A Practical Guide To 3D Ultrasound

OBSTETRICS & GYNECOLOGY
This highly illustrated practical guide to 3D ultrasound covers all the

basic technical aspects necessary to incorporate it into daily clinical
practice. The text contains over 350 ultrasound images and covers basic
technical modalities and tools; it also discusses clinical applications for
various fetal anatomical structures and systems, covering both normal
and abnormal fetal development. The guide is filled with easy-to-learn
instructions for the various techniques which are presented in step-
by-step tables and corresponding images. In addition, each chapter
concludes with a table of helpful practical tips.
Reem S. Abu-Rustum, MD, FACOG, FACS, Director, Center For Advanced

Fetal Care, Tripoli, Lebanon
Reem S. Abu-Rustum
K21746
ISBN: 978-1-4822-1433-8
90000
9 781482 214338
K21746_Cover_mech.indd All Pages 11/4/14 2:21 PM

A Practical Guide to
3D Ultrasound
A Practical Guide to
3D Ultrasound
Reem S. Abu-Rustum, MD
Director, Center For Advanced Fetal Care
Tripoli, Lebanon
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
© 2015 by Taylor & Francis Group, LLC
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This book is dedicated to
All the “perfect imperfections”,
The fetuses scanned through the years…
and
To those through whom I came
And those who through me came
With eternal love and appreciation...
Contents
Foreword....................................................................................................................................................................................... ix
Preface.......................................................................................................................................................................................... xi
Chapter 1 Terminology and Basics........................................................................................................................................... 1
Chapter 2 Volume Acquisition.................................................................................................................................................. 9
Chapter 3 Volume Manipulation............................................................................................................................................. 13
Chapter 4 Volume Display...................................................................................................................................................... 25
Chapter 5 Spatiotemporal Image Correlation......................................................................................................................... 33
Chapter 6 3D Tools................................................................................................................................................................. 41
Chapter 7 Clinical Applicability in the First Trimester.......................................................................................................... 49
Chapter 8 Clinical Applicability in the Fetal Face................................................................................................................. 59
Chapter 9 Clinical Applicability in the Fetal Central Nervous System.................................................................................. 73
Chapter 10 Clinical Applicability in the Fetal Skeleton........................................................................................................... 85
Chapter 11 Clinical Applicability in the Fetal Cardiovascular System.................................................................................... 95
Chapter 12 Clinical Applicability in the Fetal Chest..............................................................................................................111
Chapter 13 Clinical Applicability in the Fetal Gastrointestinal Tract.....................................................................................117
Chapter 14 Clinical Applicability in the Fetal Genitourinary System................................................................................... 125
Chapter 15 3D Applications in Obstetrics...............................................................................................................................131
Chapter 16 3D Applications in Gynecology........................................................................................................................... 139
Chapter 17 Coding and Entertainment Ultrasound.................................................................................................................147
References................................................................................................................................................................................. 149
Index.......................................................................................................................................................................................... 157
vii
Foreword
Three-dimensional (3D) ultrasound was introduced to the This textbook, A Practical Guide to 3D Ultrasound,
medical community over 20 years ago when investigators created by Dr. Reem S. Abu-Rustum, helps fill this
in Europe and North America reported imaging fetal and important void. The chapters contain clear instructions
gynecological structures. In 2001 I purchased my first on how to image fetal as well as gynecological structures.
3D/4D ultrasound machine for clinical use and began an The beautiful images provided by the author are perhaps
exciting journey incorporating this technology into my the most compelling part of the textbook. The high quality
clinical practice. For the past 13 years 3D/4D technology of the images and the clarity of the instructions contained
has advanced to a point that it is indispensable for the serious within the text underscore the experience of Dr. Abu-Rustum
clinician who performs obstetrical, gynecological, and fetal in the 3D/4D ultrasound arena. This book will benefit both
echocardiographic examinations. the novice as well as the experienced physician/sonographer
As a result of this technology, there has been an explosion who uses 3D/4D technology in obstetrics and gynecological
of diagnostic tools, new terminology and concepts that have imaging.
required the practice of diagnostic ultrasound to be at a high Greggory R. DeVore, MD
level of commitment by the physician/sonographer providing Clinical Professor
ultrasound services to patients. While 3D/4D ultrasound is Department of Obstetrics and Gynecology
an exciting imaging modality, most of the medical literature David Geffen School of Medicine at UCLA
relating to this technology focuses on diagnostic results, Los Angeles, California, USA
with few articles addressing how to use the technology. A
comparison might be made when years ago travelers were Director of the Fetal Diagnostic Centers
told of the benefits of flying great distances by airplane, but Pasadena, Tarzana, and Lancaster, California, USA
did not understand that an experienced pilot was necessary
for this to be accomplished! Director of Perinatology
Providence Tarzana Medical Center
Tarzana, California, USA
ix
Preface
A Practical Guide to 3D Ultrasound was conceived with the This guide would not have been written had it not been for
beginner in volume sonography in mind. Having decided to the unconditional love and support of my lifelong motivator,
venture into this new world with added depth 10 years ago, I mentor and guide, my father Dr. Sameer Abu-Rustum, my
felt overwhelmed by all the terminology and the techniques mother Lina, my husband Kamil, my children Maria and
being used. Subsequently, I attended several courses and had Karim, and my sister Mira; they all believed in me and
the honor of visiting many labs examining all the basics in encouraged me over the years to persevere and complete this
order to decide what would be of utmost utility in my daily project despite many challenges.
clinical practice. As a result of this exposure to the experts, In addition, I wish to express my gratitude to Dr. Greggory
as well as a review of the clinically applicable literature, this DeVore for his invaluable guidance and constructive critique
guide was put forth. It is by no means comprehensive, but of this guide. Last but not least, I thank my editor, Mr. Robert
aims at summarizing all the basics in a concise and practical Peden, who saw the value of this project when I approached
manner, so that it can be used as an introduction to ease the him with my ambitious proposal; without his backing, this
transition into the third dimension. guide would not have been possible. I also thank Ms. Kate
I wish to acknowledge Drs. Amelia Cruz, Patrick Duff, Nardoni for all her meticulous work in putting this guide
and Douglas Richards, who first handed me the transducer, together.
and Dr. Kypros Nicolaides for sparking my interest in fetal May this guide maximize the utility of your volume
medicine. I also wish to recognize the tremendous impact sonography, enabling you to feel more secure in your
that the work of Drs. Alfred Abuhamad, Beryl Benacerraf, diagnostic capabilities and better able to reassure your
Bernard Benoit, Rabih Chaoui and Greggory DeVore has had patients as to the health of the future generations.
on my practice and on the birth of this guide; their pioneering
work has served as a constant source of inspiration over the Reem S. Abu-Rustum, MD
years. Center for Advanced Fetal Care
I am forever indebted to the wind that propelled me Tripoli, Lebanon
forward and the sun that lit my professional path, Dr. Keith
Stone.
6W0D 8W1D 10W0D 12W4D
15W0D 18W1D 20W0D 23W0D
23W0D 33W0D B-Day!
S H’S 9 MONTHS
JOURNEY TO LIFE...
By: Reem S. Abu-Rustum
xi
1 Terminology and Basics
Introduction Z
Welcome to the world of volume sonography, a world with
added depth that enables you to obtain planes previously VOXEL = 3D
unattainable using conventional two-dimensional (2D) X
sonography. In volume sonography, the concept of the “voxel”
replaces the “pixel,” where you now have three intersect-
ing orthogonal or perpendicular planes with which you are
working—the X, Y, and Z planes (Figure 1.1). Where these
three planes intersect is the “reference dot,” an identifiable, Y
locatable point of interest that can be defined through its rela-
Y
tionship within the three planes. Within any acquired three-
dimensional (3D) volume is an infinite number of planes, PIXEL = 2D
stacked on top of each other, and containing within it all the
information needed to analyze that specific area or organ of
interest (Figure 1.2). For example, in the first trimester, a vol-
X
ume of the entire fetus may be obtained for analysis at any
subsequent point in the future (Abu-Rustum et al. 2012). This
volume, if obtained correctly, contains all the planes needed Figure 1.1 A cubic volume illustrating the three orthogonal
for a full evaluation of the first-trimester fetus (Figure 1.3). planes along the X, Y, and Z axes, representative of an acquired 3D
This also applies to a volume of the fetal heart that contains volume. At the bottom left-hand corner is a 2D rectangle along the
within it all the anatomic planes necessary for a complete X and Y axes, illustrating the 2D concept of a pixel. On the top right
assessment of the fetal heart and vessels (Abuhamad 2004). is a 3D rectangle along the X, Y, and Z axes, demonstrating the 3D
Once the volume of data is obtained and stored, it can subse- concept of a voxel.
quently be reformatted, post-processed, and displayed inter-
changeably in the multiplanar (Figure 1.4), surface-rendering
mode (Figure 1.5), or in any other mode at any given point Terminology
in the future.
With volume sonography, there is a new vocabulary to
learn (Table 1.1). Some of these terms are generic and oth-
Basic Concepts in the ers are specific to certain manufacturers. This is why one
Multiplanar Mode must become familiar with all the basic terms, their syn-
1. Marker dot: reference dot onyms, and their meanings. It then becomes intuitive as to
2. Address of the marker dot is determined by what is to be used where. The basic concept lies in obtain-
the intersection of the X, Y, Z axes (Figure 1.6) ing what is called a static volume and then visualizing it in
the three orthogonal planes in the multiplanar view. If it is
subsequently decided to manipulate the volume in order to
visualize the image using any of several display modes, this
The cornerstone of volume sonography is formed by three generates the rendered image. This can be surface mode
main concepts. These are addressed individually in the sub- (Figure 1.7), maximal mode (Figure 1.8), minimal mode
sequent chapters. (Figure 1.9), inversion mode (Figure 1.10), or any combina-
tion thereof, to name a few.
Basic Concepts in Volume Advantages of Volume Sonography

Sonography With volume sonography, it is now possible to evaluate
1. Volume acquisition planes not previously accessible by 2D ultrasound. In addi-
2. Volume manipulation tion, depth perception is now added. The stored volumes are
3. Volume display: multiplanar or rendered available for educational purposes: they can be utilized for
learning anatomy, and they facilitate off-line consultation
1
2 A Practical Guide to 3D Ultrasound
Figure 1.2 A 3D volume of the

chest of a 22w0d fetus displayed in
the multiplanar mode. This volume
contains within it all the 2D anatom-
ical planes necessary for a complete
assessment of the heart. These 2D
planes exist in a defined spatial rela-
tionship with respect to each other,
and they may be retrieved out of a
standardized volume utilizing a spe-
cific navigational approach based on
the established spatial relationships
between them.
Figure 1.3 A 3D volume of a

13w2d fetus depicted in the mul-
tiplanar mode (three orthogonal
planes A, B, and C) and surface ren-
dered in the bottom right-hand cor-
ner, utilizing HDlive. This volume
contains within it all the 2D planes
necessary for a complete evaluation
of this fetus. These 2D planes may
be generated out of the volume by
navigation along the three axes.
Terminology and Basics 3
Designation for
the Cross Hairs
20w6d fetal face displayed in the
three orthogonal planes. Note the
position of the reference dot (O). It is
the intersection of the cross-hairs in
each of the 3 planes.
with experts and over the web. With volume sonography, it

is now possible to evaluate such areas as the top of the fetal
head, the fetal sutures (Figure 1.11), and the mid-sagittal
plane of the fetal head (Figure 1.12). In addition, beam steer-
ing allows the visualization of previously unattainable views
such as the posterior aspect of structures. As such, the level of
a neural tube defect may be localized, and skeletal malforma-
tions may be characterized.
Much in terms of fetal behavior can be studied as well by
watching fetal movement, awake and sleep cycles, and eye-
lid movement, all of which further enhance fetal bonding. In
gynecologic ultrasound, it is now possible to evaluate the cor-
onal plane of the uterus (Figure 1.13), which enhances sen-
sitivity in the detection of müllerian abnormalities (Bocca et
al. 2012; Sakhel et al. 2013). Tumors may be localized more
precisely, ovarian cysts may be differentiated from hydrosal-
pinges, and the tubes may be studied using contrast agents, in
addition to facilitating ultrasound-guided biopsies. Volumes
may also be rotated 360 degrees to access the back of areas
under evaluation. Post-processing tools such as the inversion
mode may be applied to highlight areas under examination.
This may optimize the visualization of cystic structures
(Figure 1.10). Even though there may not be any added diag-
nostic value to some of these modalities, they certainly help
in visual clarification and education, for both physicians and Figure 1.5 The same volume of the fetus in Figure 1.4 displayed
the involved families. using surface rendering.
Reference Dot
A C
Figure 1.6 A 3D volume of a 13w5d fetus. (A) This volume contains within it all the 2D anatomical planes necessary for a complete
assessment of the fetus. The reference dot, which is the intersection point of all three orthogonal planes, is placed on the fetal heart. It thus
localizes the fetal heart in all three orthogonal planes. (B) A 3D model illustrating the unique acquisition in the first trimester: it is possible
to obtain a volume of the entire fetus with a single 3D volume sweep. (C) A 3D model depicting the three intersecting orthogonal planes.
Figure 1.7 Samples of 3D sur-

face-rendered volumes depicting the
external fetal surface. (A) At 10w5d
using dynamic rendering. (B) At
22w2d using HDlive. (C) At 12w4d
A B C
using HDlive.
Figure 1.8 A 3D volume of a 15w3d fetus displayed in skeletal mode. This

modes optimizes the bony structures while minimizing all other gray-scale struc-
tures creating an image akin to an x-ray; hence, it is also referred to as x-ray mode.
Table 1.1 Basic Terminology in Volume Sonography: Synonyms and Clinical Applicability
Key Word Synonym Clinical Applicability
3D Static 2D images, acquired together as part of For evaluating the surface or internal areas of interest
a volume and displayed in the three
orthogonal planes
4D Multiple volumes acquired per second Aids in visualizing fetal movement, facial grimaces, volume of a beating heart
and displayed to depict “3D in
motion”
CRI Compound resolution imaging Enhances the image resolution
Glass body Enhanced Doppler information in a Allows for vascular mapping and studies of vascular structures by minimizing the
gray-scale background gray-scale background and highlighting the vascular structure
HDlive 3D/4D technology with a virtual Gives a real surface-rendered image of the fetal face and outer surface; may also be
internal movable light source and used to visualize internal structures and can be combined with other 4D modalities
sophisticated skin-rendering
techniques
Inverse mode Inverts the gray-scale image where the Attenuates fluid-filled structures in the fetal brain, heart, gastrointestinal and
anechoic structures become genitourinary tracts, ovarian pathology, and any other fluid-filled areas
echogenic and vice versa
MagiCut Electronic scalpel with which to Allows volume editing in order to remove access areas and optimize visualization
sculpt through the volume of the area under study
Maximum mode x-ray mode Facilitates the study of all bony structures
Minimum mode Enhances Doppler information while Highlights the vascular tree and any fluid-filled, anechoic structures; best for
taking out all other gray-scale evaluation of the heart and fluid-filled structures
background information
OmniView The “any slice” technique Allows the slicing of any volume along any line, whether curvilinear or straight, to
display hard-to-obtain planes
Reference dot Marker dot, marker point The point of intersection of all three orthogonal planes through which rotation
along the three axes may be carried out
ROI Region of interest Allows the selection of an area of interest within the volume under study which
may be viewed in any of four directions
SonoAVC Automated volume calculator Allows the automatic selection of fluid-filled areas, color-codes them, and calculates
their volume; of maximal utility in ovarian follicular monitoring
SRI Speckle reduction imaging Refines the image by reducing the ultrasonographic speckle
STIC Spatiotemporal image correlation Enables obtaining and navigating through a volume of a beating heart, with or
without color Doppler, throughout one full cardiac cycle
Surface Image rendering of the fetal surface Surface topography to visualize the face and external structures; may also be
rendering utilized for the internal study of organs
TUI Tomographic ultrasound imaging A slicing technique, equivalent to CT, that generates multiple parallel slices, at a
user-set distance in mm, of the volume containing an area of interest, facilitating
the study of the spatial relationships between structures
VCAD Volume computer-aided diagnosis Automatic image retrieval of predefined standardized cardiac planes out of a
volume of the fetal heart which may allow a complete examination of the cardiac
structures out of the standardized volume
VCI-A and Volume contrast imaging Allows thick-slice scanning in order to decrease artifacts in either plane A or C;
VCI- C static VCI allows marked improvement in image quality
VOCAL Virtual organ computer-aided analysis Volume calculation of areas in question such as ovarian cysts, follicles, urine
production, lung mass, and so on, out of an acquired volume
interpreted as pathology. In addition, artifacts may be a result

RA of manipulation and slicing, such as with the employment
of the post-processing tool MagiCut. As such, care must be
AoA employed when displaying and interpreting the images.
IVC
Basic Causes of Artifacts
1. Motion of the fetus or mother
2. Rendering techniques
SVC
3. Shadowing artifacts
Reference
Dot
Artifacts may also raise the concern of the family and cause
DAo the inexperienced sonographer to overdiagnose (cleft lip) or
underdiagnose a certain condition if the area under exami-
Figure 1.9 A 3D volume of a 33-week fetus displayed in mini- nation is obscured. In addition, some of the most dangerous
mal mode. This volume utilizes color Doppler and depicts the aortic artifacts are generated as a result of the use of power and
arch (AoA) where the red reference dot is, descending aorta (DAo), color Doppler. For instance, when evaluating the ventricu-
as well as the right atrium (RA) with the superior and inferior venae lar septum, erroneous diagnosis of ventricular septal defects
cavae (SVC, IVC). may be made.
In gynecology, one of the most significant artifacts is the
Perhaps one of the greatest advantages of volume sonogra- echo enhancement artifact. This was described by Abuhamad
phy is the ability to standardize the examination of volumes, (2006) and is caused by the shadowing in the posterior myo-
defining spatial relationships between various anatomic metrium, whereby the myometrium now takes on the sono-
planes and organs, and enabling the automatic retrieval of graphic appearance of the endometrium. This artifact may
predefined planes of a specific area in question. This has occur when attempting to visualize the mid-coronal plane
been accomplished by Abuhamad et al. (2004, 2005, 2007) of the uterus, approaching it posterior to the myometrium.
with automation of the fetal heart, and the possible applica- If this volume is subsequently rendered in the multiplanar
tion of the same principles has been addressed in the first- mode, or when obtaining a thick slice, it may be erroneously
trimester fetus (Abu-Rustum et al. 2012). suggestive of a müllerian abnormality.
Pitfalls in Volume Sonography Conclusion

