بسم هللا الرحمن الرحيم

Dr. Ahmed Esawy

MBBS M.Sc

MD

Dr/AHMED ESAWY

3D 4D ULTRASOUND

NORMAL FETUS

Dr/AHMED ESAWY

Dr/AHMED ESAWY

-D Principle “Physical Basics” :3

3D ultrasounds work by taking thousands of

image 'slices' in a series (called a 'volume of

echoes'). The volumes are then digitally stored

and shaded to produce 3 dimensional images that

look more life-like.

Dr/AHMED ESAWY

Factors control image quality in 3D,4D image

MOTHER :

Abdominal wall thickness

Colitis

Mother breathing

obesity

Dr/AHMED ESAWY

Factors control image quality in 3D,4D image

Dr/AHMED ESAWY

FETUS

Position(face down,adducted thigh for sex

Age of fetus

Movments of fetus

multiple fetus

Amniotic fluid volume : oligohydramnios

Operator : skills ,experience

Machine : capabilities

Intersting views

Face view

sex view

pulsating heart view

Dr/AHMED ESAWY

Dr/AHMED ESAWY

-D Principle “Physical Basics” :3

3D ultrasounds work by taking thousands of

image 'slices' in a series (called a 'volume of

echoes'). The volumes are then digitally stored

and shaded to produce 3 dimensional images that

look more life-like.

Dr/AHMED ESAWY

Factors control image quality in 3D,4D image

MOTHER :

Abdominal wall thickness

Colitis

Mother breathing

obesity

Dr/AHMED ESAWY

Factors control image quality in 3D,4D image

Dr/AHMED ESAWY

FETUS

Position(face down,adducted thigh for sex

Age of fetus

Movments of fetus

multiple fetus

Amniotic fluid volume : oligohydramnios

Operator :

Machine :

Intersting views

Face view

sex view

pulsating heart view

Dr/AHMED ESAWY

Chewing

Sleepy

whingeFirst

Smiling

Getlost

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Open eye led in 2nd half of pregnancy

The gestational sac in 2D ultrasound at 4–6 weeks' gestation

:The gestational sac in 2D ultrasound at 4–6 weeks' gestation

Dr/AHMED ESAWY

The gestational sac in 3D ultrasound at 4–7 weeks' gestation

Dr/AHMED ESAWY

Normal Anatomy: 1st Trimester

4D US 3D US

Yolk sac

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A close look at the gestational sac at 7 weeks' gestation

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:Embryo at 7–10 weeks' gestation Sonography of the embryonic period with 3D (top) and 2D ultrasound. The developing cerebral vesicles are well seen

Dr/AHMED ESAWY

Brain vesicles at 8 weeks' gestation

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Brain vesicles at 8 weeks gestation: the unfolded embryo

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Casts of the cerebral vesicles at 7–10 weeks' gestation

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End of embryogenesis and beginning of fetal period: 11 weeks' gestation

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TWINS

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triplets

3D US of triplets

4D US

What’s wrong with

this one?

Normal Anatomy

4D US of yawning fetal face 3D US of fetal face

Dr/AHMED ESAWY

Normal Anatomy

3D US of fetal arm, hand & fingers Cine 3D US of fetal arms & legs

Dr/AHMED ESAWY

Normal Anatomy

3D US of fetal spine Fetal liver, heart, intestine by 3D US Dr/AHMED ESAWY

Normal Anatomy

3D US of triplets 3D US of twins

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Normal Face:

2D and 3D US

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Fetal faces

Dr/AHMED ESAWY

combination of sagittal and coronal sections allows a detailed evaluation of the fetal face from early gestation

The fetal face 2D sonography of the fetal face

CRESTA ALVEOLAR

POSTERIOR PALADAR DURO

VELO DEL PALADAR

UVULA

LABIO SUPERIOR

Dr/AHMED ESAWY

3D sonography of fetal face

3D ultrasound is an ideal tool for the evaluation of the fetal face Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Male female

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Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

29w0d

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32w3d

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29w4d2

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21w0d

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27w4d

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23w1d

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7-5-2012

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20w5d

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26w4d

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24w2d

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28w3d

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13w6d

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25w3d

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20w5d

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20w5d2

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16w1d

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BOOXING

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Sucking Thumb

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Hiding Face

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Sucking Lip

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Side View

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Hide Face

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Screaming

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Sad

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Shouting

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Stretching

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Twins Playing

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Yawning

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Smiling

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Nice Hands

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Early Dancing

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Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

