Megumi Ito

Three-Dimensional HDlive Rendering Images of the Fetal Heart

Our objective is to describe our experience with reconstruction of normal fetal cardiac structures and congenital heart anomalies using the 3-D HDlive rendering mode with spatiotemporal image correlation (STIC). Four normal fetuses and three fetuses with congenital heart anomalies (Ebsteins anomaly, hypoplastic left heart syndrome and tetralogy of Fallot) at 25-35 wk of gestation were studied using the 3-D HDlive rendering mode with STIC. In normal fetuses, the natural appearance of the dynamic motion of the foramen ovale flap and both atrioventricular valves was clearly visualized in real time in the four-chamber view. Moreover, new, realistic sensations of each leaflet of atrioventricular valves and semilunar valves of the pulmonary artery were obtained in the en face view of both atrioventricular valves and great vessels. In the case of Ebsteins anomaly, the procedure rendered the natural and anatomically realistic appearance of significantly low attachment of the tricuspid valve and atrialized portion of the right ventricle. In hypoplastic left heart syndrome, thickened tricuspid and dysplastic pulmonary valves were clearly revealed. In tetralogy of Fallot, an overriding aorta and ventricular septal defect were realistically depicted. The 3-D HDlive rendering mode with STIC provides entirely new visual experiences for obstetricians and pediatric cardiologists owing to the anatomically realistic depiction of normal and abnormal fetal cardiac structures of the beating heart.

Three-dimensional HDlive rendering image of cystic hygroma

Three-dimensional (3D) HDlive rendering images with both adjustable lighting and new skin-like colors give the normal embryo and fetus, fetal anomalies, and intrauterine abnormalities a natural and anatomically realistic appearance [1–4]. Cystic hygroma is characterized by septated fluid-filled sacculations of the bilateral neck and nuchal region that result from lymphatic dysplasia [5]. We present our experience of cystic hygroma reconstructed employing the three-dimensional (3D) HDlive rendering mode. A total of three cystic hygromas at 11-17 weeks’ gestation were studied employing transvaginal or transabdominal 3D sonography with the HDlive rendering mode (VOLUSON E8, General Electric Medical Systems, Zipf, Austria). Using a curved array transabdominal transducer (4–8.5 MHz) or mechanical transvaginal transducer (4.5–11.9 MHz), the sweep took less than a few seconds at an angle of 70 –85 . The data set was stored on a 700-MB CD-R and could be retrieved for further analysis [3, 4]. All volume data for each fetus were examined, and optimal images were selected for further analysis. Three-dimensional reconstruction was carried out using the HDlive rendering algorithm. The light source was adjusted until the structures of interest were visualized for the examiner to create favorable lighting and shadowing effects [4]. The 3D HDlive rendering mode provided new realistic sensations for the diagnosis of cystic hygroma (Figs. 1, 23). There have been three reports on conventional 3D sonographic diagnosis of cystic hygroma [5–7]. However, conventional 3D surface rendering images are not realistic. In the present report, the 3D HDlive rendering mode provided extraordinarily natural and realistic imaging of cystic hygroma, with greater detail and clarity than are possible with conventional 3D sonography. In particular, the 3D HDlive rendering mode provides new realistic sensations for the diagnosis of cystic hygroma in utero, and it seems to be almost impossible to differentiate between gross specimens and 3D HDlive rendering images, because nearphotographic images were obtained by employing the 3D HDlive rendering mode.

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

Antenatal three-dimensional sonographic diagnosis of persistent cloaca

We present a case of fetal persistent cloaca diagnosed by two- (2D) and three-dimensional (3D) sonography and the HDlive rendering mode. 2D sonography revealed a bicornate uterus with hydrometra, bilateral hydrosalpinx, a single umbilical artery, and ascites. 3D sonography and the HDlive rendering mode clearly showed these intra-abdominal structures. To the best of our knowledge, this is the first report of persistent cloaca employing antenatal 3D sonography and the HDlive rendering mode.

