3- and 4-Dimensional 3- and 4-Dimensional Ultrasound Imaging in Ultrasound Imaging in Obstetrics Obstetrics Curtis Lowery, M.D. Curtis Lowery, M.D. Professor and Section Head Professor and Section Head of MFM of MFM Medical Director of ANGELS Medical Director of ANGELS
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3- and 4-Dimensional Ultrasound Imaging in Obstetrics Curtis Lowery, M.D. Professor and Section Head of MFM Medical Director of ANGELS.
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3- and 4-Dimensional 3- and 4-Dimensional Ultrasound Imaging in Ultrasound Imaging in ObstetricsObstetrics
Curtis Lowery, M.D.Curtis Lowery, M.D.Professor and Section Head of MFMProfessor and Section Head of MFMMedical Director of ANGELSMedical Director of ANGELS
2D to 3D2D to 3D
The mental process of The mental process of converting 2D into 3D converting 2D into 3D images is not an easy images is not an easy one, and is dependent on one, and is dependent on individual skills and individual skills and training.training.Therefore, it is not Therefore, it is not surprising that the skills surprising that the skills involved in interpreting involved in interpreting ultrasound images are not ultrasound images are not uniform and vary between uniform and vary between practitioners.practitioners.
Ewigman BG, Crane JP, Frigoletto FD, LeFevre ML, Bain RP, McNellis D. Effect of prenatal ultrasound screening on perinatal outcome. RADIUS Study Group. N Engl J Med 1993; 329:821–827.LeFevre ML, Bain RP, Ewigman BG, Frigoletto FD, Crane JP, McNellis D. A randomized trial of prenatal ultrasonographic screening: impact on maternal management and outcome. RADIUS (Routine Antenatal Diagnostic Imaging With Ultrasound) Study Group. Am J Obstet Gynecol 1993; 169:483– 489. Grandjean H, Larroque D, Levi S. Sensitivity of routine ultrasound screening of pregnancies in the Eurofetus database. The Eurofetus Team. Ann NY Acad Sci 1998; 847:118–124.Levi S. Ultrasound in prenatal diagnosis: polemics around routine ultrasound screening for secondtrimester fetal malformations. Prenat Diagn 2002; 22:
Disparities in DiagnosisDisparities in Diagnosis
Methods of 3-D ImagingMethods of 3-D Imaging
Freehand acquisition using a conventional Freehand acquisition using a conventional 2-dimensional ultrasound (2DUS) 2-dimensional ultrasound (2DUS) Freehand (2DUS) acquisition using a Freehand (2DUS) acquisition using a conventional 2DUS transducer with conventional 2DUS transducer with position sensing position sensing Automated acquisition using dedicated Automated acquisition using dedicated mechanical volume probes mechanical volume probes Real-time 3D imaging using 2D array Real-time 3D imaging using 2D array transducerstransducers
There are three planes involved in the acquisition of a volume, A, B, and C. In this example of a scan with a fetus lying on its back the Planes are as follows:
1) A Plane - Transverse2) B Plane - Longitudinal3) C Plane - Horizontal
The three planes always maintain a 90-degree relationship to each other. No matter where you move the transducer or how you rotate acquired volumes the three planes will maintain their 90-degree relationship. Thus it is important to understand that any adjustment to one plane will affect the other two planes.
Benefits of 3DUSBenefits of 3DUS1)1) The ability to review volume data interactively after the The ability to review volume data interactively after the
patient has left the examination roompatient has left the examination room2)2) The possibility of using different planes of section for the The possibility of using different planes of section for the
evaluation of anatomic structures other than the original evaluation of anatomic structures other than the original acquisition plane acquisition plane
3)3) The possibility of rotating the volume data set so that The possibility of rotating the volume data set so that anatomic structures can be examined from different anatomic structures can be examined from different perspectivesperspectives
4)4) The availability of a variety of rendering methods that The availability of a variety of rendering methods that allow examiners to visualize different characteristics of allow examiners to visualize different characteristics of the same structure (eg, the same volume data set of the the same structure (eg, the same volume data set of the fetal back can reveal the external aspect of a fetal back can reveal the external aspect of a meningomyelocele when rendered in the surface mode meningomyelocele when rendered in the surface mode or, alternatively, the underlying bones when the volume or, alternatively, the underlying bones when the volume data set is rendered in the maximum-intensity mode)data set is rendered in the maximum-intensity mode)
Luís F. Gonçalves, MD,J Ultrasound Med 2005; 24:1599–1624
Benefits of 3DUSBenefits of 3DUS
5)5) Improved accuracy for volume measurements, Improved accuracy for volume measurements, including the possibility of measuring the including the possibility of measuring the volume of irregular objects volume of irregular objects
6)6) The possibility of standardizing ultrasound The possibility of standardizing ultrasound examinationsexaminations
7)7) The ability to transmit data over networks for The ability to transmit data over networks for consultation in tertiary care centersconsultation in tertiary care centers
8)8) The potential to use offline software programs The potential to use offline software programs as an interactive educational toolas an interactive educational tool
Fetal FaceFetal Face
Photography-Photography-like imageslike images
Facial Facial movementsmovements
Good views Good views 70%70%
Electronic fetal Electronic fetal scalpelscalpel
Fetal FaceFetal Face
Multiplanar and Multiplanar and rendered displaysrendered displaysMultiplanar: examiner Multiplanar: examiner to “navigate” through to “navigate” through the volume data set the volume data set simultaneously in the simultaneously in the 3 orthogonal planes3 orthogonal planesPrecise location of an Precise location of an anatomic structure or anatomic structure or abnormality abnormality
Demonstrations of 4-D offline Demonstrations of 4-D offline Volume Set AnalysisVolume Set Analysis
Combined 2DUS and 3DUSCombined 2DUS and 3DUS
N=96 facial cleftsN=96 facial clefts
Concordance between prenatal and Concordance between prenatal and postnatal diagnoses was observed in postnatal diagnoses was observed in 87.5%87.5%
Underestimated the severity of the clefts in Underestimated the severity of the clefts in 8.3% (8/96) of the cases 8.3% (8/96) of the cases
Overestimated in 4.1% (4/96).Overestimated in 4.1% (4/96).