3D small anatomical fetal face details in 2nd half of pregnancy

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• Fetal face in first half of pregnancy 10th ,12th ,4th ,18th of pregnancy

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• fetal face details in 2nd half of pregnancy

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• Various display of fetal face movment

Dr/AHMED ESAWY

• Different fascial expression : isolated eye blinking,yawing ,grimacing,tongue ,expulsion, mouthing and swallowing Dr/AHMED ESAWY

Dr/AHMED ESAWY

ROLE OF 3D 4D SCAN

IN FETAL ANOMALLY

3D image for fetus with cleft lip.

Dr/AHMED ESAWY

The fetal palate

3D ultrasound allows the visualization of the fetal palate Dr/AHMED ESAWY

3D tomography of fetal face

Dr/AHMED ESAWY

Varieties of fetal facial clefts

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Isolated cleft lip

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CLEFT LIP

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Cleft lip and palate

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Bilateral cleft lip and palate

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CLEFT LIP

3D US of the Fetal Face Dr/AHMED ESAWY

Cyclops : one eye in middle of head

Facial anomalies with holoprosencephaly

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Lateral cleft of the fetal face

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Rendered view of normal primary palate (anterior alveolar ridge) and cleft palate

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Micrognathia

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Binder syndrome

:Binder syndrome or maxillo-nasal dysplasia Dr/AHMED ESAWY

Skin tag

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• Ear, face appendix

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Beckwith Wiedemann syndrome

:Beckwith Wiedemann syndrome Dr/AHMED ESAWY

hypotelorism

• Decrease distance between orbits

• Normal distance isthat there is enough space for one orbit

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hypertelorism

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Definition: Otocephaly is a grotesque anomaly characterized by absence or hypoplasia of the mandible, proximity of the temporal bones, and abnormal horizontal position of the ears.

Otocephaly

Diagnosis: This condition should be suspected when it is impossible to visualize the jaws, and ears are seen in a very low position.

Dr/AHMED ESAWY

3D US of fetal face

Otocephaly

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Otocephaly

3D US of the face revealed:

Midline Proboscis Low set midline ears

Cyclopia Absent mandible

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Apert syndrome

:The combination of hypertelorism, a large metopic suture and finger abnormalities is suggestive of Aper syndrome

Dr/AHMED ESAWY

Spina Bifida

• Findings:

• Widening of the vertebral column in the affected region appears as a U shape in transverse section.

• A cystic elevation is found dorsal to the vertebral column

• Associations: Arnold Chiari malformation, hydrocephalus.

Dr/AHMED ESAWY

3D US of fetal spine showing a lower lumbar midline defect Dr/AHMED ESAWY

Dr/AHMED ESAWY

Dr/AHMED ESAWY

• Rendered view of scoliosis in 22-week fetus.

• Scoliosis is at T5 level

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Rendered image of club foot.

Dr/AHMED ESAWY

Dr/AHMED ESAWY

3D ultrasound of the fetal skull

:The bones that form the fetal skull and the interposed sutures and fontanelles are visualized using an application of 3D ultrasound

Dr/AHMED ESAWY

ANENCEPHALLY

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ACRANIA

3D US of fetal head showing absent cranial vault

Dr/AHMED ESAWY

Trigonocephaly

:An abnormal shape of the skull with a triangular forehead and a premature closure of the metopic suture is suggestive of trigonocephaly, a rare form of craniostenosis that is frequently associated with other anomalies

Dr/AHMED ESAWY

Normal Fetal Hand: 3D US

Dr/AHMED ESAWY

Normal hand (A) and a picture of bilateral polydactyly (B). Arrows point to extra digits

Dr/AHMED ESAWY

Polydactyly: 3D US

Dr/AHMED ESAWY

Definition:

Presence of less than five digits on hand or feet

US Findings:

Oligodactyly is usually easily diagnosed by US.

Should be differentiated from Ectrodactyly (split hand)

It is associated with Cornelia de Lange Syndrome (multiple cardiac, GIT, skeletal & facial anomalies)

Oligodactyly (three fingers)

Dr/AHMED ESAWY

3D US of fetal hands

Oligodactyly (three fingers)

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3D US of fetal upper limbs

Bilateral club hand

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3D US of fetal hands

Bilateral club hand

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3D image for fetal foot with six Toes.

