity in association areas. Clinically relevant data on cognitive functions of the fetus could be important for the management of fetal pain and treatment of preterm infants as well as for improved neurodevelopmental outcome of fetuses from high-risk pregnancies. Finally, the brain's developmental journey, including development of cognitive functions, continues with the same intensity in the postnatal period.