The basic principle for generating a good 3D image is a good Volume sonography is here to stay and is of tremendous
underlying 2D image. For this reason, all the limitations of value in education, consultation, and clarification of chal-
2D sonography are manifested in 3D with an added dimen- lenging findings to both physicians and families. In provides
sion: the quality of the 3D image is limited by the resolution additional information in experienced hands with a properly
of the 2D image and it becomes critical to optimize the 2D acquired/displayed volume from an optimally obtained 2D
image prior to acquiring a volume in order to obtain the best image. Nonetheless, there is a steep learning curve with new
results. A suboptimal 2D image will result in a suboptimal terminology and various new technological concepts with
3D image. There is a steep learning curve in how to best which the sonographer must become familiar. In addition,
acquire a 3D volume out of which it is possible to retrieve the one must keep in mind the inherent limitations, and the
optimal images. Resolution is limited in the coronal plane. sonographer must try to avoid artifacts when acquiring a
Although the efficiency of the sonographic machines has volume in order to avoid false-positive interpretations and to
improved drastically over the years, volume sonography is spare the family undue anxiety.
more time consuming because considerable time for acquisi-
tion and post-processing is still required for optimal results.
A good fluid interface is necessary to optimize the image.
The third dimension further compounds the introduction
of artifacts into the additional dimension, and this is fur-
ther compounded by the presence of challenging structural
anomalies.
The three main factors contributing to artifacts in volume
sonography are motion (fetal or maternal), rendering tech-
nique (Figure 1.14), and shadowing artifacts (Figure 1.15).
Poor rotation and off-center tilt may erroneously be
Figure 1.10 A 3D vol-

ume of a 13w3d fetus where
the fetal bladder is clearly
visualized in planes A and
B. Rendering the volume in
the lower right-hand corner, Bladder
utilizing inversion mode,
results in attenuation of the
cystic bladder where it now
appears echodense, whereas
the remaining structures
become echolucent, and
hence nonvisible.
Figure 1.11 A 3D ren-

dered volume of a 22w6d
fetal face optimized for the
maximum mode enabling
evaluation of the frontal
metopic suture (*).
Figure 1.12 A 3D volume of a 27w1d fetus from which the mid-

coronal plane depicting the corpus callosum was generated. This
plane is a challenging plane to obtain by conventional 2D sonogra-
phy, and with navigation within an optimized volume of the fetal
head it becomes feasible
Practical Pearls
•• Understand the main concepts of volume

sonography and the fact that within any vol-
ume all the necessary anatomical planes are
contained
•• Understand the difference between 2D and 3D
and the concept of the three orthogonal planes
•• Understand the importance of the reference
dot as the grounding point in all three planes
in the multiplanar mode
•• Learn and understand the basic terminology
•• Keep in mind both the advantages and the
disadvantages of volume sonography
•• Be mindful of artifacts and make every
attempt to minimize them
Figure 1.13 A transvaginal volume of the uterus during the

luteal phase from which the mid-coronal plane is obtained. This
allows proper evaluation of the endometrial cavity in order to assess
for müllerian abnormalities.
Figure 1.14 A 3D surface-rendered volume of a 22w3d fetus. In Figure 1.15 A 3D surface-rendered volume of a 21w5d fetus
this volume, rotation of the fetus has generated artifact suggestive using HDlive. In this volume, shadow artifact by the fetal hand
of a skull abnormality. Caution must be exercised in such cases to has resulted in an image that may raise concern for a facial cleft.
reassure the family as to the well-being of the fetus and to regener- With experience, the sonographer can anticipate such artifacts and
ate an artifact-free image of the fetal head. would exercise caution prior to generating such images so as to
avoid undue parental anxiety.
2 Volume Acquisition
Introduction Size of Box
The absolute determining factor for the quality of any 3D/4D The size of the box represents the entire area of interest. An
volume is the quality of the underlying 2D image and how example would be when acquiring a volume of the fetal heart
the actual volume was acquired. As such, one must have the at the level of the four-chamber view. The examiner needs
foresight as to what the volume is to be used for so that it is to decide how much of the chest is to be included around the
properly acquired in order to be able to generate adequate heart in order to set the acquisition box around that area of
images for evaluation. interest. This is exemplified in plane A, the reference plane,
in the multiplanar view (Figure 2.1).
Principles of Volume Acquisition

Whenever a volume is acquired, there are 3 basic prin-
ciples to keep in mind for optimization:
1. The target area in question in order to set the

size of the box for image acquisition (Figure
2.1)
2. The depth of the structures to be evaluated
(angle of acquisition) (Figure 2.2)
3. The quality of the resolution that is desired
for optimal image interpretation (quality of
acquisition)
Each of the above three prerequisites plays a factor in the

time needed to acquire the volume. The greater the require-
ments, the larger the volume and the higher its resolution,
and the more time required to “sweep” through and acquire
it, which allows more room for fetal motion and thus arti-
fact introduction. In obstetrical ultrasound, fetal motion
becomes a major limiting factor, especially in the B and C
planes. For this reason, when fetal motion is anticipated,
one must choose the smallest box, the smallest angle, and Figure 2.1 In order to acquire a 3D volume of the fetal heart at
the least acceptable resolution to swiftly sweep through and 22w1d, the box of acquisition needs to be placed around the area of
acquire as motion-free a volume as possible. In gynecology, interest prior to acquiring the volume. The angle of acquisition is
and in the absence of any motion of the organs under study, then selected, 30 degrees in this case, and the quality of the volume
the quality of the volumes acquired is usually not affected is selected. The volume is subsequently acquired and saved.
by motion. Therefore, the image can be optimized by using
a slower sweep speed, thus generating more voxels and a
higher-quality image.
Angle of Acquisition
Volume Acquisition This is determined by how much above and below the area
in question the volume should extend. For instance, when
As previously stated, the key to a good 3D volume is an acquiring a volume of the fetal heart at the level of the four-
underlying good 2D image and proper acquisition, keeping chamber view, is the plan to just include the heart or have
in mind the three basic keys to acquiring a volume: size of a volume that spans from the thyroid to the stomach? This
the box, angle of acquisition, and quality of acquisition. is exemplified in plane B, constructed from the 3D volume
9
data set in the multiplanar view (Figure 2.2). The angle Quality of Acquisition
depends on the type of transducer being used. In general, it
is double the distance that the probe moves on either side of The quality of acquisition determines its resolution. The higher
the reference plane. For instance, if the angle chosen is 30 the quality, the longer it takes to acquire the volume, thus there
degrees for the fetal heart, then the probe would acquire 15 is more chance for fetal movement and a greater probability
degrees on either side of (above and below) the four-cham- of artifacts. Keep in mind that a higher quality is required for
ber view, for a total of 30 degrees. Plane C is the third plane, the evaluation of internal structures, whereas a lower quality is
perpendicular to A and B and reconstructed from the vol- sufficient for the evaluation of the external surface. This does
ume data set. not hold true in areas without motion artifact, such as when
acquiring a volume of the uterus in gynecology where you
can use the widest angle and the largest box with the highest
resolution with minimal artifacts generated. Tables 2.1 and 2.2
cover the basic steps for volume acquisition.
A B
Figure 2.2 Once the volume is displayed in the multiplanar

mode, plane A depicts the initial 2D plane of acquisition; plane B is
perpendicular to it and generally reflects the depth of the structures
to be evaluated (angle of acquisition selected for the volume). In this
case, 30 degrees is selected, and this includes the area between the
stomach all the way cephalad to the thyroid as shown in plane B.
plane C is perpendicular to both planes A and B. The quality used
for this volume is mid 2. Note that the schematic angle in plane B
C
is not to scale.
Table 2.1 Steps to Acquiring a Volume of the Fetal Heart and Chest
Step 1: Obtain the plane of the four-chamber view after having optimized your basic 2D settings (Figure 2.1)
Step 2: Select an angle of acquisition of 30 degrees a; this volume should subsequently span from the fetal stomach to the thyroid for a second-
trimester fetus
Step 3: Set the quality of the acquisition of the volume to “high” in the absence of fetal motion, and to “medium” in case of fetal motion
Step 4: Hit “freeze” as this should automatically sweep through the fetal chest, spanning 15 degrees above and below the four-chamber view in order
to acquire the volume and display it in the multiplanar mode along the three orthogonal planes
Step 5: Check plane A to make sure this displays the initially acquired reference plane (Figure 2.2)
Step 6: Check plane B to make sure it spans from the fetal stomach to the thyroid (Figure 2.2)
Step 7: Save the volume if it is adequate for later manipulation and offline analysis
a The degree of the sweep is related to gestational age. For example, 20 degrees at 20 weeks of gestation, 30 degrees at 30 weeks of gestation.
Table 2.2 Steps to Acquiring a Volume of the Fetal Face

Step 1: Obtain an image of the fetal profile after having optimized your basic 2D settings (Figure 2.3)
Step 2: Select an angle of acquisition of 65 degrees; this volume should subsequently span the entire width of the fetal face of a second-trimester
fetus
Step 3: Set the quality of the acquisition of the volume to “high” in the absence of fetal motion, and to “medium” in case of fetal motion
Step 4: Hit “freeze ” as this should automatically sweep through the volume, spanning 32.5 degrees on either side of the fetal profile, in order to
acquire the volume and display it in the multiplanar mode along the three orthogonal planes
Step 5: Check plane A to make sure this displays the initially acquired reference plane (Figure 2.4)
Step 6: Check plane B to make sure it spans the entire width of the fetal face (Figure 2.4)
Step 7: Save the volume if it is adequate for later manipulation and offline analysis
Volume Acquisition 11
Figure 2.3 Face acquisition. (A) In order to acquire a 3D volume of the fetal face, optimize your 2D settings, and place the box of
acquisition around the fetal face while attempting to capture the image with a good amniotic fluid interphase in front of the fetal face.
The angle of acquisition is then selected, 65 degrees in this example, and the quality of the volume is then set. The volume is subsequently
acquired and saved. (B) A 3D model showing the plane of acquisition commencing with the fetal profile.
Figure 2.4 Once the volume is acquired it may be displayed in the multiplanar mode and surface rendering. Note the position of the box
of acquisition in plane A. The depth, represented by the angle of acquisition, is depicted in plane B and encompasses the entire width of the
face extending beyond each of the two orbits. The angle of acquisition can be seen in the top right-hand corner (underlined) as mid 2. In
addition, the quality of the volume is mid 2 (dashed underline).
Conclusion Practical Pearls
The key to the success in volume sonography is in an opti-

mal underlying 2D image. The volume should be acquired • To optimize volume acquisition and to
with the appropriate size with which to fully evaluate the minimize artifact, use the smallest acquisition
area under examination, keeping in mind the limitations of box, the smallest necessary angle, and the least
acquiring a volume of high resolution and a large volume. acceptable quality
As a general rule, longer acquisition is accompanied by • Most sonograghic machines come with factory
fetal motion, thus introducing more artifacts. presets that are helpful whether evaluating
the fetal surface, skeleton, or heart, and these
presets may be individualized
• Once the ideal settings are arrived at for a
particular area, individual settings may be
programmed into the system
• For external surfaces, a lower quality may be
utilized for volume acquisition
• For internal structures, a higher quality for
acquisition yields better results
3 Volume Manipulation
Introduction The Reference Dot
This chapter focuses on volume manipulation so that the user The reference dot is the intersection point between all three
can optimize the image planes for display of the multiplanar orthogonal planes. Volume manipulation is facilitated by
(Figure 3.1) and render formats (Figures 3.2 and 3.3). placing the reference dot at a specific point within the vol-
ume. This subsequently becomes the pivotal point around
which the volume may be rotated along any of the three axes,
Volume Manipulation without losing its position, as it remains displayed in all three
orthogonal planes. The reference dot can be moved around so
After the volume is acquired, it is possible to manipulate and that it is set at a particular point of interest within the volume,
navigate through the volume utilizing the most appropriate and it can be seen in all three orthogonal planes simultane-
technique for a complete assessment of the area of interest. ously if the multiplanar mode is selected (Figure 3.4). For
This may be accomplished utilizing rotation through the ref- instance, if a volume of the fetal abdomen is obtained with
erence dot along the three axes. The volume may be manipu- the primary focus on the fetal stomach, then the reference
lated further by changing the size and direction from which dot can be placed on the fetal stomach and it is subsequently
the region of interest is examined. identified in all three orthogonal planes (Figure 3.5). In the
volume of the fetal abdomen, one would not lose the stomach,
if it is the focal point of interest, and any manipulation within
Basic Concepts for Volume that volume will occur around the stomach where it remains
Manipulation clearly displayed at all times and in all three orthogonal or
1. Placing the reference dot on the target area perpendicular planes, as the primary designated structure. If
within the volume tomographic ultrasound imaging (TUI) were to be utilized,
2. Rotating along the X, Y, and Z axes through the then the reference dot would locate the stomach in each of
reference dot the planes displayed (Figure 3.6). If the aorta becomes the
3. Selecting the size and direction from which to primary point of interest, then the reference point may be
view the region of interest moved from the stomach to the aorta for navigation within
the volume, with the aorta as the pivotal point (Figure 3.7).
Reference Dot
Figure 3.1 A 3D volume of the fetal

face at 32w1d displayed in the multiplanar
mode with the volume displayed in three
orthogonal 2D planes – planes A, B, and
C – all intersecting in the reference dot.
13
Figure 3.2 The same volume from Figure 3.1 displayed using surface rendering. In this case, the sonographer may also select to display
the volume in only one pane so that the rendered image will be the only image displayed without showing the images in planes A, B, and C.
Figure 3.3 A 3D volume of a 22w4d fetal chest displayed using the skeleton mode,
also known as maximum mode, clearly depicting the rib cage and all 12 ribs. Here the
single-pane view has been selected.
Volume Manipulation 15
Reference Dot
Figure 3.4 A transvaginal 3D volume of a multicystic ovary displayed in the three orthogonal planes
with the reference dot clearly visible in planes A, B, and C.
Reference Dot
Figure 3.5 A 3D volume of the abdomen of a 22w1d fetus acquired with an angle of 55 degrees and a
quality of high 2 (information in the top right-hand side of the image) displayed in the multiplanar mode.
The reference dot is placed in the fetal stomach, localizing it in each of the three planes.
Figure 3.6 The same 3D volume obtained for Figure 3.5 is now displayed using TUI with a slice thick-
ness of 2 mm. The reference dot remains in the stomach in all the planes. This becomes most useful in
determining spatial relationships between organs, or when evaluating the boundaries of a tumor.
Figure 3.7 The same 3D volume obtained for Figures 3.5 and 3.6 is still displayed using TUI with a
slice thickness of 2 mm; however, now the reference dot is moved to the aorta and it localizes the aorta in
all eight panes.
Rotation along the X, Y, and Z Axes Scrolling through the Volume
To further navigate within the volume, rotation can be accom- It is also possible to scroll through the volume moving cepha-
plished along any of the three orthogonal planes (the X, Y, and lad or caudad. This can be carried out in any of the three
Z axes), with the reference dot as the point around which the orthogonal planes. For example, in the volume of a first-tri-
rotation occurs. Rotation along the X axis is accomplished mester fetus, this may be accomplished by moving the refer-
as if rotating in a ‘rotisserie’ mode (Figure 3.8). Rotation ence dot in plane A cephalad to reach the fetal head in plane
along the Y axis is in the orientation of the motion of a ‘drill’ B (Figure 3.11), or caudad to reach the fetal abdomen in plane
(Figure 3.9). Rotation along the Z axis is in a clockwise/coun- B (Figure 3.12). This may also be accomplished using the
terclockwise fashion within the image through the reference ‘depth’ button on the machine.
dot, in a ‘rocking’ motion (Figure 3.10).
Basic Concepts in Rotating Around Basic Concepts For Scrolling

an Axis Through the Reference Dot Through the Volume
1. X axis rotation is similar to the motion of a 1. Scrolling may be accomplished by moving the
‘rotisserie’ reference dot
2. Y axis rotation is similar to the motion of a ‘drill’ 2. Scrolling may be accomplished by using the
3. Z axis rotation is similar to a back and forth ‘depth’ button
‘rocking’ motion
A
X
Figure 3.8 3D volume of a 12w6d fetus displayed in the multiplanar mode. (A) The initial volume. (B) The volume after it has been
rotated along the X axis through the reference dot in the fetal neck in reference plane A as if rotated around a rotisserie. (C) 3D model depict-
ing X rotation.
Z
C
Figure 3.9 3D volume of a 12w6d fetus displayed in the multiplanar mode. (A) Initial volume. (B) Volume after it has been rotated along
the Y axis through the reference dot in the fetal neck in reference plane A as if rotated along the rotational axis of a drill. (C) 3D model
depicting Y rotation.
C Z
Figure 3.10 3D volume of a 12w6d fetus displayed in the multiplanar mode. (A) Initial volume. (B) Volume after it has been rotated
along the Z axis through the reference dot in the fetal neck in reference plane A as if in a rocking motion. (C) 3D model depicting Z rotation.
Reference Dot Reference Dot

A A
Reference Dot
Reference Dot
B B
Figure 3.11 3D volume of a 12w6d fetus displayed in the Figure 3.12 3D volume of a 12w6d fetus displayed in the
multiplanar mode. (A) Initial volume with the reference dot at the multiplanar mode. (A) Initial volume with the reference dot at the level
level of the fetal neck in plane A generating an axial image of the of the fetal neck in plane A generating an axial image of the neck in
neck in plane B. (B) Volume after the reference dot in plane A has plane B. (B) Volume after the reference dot in plane A has been moved
been moved cephalad to the fetal head generating a new image in caudad to the fetal abdomen generating a new image in plane B of the
plane B of the fetal cranium. fetal abdominal circumference plane with a visible fetal stomach.
Size and Direction of the Region of Interest

of the acquisition box may be changed to focus on a specific
Another way to manipulate the volume, in the render mode, area outside or within the volume. For instance, the same
is by changing the direction and/or size with which the region volume may be viewed from the top down (Figure 3.14) or
of interest is viewed. For any volume displayed in the three from the bottom up (Figure 3.15). This is depicted by the
orthogonal planes in the multiplanar mode, the reference green color, signaling the direction of viewing the region
plane is plane A. With the acquisition box still visible in of interest (Figures 3.14 and 3.15). The size of the box may
plane A, it is clear that it has four sides (Figure 3.13). Any of also be altered to look within the volume – for example, to
these four sides may then be selected as the direction from evaluate the fetal stomach in a volume of the fetal abdomen
which to view the volume or render it. In addition, the size (Figure 3.16).
Figure 3.13 3D volume

of the fetal abdomen of a
22w1d fetus. Note the box
of acquisition. It has four
sides. The green side indi-
cates the direction of view-
ing the region of interest.
The sides of the box indicate
the borders of the region of
interest which is large in this
example. In this volume, the
direction of viewing/ren-
dering the volume is top to
bottom, as indicated by the
green line.
Figure 3.14 3D volume

of a 32w5d fetal face dis-
played in the multiplanar
mode and surface rendered
using HDlive. The direc-
tion of evaluating/rendering
the region of interest is top
to bottom as indicated by
the green line in plane A,
enabling visualization of
the fetal face. The umbili-
cal cord creates an artifact
along the forehead.
Figure 3.15 This is the

same volume rendered in
Figure 3.14; however, in this
instance the direction of the
region of interest is flipped
180 degrees. It is bottom
to top, as indicated by the
line in plane A. As a con-
sequence, the final rendered
image is not clear and does
not depict the fetal face.
Limb
Stomach
Limb
A B
Figure 3.16 This is the same 3D volume of Figure 3.13. (A) The region of interest encompasses the entire abdomen with the direction
of view top to bottom starting outside the fetal skin as depicted by the line in plane A. This is depicted in the final rendered image where
a fetal limb is seen. (B) The size of the region of interest is changed and now the green viewing line starts at the level of the fetal stomach,
which can be seen in the final rendered image.
Stomach
Reference Dot
Figure 3.17 3D volume of the heart of a 21w6d fetus is acquired and

displayed in a single-pane view from plane A, with the reference dot
placed along the crux of the heart.
X DAo AoA
Figure 3.18 This is the same volume as in Figure 3.17. “Spinning” along the Y axis is carried out, resulting in complete visualization of
the aortic arch (AoA), head and neck vessels (*), and the descending aorta (DAo)
DA
Figure 3.19 Scrolling cephalad from the four-chamber view in

Figure 3.17, the three-vessel view is generated with the reference dot
placed along the ductus arteriosus (DA).
Reference Dot DA
Figure 3.20 Commencing

from the image in Figure 3.19,
where the reference dot was
placed in the ductus arte-
riosus, it is possible to “spin” X
along the Y axis in order to Reference Dot
generate a view of the ductus
Z
arteriosus (DA).
SVC
Figure 3.21 Returning to the three-vessel view, the reference dot is

now placed along the superior vena cava (SVC).
RA
Figure 3.22 “Spinning”

along the Y axis now gener-
ates the bicaval view with the
superior and inferior venae X IVC
cavae (SVC, IVC) clearly
SVC
seen entering the right atrium
Z
(RA).
DeVore’s Spin Technique
The perfect example to illustrate the rotation along the three

axes along a fixed reference point is DeVore’s spin technique
for evaluating the fetal heart (DeVore et al. 2004). Table 3.1
describes, in a stepwise fashion, how rotation along the X and
Y axes and navigating through a volume acquired at the level
of the four-chamber views allows the display of the outflow
tracts.
Table 3.1 Steps in the Spin Technique Displaying the Outflow Tracts Out of a Volume of the Fetal Chest
Step 1: Select the 4 chamber view as your reference plane with the ultrasound beam perpendicular to the ventricular septum (Figure 3.17)
Step 2: Obtain a 3D sweep with an angle of acquisition of 30 degrees and a mid to high quality for the volume
Step 4: Place the reference point along the crux of the heart (Figure 3.17)
Step 5: Rotate the volume along the Y axis to depict the aortic arch along its entire length (Figure 3.18)
Step 6: Go back to the initial volume and scroll cephalad to the 3-vessel view and place the reference dot on the ductus arteriosus (Figure 3.19)
Step 7: Rotate along the Y axis to depict the ductal arch (Figure 3.20)
Step 8: Go back to the 3-vessel view and place the reference dot in the superior vena cava (Figure 3.21)
Step 9: Rotate along the Y axis to depict the bicaval view with the superior and inferior venae cavae visible entering the right atrium (Figure 3.22)
A volume may be manipulated by rotation along the X, Y,

and Z axes, with the reference dot serving as the pivotal point • The reference dot is the pivotal point around
around which the rotation is carried out. In addition, it is pos- which to navigate through the volume
sible to scroll through any volume, along any of the three • Remember the three main analogies of
planes, by moving the reference dot or by utilizing the “depth” rotating around the three axes: rotisserie (X),
button available on the ultrasound machines. Adjusting the drill (Y), and rocking (Z) (Abuhamad oral
size of the region of interest and the direction of viewing communication 2004)
enables the external or in-depth study of any volume. The • You may scroll through the volume utilizing
sonographer’s clear understanding of how to manipulate the parallel shift or by moving the reference dot
acquired volume, coupled with the knowledge of which ren- • Whenever a volume is displayed in the
dering technique is optimal for each particular area under multiplanar mode, any of the three planes
study, is critical to enable the varied and detailed study of the A, B, or C may be selected for further
developing fetus, as illustrated in subsequent chapters. manipulation. The activated image/plane is
designated by a scale next to it
• Any volume may be viewed from four
directions, represented by the four sides of
the acquisition box in reference plane A or
whichever of the three planes is selected as
the reference plane
4 Volume Display
Introduction altered by changing the direction of the region of interest