Antenatal three-dimensional sonographic features of multicystic dysplastic kidney

Multicystic dysplastic kidney (MCDK) is characterized by multiple macroscopic renal cysts of variable size. ‘‘The precise incidence of MCDK is unknown. However, MCDK is one of the most common anomalies which can affect one or both kidneys.’’ [1]. There have been only two reports on the antenatal three-dimensional (3D) sonographic diagnosis of MCDK with various rendering modes such as the surface rendering mode, transparent mode, X-ray mode, gradient light mode, and inversion mode [2, 3]. We present a case of bilateral fetal MCDK diagnosed by 3D sonography with inversion and HDlive rendering modes. A 24-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of bilateral MCDK and severe oligohydramnios at 27 weeks and 6 days of gestation (Fig. 1). Two-dimensional (2D) sonographic biometric measurements were consistent with 26 weeks of gestation. 3D sonography with an inversion mode (VOLUSON E8; General Electric Medical Systems, Zipf, Austria) clearly showed numerous renal cysts, and the anatomical relationships among bilateral multiple renal cysts, the gallbladder, and the umbilical vein could be easily understood (Fig. 2). The 3D HDlive rendering mode showed peripheral circular arrangements of the cysts in both kidneys (a necklace-like appearance) (Fig. 3). At 35 weeks and 1 day of gestation, a male infant weighing 2,455 g was delivered vaginally, with an umbilical artery pH of 7.001, and Apgar scores of 1 and 2 at 1 and 5 min, respectively. The baby died at 7 h and 20 min after birth. Permission to conduct an autopsy was not granted by the parents. There have been numerous reports on the prenatal diagnosis of MCDK by conventional 2D sonography [1, 4, 5]. However, the severity and extent of MCDK, and the whole view cannot easily be visualized with conventional 2D sonography [2]. In the present case, the region, severity, and extent of MCDK depicted by the 3D inversion mode were more readily discernible than by conventional 2D sonography. Therefore, the 3D inversion mode provides parents and families with important information, and has the potential to supplement conventional 2D sonography in diagnosing MCDK. There have been four reports on sonographic imaging of a normal embryo and fetus, abnormal fetus, placenta, and umbilical cord using the 3D HDlive rendering mode [6–9]. In the present case, the 3D HDlive rendering mode provided a natural and anatomically realistic appearance of cut-views of MCDK. In particular, the peripheral circular arrangement of the cysts in MCDK seemed to be more readily discernible than that obtained by conventional 2D sonography. However, 3D sonography with inversion and HDlive rendering modes was an adjunctive tool only, and there was no evidence that it altered any aspect of the diagnosis, outcome, or subsequent counseling.

HDlive imaging in diagnosis of uterine artery pseudoaneurysm during pregnancy

A uterine artery pseudoaneurysm (UAP) is a rare condition during pregnancy1. HDlive Flow with HDlive silhouette mode facilitates the spatial visualization of blood vessels whilst simultaneously displaying landmarks of the surrounding anatomical structures2. We used this imaging technique in the diagnostic work up of a woman with UAP during pregnancy. A 35-year-old Japanese primigravida was referred to our clinic because echo-free spaces had been observed in her cervix on ultrasound examination at 34 weeks

HDlive Flow silhouette mode and spatiotemporal image correlation for diagnosing congenital heart disease

With the latest advancement of three-dimensional (3D)/four-dimensional (4D) ultrasound machines, HDliveFlow will facilitate more precise evaluations of the fetal and placental circulations [1–5] and gynecologic disorders [6–10]. HDliveFlow silhouette mode is the latest technology to demonstrate vitreous-like clarity of the blood flow. This technique has the ability to preserve and delineate the outline and borders of the blood flow, while showing its core as transparent.

HDliveFlow with spatiotemporal image correlation for the diagnosis of congenital heart disease

With the latest advancement of three-dimensional (3D)/four-dimensional (4D) ultrasound machines, HDliveFlow will facilitate more precise evaluations of the fetal and placental circulations [1–5] and gynecologic disorders [6–10]. HDliveFlow silhouette mode is the latest technology to demonstrate vitreous-like clarity of the blood flow. This technique has the ability to preserve and delineate the outline and borders of the blood flow, while showing its core as transparent.

