3D Sonography in Obstetrics - SD

Introduction

I am Dolores Pretorius,
and I'm from the University of California, San Diego,
where I'm a professor.
And I'm gonna talk today about three dimensional ultrasound
and obstetrics, where you use it clinically.
I wanna just give you a couple learning points of
what you should learn today.
When you finish this talk, you should have an idea of
what applications we use 3D ultrasound for.
In evaluating the fetal brain, you should know
where clefts lips occur
and where to look for 'em among the pictures
and how to render the cranium to see sutures.
Now of course you're gonna learn a lot of other things,
but I want you to try to focus on these three things
and make sure at the end of the talk you can do that.

Overview of 3D Ultrasound Applications

Here's a 3D picture of a little fetus,
and you can see that the appearance of the baby
after delivery is really very similar.
If you look at the nose, if you look at the area
of the lips, look at the area of the philtrum right between the nose
and the lips, it really looks very similar.
Where do we use 3D ultrasound for
in evaluating congenital anomalies?
Probably the most common referral that I get
for 3D ultrasound is for facial anomalies such
as cleft lip and palate.
Yes, we do get them for other facial anomalies such
as profile like micrognathia.
If you can't find the nasal bone,
sometimes 3D can be really helpful
to decide whether you do have a nasal bone there or not.
We also use it for ear anomalies, so families
that have prior children born with congenital syndromes
that have ear anomalies.
3D is really much more helpful, I believe,
than 2D ultrasound in the brain.
We are using it more and more as a troubleshooting
and trying to measure different structures
and figure out whether they're normal or not.
And I will show you several of those types
of applications.
People are talking about 3D ultrasound
for cardiac anomalies,
but in my hands we use it predominantly for teaching,
how to get those outflow tracks, how
to understand the three dimensionality of the heart.
And we are just beginning to use it to look
for actual anomalies themselves.
We do use it for spinal anomalies,
particularly identifying the level of a spinal abnormality
or a fetus that's in a terrible position to look at the spine.
We use it for some extremity anomalies such
as club feet or cutoff fingers
or abnormal orientation of the hands or feet.
And then lastly, we use it for some
vascular anomalies like vasa previa.
How far is the villous cord insertion from the cervix?
I can't quite get it in the right plane.
I can take a volume and identify how far away it is.