(ROI). This allows for viewing a specific area from any of
Once a 3D volume is acquired, it may be displayed in the the four sides. An example would be looking at the atrioven-
multiplanar mode, discussed in Chapter 3, or it may be ren- tricular (AV) valves. The approach may be from the apical or
dered in a multitude of other ways, the most recognized of the basal orientation (Figure 4.3 and 4.4). Table 4.1 covers a
which is the surface mode (Figure 4.1), depicting the fetal stepwise approach to altering the ROI orientation in order to
face. The surface mode is the most commonly used display visualize the AV valves.
mode to demonstrate features of the fetal face. Unfortunately, For the various rendering modes, the 2D image settings must
this display format has generated a bad name for 3D ultra- be optimized and a sweep through the area in question is
sound because of its nonmedical use for “entertainment obtained, and subsequently the various rendering modalities
ultrasound.” This becomes more problematic with the advent may be utilized.
of HDlive (Figure 4.2) and the amazingly lifelike quality of
the fetal images. Although 3D ultrasound may sometimes be
misused, it has tremendous potential as a diagnostic tool to Surface Rendering/HDlive
assist the clinician and sonographer in the quest for detailed
evaluation of anatomical structures. In surface rendering of the fetal face, a prerequisite is a good
There are various additional rendering modalities with fluid interphase in front of the fetal face. In addition, one
which to display a volume such as the maximum mode (for must acquire a volume without the fetal cord or extremities
display of the skeleton) and minimum and inversion modes covering the face, and at a time when there is minimal fetal
(for display of vascular and fluid-filled structures). To com- motion. In order to obtain a 3D image of the fetal profile, the
plement the various display modes, different rendering col- volume must also be acquired en face (Figure 4.5). If the goal
ors can be selected to optimize the visualization of the target is to obtain a portrait of the fetal face, the volume acquisition
area in question. These may be combined in a multitude of begins by imaging the fetal profile (Figure 4.6). The volume
ways, and this is the focus of this chapter. may be obtained using either of the above approaches and
When rendering a volume, manipulation along the three axes manipulated to generate the face or profile. However, this
may still be required for image optimization. In addition, the approach may result in the introduction of additional arti-
orientation from which to view the acquired volume may be facts, hindering the quality of the final rendered images.
Figure 4.1 A 3D volume

of a 23w4d fetal face dis-
played in the multiplanar
mode and rendered using
surface rendering. Note the
size of the box for the region
of interest, the direction of
viewing the region of interest
(top to bottom), the quality
of the acquired volume (set
at high 2) and the angle of
acquisition of 55 degrees (top
right-hand corner).
25
Figure 4.2 A 3D volume of the fetal face at 21w6d displayed using HDlive, a
new surface-rendering mode with an adjustable internal light source.
Table 4.1 Steps in Altering the ROI Orientation while Viewing the AV Valves
Step 1: Select the four-chamber view as your reference plane with the ultrasound beam parallel to the ventricular septum
Step 2: Obtain a 3D sweep with an angle of acquisition of 15 degrees and a mid to high quality for the volume
Step 3: Place the render box over the AV valves with the ROI orientation from the basal (atrial) side
Step 4: The AV valves are now depicted in the rendered image (Figure 4.3)
Step 5: Change the ROI orientation now to the apical (ventricular side) (Figure 4.4)
Step 6: The leaflets of the AV valves may now be visualized from the ventricular side in the final rendered image
Figure 4.3 A 3D volume with

Atria color Doppler of the heart of a
25w4d fetus displayed using the
glass body mode which minimizes
the gray scale and highlights the
color Doppler. Here the box for the
region of interest has been set to
include the atrioventricular valves
with a direction from bottom to
top, basal approach, depicting
Ventricles looking down from the atria. Note
the closed valves during systole.
Volume Display 27
Figure 4.4 The same 3D

volume with color Doppler of the
heart of a 25w4d fetus from figure
4.3 displayed using the the glass
body mode, which minimizes
the gray scale and highlights the Ventricles
color Doppler. Again, the box for
the region of interest has been
set to include the atrioventricu-
lar valves; however in this case,
the direction of view is from top
to bottom, apical view, depicting
looking up from the ventricles.
Note the closed valves during
systole. Atria
Figure 4.5 Acquisition for

generating the fetal profile. (A)
A 3D volume of the fetal face of
a 26w1d fetus. In order to depict
the fetal profile, the acquisition
plane A must be en face with a
good amniotic fluid interphase in
front of the fetal face. Note the
size of the region of interest and
the direction of view being top to
bottom. (B) A 3D model depict-
ing an en face acquisition. A B
Figure 4.6 Acquisition for

visualizing the fetus en face. (A)
A 3D volume of the fetal face of
a 26w1d fetus, the same fetus in
figure 4.5. However, in this case,
In order to depict the fetal face
en face, the acquisition plane (A)
must be of the fetal profile with
a good amniotic fluid interphase
in front of the fetal face. Note the
size of the region of interest and
the direction of view being top to A B
bottom. (B) A 3D model depict-
ing a side acquisition.
Figure 4.7 A 3D volume of

the face of a 23w4d fetus ren-
dered using various modalities.
(A) Surface rendering using default
settings. (B) Dynamic rendering.
A B C (C) HDlive.
Figure 4.8 A transvaginal 3D volume

of an (A) 8w0d fetus, (B) 12w4d fetus fetus
surface rendered using HDlive. However,
in this case, the light source was moved so
that it shone from behind the fetus creat-
A B
ing these unique image.
The rendered image may be displayed in the surface skin-rendering techniques to generate lifelike images. The
mode (default setting on most machines); dynamic render- sonographer must keep in mind that for optimal results, it is
ing; or HDlive (Figure 4.7), which utilizes sophisticated necessary to remove any cord, placenta, or extremities by the
electronic scalpel (MagiCut) and to optimize the image prior
to activating HDlive. A unique feature of HDlive is the avail-
Basic Concepts in Obtaining ability of a movable internal light source that may be adjusted
a Surface-Rendered Image for optimal image display (Figure 4.8).
of the Fetal Face
1. A fluid–tissue interphase is required for opti- Maximum Mode
mal rendering of the image
2. Avoid obtaining a volume with the fetal cord The maximum mode is utilized to display the fetal skeleton
or an extremity covering the face – the ribs, spine, extremities, bony face, sutures of the fetal
3. To visualize the fetus face en face, start with skull, or cranium. The same basic principles of volume acqui-
the fetal profile (sagittal view) as the reference sition discussed in Chapter 2 apply here with respect to vol-
plane ume acquisition and the need to optimize the basic 2D image.
4. To visualize the fetal profile, start with an en However, when choosing the “render” mode, the maximum
face reference plane (coronal view) of the fetal mode is selected and the region of interest is selected around
face the area in question (Figure 4.9).
Volume Display 29
1 S
12
Figure 4.9 A 3D volume of a 21w4d fetus displayed in the skel-
etal (maximum) mode. Note that this mode highlights the bony
structures and enables visualizing the clavicles (C), scapula (S) as
well as all 12 ribs (1–12).
Figure 4.10 A 3D volume of the Circle of Willis with color

Doppler in a 22w36d fetus displayed using the minimum mode,
which removes all gray scale.
Minimum Mode/Glass Body Mode
Whenever vascular or fluid-filled structures such as fetal ves- the vasculature of the Circle of Willis, where color Doppler
sels, heart, stomach, kidneys, or bladder are under exami- is also employed (Figure 4.10). In addition, high-definition
nation, the minimum mode may be utilized. The minimum flow and B flow may be utilized instead of color Doppler to
mode optimizes the parameters for visualizing the echo- further evaluate the area under study. The glass body mode
lucent areas. For example, if the Circle of Willis is to be is a compromise between minimum mode and regular imag-
evaluated, the 2D and color Doppler image settings should ing, where the gray scale is minimized but not completely
be optimized and the Circle of Willis should be the start- removed. This aids in maintaining the volume orientation of
ing reference plane when acquiring the volume. A 3D sweep the vasculature within the anatomical structures being stud-
may then be obtained, and the minimum mode is selected ied (Figure 4.11).
in order to remove all the gray-scale areas and to highlight
Inversion Mode of the area in question. An example of the utility of the inver-
sion mode is in evaluating a multicystic ovary (Figure 4.12).
The inversion mode is usually complementary to the mini- In addition, the inversion mode is useful for rendering a cast
mum mode, where the echolucent area under study in the of the area in question; for instance a ventricular septal defect
minimum mode may be “inverted” so that the gray scale (VSD) (Figure 4.13). A stepwise approach to inverting a vol-
is minimized and echolucent structures become echogenic, ume is described in Table 4.2.
further facilitating characterization and volume calculation
Table 4.2 Steps for Employing Inversion Mode in a Cystic Ovary

Step 1: Acquire a volume of the adnexa and display it in the multiplanar mode using maximal quality (Figure 4.12a)
Step 2: Select the inversion mode and render the volume (Figure 4.12b)
Step 3: Change the direction of the region of interest as needed (Figure 4.12c)
Step 4: Utilize MagiCut and adjust the threshold, transparency, and color of the image for optimal results (Figure 4.12c)
H&N
AoA
V
Figure 4.11 A sagittal 3D volume of a 22w6d fetus with color
C Doppler displayed using glass body mode. Here the gray scale is
minimized and the fetal vasculature is highlighted. In this case,
the aortic arch (AoA), with the head and neck vessels (H & N),
descending aorta (DAo) as well as the inferior vena cava (IVC)
are seen.
Volume Display 31
A B
C D
Figure 4.12 A transvaginal 3D volume of a multicystic ovary rendered using inversion mode. (A) Multiplanar display using VCI at a
slice thickness of 2 mm. (B) The volume is rendered using inversion mode. (C) The direction of the region of interest is changed to “top
to bottom” in reference plane A. (D) MagiCut as well as manipulation of the threshold, transparency and color are carried out for optimal
results for visualizing the cysts.
Figure 4.13 A 3D volume of the heart of a

32w0d fetus displayed in the multiplanar mode
with rendering using the inversion mode. The
fetus was found to have a ventricular septal
defect (VSD) whose presence was confirmed
using inversion mode. The flow across the VSD
VSD
is now highlighted as seen in the rendered image.
Tomographic Ultrasound Imaging (TUI) Practical Pearls
Tomographic ultrasound imaging (TUI) is the sonographic

equivalent of CT scanning. Utilizing this volume mode • There are several rendering modalities that
enables the generation of multiple slices of the acquired may be utilized depending on the area under
volume under study, to a set distance in mm, in any of the study
three orthogonal planes, in a chosen number of panes. This • The minimum mode is ideal for fluid-filled
is of particular utility in the first trimester, where a single structures such as the heart and vessels
volume can be obtained of the entire fetus and then, utiliz- • The maximum mode is ideal for evaluating
ing TUI, most of the fetal anatomic and biometric planes the bony structures
may be generated, starting from the transverse plane of • Optimization of the underlying 2D image
the abdominal circumference (Figure 4.14). TUI is also of prior to volume acquisition is critical
utmost utility in determining the size of a mass or lesion • Rotation along the three axes as well as
and its relationship to the adjacent organs. It facilitates scrolling within the volume further refine the
mapping the lesion’s locale to within 0.5 mm and aids in quality of the rendered image
determining the extent of spread to and involvement of sur- • Though one is tempted to immediately utilize
rounding structures. HDlive for the evaluation of the fetal face,
a higher-quality image is generated if the
volume is first acquired using the default
Conclusion settings; once the image gain and threshold
have been adjusted and MagiCut utilized,
The trilogy of volume acquisition, manipulation, and dis- HDlive may be activated for optimal results
play form the foundation for optimal image generation when (Benoit, oral communication 2012)
employing 3D ultrasound. The sonographer must become
familiar with all the key components and must not be afraid
to experiment with the various modalities in order to gain
expertise and maximize the use of the various capabilities of
the sonographic machine.
HD FB
Cl
H
S
LL
B
B
A
Figure 4.14 Tomographic ultrasound imaging (TUI). (A) A 3D volume of a 12w5d fetus displayed using TUI with an interslice distance
of 6 mm and VCI at a slice thickness of 2 mm. The planes depicting the head (HD), facial bones (FB), heart (H), stomach (S), cord insertion
(CI), bladder (B), and lower limbs (LL) are generated out of the volume. (B) A 3D model depicting the axial slicing of TUI.
5 Spatiotemporal Image Correlation
Introduction study of normal anatomy and standardizing the approach

to the evaluation of the various cardiac planes (Paladini et
Spatiotemporal image correlation (STIC) was first intro- al. 2008b; Rizzo et al. 2008; Yeo and Romero 2013), in the
duced by DeVore et al. in 2003 (DeVore et al. 2003; Viñals study of cardiac function (Molina et al. 2008; Uittenbogaard
et al. 2003). It is a unique volume sonographic feature in et al. 2009; Hamill et al. 2011; Simioni et al. 2011), and in
which a 4D volume of the fetal heart is acquired. Acquiring the evaluation of congenital heart defects (Viñals et al. 2006;
the volume using STIC overlays multiple 2D images of the Gindes et al. 2009; Turan et al. 2014). In addition, STIC has
beating heart, generating a volume of a full cardiac cycle that enabled the off-line consultation with experts for the analysis
may then be displayed as 2D images (Figure 5.1) or a con- of stored STIC volumes, which allows the expert to evalu-
tinuous cineloop. It is considered a 4D technique because the ate the fetal heart in a full cardiac cycle at a remote site
volume is displayed in motion, and various color modalities (Espinoza et al. 2010).
may be incorporated into the volume as well (Figure 5.2). In
addition, this volume of the beating heart may be manipu-
lated along any of the 3D orthogonal planes and through any
selected reference point, and may be studied while beating
through a full cardiac cycle. Combining a STIC volume with
Basic Concepts in Obtaining
TUI provides invaluable information as well where the image
a STIC Volume
resolution may be enhanced by activating VCI.
1. An apical view for acquisition is ideal
2. Avoid obtaining a volume with an extremity
Spatiotemporal Image Correlation (STIC) in front of the chest
3. When setting the acquisition box, include the
STIC has had well-documented utility in the evaluation of fetal heart and not the entire chest
the fetal heart throughout gestation. There is ample litera- 4. The angle of acquisition need not be more
ture explaining the technology (DeVore et al. 2003; Viñals than 15 to 20 degrees
et al. 2003; Chaoui et al. 2004) and addressing its use in the
Reference Dot
Figure 5.1 A 4D STIC volume of a 21w3d

fetus acquired with color Doppler at an angle
of 25 degrees. It is displayed in the multiplanar
“niche” mode. The image in the bottom right-
hand corner locates precisely where we are
within the volume, with the reference dot as the
pivotal point clearly displayed in all four panes.
33
The uniqueness of this technique is that the fetal heart can manufacturers have made it possible to carry out the off-line
be examined off-line, throughout a full cardiac cycle, dur- M-mode analysis on a STIC volume, and it is possible to
ing systole (Figure 5.3) and diastole (Figure 5.4), allowing a change the orientation of the M-line (Figure 5.7). It is also
complete and thorough evaluation of both structure and func- possible to invert a STIC volume (Figure 5.8) and to add it
tion. Navigating through a STIC volume enables the study to any of the color modes—color Doppler, power Doppler,
of wall motion (the study of atrioventricular and semilunar or high-definition flow – to further study the valves and the
valves in systole and diastole) (Figures 5.5 and 5.6). Certain vasculature in motion.
RV
LV
Figure 5.2 The same STIC volume from

Figure 5.1 rendered using minimum mode, in
a back-to-front direction in plane B, depicting
the right ventricle (RV) and left ventricle (LV)
RVOT
as well as the right ventricular outflow tract
(RVOT).
Figure 5.3 Navigating through the same

STIC volume enables evaluation of the beating
heart throughout the cardiac cycle in all three
planes simultaneously. This depiction is during
systole, with the atrioventricular valves closed
and the ventricles empty.
Spatiotemporal Image Correlation 35
Figure 5.4 The same STIC volume with

color Doppler in diastole, with good flow across
the atrioventricular valves and symmetrical and
equal filling of both ventricles.
Figure 5.5 The same

STIC volume displayed in
the three orthogonal planes, AV AV
with the reference dot in
the left ventricular outflow
tract. (A) Systole with the
aortic valve (AV) open and
with complete disappear-
ance of the leaflets of the
AV as localized by the ref-
erence dot. (B) Diastole with
the AV closed and the leaf-
lets visible as an echogenic A B
bright center, as localized by
the reference dot.
Figure 5.6 The same

