Gerson Ribeiro

Applicability of three-dimensional imaging techniques in fetal medicine

Objective To generate physical models of fetuses from images obtained with three-dimensional ultrasound (3D-US), magnetic resonance imaging (MRI), and, occasionally, computed tomography (CT), in order to guide additive manufacturing technology. Materials and Methods We used 3D-US images of 31 pregnant women, including 5 who were carrying twins. If abnormalities were detected by 3D-US, both MRI and in some cases CT scans were then immediately performed. The images were then exported to a workstation in DICOM format. A single observer performed slice-by-slice manual segmentation using a digital high resolution screen. Virtual 3D models were obtained from software that converts medical images into numerical models. Those models were then generated in physical form through the use of additive manufacturing techniques. Results Physical models based upon 3D-US, MRI, and CT images were successfully generated. The postnatal appearance of either the aborted fetus or the neonate closely resembled the physical models, particularly in cases of malformations. Conclusion The combined use of 3D-US, MRI, and CT could help improve our understanding of fetal anatomy. These three screening modalities can be used for educational purposes and as tools to enable parents to visualize their unborn baby. The images can be segmented and then applied, separately or jointly, in order to construct virtual and physical 3D models.

Virtual bronchoscopy through the fetal airways in a case of cervical teratoma using magnetic resonance imaging data.

Cervical teratomas are rare congenital tumors, usually solid or cystic (3–5% of all teratomas), with an incidence of 1:20 000 to 1:40 000 among live births (Nascimento et al. 2007). This malformation is usually diagnosed during the prenatal period by ultrasound exam in the second and third trimesters. Knowledge about the degree of compression of the fetal airways during the prenatal period is important for the obstetrician/neonatology team to plan the correct management strategy during delivery (Azizkhan et al. 1995). A 28-year-old primiparous pregnant woman was referred to our service with a diagnosis of fetal neck mass at 21 weeks during the second trimester ultrasound exam. Another ultrasound exam showed a large solid/cystic mass measuring 41 × 24 mm in the fetal cervical region, and no other fetal abnormalities were observed. Subsequent follow-up ultrasound exams showed a normal amniotic fluid index. We decided to perform a three-dimensional ultrasound (3DUS) and magnetic resonance imaging (MRI) at 36 weeks for a better assessment of the fetal airways to plan the delivery (Fig. S1). The ultrasound exam was performed using a Voluson E8 apparatus (General Electric Medical System, Zipf, Austria) equipped with a convex probe (RAB 4-8L). The 3D images were shown on the screen in multiplanar (three orthogonal planes–axial, sagittal, and coronal) and rendering modes. The MRI exam was performed using a 1.5-T scanner (Siemens, Erlangen, Germany). The protocol involved a T2-weighted sequence in the three planes of the fetal body (HASTE; repetition time (TR), shortest; echo time (TE), 140 ms; field of view, 300–200 mm; matrix, 256 × 256; slice thickness, 4 mm; acquisition time, 17 s; 40 slices). In addition, we applied 3D T2-weighted true fast imaging with a steady-state precession (true fisp) sequence in the sagittal plane (TR, 3.02 ms; TE, 1.34 ms; voxel size, 1.6 × 1.6 × 1.6 mm; FA, 70; PAT, 2; acquisition time, 0.26 s). The entire examination time did not exceed 30 min (Fig. S2). A 3D physical model of the fetal airways was generated using the overlapping image layers generated by the MRI, using the software Mimics (Materialise, Leuven, Belgium), which allowed delineation of the airway surface using contrast detection in the relevant areas of interest. The generated 3D model was exported using the standard triangular language file format and then converted into an OBJ file using the MAYA 3D modeling software (Autodesk, San Rafael, CA, USA). The software allowed the correct virtual positioning of the observation cameras, while working with multiple onscreen windows, and the lighting parameters could also be adjusted to optimize the visualization. Finally, a path was plotted through the 3D model to create a simulated movie for the analysis of the fetal airway (Fig. 1). A virtual navigation through the fetal airways allows the visualization of the upper respiratory tract from the pharynx downward through the tracheobronchial tree. In our case, the virtual bronchoscopy did not identify the compression of the fetal airways (Video clip). A cesarean section was planned at 37 weeks, through which the woman gave birth to a live female baby weighing 3.175 g, with a height of 49.5 cm, and Apgar scores of 8 and 9 at the 1 and 5 min, respectively. After 48 h of delivery, the neck mass was surgically removed, without the need for endotracheal intubation. Both the mother and child were discharged from the hospital on the 7 day after delivery. Virtual bronchoscopy is a new, noninvasive technique that allows the assessment of patency of the fetal airways (Werner et al. 2011). The efficacy of this technique in assessing the fetal airway patency has been proven in four fetuses with cervical teratomas (Werner et al. 2013). In our case report, the virtual bronchoscopy confirmed the fetal airway patency and allowed an adequate management of the delivery by the obstetrician/neonatology team, without the necessity of invasive procedures such as ex utero intrapartum treatment (EXIT). In summary, we reported a case of fetal cervical teratoma with a favorable postnatal outcome using virtual navigation through the fetal airways. We believe that virtual bronchoscopy may be an effective method to assess the fetal airway patency in cases of neck masses or other extrinsic compressive lesions of the upper respiratory tract.