Facial Clefts

I wanna start with facial clefts
because it's our most common referral.
And this is a diagram from an article from 2006
where you can see the normal alveolar ridge here.
And this is the hard palate here.
And then the soft palate is back here.
And a unilateral, we tend to get our cleft right here,
often going up into the nostril, just into the lip.
Whereas here we have a cleft lip
and palate going all the way through the alveolar ridge.
There we have a bilateral cleft lip and palate.
And this picture does remind you that sometimes it's hard
to decide whether you're looking at a cleft
or whether you're looking at the nostrils themselves.
Here is a unilateral cleft lip
and hard palate going all the way back.
And here's a bilateral cleft going all the way back
and there are lots of variations.
You can have a hard palate coming on the right
and you can have just a lip on the left.
So it is something that you have to definitely look at on both sides.
We can also have isolated clefts of the hard palate
or of the soft palate,
and these are much more problematic in being
able to identify.
But there are case reports
now identifying some of these.
Now this is a paper that came out of our lab at UCSD,
and we learned a lot from just making this picture,
because we learned
that the primary palate is really just the first four tooth
buds and the rest
of the alveolar ridge back here is really
the secondary palate.
Where we see from here back,
and it's from this little point called the incisive
foramen, back as the secondary palate.
Here you can see the clefts generally occur
through that lateral incisor that the second tooth bud over is where we get the clefts.
So if you can see the front four tooth buds,
you probably do not have a cleft lip
or a cleft palate.
And so
that's a very important thing in deciding when you're gonna
clear your palate.
Now I really like this diagram from Dr. Stewart Campbell,
from an editorial he wrote in the White Journal,
because it reminds us that the hard palate is up here
between the two blue areas
and the soft palate is posterior here and it's curved.
So you are not going to see the soft palate clefts
or hard ones on the same plane
unless you do a curving rendering of
that palate.
Now Dr. Millard is a plastic surgeon who's sort of the guru
of clefts,
and he has a huge three volume
book on plastic surgery of clefts.
And I just took a few pictures from his book,
showing this isolated unilateral
cleft lip coming back into this hard palate.
And you can see part of the normal palate here as well.
And these are masks of clefts.
Here we have a bilateral
that looks a little bit like a rabbit
with a premaxillary mass right here
that has two tooth buds in it.
Sometimes they do, sometimes they don't, but this one does
and sometimes these are kind of hard to see the cleft,
but the premaxillary mass is pretty obvious.
And then here's an isolated cleft palate back here.
And then I wanted to show this picture
that shows variations of the hard
and soft palate to remind you that they don't all
look exactly like you would imagine from our diagrams,
but some of 'em are really quite unique in
how these clefts are formed.
They're certainly midline here,
but they're not just like you might draw out and expect.
So here's a patient that has a cleft lip and palate
and this is the frontal view on 2D
and there's this area here that's worrisome.
And then on the axial view through the palate,
you can see that there's a gap here going into
the alveolar ridge.
Now you don't know exactly whether it's midline
or whether it's right or left, but this one is labeled left
and certainly turned out to be that way.
Here is a multi-slice picture through
the face and I want you to just notice the orbits.
And then we're coming down every two millimeters into the,
finally we get into the palate
and you can see the anterior alveolar ridge right there,
and a little bit better where you can see those tooth buds.
Those are the front two tooth buds.
And then here's our lateral ones,
and then we keep going down.
You see the tongue and then further down
and we see the mandible.
Now the mandible can often look very similar to the palate,
and depending upon how you angle it,
the palate will be more horseshoe like.
And the mandible tends to be just a little bit wider.
Here we have a videotape of a cleft lip and palate.
And first we are magnifying the volume in order
to get the profile in the upper left hand corner
just by panning.
And then we're rotating that face so
that it's rather horizontal right here.
And then the picture in the upper right
we are going to go ahead
and magnify our rendered view and we're gonna go ahead
and cut away a little bit of the uterus so
that we can see our little face a little better.
We put the box coming right in front
of the face and then out to the left
and then we rotate it a little bit more
and try to make it a little more symmetrical.
And then we take the image.
And now our goal is to try to make this face symmetrical
and we usually use the orbits to help us decide.
So in the upper right hand corner you can see
the two orbits.
So we're gonna try to rotate that face.
And so the orbits are flat as well.
There we go, almost there.
And I look in both the box in the upper right hand corner
and in the lower left hand to see
that the orbits are symmetrical.
And now we're coming down
and we can see the cleft right in the middle
of the screen both up here.
That's the tongue and in the mandible back up.
And here's the cleft right here.
And you can also see it on our rendered image.
Now if we tip the face up so
that the profile has the forehead tipping backward,
we will get and put our cursor on the region of the lip,
we'll get our classic 2D appearance
of the cleft lip right in here.
Of course, we can see that on our rendered image as well.
We can see this patient both pre and post repair.
And I think this picture
of the cleft is pretty representative of this little
baby.
And you can see the tongue sticking out between the cleft
and then you can see after the repair,
which really looks quite nice.
Now, that multi slice I think is incredibly helpful
to help us understand the pictures that we're taking
because this one,
is really at one millimeter slices going along the front
of the face, you can see this is a pretty typical
face right here of the frontal view
that we would get on 2D of our lip.
And it lip looks totally normal here,
but as you keep going forward, then you will see
that there is a cleft in the anterior part of the lip.
And that's because this baby has an isolated cleft lip
and a normal palate.
And I think we are imaging just the anterior portion
of the palate here, the gums so to speak,
making it look normal.
So just like everything in 2D ultrasound, you have
to scroll back and forth in order to
reconfirm when you think that you have the right picture.