Dr/AHMED ESAWY

Key Points: Definition: Multiple congenital joint contractures involving two or more body areas. US findings: Odd extremity positioning showing extended legs, flexed wrists, knotted fingers& webbed joint spaces. Polyhydramnios is associated, as well as pulmonary hypoplasia.

Arthrogryposis

Abortus

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Arthrogryposis

3D US of both

lower limbs

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Left renal diltation

3D US of fetal kidneys Dr/AHMED ESAWY

US Findings:

Two areas of fluid accumulation required from diagnosis

Body cavity serous effusions: Ascites (earliest),Pleural effusion(Bilateral), pericardial effusion

Skin and subcutaneous thickening

Placentomegally (>4cm thickness)

Polyhydramnios (early) Oligohydramnios (late)

Hydrops

Ascites

Pleural effusion oedema

Dr/AHMED ESAWY

3D US of fetal thorax & abdomen

Hydrops

diaphragm

Liver

intestine

lung

History: Gestational Age: 26 weeks Maternal Age: 33 Consanguinity: negative Family History: negative

Dr/AHMED ESAWY

2D US of the fetal thorax, with color doppler outlining the heart. An irregular cystic mass is seen opposite it.

3D US of the irregular mass

CYSTIC LUNG

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Miscellaneous

2D US of fetal Abdomen Fetal head Fetal body profile

History: Gestational Age: 15 weeks Maternal Age: 26 Consanguinity: negative Family History: negative

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Miscellaneous

3D US showing:

protrusion at the anterior abdominal wall

Cystic hygroma

Fetal head profile

Subcutaneous Edema of the back

Dr/AHMED ESAWY

• Ability to store & retrieve complete volume allows the examiner to navigate & analyze the volume (even biometry).

• Reduced scan time as volume editing can be done in the patient’s absence.

• The stored volume can be shipped on a removable disk to a 2nd examiner.

• Copying stored volumes for training purposes.

• Visualization of the 3rd plane missing in 2D scanning.

• Accurate volumetry.

• Detailed evaluation of surface structures (e.g. face)

Advantages of 3D over 2D US

Dr/AHMED ESAWY

• Confident detection or exclusion of surface defects.

• Object can be rotated & evaluated from different angles.

• Impressive experience to the parents enhancing parental bonding.

• Parents better appreciate the severity of anomalies.

• Parents are reassured from the exclusion of anomalies.

• Transparent mode provide antenatal infant X-ray.

• 4D displays real-time fetal movements.

Advantages of 3D over 2D US

Dr/AHMED ESAWY

• The examiner must get used to the size of the probe (large & heavy)

• Fetal or probe movement during data acquisition lead to motion artifacts.

• Images are dependent on: (30%) – Fetal position.

– Amniotic fluid.

– 2D image quality.

• Overlying structures interfere with the surface image

• Impressive images of the fetal face are displayed with the advancing gestation (less movements & fluid)

• Image manipulation may cause iatrogenic defects.

• Cardiac anomalies are still another problem without STIC.

• High storage capacity is needed (one volume = 3-18 MB).

Problems with 3D US

Dr/AHMED ESAWY

3D US of fetal abdominal profile. A ball like structure is well delineated

gastrochisis

2D US of fetal anterior abdominal wall showing a circular protrusion

Color doppler of the same area, the cord is beside of the protrusion

Dr/AHMED ESAWY

omphalocele

3D US of Fetal profile showing a ball like structure protruding from

the abdominal wall

2D US & doppler of Fetal anterior abdominal wall. The cord is seen at the

base of the protrusion Dr/AHMED ESAWY

Ventral Wall Defect

Located to the Right of the Umbilicus with NO Membrane Covering

Elevated MSAFP Levels

Not Associated with Chromosome Abnormalities

Increasing Incidence 1/10,000 >>>2-3/10,000

Gastroschisis

Dr/AHMED ESAWY

3D/4D Examination :-

Risk :- 3D and 4D Ultrasound is believed to be a safe, non-invasive exam that utilizes sound waves to look inside the body. Despite extensive studies over 30 years ultrasound has not been shown to cause any harm.