Rotten D, Levaillant JM. Two- and three-dimensional sonographic assessment of the fetal face, 2: analysis of cleft lip, alveolus and palate. Ultrasound Obstet Gynecol 2004; 24:402–411.
Comparison of 2DUS and 3DUSComparison of 2DUS and 3DUS
N=31 facial cleftsN=31 facial clefts
Agreement between ultrasonographic Agreement between ultrasonographic diagnosis and neonatal outcomesdiagnosis and neonatal outcomes– 87.1% (27/31) of the 3DUS examinations87.1% (27/31) of the 3DUS examinations– 45.2% (14/31) of the 2DUS examinations45.2% (14/31) of the 2DUS examinations
Overestimated the severity of the defectsOverestimated the severity of the defects– 2DUS 41.9% (13/31) of the cases2DUS 41.9% (13/31) of the cases– 3DUS 9.7% (02/31) of the cases3DUS 9.7% (02/31) of the cases
Johnson DD, Pretorius DH, Budorick NE, et al. Fetal lip and primary palate: three-dimensional versus two dimensional US. Radiology 2000; 217:236–239.
Cleft LipCleft Lip
3-D Examination of Fetal Brain3-D Examination of Fetal Brain
Severity location and Severity location and extent of anomaliesextent of anomalies
Visualization of Visualization of corpus callosumcorpus callosum
Ruano R, Molho M, Roume J, Ville Y. Prenatal diagnosisof fetal skeletal dysplasias by combining twodimensional and three-dimensional ultrasound and intrauterine three-dimensional helical computertomography. Ultrasound Obstet Gynecol 2004; 24:134–140.
Xu et al: higher visualization rates for Xu et al: higher visualization rates for congenital anomalies congenital anomalies – 3 DUS 78.0% [32/40]3 DUS 78.0% [32/40]– 2 DUS 92.7% [38/41]2 DUS 92.7% [38/41]
Scharf et al: 3DUS did not provide Scharf et al: 3DUS did not provide significant additional information (significant additional information (P P < .05)< .05)– 2DUS (68.3% [28/41]2DUS (68.3% [28/41]– 3DUS 97.5% [39/41]3DUS 97.5% [39/41]
Scharf A, Ghazwiny MF, Steinborn A, Baier P, Sohn C. Evaluation of two-dimensional versus three-dimensional ultrasound in obstetric diagnostics: a prospective study. Fetal Diagn Ther 2001; 16:333–341
Xu HX, Zhang QP, Lu MD, Xiao XT. Comparison of two-dimensional and three-dimensional sonography in evaluating fetal malformations. J Clin Ultrasound 2002; 30:515–525
echocardiography facilitated by an Internet link. Ultrasound Obstet Gynecol 2001; 18:325–328.
2 DUS vs. 3 DUS of Fetal Heart2 DUS vs. 3 DUS of Fetal HeartViñals et al: 4DUS with STIC Viñals et al: 4DUS with STIC
Obstetricians with limited experience Obstetricians with limited experience
Volume data setsVolume data sets
100 fetuses examined100 fetuses examined
Visualization rates determined: Visualization rates determined: – 4-chamber 4-chamber – left and right ventricular outflow tractsleft and right ventricular outflow tracts– 3-vessel view3-vessel view– trachea views trachea views
Viñals F, Poblete P, Giuliano A. Spatio-temporal image correlation (STIC): a new tool for the prenatal screening of congenital heart defects. Ultrasound Obstet Gynecol 2003; 22:388–394.