Retronasal Triangle and Hard Palate Visualization

Now, one of the new things that's come out in the last
couple years is this concept by Dr.
Sepulveda from Chile.
And he
has talked about the retronasal triangle.
And that is this space right here on the front of the face,
and that is part of the maxilla.
And you can see that normal retronasal triangle.
And then here you have a fetus with bilateral cleft
and this fetus had a bilateral cleft lip and palate.
And we, he did this by either taking a 3D volume
and putting a line through here
or a thick slice through there.
And you can see this is a normal picture from our lab, which
of course is not quite as beautiful as his from the
for the paper.
But the concept I really wanted you
to get across is there's the profile of our little fetus.
We put the cursor dot right in the anterior part
of the maxilla as it's shooting straight back.
And then we can see this retronasal triangle right here.
We found in our lab that we could get it with 2D ultrasound
as well as 3D ultrasound.
And so we would take lots of our retronasal triangles
with 2D
because it was relatively faster for us to do it.
But I think as I've moved forward,
I've learned some benefits to 3D.
So here's another patient in our lab
that has a bilateral cleft lip and palate at 13 weeks.
And here you can see that the clefts are relatively subtle.
This one you can see the premaxillary mass.
And then here's the clefts right here.
But it was the premaxillary mass that tipped us off
that something was wrong with the face.
And you can see there's the little cursor of
where we are in order to get this type of picture.
Now, Dr. Sepulveda just last month presented a paper, a follow-up paper
on his retronasal triangle looking at clefts in the first
trimester and showing
that he could identify them not just in the retronasal
triangle, which would be out in this region,
but that he also got the hard palate by doing the 3D volume
and looking through it.
Now he does have the rendered views, which I think are yes,
they do show the cleft, but they're pretty hard to see.
But I'm quite impressed with his pictures
of the hard palate cleft there, there,
this one's a bilateral.
And here's another unilateral,
and you can see these on this frontal view
in a picture similar to the retronasal triangle.
Dr.
Platt came up with this concept
of looking at the hard palate on a flipped face view.
And what he did was he rendered
with the face upside down with the profile down here
and across here,
and got a picture of the alveolar ridge
with the hard palate back here.
And I must confess that I am on this paper as well.
He showed it to me and I didn't believe it initially,
but over a year, starting looking at it, trying it on lots
of different patients, I became assured that he was right.
And Dr. Vinals from France
then wrote this incredible paper
of a hundred patients looking at the hard palate,
which is really the same concept of Dr.
Platt's. There's your alveolar ridge
and here's that hard palate right here.
And I am just still amazed at the types
of pictures that he was able to get.
With a little more experience.
We changed in our lab to be more intuitive
by putting the face upright
and then having our rendering line slightly curved
because of the curved nature of the palate
and looking at it upright
because it was much more intuitive to us.
And here's a typical picture with the palate right there,
the alveolar ridge, the primary palate,
and then the hard palate, the secondary palate back here.
Now, the multi-slice does help when you have
clefts because the face, the nose is asymmetrical generally.
So notice in this fetus the orbits are perfectly
symmetrical here, but as we go up
and these are one millimeter cuts, there's the nostrils,
there's the nostrils here, we keep going
and then things just begin
to not look quite right on the right.
You still don't know exactly what's going on until we get
to about here and we should be in the palate.
We have part of the alveolar ridge on one side
but not on the other.
So there's a cleft palate coming through here
and it's going all the way out to the lip.
So this is a cleft lip and palate.
And then here's our mandible down here
and here's the rendered view of that fetus.
And you can see that it kind of looks a little funny
because the nose is asymmetrical
and this is exactly what the kid looked like after delivery.
Now here's a picture showing our flipped face view
that's now been changed to be upright.
And here's our rendering line.
And you can see this cleft
of the hard palate coming back here as well.
And this is just a normal for comparison for you to see
that alveolar ridge
and that not all of them are as beautiful as
what you see in the books, and that's pretty classic.

Profiles and Other Facial Anomalies

Okay, moving beyond the clefts, we also look at profiles.
We can find a normal profile in patients
that we don't have in a good position sometimes
for 2D ultrasound,
but by taking a volume you can rotate the face
and be able to get that normal profile.
We can also assess babies
that we think might have micrognathia from 2D exams
or in looking for fetuses who have syndromes associated
with micrognathia.
And we can also look at other masses like the premaxilla
or in patients with holoprosencephaly
or encephaloceles or tumors.
And these are just a few pictures courtesy of Dr.
Platt of nice normal profiles.
I just like them because you can just imagine
your uncle looking like this or this or this
and they just all are a little bit different.
So here's a patient that has Treacher Collins syndrome
and you can see that as you look at this profile,
that the chin is just way receded and small
and that's pretty classic for micrognathia.
And this fetus also had retrognathia,
which means it's pulled posteriorly a little bit.
But we weren't even looking at the ears
and we noticed something was going on here.
And here's a normal ear for comparison.
This is this little baby's ear when it was born.
You can see it's really quite malformed.
Now, when this case came through our fetal conference saying
that one of my colleagues had called micrognathia at 13 weeks,
I was just blown away.
But when I looked at the pictures I go, yeah, for sure.
Look, here's a normal profile at 12 weeks,
which we do on all of our NT patients,
and here's the nasal bone that they're looking for
and notice the mandible versus the maxilla.
And in our case you can see that there's a maxilla,
but there's really no mandible.
So this fetus did have micrognathia at 13 weeks
and I just have another one at 13 and five, and this is 12
and three, just to show you what a normal should look like.
In comparison, we can also look for
frontal bossing in patients with skeletal dysplasias
to help narrow down whether they might have achondroplasia
like here in comparison to this normal profile.
Here the nasal bone is
quite important
in association with trisomy 21.
You can see that this is the frontal process of the maxilla.
This is not the nasal bone back here.
The nasal bones are the two dots that are anterior on this.
And you can put the cursor on
what you think is the nasal bone that we always take
and see that that cursor is right there
and that's where the nasal bones are.
These can be rendered
and you can see them on the 3D rendered view,
but personally, I usually use the 2D
or multiplanar views to find it.