Monochorionic diamniotic quadruplet pregnancy: physical models from prenatal three‐dimensional ultrasound and magnetic resonance imaging data

H. WERNER1, P. CASTRO1, P. DALTRO1, J. LOPES DOS SANTOS2, G. RIBEIRO2, G. TONNI3, S. CAMPBELL4 and E. ARAUJO JÚNIOR5 1Department of Radiology, Clı́nica de Diagnóstico por Imagem (CDPI), Rio de Janeiro, Brazil; 2Department of Arts and Design, Pontifı́cia Universidade Católica (PUC Rio), Rio de Janeiro, Brazil; 3Department of Obstetrics and Gynecology, Guastalla Civil Hospital, AUSL Reggio Emilia, Italy; 4Create Health Clinic, London, UK; 5Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil

Combination of Non Invasive Medical Imaging Technologies and Virtual Reality Systems to Generate Immersive Fetal 3D Visualizations

Advances in imaging technology have led to vast improvements in fetal evaluation. Ultrasound examination is the primary method of fetal assessment because it is patient friendly, effective, and cost efficient and is considered to be safe. Magnetic resonance imaging is generally used when ultrasound cannot provide sufficiently high-quality images. It offers high-resolution fetal and placental imaging with excellent contrast. The objective here is to describe the combination of non-invasive medical imaging technologies and virtual reality systems in fetal medicine.

Combination of ultrasound, magnetic resonance imaging and virtual reality technologies to generate immersive fetal 3D visualizations during pregnancy for fetal medicine studies

Advances in imaging technology have led to vast improvements in medicine, especially in the diagnosis of fetal anomalies. In general, two main technologies are used to obtain images within the uterus during pregnancy: ultrasound and magnetic resonance imaging (MRI). Ultrasound is an indispensable tool in fetal medicine, but when it yields unexpected results, MRI is generally performed. MRI can provide high-resolution fetal images

A Proposal for Combining Ultrasound, Magnetic Resonance Imaging and Force Feedback Technology, During the Pregnancy, to Physically Feel the Fetus

Evolutions in image-scanning technology have led to vast improvements in the fetal assessment. Ultrasound (US) is the main technology for fetal evaluation. Magnetic resonance imaging (MRI) is generally used when US cannot provide high-quality images. This paper presents an interactive bidirectional actuated human-machine interface proposal developed by the combination of a haptic device system (force-feedback technology) and a non-invasive medical image technology.

P16.06: Maternal-fetal attachment in blind women using physical model from 3D ultrasound and MRI: Poster discussion hub abstracts

Objectives: To present an interactive bidirectional actuated human-machine interface experiment developed by the combination of a haptic device system (force-feedback technology) and a non-invasive medical image technology. Methods: US scans were performed using a high-resolution electronic probe with harmonic imaging (Voluson E10, GE Medical Systems). MRI examination was performed using a 1.5-T scanner MR 450w (GE, Waukesha, USA). The haptic device adopted was the touch 3D stylus system from the American company 3D Systems. The 3D files of the fetus’ body tested on the experiment were modelled through the superimposition of the several slices obtained from MRI and fetal face from 3DUS. Results: Once the 3D shape was obtained, its virtual characteristics and the womb ambience were then created considering illumination, color textures, shades, positioning, bumpiness among others. We manipulate the physical responses of the device when the fetus shape is virtually touched. To complement the physical interaction, we introduced visual effects such as shape deformation based on the properties of the involved area and animations to simulate fetus motion. Conclusions: Advances in the technology of haptic devices open new opportunities in medical evaluation. The experiment here presented is part of the study involving additive manufacturing models of fetuses and virtual reality technologies to generate immersive 3D in fetal medicine. After the initial period of tests, the team aims to improve the experiment using new haptic devices, such as a haptic glove device in order to provide a more realistic experience of touching the fetuses.

P16.04: An interactive experiment combining US, MRI and haptic to physically feel the fetus: Poster discussion hub abstracts

Conclusions: Advances in the technology of haptic devices can open new opportunities in medical evaluation. The experiment here presented is part of the study involving additive manufacturing models of fetuses and virtual reality technologies to generate immersive 3D in fetal medicine. After the initial period of tests, the team aims to improve the experiment using new haptic devices, such as a haptic glove device in order to provide a more realistic experience of touching the fetuses. Objectives: To present an interactive bidirectional actuated human-machine interface experiment developed by the combination of a haptic device system (force-feedback technology) and a non-invasive medical image technology. Results: Once the 3D shape was obtained, its virtual characteristics and the womb ambience were then created considering illumination, color textures, shades, positioning, bumpiness among others. We manipulate the physical responses of the device when the fetus shape is virtually touched. To complement the physical interaction, we introduced visual effects such as shape deformation based on the properties of the involved area and animations to simulate fetus motion.

Three‐dimensional virtual cystoscopy: Noninvasive approach for the assessment of urinary tract in fetuses with lower urinary tract obstruction

Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, RJ, Brazil Department of Design, Pontifícia Universidade Católica (PUC‐Rio), Rio de Janeiro, RJ, Brazil Department of Obstetrics and Gynecology, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil Department of Obstetrics and Gynecology, Mayo Clinic Fetal Diagnostic and Therapeutic Center, Mayo Clinic College of Medicine, Rochester, MN, USA Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM‐UNIFESP), São Paulo, SP, Brazil Correspondence Edward Araujo Júnior, Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM‐UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP CEP 05089‐030, Brazil. Email: araujojred@terra.com.br

Prenatal Phenotype of Down Syndrome Using 3-D Virtual Reality

BACKGROUND Down syndrome is a chromosomal abnormality characterized by an additional acrocentric chromosome, resulting in an aneuploid number of 47 chromosomes (trisomy 21). Fetal face phenotype of Down syndrome is typical in the second trimester and characterized by plane face and a big and protruding tongue. CASE We present a case of Down syndrome at 29 weeks of gestation in which the fetal face was created using 3-D virtual reality model from 3-D ultrasound scan data. CONCLUSION A 3-D virtual model from 3-D ultrasound or magnetic resonance imaging scan data allowed an immersive real environment, improving the understanding of fetal congenital anomalies by the parents and the medical team.