STIC volume displayed in
the three orthogonal planes PV PV
with the reference dot in the
right ventricular outflow
tract. (A) Systole with the
pulmonic valve (PV) open
and with complete disap-
pearance of the leaflets of
the PV as localized by the
reference dot. (B) Diastole
with the PV closed and the
leaflets visible, as localized
by the reference dot. A B
VS
VS
RV
RV
LV
LV
A B
Figure 5.7 The same STIC volume displayed using M-mode. (A) Orientation for the M-mode display
starts with the right ventricle (RV), the ventricular septum (VS), then the left ventricle (LV). (B) M-line is
rotated off-line 180 degrees, whereby the orientation for the M-mode display now becomes reversed start-
ing with the LV, VS, then RV.
VS
A B
Figure 5.8 A STIC volume of a 25w4d fetal heart rendered using inversion mode. (A) Multiplanar
display with render using inversion mode. (B) Single pane displayed of a rotated final-rendered volume.
This generates a cast of the heart showing the shape of the atria, the ventricles, and the symmetry. Note the
intact ventricular septum (VS). When the cineloop is activated the function may also be assessed.
A main limitation of this technique is the resolution in the in much loss of resolution. In addition, TUI may be employed
B and C planes (Figures 5.1, 5.2, 5.5, and 5.6). If the ulti- to retrieve all the respective anatomical planes out of the vol-
mate goal is the sagittal examination of the aortic and sag- ume (Figure 5.9) (DeVore et al. 2004). Table 5.1 covers the
ittal arches or the right atrial inflow, the volume should be basic steps for inverting a STIC volume of the fetal heart,
acquired in the sagittal plane and not constructed from the which may be visualized in a multitude of ways, including a
four-chamber view, because the reconstruction would result 3D cineloop (Figures 5.10–5.15).
Table 5.1 Steps to Obtaining and Inverting a STIC of the Fetal Heart
Step 2: Obtain a 4D sweep with the acquisition box placed just around the heart, with an angle of acquisition of 15 to 30 degrees and a mid to
high quality for the volume
Step 3: Acquire the volume with color Doppler; the STIC volume is now displayed in the multiplanar mode in the three orthogonal planes as
cineloops of the beating heart (Figure 5.10)
Step 4: Render the volume with the direction of the region of interest as a back-to-front direction (Figure 5.11)
Step 5: Select inversion mode to invert the STIC volume and obtain a 4D inverted cast of the fetal heart; with the current settings, there will be
no clear cast (Figure 5.12)
Step 6: Adjust the threshold to roughly 120 and the mix to 100/0 to optimize the final rendered image (Figure 5.13)
Step 7: Select the single-image mode and rotate the volume along the three orthogonal planes and use MagiCut to remove the obscuring areas
(Figure 5.14)
Step 8: The final rendered inverted version of the fetal heart may now be displayed as a 2D image in any color (Figure 5.15) or it seen as a
cineloop of the beating heart
DV SVC
A
Az o
A HN Az
DAo
RA
IVC
A B
Figure 5.9 STIC volume of the heart of a 23w4d fetus with high-definition flow is acquired at an angle of 20 degrees starting from
the sagittal plane. (A) Volume is displayed in the multiplanar mode. (B) Volume is displayed using TUI at a 2 mm interslice distance
automatically generating all the required anatomical sagittal planes out of the single STIC volume. Note the aortic arch (AoA) descending
aorta (DAo), head and neck vessels (HN), ductus venosus (DV), hypoechogenic azygous vein (Az) (no color uptake), right atrium (RA), and
superior and inferior venae cavae (SVC and IVC).
A C
Figure 5.10 STIC acquisition. (A) STIC volume with high-definition flow of a 21w5d heart is acquired at an angle of 20 degrees. It is
displayed in the multiplanar mode. (B) 3D model depicting the level of acquisition. (C) 3D model depicting the multiple overlaid 2D images.
For a STIC, the volume would be limited to the heart.
Figure 5.11 The same volume from Figure 5.11 is now rendered using surface rendering with the direction
of the region of interest set at a back-to-front direction.
Figure 5.12 Render mode now changed to inversion. However, at the current settings no image is generated.
Figure 5.13 Mix and threshold settings are now adjusted, generating a cast of the fetal heart with the atrial
and ventricular septae visible
Figure 5.14 A single pane is now selected

and the inverted heart, premanipulation, is
shown.
A B C
Figure 5.15 Postmanipulation. (A,B,C) Volume is now rotated along the three axes, and MagiCut is utilized to crop away any obscuring
areas. Volume is displayed in various color settings. It may be viewed as a cineloop and rotated along any of the three axes. Care must be
employed to not erroneously diagnose ventricular septal defects in this case, as these are rendering artifacts.
STIC is a unique 4D technique that enables full evaluation of

the structure and function of the fetal heart, while it is beat- • STIC is a most useful modality for analyz-
ing, throughout a full cardiac cycle. It enables off-line study, ing the fetal cardiac structure and function
review, and consultation on the most challenging fetal organ. throughout a full cardiac cycle
Proper acquisition of the volume is key to facilitate naviga- • STIC enables visualization of ventricular fill-
tion through it; however, it remains limited by the suboptimal ing during diastole and ventricular emptying
resolution in the B and C planes. during systole
• STIC allows a virtual cardiac examination
and may be combined with other modali-
ties such as TUI for a thorough multiplanar
evaluation
• Remember to optimize the 2D settings prior
to acquisition
• Avoid acquiring any volumes with fetal
extremities covering the chest
• Use the smallest acquisition box and smallest
angle possible to minimize artifacts
6 3D Tools
Introduction the MagiCut tool. The main drawback is iatrogenic artifacts

from excess removal by MagiCut, as this may generate arti-
Once a volume is acquired and displayed in either the multi- facts that could distort the image, potentially alarming the
planar mode or in a rendered mode, several tools may be uti- patient. Figure 6.1 through Figure 6.4 depict before and after
lized to enhance the final images and facilitate the retrieval images where MagiCut was utilized (Table 6.1). On several
and evaluation of challenging areas. The availability of these of the newer machines, when the volume contains color
modalities varies among manufacturers, and though many Doppler there is an option to select whether to remove the
are standard, the given names are industry specific. gray-scale portion of the image, the color Doppler, or both
when selecting a specific area within the volume.
MagiCut
Volume Contrast Imaging
The electronic scalpel, MagiCut, is one of the most useful
tools, allowing the sonologist to sculpt away and remove any There are several slicing modalities that can be utilized for
structures that may be obscuring the area of interest. To use volume rendering in order to improve the visualization of
the MagiCut properly, the examiner must be aware of which the final rendered structure. One example is volume contrast
structures within the volume are to be evaluated and which imaging (VCI). This is a thick-slice technique where, instead
structures need to be removed. For optimal images, the vol- of a thin 2D image display, a thick slice along an adjust-
ume can be rotated along the three axes to ascertain the depth able thickness may be obtained, minimizing artifacts and
and direction of the structures that need to be removed using improving the quality of the image. VCI may be combined
Table 6.1 Steps to Using MagiCut

Step 1: Obtain a 3D volume of a fetus and display it in the multiplanar mode selecting surface rendering (Figure 6.1)
Step 2: Select the single image display to see the fetus in surface rendering (Figure 6.2)
Step 3: Use the line or box, depending on the shape or the object to be removed, in order to remove what is obscuring the fetal details
(Figure 6.3)
Step 4: Adjust the threshold, render mode, and light to optimize the final rendered image (Figure 6.4)
Figure 6.1 A 3D transvaginal volume

of a 12-week fetus is obtained, displayed
in the three orthogonal planes as well as
surface rendering. Note the placenta ante-
rior to the fetus in the rendered image.
41
with other modes, such as TUI. This aids in the visualiza-

tion of certain structures within the brain, such as choroid
plexus cysts, the cerebellar vermis, the corpus callosum
(Figures 6.5–6.7), and the fetal spine. VCI is also helpful in
evaluating the internal structures, such as the fetal heart and
abdominal contents, as depicted in subsequent chapters.
OmniView
OmniView is a versatile slicing tool that allows slicing along

any direction in a straight line or a curvilinear line. This
may be accomplished utilizing various thicknesses, giving
access to specific difficult-to-reach areas. It may be used as a
single line or multiple lines within the same volume for vari-
ous depictions. What is most unique about OmniView is that
it allows the simultaneous display of three non-orthogonal
planes from a single volume (Figure 6.8). There are several
areas where OmniView is of great utility, such as in evaluat-
ing the fetal palate (Tonni et al. 2012) and the skeletal system
as well as the internal organs. Further examples will be pre-
sented in the respective chapters.
Virtual Organ Computer-Aided Analysis
Virtual organ computer-aided analysis (VOCAL) is a 3D

software that facilitates calculation of the volume of a spe-
cific area under study. This can be carried out by obtaining a
volume of the area in question, such as a volume of the fetal
lung. Tracing the structure of interest and rotating it along a
180-degree axis automatically calculates and generates the
volume of the organ. This is of utmost utility in trying to Figure 6.2 The rendered image is subsequently selected and the
determine the volume of the lungs, especially in the presence fetus rotated along the three orthogonal planes to depict as much of
of congenital diaphragmatic hernia. It may also be used for the entire fetus as possible. The volume now shows both feet.
the fetal liver, spleen, a particular mass, or even a fluid-filled
area. Details on how to calculate the volume of a fetal lung
are presented in Table 6.2 (Figures 6.9–6.12).
as “SonoAVC follicle”, which is to be used in reproductive
medicine, or “SonoAVC general”, which may be used every-
SonoAVC where else. The volume for the specific color-coded, identi-
fied areas may be calculated automatically. This has several
SonoAVC is a specific volume calculation software that iden- applications: in the assessment of ovarian follicles (Table 6.3)
tifies several small echolucent areas and color codes them (Figures 6.13–6.15), in the gastrointestinal and genitourinary
in order to distinguish them from one another. It is available tracts, and in the early developing fetal brain.
Table 6.2 Steps to Using VOCAL for Calculating Lung Volume

Step 1: Obtain a 3D volume of the fetal chest and display it in the multiplanar mode (Figure 6.9)
Step 2: Activate VOCAL. Select “manual” for the “define contour.” Select “trace” for the “contour finder.” Select a rotational step of 30 degrees.
Select the reference image to carry out the measurements in (Figure 6.10)
Step 3: With each rotation of the volume, trace around the visible portion of the corresponding lung (Figure 6.11)
Step 4: In the case of a rotational step of 30 degrees, the system will prompt the sonographer to obtain 6 tracings. They would be a repetition of
step 3 (Figure 6.11)
Step 5: Once all 6 tracings have been carried out, select “done” and an automatic calculation of the volume with a 3D schematic will be displayed
automatically (Figure 6.12)
3D Tools 43
Figure 6.3 The volume is rotated along the Y axis and Figure 6.4 This is the final volume after completing MagiCut.
MagiCut is activated. MagiCut in this case employs “line Further anticlockwise rotation is carried out along the Y axis.
trace” to remove areas “within” the line. The excess placen- Finally, surface rendering is changed to HDlive, and the threshold
tal and other tissue is selected and removed. and light source are adjusted to generate this image. Note the ori-
entation of the light source depicted in the schematic at the bottom
right-hand corner of the image (*).
Table 6.3 Steps to Using SonoAVC Follicle

Step 1: Obtain a 3D volume of the ovary
Step 2: Select “SonoAVC follicle”
Step 3: Automatically, all follicles (echolucent areas) get encircled and color coded (11 follicles in the volume in Figure 6.13 and Figure 6.14)
Step 4: An automatic measurement in each of the 3 planes, together with the volume of each of the follicles, is then generated in a table
(Figure 6.15)
CB
Figure 6.5 A 3D
volume of the fetal brain
at 22w0d is displayed
using TUI at an interslice
Th
thickness of 2 mm. Note
where the interslice
thickness is designated
(*). The posterior fossa
with the cerebellum
(CB), thalami (Th),
posterior horn of the F CSP
lateral ventricle (Vp), falx
cerebri (F), and cavum
septi pellucidi (CSP) are
Vp
seen.
*
CB
Figure 6.6 The same
3D volume of Figure 6.5
now displayed using VCI
with a slice thickness of 2
Th
mm (seen at the top right-
hand corner [*]). The
posterior fossa with the
cerebellum (CB), thalami
(Th), posterior horn of the
lateral ventricle (Vp), falx
F CSP cerebri (F), and cavum
septi pellucidi (CSP) are
seen. Note the improve-
Vp
ment in the resolution and
definition of the image.
CC
A Figure 6.7 An axial

3D volume of the fetal
brain at 22w0d. (A)
OmniView is activated
and a straight line is
selected and it is drawn
from posterior to anterior
CC automatically generat-
V ing a sagittal view of the
corpus callosum (CC), a
difficult plane to obtain.
The cerebellar vermis is
also seen (V). (B) VCI is
now activated at a slice
thickness of 2.7 mm and
the color changed to sepia
generating a clearer,
B crisper image.
3D Tools 45
L R
DAo
Ao
RL
LL
S
D
Figure 6.8 A 3D volume of a 21w5d fetal chest is obtained. The OmniView algorithm is employed with VCI at a slice thickness of 1 mm
utilizing three color-coded polylines. The first line (1) is drawn from the left (L) to the right (R) of the chest across both lungs, transecting
the aorta (Ao) in plane A. It generates an image of the descending aorta (DAo) in plane B. Line (2) is drawn from the posterior aspect of
the right lung to the anterior abdominal wall, generating an image of the right lung (RL) with a clear diaphragm (D) seen in plane D. Line
(3) is drawn from the posterior aspect of the left lung to the anterior abdominal wall, generating an image of the left lung (LL) with a clear
diaphragm (D), and the stomach (S), seen in plane C.
Figure 6.9 A 3D volume of the fetal chest and abdomen is obtained and
displayed in the coronal plane utilizing VCI at a slice thickness of 2.5 mm.
Figure 6.10 VOCAL is

now activated and “manual”
is selected for the “define
contour” and “trace” for the
“contour finder.” A rotational
step of 30 degrees is chosen.
In this volume, plane C, the
coronal plane, is the chosen
reference plane in which to
Designated Rotational obtain the measurements.
Plane in Green
The dotted line in plane C
depicts the first trace made of
the area of the left lung.
A C
Figure 6.11 Rotational

steps for VOCAL. (A–D)
The system automatically
generates a new plane for
area-trace upon the comple-
tion of each of the six traces,
as in this case of a 30-degree
rotational step. Four of those
B D planes are shown here.
Figure 6.12 Once all six tracings have

been carried out, “done” is selected. The
area is highlighted in all three orthogonal
planes, and an automatic calculation
of the volume with a 3D schematic is
displayed automatically.
3D Tools 47
Figure 6.13 A SonoAVC fol-

licle. (A) 3D transvaginal volume
of the ovary is acquired, magni-
fied, and displayed in the multi-
planar mode. (B) SonoAVC follicle
is selected, which automatically
locates all the echolucent follicles
B
and color-codes them.
Figure 6.14 SonoAVC follicle

has automatically identified and
color-coded the follicles.
Figure 6.15 Volume calculation.

(A) Various identified and color-coded
follicles. (B) An automatic table is
generated, depicting automatic mea-
surements along the three axes, as
well as automatic volume calculation,
for each of the follicles, commencing
with the largest. The data for the larg-
est nine follicles are detailed in this
A B example for the right ovary.
Volume Computer-Aided Diagnosis navigation within the volume. The applicability of these vari-
ous tools is discussed further in the organ-specific chapters.
Volume computer-aided diagnosis (VCAD) is based on two
main concepts, as described by Abuhamad (2004). The first
concept states that any acquired volume contains within it all Practical Pearls
the 2D anatomical planes necessary for a complete assess-
ment of the area in question. The second concept states that
• Several tools may be utilized to maximize the
structures within that volume are organized in a constant
utility of volume sonography
relationship to each other.
• MagiCut allows sculpting and refining the
Using VCAD, one can define the spatial relationships of
image
any 2D planes of a particular organ in question, say the fetal
• VCI allows for obtaining thick slices in the A
heart, and then specific software may be utilized to auto-
and C planes
matically generate the specific 2D planes from the acquired
• In general, a VCI thickness of 2 mm is opti-
volume in order to enable full assessment of the area in
mal for the study of the fetal brain (Chaoui
question. This has already been accomplished with the fetal
oral communication 2013)
heart, and the technique is described in a stepwise man-
• It is recommended to utilize VCI on an already
ner in Chapter 11. The same principles can be applied to
acquired volume rather than live, for optimal
any organ, such as the fetal brain or the first-trimester fetus
results (Chaoui oral communication 2013)
(Abu-Rustum et al. 2012). The mid-sagittal volume tech-
• It is possible to color-code the final image
nique for assessment of the first-trimester fetus is described
with respect to a particular application; for
in Chapter 7.
instance whenever TUI is utilized in a vol-
ume, the final image’s color (whenever TUI is
employed) may be set to copper or cool blue,
or any other color (Chaoui oral communica-
Fractional Limb Volume
tion 2013)
• OmniView allows any-direction linear and
Fractional limb volume (FLV) is a novel sonographic tool
curvilinear multislicing within a volume at
based on the principle that fetal weight may be estimated
various thicknesses
from the limb volume (Lee et al. 2004, 2009). By obtain-
• In general, an OmniView line set to a VCI
ing a volume of the fetal thigh or arm, specific software
slice thickness of 20 mm enables optimal
may be employed which allows the sonographer to obtain
evaluation of the fetal spine (Benoit oral com-
several trace-measurements of the limb in question in order
munication 2012)
to calculate the fetal weight. This is described in detail in
• VOCAL enables volume calculation of
Chapter 15.
structures
• SonoAVC facilitates evaluation of multicystic/
fluid-filled structures
Conclusion
• VCAD allows an assessment of the fetal heart
and outflow tracts
Once a volume is acquired, the sonographer may need to
• Fractional limb volume allows fetal weight
apply any combination of several tools to highlight the
estimation from a limb volume
area under evaluation, remove obscuring structures, and
employ modalities to help facilitate volume calculation and
7 Clinical Applicability in the First Trimester
Introduction acquired along the mid-sagittal plane, the same plane utilized
for measuring the nuchal translucency. First-trimester presets
The applicability of volume sonography in the first trimester may be used and the volume may be acquired with an angle
is unique in that a single volume of the entire fetus may be of acquisition of 65 degrees. Subsequent to that, the volume
obtained in one sweep (Michailidis et al. 2002; Fauchon et is standardized in plane A in order to depict the plane of the
al. 2008; Bharudi et al. 2010; Antsaklis et al. 2011; Borrell et abdominal circumference in plane B, from which parallel shift
al. 2011). From the volume it is possible to retrieve planes to is then utilized to navigate cephalad through the volume in
evaluate fetal anatomy and measure the crown–rump length, order to visualize the fetal heart, upper limbs, facial bones,
limb lengths, biparietal diameter, head circumference, and orbits, plane of the biparietal diameter, and the plane of the
abdominal circumference (Abu-Rustum et al. 2012). butterfly, and caudad in order to visualize the fetal kidneys,
cord insertion, bladder, and lower limbs. Table 7.1 covers the
steps of the mid-sagittal volume technique (Figures 7.1–7.14).
Clinical Utility
There are several particular benefits to volume sonography Single-Volume Technique to Evaluate the Fetal Heart
in the first trimester and these are the focus of this chapter.
With the small size of the fetal heart and the proximity of
the 2D anatomical planes – the fetal stomach, four-chamber
view, and three-vessel view – it is possible to examine these
Benefits of Volume Sonography planes, as well as several other transverse cardiac planes,
in the First Trimester from a single volume. Using the first-trimester cardiac pre-
1. Mid-sagittal volume technique for anatomic set, it is possible to acquire a volume of at least 20 degrees at
and biometric assessment the level of the four-chamber view and employ color Doppler
2. Single volume technique for evaluating the or HD-Flow (which may be superior to color Doppler for the
fetal heart smaller vessels in the first trimester). The volume may be dis-
3. Volume NT played using TUI, which enables visualization of the plane of
4. Sonoembryology the abdominal circumference with a visible stomach (estab-
lishing fetal situs), as well as the planes of the four-chamber
view and the three-vessel view in addition to several other
transverse cardiac planes. Standardization of evaluating the
Mid-Sagittal Volume Technique first-trimester heart from a single volume using STIC modal-
ity with color Doppler was first described in 2009 (Turan
The mid-sagittal volume technique was described in 2012 et al.) and enables full cardiac assessment in up to 85% of
(Abu-Rustum et al.) in which a single volume of the fetus is fetuses (Table 7.2; Figures 7.15–7.18).
Table 7.1 Steps for the Application of the Mid-Sagittal Volume Technique
Step 1: The volume is acquired from a sagittal plane with an angle of acquisition of 65 degrees (Figure 7.1)
Step 2: The volume is then standardized in reference plane A via rotation along the X, Y, and Z axes to optimize the depiction of the fetus in the
mid-sagittal plane (Figure 7.2)
Step 3: In reference plane A, the reference dot is then placed on the fetal spine at the level of the diaphragm, automatically generating the axial plane
of the fetal abdominal circumference, with a visible stomach, in plane B (Figure 7.3)
Step 4: Plane B is then selected as the reference plane, and rotation along the Z axis is employed to optimize the location of the spine to 12 o’clock
(Figure 7.4)
Step 5: Parallel shift is then utilized to navigate cephalad within the volume, from reference plane B, to generate six anatomic planes
(Figures 7.5–7.10)
Step 6: Parallel shift is then utilized to navigate caudad within the volume, from reference plane B, to generate four anatomic planes
(Figures 7.11–7.14)
49
Figure 7.1 3D volume of a 13w1d

fetus is acquired using first-trimester
presets and an angle of acquisition of
65 degrees. The volume is displayed in
the multiplanar mode, depicting all three
orthogonal planes.
Figure 7.2 The volume is subse-

quently rotated along the X, Y, and Z
axes in plane A to depict the fetus in as
mid-sagittal a lie as possible, the same
plane in which the nuchal translucency is
measured.
Stomach
Reference Dot
Figure 7.3 In plane A the reference

dot moved to the fetal spine at the level of
the diaphragm. This automatically gener-
ates the axial plane of the fetal abdomi-
nal circumference in plane B, with a
visible stomach.
Clinical Applicability in the First Trimester 51
Upper Limbs
Stomach
Figure 7.4 Plane B is then chosen as the reference plane from

which to navigate cephalad and caudad within the volume using Figure 7.6 Scrolling further cephalad, it is possible to see the
parallel shift. upper limbs.
Facial Bones
Heart
Figure 7.5 Scrolling cephalad from the plane of the abdominal

circumference, the fetal heart is reached, and it is possible to ascer-
tain situs. Figure 7.7 Scrolling further cephalad, it is possible to see the
facial bones. Depending on the degree of flexion of the fetal head,
it may also be possible to see the retronasal triangle, as is the case
with this fetus.
Orbits
Butterfly
Figure 7.8 Scrolling further cephalad, the fetal orbits and even Figure 7.10 Further cephalad, the plane of the butterfly, formed
the lenses may be seen. by the choroid plexus filling the lateral ventricles, is reached.
Kidneys
Figure 7.11 Scrolling caudad from the plane of the abdominal

circumference, it is possible to visualize the fetal kidneys.
Figure 7.9 Scrolling further cephalad, the plane of the bipari-