Fetal Head and Brain Evaluation

Okay, next I'd like to attack the topic of the fetal head
and brain, particularly looking at the cranial sutures
for craniosynostosis
or an abnormal appearance to look
for mild ventriculomegaly,
and to identify the corpus callosum in all patients
with mild ventriculomegaly.
To talk about the vermis size in patients
with suspected Dandy-Walker variants
and to talk about cystic lesions in the brain, such
as the cavum septi pellucidi, the third ventricle, the vein of Galen
aneurysms and interhemispheric cysts.
This is just a video clip showing cranial fontanelles in
this little fetus where you can see the big
main fontanelle superiorly that we use all the time
to do ultrasound on neonates.
That's the anterior fontanelle.
And then here is a rendering
of the normal skull showing the coronal suture
and the squamous suture.
And here's a fetus that has
craniosynostosis and you have no
coronal suture there seen.
Now we pick these up often by our 2D exam
and we realize that the head shape is not normal.
So here you have a normal nice oval head shape
and you can even see part of the coronal suture right there.
Part of the lambdoidal suture right here.
And then here you have a fetus that has craniosynostosis
and you can see that it's kind of
indented at the region of the coronal sutures.
Now I just wanna remind you which sutures they are.
The coronal is this one.
That's between the parietal bone
and the frontal bone.
And the parietal bone. This is the squamous
suture the lambdoidal suture the mastoid.
And then the zygoma right here, when you look on axial,
you can see the sagittal suture
and the anterior fontanelle, the coronal suture
and the metopic suture.
So here we have our fetus with craniosynostosis.
And what's important to notice is that we need to take a
narrow volume right along the
anterior portion, so that we just get one side
of the head in our rendered pictures to look at whether
that is intact or not.
And if we that one has craniosynostosis,
whereas this one we narrowed along the front
and you can see that nice normal suture.
And then here we have, we can narrow it along the bottom
of the head and we can get the other coronal suture
and that's that squamous suture there
and that's part of the lambdoidal suture in the back.
If you wanna look at the sagittal suture, you need
to render it along the superior aspect on a profile view.
And then you can get this beautiful fontanelle anterior
fontanelle right here, seeing what size it is now.
Chao and
Bernard Benoit published this paper looking at
metopic sutures and showing
what a normal metopic suture looks like at 19, 23 and 30 weeks.
And then an abnormal one that they called V-shaped
and then a Y shaped one and then a U-shaped one.
And then here we have premature closure like we did in the
case I just showed you.
And then here's some additional wormian
bones in both of these cases.
So how do you get that?
You come along the anterior or frontal part of the face
and you do a thin rendering right along that region in order
to get this type of picture.
Because one of the problems
with 3D is we'll show you beautiful pictures,
but then how do you get them?
So looking at the multiplanar view is critical in being able
to identify how you get the pictures we're showing.
Now, just to show you that it's not so simple,
this was a family that came in with a history
of familial craniosynostosis defect
and mom had it herself.
And this fetus I studied at 18 weeks
and you can see that it looks pretty far apart.
And in comparison to those normals that I just showed you,
look at this at 19 weeks,
it's pretty closed by then.
And so I had comparisons and I was quite concerned
and I told the family I was concerned
that the fetus might have the same ossification defect,
but when she came back three weeks later at 21 weeks,
she looked normal to us.
So I think we still have a little ways
to go in understanding the normal variations of
what we should be able to see in our normal population
as well as our abnormals.
Next I'd like to just show you a fetus that
might have mild ventriculomegaly that we always go
and try to find the corpus callosum on top
to see if we can identify it
because often mild ventriculomegaly will be associated
with absence of the corpus callosum,
particularly when those ventricles look parallel
or teardrop shaped.
Here is a patient that has a cyst in the middle
of the brain and we put the cursor right in the middle of that
and we see from the sagittal view
that this would be the cavum septi pellucidi
and this would be the cavum vergae.
And it helps us identify
that this is just a normal structure.
I wanna remind you what that looks like.
Here's the cavum septi pellucidi
and here's the cavum vergae posterior to it.
And sometimes it disappears first and collapses,
but in our fetuses we often see it
and you can also have a cavum velum interpositum
behind that.
In patients that have agenesis of the corpus callosum,
you see that cyst here and you don't see any,
and you can see that cyst is kind of elevated.
And this can be the third ventricle that's elevated
because there's no corpus callosum.
And I think when we turned on color here, the color
wasn't particularly helpful in this case,
but sometimes it's very helpful
because you can't find the pericallosal artery.
Now probably the most common place I'm using
3D in the brain right now is to look at patients
that have suspected Dandy-Walker variants.
We see this kind of cystic area in the posterior fossa
and it's connecting up into the region
of the fourth ventricle
and yet the cisterna magna, we can see a normal part
of cisterna magna and we just don't know whether it has
Dandy-Walker variant or not.
We know that this is normal up until 18 weeks based on work
that Dr. Rembouskos has done.
So we'll bring them back,
but then we measure the vermis.
And how do we do that? We line the head up so
that it's symmetrical so that we have the face on
in a profile view and the spine coming down.
So it's all intuitive and then we know where the vermis is
because we can look at it in our other planes
and decide where the upper portion is in the lower portion.
And then we can measure this
and we can plot it on tables to see
whether it's within normal limits or not.
So here is a patient that does have a Dandy-Walker variant
with the cystic structure from the cisterna magna going up
into the fourth ventricle.
And then when we do our sagittal with the spine coming down,
we can measure that vermis and see that it is small.