Examination Time :- 3D/4D ultrasound requires the same time as a traditional ultrasound - from 20 to 30 minutes, depending on a number of factors, such as the position of the baby.

Preparation :- Does not require any special preparation.

Dr/AHMED ESAWY

Maximum intensity-rendered image of the thorax and spine at 19 weeks. The posterior ribs and spine are visualized.

Dr/AHMED ESAWY

Surface-rendered image of a normal face at 31 weeks.

Dr/AHMED ESAWY

Acquiring 4-D volumes using the rendering line to set up the acquisition. (A) Acquisition plane of fetal face.Notice that no structures are present between the face and the rendering line (dotted line).

B) Rendered image of face resulting from sweep in (A). Notice that the 3-D sweep is made with the face in a profile or sagittal plane while the rendered image (B) is frontal, or 90° from the acquisition plane

Dr/AHMED ESAWY

Standard orientation of the fetal face. Upper left image in profile. Upper right image is symmetrical orbits. Lower left image is coronal view. Lower right image is rendered image of fetal face. The marker dot is on the fetal nose.

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Display of the upper lip in the multiplanar view at 29 weeks. Face is tipped posteriorly slightly to show the fetal lip (arrow) optimally in the coronal plane. Marker dot is on the upper lip in all 3D multiplanar images.

Dr/AHMED ESAWY

Narrowed region of interest to display fetal face. The boundaries of the region of interest box are narrowed to eliminate echoes in the volume that do not contribute to the surface of the face.

Dr/AHMED ESAWY

Multiplanar view of normal primary palate (anterior alveolar ridge). The face is in profile in upper left. The marker dot is on the palate. The green reference line overlying the upper lip on the rendered image localizes the palate on the upper right-hand axial image.

Dr/AHMED ESAWY

Multiplanar and rendered view of cleft in primary palate and lip (anterior alveolar ridge). The left upper is an image of the profile; the right upper is cleft of primary palate (short arrow) in an axial view; bottom left image is coronal view of cleft lip (long arrow), and bottom right is a rendered image of cleft lip. The green line represents the level of cleft palate on the coronal view

Dr/AHMED ESAWY

ARTIFACT

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Artifact from an intrauterine device (IUD) simulating an IUD within the sac.

Dr/AHMED ESAWY

Rendering artifact creasting the false image of “hole in the head.” This occurs due to the boundaries of the rendering box passing through the cranium

Dr/AHMED ESAWY

Motion artifact presented as “conjoined twins” at 24 weeks (A). Actual image of face is shown in (B

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PRENATAL DIAGNOSIS OF ARTHROGRYPOSIS

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Definition

• Arthrogryposis Multiplex Congenita (AMC) is defined as congenital, non-progressive contractures in more than two joints and in multiple body areas.

• The term arthrogryposis derives from the Greek words arthron – joint and grypos – curved The term multiple congenital contractures can be used synonymously with arthrogryposis.

• The diagnosis is purely descriptive, and arthrogryposis can be part of a large number of different syndromes, at least 200

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classification

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Etiology

• Often unknown

• Fetal Akinesia (decreased fetal movements)

• fetal abnormalities (neurogenic, muscle, or connective tissue abnormalities,mechanical limitations to movement e.g.Oligohydramnios )

• maternal disorders (infection, drugs, trauma, other maternal illnesses)

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Causes of arthrogryposis

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Dr/AHMED ESAWY

Fetal Arthrogryposis Secondary to a GiantMaternal Uterine Leiomyoma

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Drawing of an infant with arthrogryposis

Dr/AHMED ESAWY

Arthrogryposis Clubfoot (arrow).

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Arthrogryposis Straight knee joints (arrow).

Dr/AHMED ESAWY

Arthrogryposis Hip joints bending upward stiffly (arrow) and straight knee joints (arrowhead) under maximal

translucent mode.

Dr/AHMED ESAWY

Arthrogryposis Elbows bending up stiffly (arrow) and straightened knees (arrowhead). Note the same

position of the fetus

Dr/AHMED ESAWY

FETAL AKINESIA DEFORMATION SEQUENCE (FADS)

• heterogeneous group of conditions resulting in multiple joint contractures, including bilateral talipes and fixed flexion or extension deformities of the hips, knees, elbows and wrists. This sequence includes congenital lethal arthrogryposis, multiple pterygium and Pena–Shokeir syndromes

Dr/AHMED ESAWY