etal diameter is reached.
Cord Insertion
Bladder
Figure 7.12 Scrolling further caudad, the cord insertion may be Figure 7.13 Scrolling further caudad, the fetal bladder may be
visualized. seen.
Lower Limbs
Figure 7.14 At the level of the bladder and scrolling even fur-
ther caudad, the fetal lower limbs may be seen.
Table 7.2 Steps for the Application of the Single Volume Technique for Evaluating the Fetal Heart
Step 1: The volume is acquired from a transverse plane at the level of the four-chamber view, with HD-Flow, using an angle of acquisition of 55
degrees (Figure 7.15)
Step 2: The volume is then standardized in reference plane A via rotation along the Z axis in order to place the fetal spine at 6 o’clock and the
cardiac apex to the left of the image (Figure 7.16)
Step 3: In reference plane A, the reference dot is then placed at the crux of the heart (Figure 7.17)
Step 4: Plane A is then selected as the reference plane and TUI at an interslice thickness of 1.2 mm and set to 15 slices is used to display the
volume (Figure 7.18)
Step 5: From the displayed volume, the planes of the abdominal circumference with a visible stomach, the four-chamber and three-vessel view
become apparent (Figure 7.18)
Figure 7.15 3D vol-

ume is acquired at the
level of the four-chamber
view, after the application
of HD-Flow, using first
trimester cardiac presets
and an angle of acquisi-
tion of 55 degrees. The
volume is subsequently
displayed in the multi-
planar view depicting all
three orthogonal planes.
Fetal Spine
Figure 7.16 The vol-

ume is then standardized
in plane A by rotation
along the Z axis in order
to place the fetal spine in
the 6 o’clock position.
Reference Dot
Figure 7.17 The ref-

erence dot is then placed
at the crux of the heart in
plane A.
Ao
3VV
Figure 7.18 The vol- PA
ume is then displayed
using TUI set at 15 slices
1.2 mm apart. Through
this display, it is possible RV
to see the fetal stomach
RA
(S), the left-sided aorta LV
in cross-section (Ao), the LA
four-chamber view with FO
the ventricles and atria
(RV, LV, RA, and LA),
the foramen ovale (FO),
and the three-vessel view
Ao
(3VV) with the aorta
(Ao) and pulmonary S
artery (PA).
Volume Nuchal Translucency may be obtained and it can be studied at various gestations,
as has been described by Kim et al. (2008), for the potential
Volume nuchal translucency (NT) is a specific volume-based early recognition and identification of underlying central ner-
software available on select ultrasound machines in which vous system abnormalities.
a volume of the first-trimester fetus is acquired in the mid-
sagittal plane. After acquisition of the volume and using the
applicable presets on the machine, there is automatic gen- Limitations of Volume Sonography in the
eration of an optimized, magnified mid-sagittal image of the Evaluation of the First-Trimester Fetus
fetal head and thorax (Figure 7.19). Subsequently, the opera-
tor places a box over the optimal area for measuring the NT Although volume sonography has great advantages in the
for automatic generation of the fetal NT. first trimester, facilitated by the ability to obtain a single vol-
ume of the entire fetus for later off-line analysis, there remain
several limitations. At this point in gestation the fetus is often
Sonoembryology in a flexed position, with the upper limbs obscuring the face.
In addition, there tends to be significant fetal motion beyond
Another in vivo application for volume sonography in the 13 weeks, resulting in artifact introduction. As a result, the
first trimester is to facilitate the study of the fetal ventricu- optimal time for volume acquisition is after 12 weeks, when
lar system (Figure 7.20). This requires expertise and a clear the fetus is in a near-still sagittal lie. One must also keep in
understanding of fetal embryology. By applying the inversion mind the developmental limitations, such as normal fetal gut
mode, and possibly employing SonoAVC to volumes of the herniation, in order to avoid misdiagnoses which could cause
developing fetal brain, a cast of the fetal ventricular system undue parental anxiety.
Figure 7.19 Using

volume NT, available
on select ultrasound
machines, a 3D volume
of the fetal head and
upper chest is acquired
in the mid-sagittal plane.
After the acquisition of
the volume and using
the applicable presets on
the machine, there is the
automatic generation of
an optimized, magnified
mid-sagittal image of
the fetal head and tho-
rax (right-hand image)
with the correspond-
ing orthogonal planes
depicted in the two left-
hand images.
Figure 7.20 A transvaginal volume of an 8w4d fetus is acquired and displayed using TUI at an interslice thickness of 0.5 mm and with
VCI at a slice thickness of 1 mm depicting the developing ventricular system.
Conclusion of first-trimester of fetal brain volumes utilizing the various

3D modalities such as the inversion mode may enhance the
The proper application of volume sonography in the first tri- comprehension of fetal development. As technology evolves,
mester facilitates the complete fetal anatomic and biometric automation may ultimately enable a full first-trimester fetal
assessment from a single volume acquired in a mid-sagittal assessment by generating all of the anatomic and biometric
plane (Figure 7.21) (Abu-Rustum et al. 2012). With the proper first-trimester planes required for evaluation of the first-tri-
acquisition and display of a single volume of the first-trimes- mester fetus. With the introduction of noninvasive prenatal
ter fetal heart utilizing HD-Flow, it may also be possible testing, it is inevitable that the role of the first-trimester scan
to generate most of the transverse cardiac planes neces- will shift from screening for aneuploidy to a full fetal ana-
sary for the evaluation of the fetal heart. Off-line analysis tomic evaluation (Abu-Rustum 2014).
Figure 7.21 From a single 3D volume of a first-trimester fetus, it is possible to generate all the planes required for an anatomic
and biometric assessment (RK and LK, right and left kidneys; O, orbits).
Practical Pearls
• To maximize the success of retrieving all the • It is possible to automatically generate the plane
respective anatomic and biometric planes out of a for measuring the fetal NT out of an acquired
single volume, start with as true a mid-sagittal lie volume and to utilize specific software to auto-
as possible, optimize the 2D settings, acquire the matically measure the optimal NT using certain
volume with an angle of 65 degrees sonographic machines
• Standardize the volume at the level of the abdomi- • Applying the inversion mode to a volume of the
nal circumference plane and scroll cephalad as first trimester fetal brain allows the generation of
well as caudad for a full assessment of the fetus in a cast of the fetal ventricular system
the first trimester • In the first trimester and with the small size of the
• For evaluating the fetal heart, acquire a 3D vol- fluid-filled structures, it may be easier to utilize
ume starting at the level of the four-chamber view SonoAVC follicle (Benoit oral communication
using HD-Flow with an angle of acquisition of 55 2012) to invert key structures in the brain and
degrees abdomen
• Display the volume using TUI at 12-15 slices 1.2–2 • VCI is most helpful in the analysis of a first tri-
mm apart in order to establish fetal situs by visual- mester volume
izing the plane of the abdominal circumference as
well as the planes of the four-chamber view and
the three-vessel view
8 Clinical Applicability in the Fetal Face
Introduction
Facial Abnormalities Where Volume
Nowhere is the beauty of volume sonography more appar- Sonography is of Added Value
ent than in the evaluation of the fetal face, especially today 1. Facial clefts
with the availability of HDlive (Figure 8.1). The fetal face 2. Facial tumors
is an area where 3D ultrasound has been proven to be of 3. Orbital abnormalities
added clinical value in comparison to 2D sonography. In 4. Nasal abnormalities
1995 Devonald et al. described quasi-3D imaging as com- 5. Maxillary/mandibular abnormalities
plementary to 2D imaging in the evaluation of the fetal face 6. Neck abnormalities
(Devonald et al. 1995), followed by Merz et al.’s report using 7. Other
transabdominal and transvaginal 3D ultrasound to detect or
exclude facial abnormalities in 618 fetuses between 9 and
37 weeks. Merz concluded that 3D ultrasound provided
convincing evidence for its use in the evaluation of normal Facial Clefts
and abnormal fetal anatomy (Merz et al. 1997). However,
imaging of the fetal face has been one of the main rea- While the patient and family members are eager to see the
sons for the improper utilization of volume sonography for fetal face, imaging of this structure by the physician is impor-
“entertainment ultrasound,” and has resulted in abuse by tant to exclude facial abnormalities that at times may be iso-
some sonographers and physicians who have capitalized on lated or may present as part of a syndrome. The area that has
the emotional component of 3D imaging. The purpose of been studied extensively, using 3D ultrasound, is the prenatal
this chapter is to demonstrate the value of 3D ultrasound diagnosis of facial clefting. Although a cleft lip can be easily
beyond just the “pretty face,” where much skill needs to be visualized by surface rendering after artifactual shadowing
acquired and many techniques need to be mastered to use has been excluded from the cord, placenta, limbs, or digits
volume sonography to its fullest potential in evaluating the (Figure 8.2), the hard and soft palate prove to be much more
fetal face. difficult to image.
Clinical Utility
Volume sonography has been shown to be of added utility

in identifying several abnormalities of the fetal face, the
most common areas of which are listed below. Please refer to
Chapter 2, where Table 2.2 and Figure 2.3 and 2.4 cover the
basic steps for acquiring a volume of the fetal face.
Figure 8.1 3D volume of a 23w6d fetus rendered using HDlive.

Note the details of the face: the eyelids, philtrum, and nostrils.
59
Figure 8.2 3D volume of a

26w6d fetus with bilateral cleft
lip. (A) Volume is rendered using
surface mode. (B) Volume is ren-
dered using HDlive. These images
helped clarify the findings to the
A A B B family.

19w0d fetus with a cleft palate is
displayed in the multiplanar mode
using skeletal mode. The reverse-
face technique is utilized, clarify-
ing the presence of the cleft palate
(arrow).
Figure 8.4 3D
volume of a
20w4d fetus with
multiple anoma-
lies. (A) Volume
is displayed in
the multiplanar
mode using skel-
B
etal mode. The
reverse-face tech-
nique is used to
show bilateral
deep cleft pal-
ates (arrows). (B)
A Volume is dis-
C
played using sur-
face mode, clearly depicting a frontal encephalocele, which mimics an orbital tumor and left exophthalmos. These images helped clarify the
complex anomalies to the family. (C) Postmortem image confirming the findings of a deep right cleft lip and palate, a left cleft lip and palate,
and left exophthalmos. The encephalocele ruptured during delivery (postnatal image courtesy of Adba Frangieh, MD).
Clinical Applicability in the Fetal Face 61
Figure 8.5 The same 19w0d

fetus as in Figure 8.3, evaluated
using the flipped-face technique,
where the image in plane A has
now been flipped upside-down by
90 degrees. The cleft in the alveolar
ridge and hard palate is visualized
(arrow).

22w6d fetus with an intact palate
is evaluated using the OmniView
algorithm with VCI. Here three
polylines are used which facilitate
the simultaneous display of three
nonorthogonal planes, showing the HP
uvula (U) and intact hard palate
(HP).
The clinician can use several imaging approaches to iden- shadowing anteriorly from a limb, the cord, or the placenta.
tify the facial structures such as the reverse-face (Figure 8.3 In 2005, Campbell et al. reported on the use of this tech-
and 8.4), flipped-face (Figure 8.5), OmniView (Figure 8.6), nique in eight cases of facial clefting (Campbell et al. 2005)
oblique face, or a modification of all the above. The gold with a high degree of diagnostic accuracy. However, a cleft
standard for the proper technique has yet to be established. in the soft palate was missed in one case.
Additional key points to keep in mind are how to acquire the In 2004, Rotten carried out a systemic analysis of the fetal
image plane for evaluation of the fetal face. Options include face on 10,500 fetuses. Using 2D, a true mid-sagittal plane
the standard mid-sagittal view, the axial or coronal view. was acquired, and subsequently a coronal view, for a thor-
The reverse-face technique was described by Campbell ough evaluation of the fetal face. However, using 3D and 4D
and Lees (2003) (Table 8.1). In this technique, an attempt allowed for an easier, more rapid, and more accurate assess-
is made to acquire a volume commencing from the sagittal ment of the normal fetal face (Rotten and Levaillant 2004a).
plane, display it in the multiplanar mode, and then rotate Rotten then carried out one of the largest case series, on 96
the image in plane A by 180 degrees along the vertical Y fetuses with various facial clefts. This was a retrospective
axis. The render box is subsequently placed in the back-to- review in which it was demonstrated that 3D/4D was superior
front orientation to visualize the palate by scrolling through to non-3D/4D imaging (Rotten and Levaillant 2004b).
the volume. The benefit of this technique is avoiding any
Table 8.1 Steps to Applying the Reverse-Face Technique

Step 1: Obtain a mid-sagittal view of the fetal face after optimizing all the 2D parameters using the surface-rendering mode (Figure 8.7 and 8.8)
Step 2: Change the direction of viewing the region of interest to “back-to-front” (Figure 8.9)
Step 3: The hard palate should now be visible in plane C (Figure 8.9)
Step 4: The render mode, threshold, and various settings may be adjusted to optimize the final rendered image (Figure 8.10 and 8.11)

22w2d fetus with a cleft lip is
obtained, rotated along the three
orthogonal planes to depict the
fetus in a sagittal plane in plane A.
Figure 8.8 The same 3D vol-

ume of the 22w2d fetus in Figure
8.7 is now rendered using x-ray
mode.
In the flipped-face technique described by Platt in 2006 shadowing. As with the reverse-face technique, the ability to
(Table 8.2), a 3D volume is obtained with the fetus in the supine visualize the soft palate is limited (Platt et al. 2006).
position and displayed in the multiplanar mode. Subsequently, Benacerraf et al., in 2006, described a case of Fryn’s
the image in plane A is flipped by 90 degrees so that the fetus syndrome in which the fetus had multiple abnormalities.
is now vertical with the chin up. The render box is then placed Here, 3D and fetal magnetic resonance imaging (MRI) were
over the mandible, the size minimized to enhance resolution, employed. Using the en-face thick-slice (VCI) technique, a
and the volume is scrolled through from the chin to the nose. cleft palate was detected which proved key to the prenatal
The main limitation in this technique is acquisition without diagnosis of Fryn’s syndrome (Benacerraf et al. 2006).
Figure 8.9 The direction of the

render box for the fetus in Figure
8.8 is changed so that it is now
back-to-front, with the settings
optimized for visualizing the bony
structures. This allows ascertain-
ing the intactness of the alveolar
ridge (arrow).
Figure 8.10 This is another

example of the reversed-face tech-
nique on a 21w5d fetus with a cleft
palate clearly visualized in the final
rendered image in plane D (arrow).
In 2007 Faure introduced yet another technique, ante- Pilu described a novel technique for the palate: angle of
rior axial 3D view, seen from the underside to visualize insonation with 3D. This technique was used in 15 normal
the secondary palate. The key differentiating factor for this fetuses at 19–28 weeks and one fetus with a cleft at 33
technique is that the volume is acquired from the axial and weeks (Pilu and Segata 2007). The main goal of this tech-
not the mid-sagittal plane, as in the previously described nique was to insonate at a 45-degree angle to avoid shad-
reversed- or flipped-face techniques. In the prospective study, owing from the alveolar ridge. The modes used were the
Faure assessed 100 fetuses at 17, 22, 27, and 32 weeks. With multiplanar, surface display (maximum mode) in addition
the transducer just in front of the alveolar ridge, all aspects to TUI and VCI. The authors concluded that in normal
of the posterior palate were studied by visualizing seven fetuses, the axial and coronal acquisitions were as helpful,
defined anatomic landmarks. Sonographic findings were sub- but in the abnormal cases, the coronal acquisition proved
sequently compared to surgical fetopathological specimens. to be more helpful. However, the authors remained uncer-
The ideal time for utilizing this technique was determined to tain as to this technique’s utility in isolated clefts of the
be at 20–24 weeks (Faure et al. 2007). soft palate.

fetus from Figure 8.10 in which
the image mix settings have been
adjusted further, enabling ascer-
tainment of the cleft palate.
Table 8.2 Steps to Applying the Flipped-Face Technique

Step 1: Obtain a volume starting from the mid-sagittal view of the face utilizing the surface-rendering mode as was done for the “reverse-face”
technique (Figure 8.12)
Step 2: Place the reference dot just below the philtrum (Figure 8.12)
Step 3: Rotate the image in plane A around the Z axis by 90 degrees (Figure 8.13)
Step 4: Place the render box over the mouth and adjust its size to encompass the bony area under examination (Figure 8.13)
Step 5: Scroll through the axial plane and adjust the render mode in order to see the lips, alveolar ridge, mandible, maxilla, and hard and soft palates
(Figure 8.14)

fetus previously examined using
the reverse-face technique, now
examined using the flipped-face
technique. The initial steps are
the same, with an acquired vol-
ume displayed in the maximum
mode starting with a sagittal plane
in plane A. The reference dot is
placed just below the philtrum.
McGahan et al. in 2008 used the 3D multislice display In 2008 Zoppi et al. reported on an isolated case of a cleft
(TUI) to help identify facial clefts. The technique was stan- palate in a high-risk patient who had been missed on routine
dardized in both the axial and sagittal planes. This enabled sonographic evaluation. However, re-evaluation of the stored
full visualization of the fetal face from the palate to the orbits volume, using an axial 3D reconstruction, enabled visualiza-
in nine slices, where the interslice thickness was set at 3.7 tion of the cleft (Zoppi et al. 2008). From this report, one can
mm (McGahan et al. 2008). infer that even if an isolated cleft palate is missed on rou-
tine evaluation, if there is a suspicion of a cleft palate, the
Figure 8.13 Post acquisition,

the image in plane A is rotated
along the Z axis by 90 degrees.
The reference box is minimized in
size to generate a view of the pal-
ate which clearly depicts the cleft,
starting with the alveolar ridge and
extending inward (arrow).
Figure 8.14 The image mix

settings are changed from Figure
8.13 to examine the cleft palate
further.
examiner could carry an off-line re-examination of the vol- As a result of the availability of so many different tech-
ume, utilizing all the available techniques, to further deter- niques with which to evaluate the face, a study was carried out
mine the presence or absence of a cleft palate. If that were to by Martínez Ten in 2009 to compare the various techniques
be confirmed, the parents would be re-contacted to make the for visualization of the soft palate (Martínez Ten et al. 2009).
necessary arrangements for follow-up and further care and Ten fetuses with clefts and 50 normal fetuses, at 20–33 weeks
management. of gestation, were evaluated. The authors concluded that in
Faure et al. in 2008 noted that the arching of the soft pal- order to visualize the soft palate, a near-perfect volume must
ate puts it in a different plane than the hard palate, which be obtained with a good fluid interphase between the fetal
contributes to the inadequacy of its visualization. They sug- tongue and palate. The oblique and flipped-face techniques
gested that this can be avoided by employing the 30 degree, proved to be the superior techniques.
3D-inclined axial view. This was evaluated on 87 low-risk In 2009 Wong et al. re-examined the fetal palate from
fetuses at 21–25 weeks, in which a volume was obtained stored volumes of 31 normal fetuses at 15–35 weeks. It was
for examination of the soft palate. The images were subse- determined that visualizing the uvula, which corresponds to
quently compared to pathological specimens. Although this the soft palate, is most difficult at less than 19 weeks and
technique’s reproducibility was not evaluated, it was found to beyond 35 weeks, when the angulation of the arch is even
be of utility in assessing intactness of the soft palate (Faure greater, putting it in a more difficult plane to access in com-
et al. 2008). parison to the plane of the hard palate (Wong et al. 2009).
Most recently, in 2012 Tonni et al. reported on the In 2005 Paladini et al. used volume sonography on a cav-
“OmniView Algorithm” as a new 3D technique for the ernous hemangioma of the face and neck. This was of utmost
study of the fetal hard and soft palates, in which it is pos- utility in counseling the family, and in consultation with the
sible to simultaneously display three nonorthogonal planes surgeons to plan care for this fetus (Paladini et al. 2005).
commencing from a fetus in a mildly flexed position (Tonni Another report on a palatal teratoma by Merhi et al. in
et al. 2012). Ideally, there needs to be fluid in the orophar- 2005 concluded that 3D and color Doppler helped clarify the
ynx and the absence of the cord or limbs from in front of extent of the teratoma, which may have been missed by 2D,
the face. Here, skeleton mode is used to acquire the vol- and determined that there was no need for an EXIT proce-
ume from the top of the head to the chin, using an angle dure. This facilitated planning of intrapartum/postpartum
of roughly 65 degrees. The OmniView algorithm is then care (Merhi et al. 2005). In contrast, Shih et al. reported on
employed utilizing three polylines. The first line is drawn the use of 3D and MRI in the case of an oral tumor, an epig-
from the posterior aspect of the palate down to the chin, nathus, and in this case it helped prepare for an EXIT proce-
generating an image of the labia, alveolar ridge, and the dure by clarifying the extent of the tumor and the obstruction
uvula (indicating an intact palate). The second line is drawn to the airway (Shih et al. 2005). Sherer et al. reported a simi-
from the anterior and posterior nasal spines to the tip of lar case in 2006 where, again, 3D of a massive fetal epigna-
the uvula. This generates an image that shows the labia and thus helped in the decision regarding an EXIT procedure by
alveolar ridge. The third is a vertical line extending behind delineating the extent of the tumor (Sherer et al. 2006).
the frontal bone down to the chin, the equivalent of the
reverse mode. This generates an image of the hard palate
and tongue (Figure 8.6). Orbital Abnormalities
In summary, the ideal technique for the evaluation of
the fetal face for the various types of clefts has yet to be Although orbital abnormalities (Figure 8.4) are not that
ascertained. For this reason, it is important to be aware of common, they do carry serious implications. In 2000,
all the available techniques and when indicated, whether Blaas et al. reported on a nine-week fetus with holopros-
because of history, current suspicion, or the mere pres- encephaly, cyclopia, and a proboscis (Figure 8.15) using
ence of a cleft lip, to employ these various modalities in an transvaginal scan “any plane” 3D slicing technique. This
attempt to ascertain intactness or involvement of the hard enabled reconstruction of facial planes otherwise unavail-
and soft palates. able through 2D and provided valuable additional informa-
tion (Blaas et al. 2000b).
Facial Tumors
Clinical Utility of Volume
There is a multitude of facial tumors where volume sonog- Sonography in Orbital Abnormalities
raphy has been utilized to further characterize the mass in 1. Ascertaining the presence of cyclopia,
question, and to aid in planning the intrapartum and postpar- anophthalmia
tum care of these babies. One of the earliest reports was by 2. Ascertaining the presence and extent of
Shaw et al. in 2004 in a case of congenital epulis, a gingival dacrocystoceles
granular cell tumor. In this case, 3D aided in the visualiza-
tion of the mass; however, it was misleading in giving the
impression that an EXIT procedure was needed, where in Sepulveda et al. reported on 10 cases of congenital dac-
reality it was not (Shaw et al. 2004). An EXIT procedure rocystocele. In 3/10 cases, volume sonography was used
(ex utero intrapartum treatment) is performed at the time and helped clarify the abnormality. This was in terms of the
of cesarean delivery whenever fetal airway obstruction is extent of the dacrocystocele’s extension into the nasal cavity
suspected. Using EXIT, the fetal airway is secured prior to as well as any connection between the nasal cavity and the
clamping the umbilical cord. orbits. The results were comparable to MRI and deemed wor-
thy of considering 3D as the standard for scanning in these
cases (Sepulveda et al. 2005).
Clinical Utility of Volume Johnson et al. used 3D in a case of oculoauricularfrontonasal
Sonography in Facial Tumors syndrome. In this case, 3D provided invaluable information to
1. Sizing of the tumor the couple in appreciating the abnormality (Johnson et al. 2005).
2. Assessing extent of airway involvement and Most recently, Wong et al. used the reverse-face view to
determining the need for an EXIT procedure visualize a case of anophthalmia. The benefit of this tech-
nique was in eliminating the shadows and clarifying the
abnormality (Wong et al. 2008).
Nasal Abnormalities To overcome the limitation of ascertaining the presence

of the fetal nasal bone utilizing volume sonography, Benoit
The presence or absence of the nasal bone, as well as its hypo- and Chaoui employed 3D maximum mode in assessing the
plasia, in the first and second trimesters has great implications presence of the fetal nasal bone (Figure 8.16). In this study,
in the fetus’ risk assessment for trisomies. Rembouskos et al. 38 fetuses were evaluated at 17–33 weeks of gestation. Of
evaluated the role of volume sonography in determining the those, 18 were normal and 20 had trisomy 21. On 2D alone,
presence or absence of the fetal nasal bone. It was found that 9/20 trisomy 21 fetuses had hypoplastic or absent nasal
the key to ascertaining its presence was the initial 2D image, bones. However, using 3D and the x-ray mode, only three of
as utilizing 3D alone in cases of a suboptimal angle of acquisi- those nine had true absence or hypoplasia of the nasal bone,
tion may lead to false-positives (Rembouskos et al. 2004). since in those cases the abnormality involved one of the two
nasal bones. Hence unilateral abnormalities of the fetal nasal
bone were a new reported finding in trisomy 21, which, when
Clinical Utility of Volume present, may lead to misdiagnosis on 2D ultrasound. Benoit
Sonography in Evaluating concluded that the maximal mode may aid in determining
the Fetal Nose whether there is true hypoplasia or absence of the fetal nasal
1. Ascertaining the presence of both nasal bones bone (Benoit and Chaoui 2005).
utilizing the maximum mode
2. Measuring the width of the nasal bone gap in
first trimester fetuses
Figure 8.15 Fetus with

A
proboscis examined at 12w6d
and 14w6d. (A) Proboscis is
suspected on 2D evaluation.
(B) TUI of the fetal brain con-
firms abnormal intracranial
anatomy with no “butterfly”
created by the choroid plexus.
(C, D) Fetus evaluated using
surface rendering, clarifying
the proboscis to the examiner
B C D as well as the family.
NB
A B
Figure 8.16 3D volume of a 22w6d fetus. (A) Volume displayed using surface rendering. (B) Subsequently, the volume is displayed in
the maximum mode, clearly depicting both nasal bones (NB).
Subsequent to Benoit’s study, Peralta et al. carried out a

study on 450 fetuses in the first trimester to try to detect a Clinical Utility of Volume
gap between the two nasal bones in the first trimester (Peralta Sonography in Evaluating
et al. 2005). In this study, a 3D volume was obtained at the the Maxilla and Mandible
time of the nuchal translucency assessment, which was ana- 1. Facilitates obtaining the true mid-sagittal sec-
lyzed using the multiplanar mode. Twenty percent of normal tion to assess the fetal profile
fetuses, were found to have a normal gap, a finding that may 2. Facilitates the measurement of the maxillary
potentially lead to misdiagnosis of an absent nasal bone. and mandibular size
In addition, with the lateral resolution of most machines
approximately 0.6 mm, if the gap were to be greater than 0.6
mm, this could lead to the conclusion of an absent nasal bone.
Dagklis et al. reported on the use of the 3D multiplanar
mode for measuring the maxillary depth to detect midfacial
Maxillary/Mandibular Abnormalities hypoplasia in 862 normal fetuses and 80 trisomy 21 fetuses.
They found that the maxillary depth is shorter in trisomy 21
The maxillary/mandibular area may be key in several fetuses (hence the flat face) by approximately 0.3 mm. The
dysmorphic syndromes (Figure 8.17). As a consequence, results of their study demonstrated that this measuement
visualizing the fetal profile is of importance in all fetuses. was not useful because the small difference between nor-
However, obtaining the perfect mid-sagittal section is not mal and abnormal fetuses was within the limits of the axial
always feasible. This is where volume sonography, with the resolution of the sonographic machine (Dagklis et al. 2006).
ability to navigate through the volume, may be utilized. Subsequently, Roelfsema et al. used 3D to determine nor-
In 2002 Lee et al. reported on nine cases of micrognathia mograms for maxillary and mandibular size in 126 fetuses
in which 3D increased the chances of obtaining the true mid- at 18–34 weeks, demonstrating that the measurement was
sagittal section. In addition, surface rendering proved to be more feasible when utilizing 3D rendering (Roelfsema et
as useful as the multiplanar mode as an adjunct to the initial al. 2006).
2D image (Lee et al. 2002b).
A B
Figure 8.17 3D volume of a 22w0d fetus with microretrognathia is obtained. (A) Volume is displayed in the three orthogonal planes.
Note the reference dot localizing the nasal bone in all three planes. Note the mandible (*) in plane A. (B) Volume is rendered using the
surface mode, clearly depicting the microretrognathia.
Neck Abnormalities
One of the earliest reports on the use of volume sonogra- Sonography in Evaluating
phy was describing facial tumors and differentiating a cystic the Fetal Neck
hygroma from a thickened nuchal translucency (Figure 8.18 1. Characterizing neck tumors and differenti-
and 8.19). Bonilla-Musoles et al. rescanned 25 fetuses and ating a cystic hygroma from a thick nuchal
used volume sonography to characterize their neck masses. translucency
Characteristics used were bullae as well as the extent, ampli- 2. Proper sizing of fetal goiter and determining
tude, and the lack of membrane regularity, to further define the extent of response to therapy
the malformation as a cystic hygroma or a nuchal translu-
cency. It was concluded that 3D was helpful in 70% of the
cases (Bonilla-Musoles et al. 1998).
A B
Figure 8.18 3D volume of a 16w5d fetus with a septated cystic hygroma. (A) Volume is displayed in the multiplanar mode. (B) Volume
is displayed using TUI at an interslice thickness of 2 mm and VCI at a slice thickness of 2 mm, and using sepia as the color. The reference
dot is placed in the largest cyst, localizing it in all eight panes.
A B C
Figure 8.19 A transvaginally acquired volume of 9w3d fetus with a visible nuchal translucency. (A) Fetus in 2D showing the NT. (B) NT
as seen utilizing surface rendering. (C) NT as seen using HDlive render mode.
A fetal goiter was examined by 3D and power Doppler In addition, and due to the complexity of the evaluation of
angiography by Nath et al. The true benefit was in following the fetal face, Roelfsema et al. have developed a comprehensive
its volume and response to therapy, but most importantly, in detailed sonographic technique for establishing fetal craniofa-
aiding the parents to appreciate the goiter, and this proved to cial biometry. This craniofacial variability index (CVI) con-
be the major incentive for their compliance (Nath et al. 2005). sists of 16 different measurements of the fetal face. For their
evaluation, 136 normal fetuses and six abnormal fetuses were
evaluated by volume sonography at 18–34 weeks of gestation.
Other Uses of Volume Sonography Anthropometry and cephalometry were utilized in establish-
in Evaluation of the Fetal Face ing Z scores. The study concluded that when, in the absence
of intrauterine growth retardation, two or more abnormal Z
Several other areas in the fetal face have been evaluated by scores are present, this may be indicative of dysmorphology
volume sonography, as listed below. (Roelfsema et al. 2007a). In a subsequent study by the same
group on seven syndromic fetuses and seven with isolated
facial clefts, a higher CVI was found in the more severe bilat-
eral clefts. In addition, CVI was higher and there were more
abnormal Z scores in the syndromic fetuses versus those with
isolated clefts. The conclusion was that this could be a differ-
Other Uses for Volume Sonography entiating method between syndromic fetuses and those with
in the Evaluation of the Fetal Face isolated facial clefts (Roelfsema et al. 2007b).
1. Ectodermal dysplasia In summary, the fetal face, a most elusive, complex area
2. Congenital ichthyosis “Harlequin” fetus of the fetus, can undergo extensive evaluation with the use
3. Determining the in-utero craniofacial vari- of volume sonography. The key is to look beyond the “pretty
ability index (CVI) face,” become familiar with the complex techniques, and
4. Dysmorphologies: cebocephaly, trisomies, oto- know when to employ them in order to differentiate syn-
cephaly, Treacher Collins, cat-eye syndrome dromic cases from those with isolated abnormalities.
Limitations of Volume Sonography in

the Evaluation of the Fetal Face
Several case reports have concluded that 3D is helpful in visu- Though volume sonography certainly helps clarify several
alizing the details of the face, ears, and lips in confirming complicated facial abnormalities and may help provide more
ectodermal dysplasia, trisomy 18, frontonasal malformations, evidence to a potential underlying chromosomal aberration
cat-eye syndrome, cebocephaly, otocephaly, cases of unusual (Figure 8.20), it nonetheless may provide false reassurance.
facial clefting, and Treacher Collins syndrome. The greatest Caution must be exercised in cases of trisomies where a 3D-
benefit was in helping the parents appreciate the abnormality rendered image may be highly suggestive of a normal fetus
(Lin et al. 1998; Hsu et al. 2002; Shipp et al. 2002; Tanaka et with no discernable facial features to suggest a fetus affected
al. 2002; Sepulveda et al. 2003; Volpe et al. 2004; Pilu et al. by trisomy 21. This is precisely why the suspicion should
2005; Allen and Maestri 2008; Allen et al. 2008; Zheng et al. rely on the well-established basic 2D sonographic markers.
2008). In addition, although volume sonography has been shown to
Another utility for volume sonography has been demon- be of value in certain cases of skin abnormalities such as in
strated by Benoit (1999), Bongain et al. (2002), and Vohra et the “Harlequin” fetus (Bongain et al. 2002), it has not been
al. (2003): the prenatal diagnosis of congenital ichthyosis, the shown to be of diagnostic value in cases of skin denudation
“Harlequin” fetus. This is a rare congenital abnormality that syndromes (Abu-Rustum et al. 2013) (Figure 8.21).
cannot be diagnosed by 2D alone. Utilizing volume sonog-
raphy enables confirmation of the typical “fish mouth” and
fixed upper extremities.
A B
Figure 8.20 3D volume of a 21w2d fetus with suspected trisomy 21. (A) 2D image of the fetal profile with an abnormally close man-
dibular-maxillary line (dotted line) and prenasal thickness (*). (B) Volume displayed using HDlive depicting the up-slanting palpebral
fissures and small nose. This fetus was confirmed to have Down syndrome.
Figure 8.21 3D volume of a 33w2d fetus presenting with poly-

hydramnios, echogenic amniotic fluid, and echogenic debris within
the stomach. Evaluation of the fetal face was falsely reassuring. The
patient delivered on the same day of the scan and the newborn was
found to be affected by epidermolysis bullosa with extensive facial
involvement. Depiction of skin denudation is a major limitation of
3D ultrasound.
Conclusion in mind the various artifacts that may be introduced and that
might ultimately lead to false diagnoses or reassurances.
Volume sonography has an important role in the clarification Therefore the user must be familiar with the available tech-
of abnormalities involving the fetal face. It also has a great niques and should gain expertise in utilizing them in normal
role in early reassurance, which may be possible from the fetuses in order to be able to properly utilize them in cases of
first trimester, to ease the anxiety of families having prior a suspected abnormality. The gold standard remains a good
affected offspring (Figure 8.22). The greatest benefit is in the 2D image. Any suspicion of a facial abnormality may be clar-
extensive evaluation of facial clefts. Nonetheless, the tech- ified further with the proper utilization of 3D sonography.
niques are complicated, require expertise, and one must keep
Practical Pearls
• The key to a good 3D image is a good 2D

image
• Attempt getting a volume with a good fluid
interphase
• Avoid volumes with motion, a limb, the pla-
centa, or cord in front of the fetal face
• When evaluating the fetal face, get a volume
of the profile for a final en-face rendered
image. You may also use VCI-C by putting
the green line in front of the profile
• When evaluating the fetal face, get an en-face
volume for a final rendered image of the pro-
file. An oblique approach may even provide
a better image and it requires less fluid as an
interphase (Benoit oral communication 2012)
• For evaluation of the external surface, a lower
quality for volume acquisition may be utilized
as it may generate a smoother face (Benoit
• To generate a nice profile on a black back-
ground commence with an en-face fetal face,
MagiCut the half of the face of lower quality
then rotate the face by 90 degrees to depict
the profile (Benoit oral communication 2012)
• To examine the fetal palate, use the maximum
mode in the reverse-, flipped- or oblique-face
techniques, or any combination of the above
Figure 8.22 3D volume of the fetal face of a 12w3d fetus
• The OmniView algorithm enables the simul-
rendered using HDlive, depicting an intact upper lip and providing
taneous display of 3 non-orthogonal planes of
invaluable early reassurance to a family with a prior affected child.
the face
• You may lower the gain for evaluating the face
or decrease the gain while post-processing
• When rendering with HDlive, adjusting the
shadow softness leads to more natural images
of the fetus (Benoit oral communication 2012)
9 Clinical Applicability in the Fetal
Central Nervous System
Introduction
Utility of Volume Sonography
The brain is one of the most challenging areas to image in the in CNS Evaluation
fetus. This is due to the fact that for a full evaluation, several 1. Sonoembryology
planes are required, and those planes are not parallel to each 2. Skull
other. Some of these planes are oblique, making the evalu- 3. Cranial sutures
ation difficult. In addition, there is the challenge of obtain- 4. Corpus callosum
ing the mid-coronal plane, and this further limits a complete 5. Vascular malformations
assessment. With the advent of volume sonography, visual- 6. Other areas
izing all these planes can be facilitated if one were to obtain
a 3D volume of the brain and then properly navigate through
it, utilizing the various available tools and techniques.
Sonoembryology
Clinical Utility Several authors have looked at the role of volume sonography
in fetal development. One of the earliest studies was by Blaas
Although a good 2D image remains the mainstay and the et al. (1995) in which they were able to visualize structures of a
basis for a good 3D image, numerous studies have addressed few mm using 3D sonography. Viñals et al. used volume- con-
the utility and advantages of volume sonography for the fetal trast imaging (VCI) on 203 fetuses to establish normograms for
central nervous system (CNS). The primary areas of inter- the developing cerebellar vermis at 18–23 (Viñals et al. 2005).
est that have demonstrated added benefit are those involv- In 2007, Mittal et al. used volume sonography to look at the
ing sonoembryology and characterizing normal development development of the sylvian fissure starting at 12 weeks. They
(discussed in Chapter 7), evaluating the cranial sutures were able to identify 99% of sylvian fissures from 12 weeks on
(Figure 9.1), the corpus callosum (Figure 9.2), angiography (Mittal et al. 2007). Sepulveda et al. used 3D sonography to
of vascular malformations, as well as clarifying subtle differ- ascertain holoprosencephaly at 9w6d (Sepulveda et al. 2007)
ences, leading to more accurate diagnoses in CNS anomalies. (Figure 9.3). Roelfsema et al. reported on the use of 3D for
Figure 9.1 Metopic sutures. (A) Maximum

mode is used to render the volume from a 24w2d
fetus, clearly depicting the metopic suture (*).
(B) Maximum mode is used to evaluate a 34w4d
fetus with suspected craniocynostosis. Note the
absence of a clearly visible metopic suture in
A B
contrast to the fetus on the left.
73
prenatal skull development (Roelfsema et al. 2007c ). Kim et

al. carried out a hallmark study on the development of the fetal Clinical Utility of Volume
ventricular system using the inversion mode and MagiCut in Sonography in Sonoembryology
fetuses at 7–12 weeks (Kim et al. 2008). Most recently, Zalel et 1. Confirming holoprosencephaly in the first
al. used VCI and TUI to assess the timing of the appearance of trimester
the cerebellar vermis, which was detected in 40% of fetuses at 2. Following the natural development of differ-
18 weeks, 94% of fetuses at 22 weeks, and 100% of fetuses at ent areas of the brain
25%. Nonetheless, this technique was not very useful for other 3. Determining the sensitivity of ultrasound at
structures in the posterior fossa (Zalel et al. 2009). each gestational age for visualizing various
intracranial structures
Cavum Septi
Pellucidi
Corpus Callosum
Figure 9.2 3D volume of a 22w6d fetus

displayed in the multiplanar mode. The vol-
ume is acquired from the axial plane, plane
A, automatically generating the plane of the
corpus callosum in plane C.
A B
Figure 9.3 TUI of a normal and an abnormal brain. (A) TUI of a 12w5d normal fetal brain at an interslice thickness of 0.6 mm and a
VCI thickness of 2 mm, depicting the “butterfly” formed by the choroid plexus filling the lateral ventricles. (B) TUI of a 12w6d abnormal
fetal brain with holoprosencephaly at an interslice thickness of 0.6 mm and a VCI thickness of 2 mm. Note the absence of the butterfly, and
the single ventricle (*).
Clinical Applicability in the Fetal Central Nervous System 75
The Skull
3D ultrasound helps clarify various anomalies of the bony Sonography in Evaluating the Skull
skull, namely in cases of acrania and encephaloceles. Various 1. Ascertains the intactness of the skull
modalities may be used, with the maximum mode being the 2. Helps determine the extent of involvement of
most applicable, in order to show the bony defect. It is also the brain and spine in case of a malformation
possible to combine TUI with VCI in addition to surface ren- 3. Clarifies the anomaly to the family
dering. Care must be taken in these cases, as the images gener-
ated may sometimes be quite unsettling for the family, and it is
advisable to check with the family whether they prefer not to
see any “colored” images. In such cases, off-line analysis may
be carried out on stored volume data sets (Figures 9.4–9.6).
Figure 9.4 3D volumes of

fetuses with acrania. (A) Surface-
rendered 3D volume of a 12w0d
fetus depicting protruding brain
tissue and lack of bony structures
above the orbits, consistent with
acrania. (B) Another fetus with
acrania at 13w3d. The volume
is displayed using the maximum
mode and showing absence of the
skull. A B

12w0d fetus with acrania. (A)
Volume is displayed using surface
mode. (B) Volume is displayed
using maximum mode confirming
A B
absence of the bony skull.
*
A B
15w3d fetus with a cystic structure
posterior to the head. (A) Volume *
displayed in the multiplanar mode
with surface rendering using *
HDlive, confirming the presence
of a posterior encephalocele. (B)
Close up of the defect (*). A B
Cranial Sutures et al. 2001). Dikkenboom et al. used 3D at 18–24 weeks to

successfully visualize the cranial sutures in 82%–100% of
Abnormal development of the metopic sutures has been asso- cases. The sagittal and posterior sutures were seen in less
ciated with several syndromes. However, visualizing these than 50% of cases and the visualization was less accurate
sutures (Table 9.1) and differentiating between molding and with advancing gestation (Dikkenboom et al. 2004). Faro et
craniosynostosis has great limitations when 2D ultrasound is al. used surface and maximum modes to look at the process
used. This is where 3D has had an invaluable role. Benacerraf of ossification of the frontal bones and subsequent metopic
et al. reported in 2000 on the role of 3D in arriving at a more suture development (Faro et al. 2005). Chaoui et al. (2005)
definitive diagnosis of skull abnormalities, using 3D in a case characterized the abnormal development of the metopic
of Pfeiffer syndrome at 26 weeks (Benacerraf et al. 2000). sutures in various abnormalities that may lead to their pre-
Another study was carried out by Krakow et al. in which 3D mature closure, such as in cases of holoprosencephaly or in
facilitated the visualization of the entire length of the suture the case of corpus callosum abnormalities. Rochelson et al.
lines, an otherwise impossible task, using 2D alone (Krakow carried this further, using geometric morphometric analysis
Table 9.1 Steps to Visualizing the Sutures

Step 1: Obtain a volume of the mid-sagittal fetal face (Figure 9.7)
Step 2: Render the volume using maximum mode (Figure 9.8)
Step 3: Adjust the size of the render box with a primary focus on the metopic sutures (Figure 9.9)
Step 4: Flip the rendered image by 180 degrees (Figure 9.10)
Step 5: Select the single-pane view and rotate the volume along the X, Y and Z axes as needed to optimize the final rendered image (Figure 9.11)

21w2d fetus acquired starting from
the sagittal plane and displayed in
the multiplanar mode.
Figure 9.8 The same 3D volume

of the 21w2d fetus in Figure 9.7 is
subsequently displayed using the
maximum mode.
Figure 9.9 The same 3D vol-

ume of the 21w2d fetus in Figure
9.8 displayed in maximum mode.
The size and location of the render
*
box have been adjusted to focus on
the metopic suture (*).
Figure 9.10 The final ren-

dered image is now rotated by 180
degrees.
applied to 3D to quantify skull shape differences in normal

and abnormal fetuses (Rochelson et al. 2006). In 2008, Fuchs
et al. used translabial ultrasound to study the sutures and
found VCI helpful in seeing details and the extent of rota-
tion in labor (Viñals et al. 2005). Paladini et al. used VCI to
examine the anterior fontanelle and found that it increases
with advancing gestation but that its relative size to the vol-
ume of the fetal head decreases. It may be enlarged in fetuses
with trisomy 21 (Paladini et al. 2007, 2008a).
Clinical Utility of
Volume Sonography in
Figure 9.11 The
Evaluating the Sutures
single-pane view is
1. Differentiating molding from craniosynostosis selected to visualize
2. Visualizing the entire length of the suture line the metopic suture
3. Measuring the size of the anterior fontanelle (*) of the 21w2d
fetus.
The Corpus Callosum

One of the biggest challenges in imaging the fetal brain is Sonography in Visualizing
visualizing the corpus callosum, especially in cases of ven- the Corpus Callosum
triculomegaly where it must be assessed to rule out agenesis 1. Transvaginal transfontanelle view is extremely
of the corpus callosum (Figure 9.12 and 9.13). This is where helpful
volume sonography proves to be of benefit: through the use of 2. Multiplanar mode of properly acquired axial
the multiplanar mode with VCI (Table 9.2). As a result, vari- planes automatically generates corpus callo-
ous anomalies of the fetal brain (Figure 9.14 and 9.15), espe- sum views
cially midline anomalies, are more easily visualized, enabling 3. Useful in ascertaining agenesis of the corpus
more accurate diagnosis of anomalies (Malinger et al. 2006). callosum
Timor-Tritsch reported that transvaginal transfontanelle 3D
sonography is instrumental in diagnosing agenesis of the cor-
pus callosum (Timor-Tritsch et al. 2000). Plasencia assessed
the corpus callosum at 20–24 weeks and reported that the key
is the angle of initial acquisition: if the acquisition is mid-sag-
ittal, it has an echolucent appearance. If the acquisition is axial,
it may appear echogenic (Plasencia et al. 2007).
Table 9.2 Steps to Visualizing the Corpus Callosum

Step 1: Obtain a volume of the fetal head starting from the axial plane
Step 2: Select the multiplanar mode and employ VCI (Figure 9.12A)
Step 3: Plane (C) will automatically generate a display of the corpus callosum in the multiplanar mode (Figure 9.12A)
Step 4: Select the single-pane view of plane C and magnify/crop as needed to optimize the final image of the corpus callosum (Figure 9.12B)
CSP CC
CSP CC
A B
Figure 9.12 3D volume of a 27w1d fetus. (A) Volume acquired from the axial plane, plane A, and displayed in the multiplanar mode,
automatically generating the sagittal plane in plane C. Plane C shows the corpus callosum (CC) and the cavum septi pellucidi (CSP). (B)
Single-pane view is now selected, with a clearly visualized corpus callosum and cavum septi pellucidi. This is a difficult plane to obtain
during routine scanning, and navigation through a properly acquired 3D volume facilitates ascertaining the presence of the corpus callosum.
CB
CC
Th
CSP
Falx
CSP
A Vp C
CSP
CB
CC
D
V
B
Figure 9.13 Accessing difficult planes in a 22w0d fetus. (A) Volume displayed in TUI at an interslice thickness of 2 mm and VCI with
a slice thickness of 2 mm, showing the axial structures. (B) The same volume is now displayed using the multiplanar mode, automatically
showing the challenging sagittal plane in plane C. (C) Using OmniView, the corpus callosum is seen. (D) Centering the render box over
the midline generates a view of the corpus callosum using HDlive. CB, cerebellum; Th, thalami; F, falx; CSP, cavum septi pellucidi; Vp,
posterior horn of the lateral ventricle; V, vermis; CC, corpus callosum.
Figure 9.14 3D volume of a 19w4d fetus with hydranencephaly displayed using TUI at an interslice thick-
ness of 3.1 mm and VCI at a slice thickness of 2 mm. Note the loss of normal architecture and the extent of
involvement.
Figure 9.15 Volume

of a 22w2d fetus with an
encephalocele and a fluid-
filled posterior fossa and
complete distortion of
the normal anatomy. (A)
Volume displayed using
TUI at an interslice thick-
A B
ness of 2 mm and VCI at a
slice thickness of 2 mm. (B)
The same volume is evaluated using SonoAVC general which automatically color codes the fluid-filled structures and calculates their vol-
ume for future monitoring.
2000). Bahlmann and Heling et al. reported on the use of

Vascular Malformations 3D power angiography in the evaluation of an intracerebral
cystic mass. It was found that the 3D power angiography
One of the areas that has received great attention in the results were comparable to MRI and that this technique
use of 3D ultrasound in the CNS has been 3D angiogra- had a significant impact on the diagnosis of fetal vascular
phy for the visualization of the pericallosal vasculature anomalies (Bahlmann 2000; Heling et al. 2000). Ruano et
(Figure 9.16) and the Circle of Willis (Table 9.3), and spe- al. reported on three fetuses and Gerards et al. reported on
cifically in cases of vein of Galen malformations. Numerous another two fetuses with vein of Galen malformations in
case reports have proven the utility of 3D angiography in which MRI was also used, and they found 3D power angi-
characterizing the aneurysmal malformation and its con- ography helpful in visualizing the vascular malformations
nections. Among the first was a case report by Lee on a (Ruano et al. 2003a; Gerards et al. 2003). Gagel et al. used
fetus at 33 weeks with a cerebral cyst in which 3D assisted 3D power Doppler scanning and found it to be similar in
in diagnosing a vein of Galen aneurysm and precisely delin- accuracy to post-partum angiography in a vein of Galen
eated the complicated vasculature. The conclusion was that malformation (Gagel et al. 2003). Most recently, Muench et
this may provide guidance in postnatal management and al. reported on the use of 3D sonography and MRI in a fetal
may help predict prognosis more accurately (Lee et al. epidural hematoma (Muench et al. 2008).
Table 9.3 Steps to Visualizing the Circle of Willis

Step 1: Obtain a volume of the fetal head starting from the axial plane at the level of the thalami (Figure 9.17)
Step 2: Display the volume in the multiplanar mode (Figure 9.18)
Step 3: Render the volume with the glass-body mode (Figure 9.19)
Step 4: Select the single-pane view and optimize the final rendered image where minimum mode may be selected (Figure 9.20)
Step 5: Going back to step 3, another option is to display the volume using TUI (Figure 9.21)
Figure 9.16 Imaging the

pericallosal artery. (A) 3D
STIC volume of a 21w6d
fetus is acquired using
HD-Flow. It is displayed
thickness of 1 mm, best
depicting the pericallosal
artery encircling the corpus
callosum in the designated
pane (*). This can be seen
A B pulsating throughout a full
cardiac cycle. (B) 3D volume
of a 38w0d fetus with an intact corpus callosum and pericallosal artery as obtained using color Doppler and displayed using the minimum
mode.

Sonography in Visualizing
Vascular Malformations
1. Visualizing vein of Galen aneurysm: charac-
terizing the malformation and delineating the
vascular connections
2. Detailed evaluation of cerebral vascular
malformations
3. Evaluation of cerebral cystic masses
Figure 9.17 3D volume of a 24w3d fetus is obtained starting

from the axial 2D plane (depicted here) at the level of the thalami.
HD-Flow is utilized depicting the Circle of Willis.
Figure 9.18 The same 3D volume

in Figure 9.12 is now displayed in the
multiplanar mode.
Other Uses of Volume Sonography in the Fetal CNS superior to 2D for visualizing the transcerebellar axial plane
in 202 fetuses at 16–24 weeks (Correa et al. 2006; Varvarigos
Several other areas involving the role of volume sonography in et al. 2002).
the fetal CNS have been studied. Those have involved midline Pilu et al. found that although 2D had better quality in
structures, characterizing choroid plexus cysts (Figure 9.22) midline anomalies, 3D was easier and as effective for rapid
and the posterior fossa (Volpe et al. 2012) (Figure 9.23) as assessment of the median plane of the head, and most use-
well as further assessing the presence of specific craniofacial ful when 2D proved to be difficult. The main downfall was
abnormalities in particular syndromes. Timor-Tritsch et al. evaluating the brainstem in this study (Pilu et al. 2006). Soto
in 2000 used the transfontanelle 3D view and showed that et al. used 3D as an adjunct to 2D to look at the skull mineral-
it proved to be of great utility for review, consultation, and ization in the absence of the occiput (Soto et al. 2006). Bault
teaching (Timor-Tritsch et al. 2000). Paladini and Volpe used used 3D sonography to examine the optic chiasm (Bault
3D to evaluate the posterior fossa and vermian morphom- 2006). Sepulveda used 3D reconstruction of the fetal skull
etry in order to characterize vermian abnormalities (Paladini and face to characterize the “helmet sign” of the forehead of
and Volpe 2006). Correa et al. found 3D neurosonography a fetus with Wolf-Hirschhorn syndrome (Sepulveda 2007).
Viñals used the transfrontal 3D approach for assessing the

midline structures. Though the overall 2D image was clearer, Clinical Utility of Volume
TUI proved to be helpful (Viñals et al. 2007; Ruano et al. Sonography in Other Areas
2004; Jouannic et al. 2005). In 2008, Levaillant and Mabille of the Fetal CNS
found 3D sonography easier than computed tomography
1. Useful for reviewing, teaching, and enabling
(CT) and just as helpful in evaluating the sphenoid bone
off-line consultation
(Levaillant and Mabille 2005). Finally, in 2009, Benavides-
2. Useful in assessing skull mineralization
Serralde et al. used volume sonography to assess the volume
3. Enables examination of midline structures
of intracranial structures in fetuses with intrauterine growth
and the optic chiasm
restriction. They found that all net volumes, primarily of the
4. May have a role in calculating the volume of
frontal areas, and with the exception of the thalamus, were
intracranial structures in IUGR
smaller. They concluded that this might be attributable to
neural reorganization in response to hypoxia (Benavides-
Serralde et al. 2009).
Figure 9.19 Volume is rendered using

the glass-body mode that minimizes the
gray-scale structures and highlights the
vasculature.
Figure 9.20 The size of the render box is now adjusted and
enlarged to encompass the entire Circle of Willis. Minimum mode
is selected which removes all gray-scale structures completely and
clearly depicts the vasculature.
Figure 9.21 Another option is to dis-

play the volume after optimization, using
TUI. In this image, the TUI interslice
thickness is 0.5 mm and the VCI slice
thickness is 2 mm
Figure 9.22 3D volume of a 21w0d fetus with brachycephaly and bilateral choroid plexus cysts displayed using TUI at an interslice
distance of 1.8 mm and a VCI slice thickness of 1 mm.
T
BS BS
Vermis
Vermis
A B
Figure 9.23 3D volume of the brain of a 22w6d fetus. (A) Navigating through the volume it is possible to
generate the plane in which the brainstem–tentorium angle is measured. (B) Navigating through the volume, it
is possible to generate the plane in which the brainstem–vermis angle is measured. This enables assessment of
the posterior fossa for any abnormalities. BS: brain stem; T: tentorium.
Limitations of Volume Sonography in Conclusion

Evaluation of the Fetal CNS
Volume sonography in the fetal CNS provides access to
The major limitation to utilizing 3D ultrasound for the fetal hard-to-reach central structures such as the corpus cal-
CNS is bone shadowing, especially with advancing ges- losum, and structures in the posterior fossa such as the
tation. This is where the transfontanelle approach, when vermis. It also allows detailed study of the vasculature and
feasible, proves to be of value in order to minimize the is useful for reviewing, teaching, and off-line consultation.
shadowing and resulting artifacts. Using 3D ultrasound in The quality of the underlying 2D image remains the key to
the study of the fetal brain is further complicated by the a successful 3D image. Combining TUI with VCI results
changing anatomy with advancing gestation in addition to in marked improvement in the quality of the images. As
the complex anomalies that distort most major anatomi- such, learning how to properly utilize the various 3D tech-
cal landmarks. The study of the vasculature is quite chal- niques and modalities is invaluable in the evaluation of the
lenging, and often times using HD-Flow rather than color fetal brain.
Doppler may be helpful.
Practical Pearls
• Whenever a skull defect is suspected, the maximum • For the evaluation of the posterior fossa and brain-
mode aids in ascertaining the presence of acrania stem, it is helpful to acquire a volume starting with
• A good acquisition of the fetal brain may be obtained an axial plane in which both the cerebellum and
through the transfontanelle window cavum septi pellucidi are seen (Chaoui oral commu-
• Starting with an axial plane, the multiplanar mode nication 2013)
will automatically show the corpus callosum in • Utilizing VCI and TUI is instrumental to high-
plane C quality sectional analysis of the brain along any of
• To avoid bone shadowing when acquiring a volume the 3 axes
of the fetal brain, apply gentle pressure with a steady • Using VCI at a thickness of 2 mm together with the
hand (Paladini oral communication 2013) transparent mode allows optimal visualization of the
• An angle of 35-40 degrees is suitable for acquiring a cerebellum (Chaoui oral communication 2013)
volume of a second-trimester fetal brain • Properly utilizing 3D ultrasound in the evaluation of
• A great advantage to displaying a volume of the fetal the fetal brain provides access to challenging struc-
brain in the multiplanar mode is the ability to study tures and planes, is a great teaching tool and enables
the axial and sagittal planes simultaneously (Pilu off-line consultation
10 Clinical Applicability in the Fetal Skeleton
Introduction
Various areas of the fetal skeletal system may be affected in

several syndromes. For this reason, proper diagnosis of limb,
thoracic, and skeletal dysplasias can be key in reaching the
proper diagnosis. This ensures appropriate parental coun-
seling for the current and future pregnancies. However, this
evaluation is limited by the 2D approach used, and it may be
enhanced through the utilization of volume sonography.
Clinical Utility
Numerous studies have been published over the years evaluat-

ing the use of volume sonography in the evaluation of the fetal
skeleton. Although evidence for the diagnostic capabilities of Figure 10.1 A
volume sonography improving clinical management has not 3D volume of a
been marked, there has been a general consensus that it is help- 23w3d fetus with
ful in further characterizing defects and clarifying diagnoses Goldenhar syn-
to the family as well as the medical team. drome displayed
using maximum
mode. Note the
shortened, curved
ribs.
Areas in which Volume
Sonography May be of Utility
1. Rib cage
2. Spine
3. Limbs
4. Skeletal dysplasias
5. Iliac angle
1
Rib Cage
2
3
Although it is not routine practice to count the fetal ribs, this
may be of use in certain syndromes. This task is almost impos- 4
sible by 2D ultrasound but has been made possible with the 5
availability of volume sonography. Assessing the number and 6
presence of hemi vertebrae (Figure 10.1) as well as abnormal 7
spacing between the ribs may be of diagnostic value. In 2002 8
Viora et al. reported that 3D sonography helped narrow the Figure 10.2 A 9
differential diagnosis in a fetus with short rib polydactyly 3D volume of
10
(Viora et al. 2002). Sallout et al. reported that 3D sonography the rib cage of a
was complementary to 2D scanning once post-processing was 24w4d fetus ren-
11
utilized to enhance the image (Sallout et al. 2006). Gindes et dered using the
al. reported on the utility of 3D ultrasound in counting the ribs maximum mode
of 75 fetuses and hinted at the possible association between and showing 11
an abnormal number of ribs (Figure 10.2) and childhood ribs.
85
malignancies (Gindes et al. 2008). Most recently, Izquierdo et

al. reported on the utility of 3D sonography in describing the Clinical Utility of Volume
degree of extension of a cleft sternum (Izquierdo et al. 2009). Sonography in Assessing the Rib Cage
Table 10.1 provides details on how to visualize the ribs. 1. Counting the ribs
2. Ascertaining the presence of hemivertebrae
Table 10.1 Steps to Visualizing and Counting the Ribs

Step 1: Start with a fetus in a sagittal lie, preferably in a spine-up position (Figure 10.3)
Step 2: Obtain a 3D sweep (Figure 10.3)
Step 3: Activate OmniView and rotate the render line to overlie the spine at the level of the rib cage with a slice thickness of 20 mm (Figure 10.4)
Step 4: Select the single-pane view for an optimal depiction of the rib cage (Figure 10.5)

a 21w4d fetus in a spine-up posi-
tion is acquired from the sagittal
plane. The volume is displayed in
the multiplanar mode.
Figure 10.4 OmniView is acti-

vated with a VCI slice thickness of
20 mm and maximum mode dis-
play in order to generate an image
of the fetal rib cage.
The Fetal Spine
The value of volume sonography in studying the fetal spine has as with the rib cage, utilizes the reference dot for navigation
been primarily evaluated with respect to development of the within a volume, and images rendered in maximum mode.
spine and localization of neural tube defects. There have been Table 10.2 describes a traditional multiplanar method for view-
many methods utilized to display the fetal spine. OmniView, ing the spine. Proper localization of the level of the defect in
Clinical Applicability in the Fetal Skeleton 87
spina bifida is of utmost importance when it comes to coun-

seling the family in regards to fetal prognosis. Schild et al.
used 3D sonography in 103 women to study the developmental
volume changes of the thoracolumbar spine between 16 and 25
weeks (Schild et al. 1999). Blaas et al. evaluated three fetuses
with spina bifida prior to 10 weeks and found that 3D was not
of much added value in detecting early spina bifida (Blaas et
al. 2000a). Lee et al. found that 3D multiplanar views were
complementary to 2D in localizing the defect, and were more
informative than the rendered views (Figure 10.10 and 10.11)
(Lee et al. 2002a).