Cardiac Applications

Cardiac 3D is
done predominantly using STIC
or spatiotemporal image correlation.
This is a technique where there's a series of volumes
that are acquired and saved
and then they're reviewed in their multiplanar images
of the heart throughout the cardiac cycle.
And it appears that the heart is beating in this
multiplanar display.
So here we have a four chamber that we're rotating on.
We're putting the cursor right on the septum
and you can see as we move the cursor up
above the left ventricle, we get a picture
of the right outflow tract in the upper right corner.
And that's because the left outflow and the right outflow
tracts are perpendicular to each other.
I wanna show you that clip one more time.
We rotate on the in the y axis
and we see the left outflow tract here.
We move our cursor up
and on the opposite plane, you see
that right outflow tract right there.
And I just wanna move that back just a little bit so you can
see where the clip stops
and you can see that bifurcation of the right outflow tract
with the aorta in the middle.
And I think that's incredibly helpful to teach people how
to get these on 2D.
Now here's the ductal arch that we find
by finding the descending aorta, lining it up
and then we rotate on it directly into the aortic arch.
And there are the vessels coming off the arch.
So this is, if you can't get your outflow tracts in your
traditional ways, we will always go
and put it along the descending aorta along the spine,
put the cursor in the middle of the aorta at about the level
of the diaphragm and then just rotate on it
and you will go from your ductal arch
to your aortic arch or vice versa.
I find this very helpful on 2D, I just go looking
for the descending aorta and start rotating on the spine
and trying to get my arches.
Now this is a patient with a muscular VSD right here
and we can see that both in the four chamber view here
and we can also see it on axial right here.
And on this view,
this is using the matrix, new matrix array transducer,
and we can see the VSD right there
and then we can see it in another plane over here as well.
Here it is, right here. There it goes.