HDliveFlow with HDlive silhouette mode in diagnosis of uterine artery pseudoaneurysm during pregnancy

A uterine artery pseudoaneurysm (UAP) is a rare condition during pregnancy1. HDlive Flow with HDlive silhouette mode facilitates the spatial visualization of blood vessels whilst simultaneously displaying landmarks of the surrounding anatomical structures2. We used this imaging technique in the diagnostic work up of a woman with UAP during pregnancy. A 35-year-old Japanese primigravida was referred to our clinic because echo-free spaces had been observed in her cervix on ultrasound examination at 34 weeks

Three-dimensional surface-rendered imaging of cord entanglement in monoamniotic twins.

Monoamniotic twins occur in about 1 % of all monozygotic twin pregnancies [1]. The recent perinatal loss rate in monoamniotic twins has been reported as varying from 10 to 20 % [2]. Although these high perinatal loss rates have been attributed to umbilical cord entanglement, intertwin transfusion syndromes, discordant fetal abnormality or growth restriction [3], the most important cause of death is entanglement and knotting of the umbilical cords [1]. Reliable antenatal diagnosis of cord entanglement is usually made by employing two-dimensional (2D) color Doppler sonography [4, 5]. Moreover, there have been four reports on antenatal three-dimensional (3D) color/power Doppler sonographic diagnosis of cord entanglement in monoamniotic twins [6–9]. To the best of our knowledge, however, there has been no report on antenatal diagnosis of cord entanglement in monoamniotic twins using 3D surface-rendered mode. This prompted us to present an antenatal diagnosis of cord entanglement employing 3D surface-rendered display. A 28-year-old pregnant Japanese woman, gravida 2, para 1, was referred to our outpatient clinic because of monoamniotic twins at 10 weeks and 4 days of gestation. Conventional 2D sonography strongly suggested cord entanglement early in the second trimester of pregnancy. 3D surface-rendered mode clearly revealed cord entanglement very close to the chorionic plate of the placenta at 20 weeks of gestation (Fig. 1). She was admitted to our university hospital at 23 weeks and 4 days of gestation. Intensive fetal surveillance with fetal heart rate (FHR) monitoring twice a day and Doppler ultrasound recordings of the middle cerebral artery and umbilical artery every day was continued until delivery. However, FHR monitoring and Doppler ultrasound recordings were both normal, and there were also no signs of twin growth discordance and intertwin transfusion syndromes. Elective cesarean section was performed at 32 weeks and 4 days of gestation in order to avoid additional risks of umbilical cord complications. Both female infants weighing 1,799 and 1,999 g were delivered with an Apgar score of 4/6 and 7/8 at 1 and 5 min, respectively. The macroscopic findings revealed a cord entanglement very close to the chorionic plate of the placenta (Fig. 2). Both neonates were admitted to our neonatal intensive care unit. The mother and both neonates followed favorable courses after delivery. Arabin and Hack [10] reported that no antenatal deaths occurred among 15 monoamniotic twin pregnancies in which cord entanglement had been visualized close to the chorionic plate, whereas 5 fetuses died in three pairs characterized by entanglement close to the umbilical insertions with the twins positioned opposite each other. These authors suggested that there might be an association between antepartum death and the location of cord entanglement. 2D and 3D color/power Doppler ultrasound have become the gold standard for the prenatal diagnosis of cord entanglement in monoamniotic twins [4–9]. However, visualization of the exact location and continuity of the cord entanglement, and the spatial relationship among cord entanglement, twin pairs and the placenta is not easily elucidated with these Doppler techniques. 3D surfacerendered mode can depict the whole view of the umbilical cord during pregnancy [11, 12]. As shown in this report, more detailed information on cord entanglement was U. Hanaoka C. Tenkumo M. Ito N. Mori H. Tanaka T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp