• Lisandra Stein Bernardes, Ana Mércia Fernandes, Mariana Azevedo de Carvalho, Juliana Ottolia, Michele Hamani, Inaeh Oliveira, Gabriel Taricani Kubota, Valquíria Aparecida da Silva, Adriano Veloso, Mario Henrique Burlachini de Cavalho, Antônio Gomes de Amorin Filho, Louise Thomsen Schmidt Arenholt, Peter Christian Leutscher, and de AndradeDaniel CiampiDCCenter for Neuroplasticity and Pain, Health Science and Technology, Faculty of Medicine, Aalborg University, Denmark; Pain Center, Department of Neurology, University of Sao Paulo, Brazil..
• Center for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark; Gynecology and Obstetrics Department, University of Sao Paulo, Brazil; SEPACO Maternity Hospital, São Paulo, Brazil; Department of Gynecology and Obstetrics, North Denmark Regional Hospital, Hjoerring, Denmark. Electronic address: l.bernardes@rn.dk.
• J Pain. 2024 Apr 8: 104527104527.

AbstractImprovements in fetal ultrasound have allowed for the diagnosis and treatment of fetal diseases in the uterus, often though surgery. However, little attention has been drawn to the assessment of fetal pain. To address this gap, a fetal pain scoring system, known as the Fetal-7 scale, was developed. The present study is a full validation of the Fetal-7 scale. The validation involved two steps: i. four fetuses with indication of surgery were evaluated in three conditions perioperatively: acute pain, rest, and under loud sound stimulation. Facial expressions were assessed by 30 raters using screenshots from 4D high-definition ultrasound films; ii., assessment of sensitivity and specificity of the Fetal-7 scale in 54 healthy fetuses and two fetuses undergoing acute pain after preoperative anesthetic intramuscular injection. There was high internal consistency with Cronbach's alpha (α) of 0.99. Intra-rater reliability of the Fetal-7 scale (test-retest) calculated by intraclass correlation coefficient (ICC) was 0.95, and inter-rater reliability was 0.99. The scale accurately differentiated between healthy fetuses at rest and those experiencing acute pain (sensitivity of 100% and specificity of 94.4%). The Fetal-7 scale is a valid tool for assessing acute pain-related behavior in third trimester fetuses and may be of value in guiding analgesic procedures efficacy in these patients. Further research is warranted to explore the presence of post-operative pain in fetuses and its effects afterbirth. PERSPECTIVE: Recordings with three-dimension ultrasound of human fetuses undergoing pre-operative anesthetic injections revealed complex facial expressions during acute pain, similar to those collected in newborns. This study presented the validation process and cut-off value of the Fetal-7 scale, paving the way for the study of pain before birth in humans.Copyright © 2024. Published by Elsevier Inc.

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