Spine, Ribs, and Extremity Anomalies

Okay, here is a picture of the ribs
and spine just to remind us that 3D can
count the ribs as well as look,
start looking at the spinal elements.
And in this paper by Dr. Goldstein and Dr.
Benoit again, you can see these beautiful pictures
of the ribs and there's 12 here.
Here's one that's an absent rib.
You have it on one side but not the other.
And here's one that had 13 ribs
and ribs can be helpful in correlating with
Down syndrome, as they can have abnormal number of ribs.
Now this is a patient that has a Chiari II malformation
and I just put this here to show you
that the rendering can sometimes be misleading.
So this was the spine coming down
and then you can see this widening out here.
And I thought it was really beautiful
and 3D was showing the spinal abnormality nicely.
And then when I heard the fellow dictating this case,
I realized she was dictating it as if it started here.
And to me the defects started right up here.
So the rendered pictures can
until you've seen quite a few rendered pictures.
I really don't think that you should make your diagnosis
predominantly from the rendered.
It should be an adjunct to your 2D ultrasound
because on 2D you can figure out
the levels as well.
You may not be perfect of which number it is,
but you can see the widening.
And here you can see on this patient the widening
of the spine on the x-ray from
after delivery, I do think
that 3D can, you can manipulate your volume nicely
to be able to figure out based on the 12th
rib where you are.
And this is someone who is at an L2 defect.
It looks almost normal.
And then by the time you get down to L5,
you can see this large mass here
with increased echogenicity in it.
This was not just a typical meningocele
but rather a myelocystocele, which was associated
with a tethered cord
and a lipoma in the back this fetus had normal
head findings, because it wasn't a typical Chiari.
Now this is a patient that had scoliosis
and she came as a referral second opinion
for scoliosis.
And you can see that 2D shows the scoliosis
and the family had already been told that.
But when we did the 3D rendering,
they could really tell the angulation of that spine
and it was no longer a scoliosis that was just a little bit
of a curvature of the spine.
But the family all of a sudden realized how much
of a deformity this was gonna be
and this fetus didn't have just regular scoliosis
but rather spondyloepiphyseal dysplasia congenita as a final diagnosis.
So I think the 3D pictures when I walked in the room,
they were already quite aware they could see it on
the monitor themselves.
This is a picture of a liver calcification
and sometimes we'll use 3D just to take a volume
to say exactly where it is
because in one plane you may not be quite sure
but when you put the three planes together you can
figure out that this really is in the liver
and it's in the right place to be in the liver.
So I think 3D is a great troubleshooting tool.
We do use it for club feet, like in this patient
where you can see it of both the right leg
and of the left leg.
And here you can see it, it's I don't have the video
to show you it rotate around,
but I think it can be quite helpful
to confirm a club foot.
This is a club hand in a 13 weeker
and you can see it on the 2D quite nicely.
That's what it is. But I think
for the family it's much more apparent on the 3D image.
This fetus ended up having trisomy 18, which is common
with fetuses that have abnormal hands
and feet in the first trimester.

Artifacts and Benefits of 3D Ultrasound

Now artifacts occur
in the 3D ultrasound just like they do in 2D ultrasound.
And you can see that it's important to identify
that this is just an artifact of the rendering.
It's not a hole in the head.
And when we first started doing 3D a lot
of patients would say where is,
why is there a hole in their head?
But it's just that the rendering box is going
through the cranium and you can see this looks like a
conjoined twin or something with two faces,
but it's just that the single fetus moved
and that you can get part of both faces when it moved.
3D can be helpful in looking at the fetal face,
particularly in displaying a normal face
or a normal anatomy when the patient is at risk for
some particular anomaly.
Perhaps there was a prior child with an anomaly
or if someone in the family.
It can also be helpful in displaying normal anatomy
and fetuses that have anomalies such
as like a phallus looking at the face
and knowing that other things look normal.
It also helps with more comprehensive understanding
of many anomalies like cleft lip and palate like anencephaly
like clenched hands with trisomy 18, straight arms
of movement disorders.
And I remember this fetus
that the mother just didn't get it,
but when you showed her this picture
of this really straight arm, all of a sudden they realized
that this wasn't really normal.
I already mentioned the encephalocele
and also some of the really short dwarfism
or skeletal dysplasias are very apparent on the 3D image.
I would comment that some families will have a bias in
how they look at the pictures.
And I know I had one patient that had a very flat
midline cleft in the face
and the family thought the 3D pictures looked quite normal
and when they saw the baby at delivery,
they were just horrified,
because it didn't look anything like
what they thought the 3D picture looked like.
Also I've had cleft lips be both directions.
Some think it looks worse,
some think it looks better than they anticipated.
That's just our little fetus with the encephalocele
and that family really adored having the picture
of the face because all
of a sudden they could think about it that way.
When looking at clefts,
I think this cleft this family at 28 weeks,
which I think it was, it's a study from a long time ago,
but the family said this cleft is just not nearly as bad
as I thought it was and they decided to
not terminate when they had planned to terminate for it.
And this mother who had seen this picture
that I showed you earlier said she was absolutely horrified
at delivery 'cause she just didn't believe
that there was a cleft
lip on the baby even though I showed her
these incredible pictures.
So in our first original series that we published in 2004
of 28 fetuses with cleft lip
and palate changed their mind regarding continuation
of pregnancy after having a 3D ultrasound.
If there is an anomaly, I think it's very helpful
to give the family a picture of the face
because all the sudden,
many families have told me they stopped thinking about the
club feet or the encephalocele when they realized there was a
baby in there and the face helped them kind of come to that.
I think in our everyday practice we show pictures
of the face to parents all the time.
It's what they want to see
and I think our pictures are getting better and better
and some days you'll get really great pictures
and other days you won't
and all depends upon the fetal lie.

Early Pregnancies and Ectopic Pregnancies

Now I'd just like to finish talking just a tiny bit about
early pregnancies
and particularly ectopic pregnancies
where I think 3D ultrasound can be incredibly helpful.
It can help differentiate an ectopic from a uterine
malformation such as a septate uterus,
and figuring out that it's really not an ectopic
or an interstitial ectopic but just a septate uterus.
And the thing to realize is that interstitial
ectopics will occur right at the edge of the uterus
as the fallopian tube is going out.
And cornual ectopics can look very similar.
They really occur when you have one horn
and then you have just a residual amount
of horn on the other side, like in a unicornuate pregnancy
and the ectopic occurs in that little cornua
of the one that's not there.
And then of course there are cervical ectopics.
It's important to locate the ectopic
or the gestational sac in three planes to be able to assess
how close it is to the myometrium
and how much myometrium there is.
So for example, this is an interstitial ectopic pregnancy
and you can see here's the endometrium of this uterus.
The uterus itself is here
and we can see this gestational sac off to the right
with a little
line right here called the interstitial line going from the
endometrium to the ectopic.
Now that's in contrast to this patient that was sent to us
to rule out an interstitial ectopic
and you can see that this gestational sac is way up here.
The rest of this endometrium looks fine,
but it's a very broad base to this gestational sac
and there's a little more myometrium
around it on the transverse plane here
than you would expect for an interstitial ectopic.
So we brought her back just to see what happened.
And four days later you can see
that her gestational sac is exactly where it ought to be,
a normal appearance in that endometrium.
And she had a normal intrauterine pregnancy.
Now this was a patient that came to us at seven weeks,
six days as a possible cervical ectopic
or a c-section scar ectopic pregnancy
and that's what she turned out to be.
And then how it unfolded was you could see the sac
and there was the endometrium on the 2D ultrasound
and you didn't know exactly where it was.
We did see some blood
or gestational trophoblastic disease up in the
normal position of the endometrium
and as we scanned on 2D going back
and forth, we even found a heartbeat on this little one
that was about
seven weeks and six days.
But then when we did 3D I think it was just really
helpful to line up the cervix here and here
and see that it was in the position perfect for
a cesarean scar ectopic.
There's a bladder right here
and it's sitting right there in the middle.
And we did end up going on to do an MRI
because they're not common.
This was our first one for us to identify,
but now they're becoming more and more common.
And here you can see the endometrium
and there's the ectopic.
So I think in your first case
or two you may feel like MRI would help to confirm exactly
where this ectopic is.
You wanna differentiate it from a cervical ectopic
or the other main thing is
just an abortion in progress.

Conclusion and Key Learning Points

What is it that you have learned today?
I think you should remember the applications
of 3D for the fetal brain.
I want you to remember agenesis
of the corpus callosum Dandy-Walker variant
and measuring that vermis.
And I want you to think about, is it just the cavum vergae?
Put your cursor right on the middle
of the cystic thing if you see a cyst in the brain
and see if it's the normal cavum
or whether it's the elevated third ventricle
or whether it could even be a subarachnoid cyst.
Where do cleft lips occur?
Look at that second lateral tooth bud at that lateral incisor
that's where you're going to identify your clefts.
So whether you're looking at 2D
or 3D, that's the position to look.
How do you render the cranium to see the sutures?
You need to acquire the volume in a specific,
with a specific suture in mind so
that you won't get shadowing so
that you can get a picture coming directly down on
that suture, whether it's the coronal suture
or whether it's the sagittal suture.
And you must
do only one side if you're looking at the coronal suture
one side at a time.
Thank you very much and I wish you luck in using 3D
ultrasound in your laboratory.