Deborah D'Agostini

Diagnostic evaluation of the fetal face using 3-dimensional ultrasound.

Evaluation of the fetal face with 3-dimensional ultrasound allows for evaluation of the fetal face using surface rendering, multiplanar and multislice displays. Three-dimensional ultrasound offers many benefits in evaluating the fetal face because it can be rotated into a standard symmetrical orientation and reviewed millimeters by millimeters by scrolling through the volumes. New rendering tools now allow imaging of the hard palate. Clinical applications where 3-dimensional ultrasound adds value as an adjunct to 2-dimensional ultrasound imaging that are reviewed in this paper include cleft lip and palate, micrognathia and other profile abnormalities, metopic suture abnormalities, presence and absence of the nasal bones, orbit abnormalities, and ear abnormalities. In addition, the literature regarding parental bonding to the fetus after viewing 3-dimensional images of their fetuses is reviewed.

Evaluation of the Fetal Secondary Palate by 3-Dimensional Ultrasonography

Objective. Diagnosis of cleft lip and palate remains a challenge with 2‐dimensional ultrasonography, particularly when clefting involves only the secondary palate. The utility of 3‐dimensional ultrasonography (3DUS) has enhanced our ability to detect clefts. We report our experience with a modification of the flipped face technique to aid in the diagnosis of clefting of the secondary palate. Methods. Ninety‐two volumes of 92 fetal faces were evaluated. Thirty‐six volumes were acquired prospectively. Fifty‐six volumes had previously been acquired and included 8 with clefting of the secondary palate. Volumes were obtained on 3DUS systems and reviewed by 4 blinded readers on personal computer workstations. Volumes were manipulated so that an upright profile was visualized. The palate was then rendered using a thin, curved render box. Statistical analysis was performed using the Fisher exact test for categorical data. Intraclass correlations were computed to assess inter‐rater agreement. Results. The mean gestational age at image acquisition ± SD was 22 ± 5 weeks. Image quality of the secondary palate was obtained and rated as adequate by at least 2 reviewers in 34% (31 of 92) of volumes. The sensitivity of cleft detection ranged from 33% to 63%, and the specificity ranged from 84% to 95%. The low sensitivity was mainly due to artifacts/shadowing. The inter‐rater reliability was 0.62 (95% confidence interval, 0.47–0.76). Conclusions. Three‐dimensional ultrasonography can be used to diagnose clefts of the secondary palate. This evaluation is limited by the fetal position and artifacts from shadowing of adjoining structures. Pseudoclefts can be created, and optimal imaging cannot be obtained in all fetuses.

Multislice display of the fetal face using 3-dimensional ultrasonography.

Objective. Multislice 3‐dimensional ultrasonography (3DUS) allows ultrasonographic volume data to be presented in parallel slices. Our aim was to develop a technique using a multislice display to specifically differentiate the maxilla (primary palate) from the mandible and to display the orbits in a single image in fetuses with normal anatomy and cleft lip/palate. Methods. Three‐dimensional ultrasonographic volumes of the fetal face were acquired in 142 patients (49 prospective and 93 retrospective). Fifteen patients had a confirmed diagnosis of cleft lip with or without cleft palate. Three readers manipulated volumes in a standardized fashion to show the orbits, maxilla, and mandible. The best interslice distance was determined. Image quality was assessed. Results. The mean gestational age of the fetuses was 23 weeks (range, 11–38 weeks). The mean interval distance used varied from 3 to 3.7 mm (range, 1–5.8 mm). The interval distance correlated with gestational age (Spearman ρ = 0.66; P < .0001). Image quality obtained through multislice evaluation of the orbits, maxilla, and mandible was high and did not vary with gestational age, interval distance, retrospective versus prospective acquisition, or 3DUS versus 4‐dimensional volumes. A higher image quality rating was associated with axial and sagittal planes of acquisition as opposed to coronal and oblique planes (Wilcoxon P < .002). All cases of cleft lip with or without cleft palate were correctly identified retrospectively. Conclusions. Multislice 3DUS evaluation of the fetal face can be performed successfully with high image quality. This technique can be used to consistently and accurately differentiate the fetal primary palate and mandible. Fetuses with cleft lip with or without cleft palate can be identified with confidence.

Prenatal diagnosis of spondylocostal dysostosis with 3-dimensional ultrasonography.

Segmentation vertebral dysplasias and rib deformities are recognized features of specific congenital skeletal anomalies. We report a case of spondylocostal dysostosis type II. The segmentation vertebral anomalies and fused ribs were diagnosed antenatally with 3-dimensional ultrasonography (3DUS).

FETAL OMPHALOCELE IN A COMMON BOTTLENOSE DOLPHIN (TURSIOPS TRUNCATUS)

Abstract:  A routine pregnancy ultrasound examination of a 30-yr-old, multiparous, common bottlenose dolphin, Tursiops truncatus, detected an approximately 16-wk (gestational age) fetus with an omphalocele, an abdominal wall defect at the base of the umbilical cord. Throughout the pregnancy, ultrasound allowed for identification of the omphalocele contents, which included a portion of the liver and intestinal loops. The maximum diameter of the omphalocele was 11.4 cm at an estimated 51-wk gestation. Color Doppler was utilized to study the blood flow within the omphalocele as well as diagnose an associated anomaly of the umbilical cord, which contained three vessels instead of four. Gross necropsy and histopathology confirmed the ultrasound diagnoses. This is the first report of an omphalocele in a T. truncatus fetus, and the first report of a fetal and umbilical cord anomaly diagnosed with ultrasound in a cetacean.

Benefits of a Systematic Approach in the Evaluation of Fetal Facial 3-Dimensional Volumes

The purpose of our study was to evaluate the accuracy and efficacy of using a systematic approach to teach maternal‐fetal medicine physicians how to display a diagnostic fetal profile and palate using 3‐dimensional ultrasonography (3DUS).

OC040: Evaluation of the secondary palate by 3‐D ultrasonography

Objectives: Diagnosis of cleft lip and palate remain a challenge with 2-D ultrasound particularly when clefting involves only the secondary palate. The utility of 3-D ultrasonography (3DUS) has enhanced our ability to detect clefts of the secondary palate. We report our experience with a modification of the flipped face technique to aid in the diagnosis of clefting of the secondary palate. Methods: Ninety-two volumes of fetal faces were evaluated. Of these, 36 volumes were acquired prospectively. The remaining 52 volumes had previously been acquired and included 8 with clefting of the secondary palate. Volumes were obtained using the Voluson 730 Expert (GE) and the IU22 (Phillips) and reviewed by four blinded readers on personal computer workstations. Volumes were manipulated so that an upright profile was visualized. The palate was then rendered utilizing a thin, curved render box. Statistical analysis was performed using Fisher’s exact test for categorical data. Intraclass correlations were computed to assess inter-rater agreement. Results: The mean gestational age of image acquisition was 22 + 5 weeks. Image quality of the secondary palate was obtained and rated as adequate by at least two reviewers in 34% (31/92) of volumes. The sensitivity of cleft detection ranged from 33–63% and the specificity ranged from 84–95%. The low sensitivity was mainly due to artifact/shadowing. The interrater reliability was 0.62 (95% CI 0.47,0.76). After review of the data, an additional 10 fetuses were studied and the secondary palates successfully visualized. These volumes were acquired slightly obliquely from the inferior aspect of the maxilla, pointing upward. Conclusions: 3DUS can be utilized to diagnose clefts of the secondary palate. However, this evaluation is limited by plane of acquisition and artifacts from shadowing of adjoining structures. Pseudoclefts can be created and optimal imaging cannot be obtained in all fetuses.

P40.01: Multislice display of the fetal face using 3D ultrasound

The test for pulmonary vascular reactivity in the fetus compares changes in branch pulmonary artery Doppler flow patterns with the mother breathing room air with maternal hyperoxygenation. A normal response to oxygen is to increase the pulmonary flow patterns and is seen in fetuses greater than 30 weeks’ gestation. Fetuses with severe growth restriction have redistribution of cardiac output to the brain, coronary and adrenal circulations. In fetuses greater than 30 weeks’ gestation with absent or reversed diastolic flow in the free loop of the umbilical artery and increased diastolic flow in the middle cerebral artery, the pulsatility of the flow in the branch pulmonary artery did not change with maternal hyperoxygenation. This indicates a fixed pulmonary vasoconstriction similar to what is seen in fetuses with pulmonary hypoplasia, yet these fetuses had normal respiratory function for gestational age after delivery. In fifteen fetuses hospitalized for growth less than 10% of prediction for age with abnormal umbilical artery Doppler flow patterns, the hyperoxygenation test was offered to mothers after obtaining consent. The results from these studies were compared to 15 fetuses whose mothers were hospitalized for pre-eclampsia, premature rupture of the membranes and abruption. Those fetuses whose growth biometry was within normal limits had normal pulmonary vascular response to the maternal hyperoxygenation test while those with severe growth restriction did not. Of those fetuses who had received antenatal steroids prior to the hyperoxygenation test, there was no effect on pulmonary vasodilatation in those with severe growth restriction but those fetuses with normal growth appeared to have an exaggerated positive response.