Volumetry in Early Pregnancy: CorrelationVolumetry in Early Pregnancy: CorrelationWith Abnormal Pregnancy OutcomeWith Abnormal Pregnancy Outcome
Acharya and Morgan reported on a study of 81 Acharya and Morgan reported on a study of 81 patients with miscarriagespatients with miscarriagesMean gestational sac diameter/crown-rump length Mean gestational sac diameter/crown-rump length ratioratio– miscarriage, 3.3 [95% confidence interval (CI), 2.51–miscarriage, 3.3 [95% confidence interval (CI), 2.51–
4.08] 4.08] – normal pregnancies, 2.1 [95% CI, 1.67–2.63]normal pregnancies, 2.1 [95% CI, 1.67–2.63]– P P = .008= .008
gestational sac volume/embryonic volume ratiogestational sac volume/embryonic volume ratio– miscarriage, 3.3 [95% CI, 2.51–4.08]miscarriage, 3.3 [95% CI, 2.51–4.08]– normal pregnancies, 459.5 [95% CI, 81.8–837.2]; normal pregnancies, 459.5 [95% CI, 81.8–837.2]; – P P = .023)= .023)
Acharya G, Morgan H. First-trimester, three-dimensional transvaginal ultrasound volumetry in normal pregnancies and spontaneous miscarriages. Ultrasound Obstet Gynecol 2002; 19:575–579.
32 Pregnancies mean32 Pregnancies meanGA of 12.3 ± 0.2 weeksGA of 12.3 ± 0.2 weeks
Basic fetal biometric Basic fetal biometric measurements measurements – Crown-rump lengthCrown-rump length– Biparietal diameterBiparietal diameter– Head Head
– NTT thicknessNTT thickness– Evaluation of the uterus Evaluation of the uterus
and placentaand placenta
Hull AD, James G, Salerno CC, Nelson T, Pretorius DH. Three-dimensional ultrasonography and assessment of the first-trimester fetus. J Ultrasound Med 2001; 20:287–293.
Fetal Anatomic and Biometric Survey byFetal Anatomic and Biometric Survey byFirst-Trimester 3DUSFirst-Trimester 3DUS
NTT <3.0 mmNTT <3.0 mm– Statistically significant overestimation of Statistically significant overestimation of
values from transvaginal and transabdominal values from transvaginal and transabdominal 3DUS3DUS
NTT >3.0 mmNTT >3.0 mm– Statistically significant underestimation of Statistically significant underestimation of
values from transvaginal and transabdominal values from transvaginal and transabdominal 3DUS3DUSWorda C, Radner G, Lee A, Eppel W. Three-dimensional ultrasound for nuchal translucency thickness measurements: comparison of transabdominal and transvaginal ultrasound. J Soc Gynecol Investig 2003; 10:361–365.
3D Volumetric Measurements3D Volumetric Measurements
Limbs to estimate: Limbs to estimate: fetal weight to 5% fetal weight to 5% birth weightbirth weight– 3DUS 20/30 fetal 3DUS 20/30 fetal
weight toweight to– 2DUS 6/30 2DUS 6/30
Lungs to predict: Lungs to predict: pulmonary hypoplasiapulmonary hypoplasia– ? Small studies? Small studies
Sonographic TomographySonographic Tomography5 volume data sets5 volume data sets– Fetal headFetal head– FaceFace– ChestChest– AbdomenAbdomen– Limbs Limbs
Examined by physicians not involved in Examined by physicians not involved in acquisitionacquisitionComplete studies 20/25Complete studies 20/25Scan times reduced by half with 3DUS Scan times reduced by half with 3DUS volume acquisitions (13.9 versus 6.6 volume acquisitions (13.9 versus 6.6 minutes minutes PP< .001)< .001)Benacerraf BR, Shipp TD, Bromley B. How sonographic tomography will change the face of obstetric sonography: a pilot study. J Ultrasound Med 2005; 24:371– 378.
Maternal BondingMaternal Bonding
100 patients100 patients
Randomly assigned to 2DUS only or Randomly assigned to 2DUS only or 2DUS + 4DUS2DUS + 4DUS
No difference in positive response ratesNo difference in positive response rates
Maternal antenatal attachment scaleMaternal antenatal attachment scale– Quality and intensity of attachmentQuality and intensity of attachment– Global attachment scoreGlobal attachment score
Rustico MA, Mastromatteo C, Grigio M, Maggioni C, Gregori D, Nicolini U. Two-dimensional vs. two- plus four-dimensional ultrasound in pregnancy and the effect on maternal emotional status: a randomizeds study. Ultrasound Obstet Gynecol 2005; 25:468–472.
ConclusionsConclusions
Additional information Additional information in the diagnosis of in the diagnosis of congenital anomaliescongenital anomalies– facial clefts facial clefts – neural tube defectsneural tube defects– skeletal malformationsskeletal malformations
New resources for New resources for fetal examinationfetal examination– MultiplanarMultiplanar– Anatomic slicingAnatomic slicing– Rendering modesRendering modes
Probable decrease in Probable decrease in examination timesexamination timesNew methods of fetal New methods of fetal biometrybiometryFetal organ volume Fetal organ volume measurementsmeasurementsVolume dataset Volume dataset acquisition and acquisition and transfertransferEducationEducation