Sonography in Assessing
the Fetal Spine
1. Enables evaluating the development of the

spine
2. Facilitates localizing the level of the lesion in
spina bifida
Figure 10.5 The single-pane view is subse-

quently selected. Note that the cervical, thoracic, and
part of the lumbar spine is visible.
Table 10.2 Steps to Visualizing the Fetal Spine

Step 1: Start with a fetus in a sagittal lie, preferably in a spine-up position; obtain a 3D volume and display it in the multiplanar mode (Figure 10.6)
Step 2: Select the maximum mode and render the volume (Figure 10.7)
Step 3: Adjust the size of the render box to optimize the rendered image with inclusion of the lumbosacral area (Figure 10.8)
Step 4: Select the single-pane, rotate by 90 degrees, and adjust the color for an optimal depiction of the spine (Figure 10.9)

21w6d fetus is obtained, starting
with the sagittal spine-up position,
and is displayed in the multiplanar
mode.
Figure 10.7 Volume is ren-

dered using the maximum mode,
with the render box covering
the entire spine down to the
lumbosacral region.
Figure 10.8 The rendered

image is rotated and the threshold
is adjusted.
Limbs improved ability in the visualization of the limbs utilizing

the multiplanar mode with volume rotation (Budorick et al.
One of the parents’ first questions is always whether their 1998) (Figure 10.12). Hata et al. carried out a prospective
fetus has all 10 fingers and toes. Although digit ascertain- study on 77 fetuses across the gestations. They used sur-
ment using 2D ultrasound is useful, it is much clearer using face rendering and not the multiplanar mode. They found
3D ultrasound where it is possible to manipulate the limbs surface rendering to be supplementary to 2D, especially
and access them from various angles. This tends to be time with respect to enhancing the ability to visualize toes and
consuming and is not recommended as part of routine fingers (Hata et al. 1998b). Several studies have also demon-
screening, but is of diagnostic value in certain syndromes strated that 3D sonography helped confirm the diagnosis of
(Benacerraf 2008). One of the earliest studies was by Lee sirenomelia (Figure 10.13) and enabled the parents to visu-
et al. on phocomelia where 3D was found to be of help to alize the abnormality. In addition, 4D assisted in determin-
the parents (Lee et al 1995). Another study of normal and ing the extent of movement or lack thereof (Monteagudo
abnormal limbs was reported by Budorick et al. in 1998 et al. 2002; Blaicher et al. 2001) (Figure 10.14). Hull et al.
in which they found that the limitations of 3D volumes studied the presence of artifacts while visualizing the lower
were the same as in 2D sonography; however, there was extremities and concluded that there were more artifacts
Figure 10.9 The single-pane view is selected and IB IB

the render color is changed, enabling evaluation of
the lumbosacral spine with the iliac bones (IB) vis-
ible on either side.

a 26w2d fetus with spina bifida. L3
(A) Volume is displayed using the
maximum mode in an attempt to L4
localize the level of the lesion. L5
(B) Using surface rendering, the S1
meningomyelocele is displayed S2
and the anomaly is clarified to the
family. A B
Figure 10.11 A 3D volume of a 20w5d fetus with

spina bifida. (A) Volume is displayed using the maxi-
mum mode, depicting the lumbosacral involvement. (B)
A B
Neonate at birth.
while visualizing the lower limbs in comparison to the Skeletal Dysplasias

upper limbs due to flexion of the upper limbs (Hull et al.
2000). In addition, 3D is helpful in ascertaining the pres- Skeletal dysplasias (Figure 10.17) cover a wide spectrum
ence of an abnormal number of digits (Figure 10.15), or club of syndromes, with subtle differences involving various
feet (Figure 10.16). areas, and varying degrees of bone ossification. Moeglin
et al. evaluated the role of surface rendering in two cases
of achondroplasia and concluded that it allowed sequential
Clinical Utility of Volume and systemic visualization of the fetal skull, rachis, thorax,
Sonography in Assessing pelvis, long bones, and extremities (Moeglin et al. 2001).
the Fetal Limbs Ruano et al. used both surface and skeletal modes as well as
1. Facilitates counting the digits 4D in the diagnosis of three cases of fetal akinesia deforma-
2. Clarifies the appearance of sirenomelia to the tion sequence. It was the 4D imaging that was of most help
parents to the parents in understanding the fixed problem and its
3. Helps in ascertaining limb abnormalities severity (Ruano et al. 2003a). In studying five cases of pre-
natal onset of skeletal dysplasia, Krakow et al. found that 3D
A B C
Figure 10.12 Volume of the hand and digits of a 27w0d fetus displayed using three modalities: (A) surface rendering, (B) dynamic
rendering, and (C) HDlive.
Figure 10.13 The lower limbs

as examined using 3D ultrasound.
(A) Buttocks and legs of a normal
21w3d fetus. (B) Volume of a 14w6d
fetus with sirenomelia rendered
using maximum mode, displaying
a single wide lower extremity with
abnormal ossification in the distal
A B portion (*).
Figure 10.14 A 22w6d fetus with

arthrogryposis. (A) Evaluated using 3D
A B
surface rendering. (B) Postmortem.
Figure 10.15 An evaluation of the

hand of a 22w2d fetus. (A) 2D image
raising suspicion for polydactyly. (B)
3D volume rendered using dynamic
rendering, clearly showing the postaxial
polydactyly. A B
Figure 10.16 A
3D volume of a
27w4d fetus with
bilateral club feet
displayed using (A)
Surface rendering
A B
and (B) HDlive.
A B
Figure 10.17 A 12w6d fetus with multiple anomalies. (A) 3D volume using surface rendering depicting rhizomelia with proximal short-
ening of the humerus and femur. (B) Postnatal image confirming the findings (postnatal image courtesy of Adba Frangieh, MD).
was helpful primarily in the face and limbs and in assessing

the relative proportion of the appendicular skeletal system Clinical Utility of Volume
as well as improving visualization to confirm the suspected Sonography in Measuring
diagnosis (Krakow et al. 2003). Sepulveda et al. reported the Iliac Angle
on a more clear image with 3D in a case of diastrophic dys- 1. Allows the standardization of measuring the
plasia, specifically in visualizing the “hitchhiker’s thumbs” iliac angle in the axial plane
(Sepulveda 2004). Ruano et al. evaluated the role of 3D and
3D helical tomography in six cases of skeletal dysplasias and
found them to be complementary to 2D and useful (Ruano
2004c). Another report on ecterodactyly-ectodermal-dys-
plasia by Allen et al. concluded that 3D was not essential Sacrococcygeal Teratoma
but was helpful especially to the parents (Allen et al. 2008).
Two studies have looked at the role of 3D in the prenatal diag-
nosis of sacrococcygeal teratomas. The first was by Bonilla-
Musoles et al. in 2002 on two fetuses where it was found that
with 3D there is the ability to rotate the image and remove
Sonograpghy in Evaluating
obscuring items, enabling determination of the degree of
Skeletal Dysplasias
sacral involvement and the extent of involvement of other pel-
1. Useful in assessing bone ossification vic organs (Bonilia-Musoles et al. 2002). Another study by
2. Aids in the systemic evaluation of the skull, Roman et al. on a first-trimester fetus with a sacrococcygeal
rachis, thorax, pelvis, long bones, and teratoma found 3D to be of most value in counseling the fam-
extremities ily and enabling them to visualize the abnormality (Roman et
3. Allows visualizing movement limitations in al. 2004).
specific disorders

Iliac Angle Sonography in Evaluating
Sacrococcygeal Teratomas
The iliac angle is reportedly wider in fetuses with trisomy 21,
but is difficult to measure. For this reason, Lee et al. evaluated 1. Helps in determining the extent of sacral
the role of 3D in an attempt to standardize its measurement in involvement
35 normal fetuses and 16 trisomy 21 fetuses. It was concluded 2. Clarifies the abnormality to the family,
that standardization was possible in the axial plane but was especially in the first trimester
found to be unreliable in the coronal plane (Lee et al. 2001).
Limitations of Volume Sonography in Conclusion

Evaluation of the Fetal Spine
Two areas where 3D ultrasound has been shown to be of clini-
As with the various organ systems covered thus far, volume cal utility with respect to the fetal skeleton are counting the
sonographic techniques require skill and training. In addition, ribs and determining the level of involvement in the case of
in the presence of an anomaly, it becomes more challenging to a neural tube defect, otherwise not possible with routine 2D
acquire the optimal volume and render it to satisfaction. sonography. In addition, 3D ultrasound is of value in evaluat-
ing the various components of the fetal skeleton and clarifying
the findings to the family as early as the first trimester (Figure
10.18). And as with other areas of the fetus, this requires
practice, skill, and an optimal basic 2D image from which to
acquire the 3D volume.
*
* *
A B C
Figure 10.18 A 3D volume of a 12w6d fetus with spina bifida

(*). The 3D images helped clarify the anomaly to the family given
the extremely early gestational age. (A) The volume is rendered
using HDlive clearly illustrating the defect. (B) The volume is
*
rendered using the skeleton mode depicting the bony defect. (C)
The volume is rendered with TUI at an interslice distance of 2
mm and VCI at a slice distance of 2 mm depicting the extent of
the defect. Note the reference dot localizing the defect. (D) The
volume is rendered using OmniView with VCI at a slice thick-
ness of 1 mm where the threshold and mix have been adjusted to
D
generate this image.
Practical Pearls
• Obtain multiple volumes of an anomaly

• VCI and OmniView are most helpful in
evaluating the fetal spine
• OmniView, using the nonlinear option, allows
tracing along the curvature of the spine for
optimal visualization particularly if the fetus
is flexed
• OmniView using two properly placed lines on
either side of the spine allows thorough study
of the fetal spine
• Always evaluate the spine with various
modalities: maximum mode, OmniView, sur-
face mode, etc.
• Remember to thoroughly evaluate the spine
all the way down to the sacrum in order to
exclude sacral agenesis
11 Clinical Applicability in the Fetal
Cardiovascular System
Introduction analysis is now possible in order to improve our detection rates
(Abuhamad et al. 2004, 2005, 2006, 2007).
One of the most complex structures, and one that has eluded
sonographers for years, is the fetal heart. This is a result of
several factors, mainly its size and the challenges of studying Clinical Utility
a tiny beating organ in a moving fetus through the maternal
abdomen. In addition, the fetal heart is the one organ whose Utilizing volume sonography, the fetal heart may be evaluated
appearance changes with the cardiac cycle; the sonographer in any of several modalities in which B-Flow (Figure 11.1),
must be aware of where in the cardiac cycle certain views are color (Figure 11.2) and power Doppler (Figure 11.3),
obtained for optimal interpretation and diagnosis. Despite the HD-Flow (Figure 11.4), and inversion mode (discussed in
technological advances and the sophisticated machines we Chapter 5, Table 5.1, Figures 5.10–5.15) may be employed
now have, congenital heart disease, which affects 8.8/1000 (Figure 11.5 and 11.6). Using these modalities, thorough
live births (Hoffman et al. 1978), is still suboptimally diag- assessment of the fetal heart is possible in order to improve
nosed prenatally, even in the best of hands, with recent reports the diagnosis of congenital cardiac defects. In fetal echo-
of 57% detection from tertiary care centers (Tegnander et al. cardiography, the volume can be displayed in any of several
2006). However, proper training and a systematic approach ways, as listed below.
have been shown to translate into improved prenatal detection
rates (Hunter et al. 2000). Early detection has been proven to
Techniques That May be Utilized for
be of great value, not only for preparing the family, but also for
the Evaluation of the Fetal Heart
a timely delivery at a tertiary care center for optimal manage-
ment of the newborn. With the advent of volume sonography, 1. Standard 3D static (Figure 11.7)
it is now possible to obtain off-line analysis and consultation 2. Rendered 3D static (Figure 11.8)
from anyone with internet access, irrespective of where they 3. STIC (Figure 11.9)
are geographically. In addition, with the introduction of auto- 4. VCAD (Figures 11.10–11.20)
mation, standardization of fetal volumes for computer-aided
Figure 11.1 A STIC volume of a 21w4d

aortic arch displayed utilizing B-Flow
in TUI with an interslice thickness of 2
mm and VCI with a slice thickness of 2
mm. This generates an image akin to that
obtained utilizing angiography.
95
RA
SVC
A
o
IVC A
DAo
Figure 11.2 A 3D volume of the right atrial inflow, aortic arch

and descending aorta of a 22w0d fetus. The volume was acquired
using color Doppler in the minimum mode, hence creating a
vascular cast. RA, right atrium; SVC, superior vena cava; IVC,
inferior vena cava; AoA, aortic arch; DAo, descending aorta.
Figure 11.4 A STIC volume of a 13w3d fetal
heart with HD-Flow. The volume is rendered in the
minimum mode creating a cast of the heart that can
be rotated along any of the X, Y, and Z axes. The
symmetry of the chambers is illustrated.
H&N
L
AoA V
O
T
PA
D
A
o
RV
LV
Figure 11.3 A 3D volume of the aortic arch Figure 11.5 A STIC volume of the fetal heart
and descending aorta of a 23w1d fetus. The volume and aortic arch at 23w0d rendered using the
was acquired using power Doppler in the minimum inversion mode and HDlive, depicting the right
mode, hence creating a vascular cast. The aortic and left ventricles (RV, LV) and outflow tracts. PA,
arch, head and neck vessels, and descending aorta pulmonary artery; LVOT, aorta.
are clearly depicted. The final rendered image is
reassuring against the presence of an aortic coarc-
tation. AoA, aortic arch; DAo, descending aorta;
H&N, head and neck vessels.
Clinical Applicability in the Fetal Cardiovascular System 97
AoA
D
A
o
Figure 11.6 A sagitally acquired STIC volume of

the fetal heart and aortic arch at 23w0d. The volume
is rendered using the inversion mode and HDlive,
depicting the aortic arch (AoA), descending aorta
(DAo), as well as the head and neck vessels (*).
S
N
Figure 11.7 A 3D volume of the fetal

heart at 22w1d is acquired at the level of the DA
four-chamber view with an angle of acqui-
sition of 38 degrees. The volume is subse-
quently displayed in the multiplanar mode.
Note the reference dot (o) at the crux of the
heart in plane A. Note that plane B depicts
the depth (cephalad and caudad extremes of
the acquired volume) and the angle of acqui-
sition, which in this case encompasses the
stomach (S) and the neck (N). In addition,
plane B depicts the ductal arch (DA).
TV
RV
RA
LV
LA
MV
Figure 11.8 A 3D volume of the heart of a 29w3d fetus is
acquired at the level of the four-chamber view with an angle of
Ao
acquisition of 53 degrees. The volume is subsequently rendered
using surface rendering. Note how clearly the four chambers are
seen (RV, right ventricle; LV, left ventricle; RA, right atrium; LA,
left atrium), the clear off-setting between the tricuspid (TV) and
mitral (MV) valves, and note the left-sided aorta in cross-section
(Ao).
A key point for the evaluation of the fetal heart is obtain- in order to enhance retrieval of the respective anatomic planes
ing the volume with as few extraneous movement artifacts out of a stored volume dataset. This was first described by
as possible (Table 11.1). Optimizing acquisition, minimizing Abuhamad (2004) and is a prerequisite for automation using
shadowing from fetal limbs, and standardizing the display VCAD (Table 11.2).
are key factors in facilitating navigation through the volume
Table 11.1 Steps to Obtaining a Standardized Volume of the Fetal Heart

Step 2: Obtain a 3D sweep with the acquisition box placed just around the heart, with an angle of acquisition of 25 degrees and select a mid to high
quality for the volume
Step 3: Acquire the volume and display it in the multiplanar mode (Figure 11.10)
Step 4: Rotate the volume in plane A along the Z axis so that the fetal spine is at 6 o’clock and the cardiac apex is in the top left corner
Step 5: Place the reference dot on the crux of the fetal heart (Figure 11.10)
Table 11.2 Steps to Utilizing VCAD for the Evaluation of the Fetal Heart
Step 1: Follow steps 1 through 5 to acquire a standardized volume of the fetal heart as described in Table 11.1
Step 3: Select VCAD as a preset which automatically displays the volume in TUI (Figure 11.11)
Step 4: Align the four-chamber view with the schematic representation by magnifying the image and rotating it along the Z axis (Figure 11.12)
Step 5: Align the fetus in plane B with the schematic by rotation along the Z axis (Figure 11.13); this becomes the starting plane (Figure 11.14)
Step 6: Navigate through the volume, utilizing the predefined cardiac planes 1 through 6 for automatic retrieval of the respective cardiac planes
(Figures 11.15–11.20)
Figure 11.9 A STIC volume of the fetal heart at 22w6d is acquired at the level of the four-chamber view
with color Doppler. The volume is rendered using minimum mode. The ventricles are clearly depicted.
Figure 11.10 Figures 11.10–11.20 exemplify the step-by-step approach to utilizing VCAD to generate
six cardiac planes out of a 3D stored volume data set of the fetal heart using 4D View software. The first
step is to acquire a 3D volume of the fetal heart at the level of the four-chamber view and display it in the
three orthogonal planes with the fetal spine at 6 o’clock and the reference dot (O) placed at the crux of the
heart as shown in plane A.
Figure 11.11 Subsequently, TUI is selected with seven images at an interslice distance of 2 mm. The reference
dot (o) is placed at the crux of the heart.
Figure 11.12 VCAD is then activated and the diagrams with which to align the images in planes A and B appear.
Note the malalignment between the schematic and the sonographic images.
Figure 11.13 The image in plane A is then magnified and rotated along the Z axis in order to align it with the
schematic, and the image in plane B is rotated in order to align the fetal spine with the dotted schematic line.
Figure 11.14 Once the image has been displayed in the optimal standardized format and aligned with the
schematic, the “start plane” button (*) is selected, and now the central image of the four-chamber view becomes the
reference plane for navigating within this volume.
LVOT
Figure 11.15 From the standardized reference plane, the cardiac 1 preset is selected which generates the left
ventricular outflow tract (LVOT) in seven planes that are 0.6 mm apart. Utilizing TUI helps correct for the minor
variations between fetuses across gestational ages.
RVOT
Figure 11.16 The cardiac 2 preset is now selected which generates the right ventricular outflow tract (RVOT) in
seven planes that are 1 mm apart.
Stomach
Figure 11.17 The cardiac 3 preset is now selected which generates the abdominal circumference plane with a
visible fetal stomach. This also helps ascertain fetal situs.
RA
IVC SVC
Figure 11.18 The cardiac 4 preset is then selected which generates the sagittal views of the right atrial inflow
(bicaval view) with the superior and inferior venae cavae (SVC, IVC) inserting into the right atrium (RA).
DA
DAo
Figure 11.19 The cardiac 5 preset is then selected which generates the sagittal views of the ductal arch (DA) and
descending aorta (DAo).
AoA
DAo
Figure 11.20 The cardiac 6 preset is then selected which generates the sagittal views of the aortic arch (AoA)
and descending aorta (DAo).
Perhaps the greatest utility for volume sonography in heart throughout a full cardiac cycle, and combining STIC
the evaluation of the fetal heart is learning the proper fetal with TUI, VCI, inversion mode, or any of the Doppler
cardiac anatomy and how to generate the necessary cardiac modalities enhances the evaluation (Figure 11.23 and 11.24)
planes out of a standardized volume, to facilitate the evalu- and helps reaffirm the location of a ventricular septal defect
ation of the fetal heart using 2D ultrasound. It is possible to (Figure 11.25), ventricular (Figure 11.26), and outflow tract
carry out a near-complete evaluation of the fetal heart from abnormalities (Figure 11.27). In addition, STIC has been
two properly acquired STIC volumes, obtained from an found to be of value in the off-line analysis of first-trimes-
axial and a sagittal sweep, and viewed in cineloop through- ter normal and abnormal fetal hearts (Chapter 7, Table 7.2,
out a full cardiac cycle (Figure 11.21 and 11.22). Numerous Figures 7.15–7.18) in order to generate the basic views and
techniques have been described for studying the fetal heart, characterize any underlying pathology. However, as always
including DeVore’s spin technique, discussed in Chapter 3 with volume sonography, the greatest limitation is the qual-
(Table 3.1, Figures 3.17–3.22), study of the fetal valves in ity of the acquired volume and the route of volume acquisi-
Chapter 4 (Table 4.1, Figure 4.3 and 4.4), and Abuhamad’s tions, whether vaginal or abdominal (Votino et al. 2013). In
VCAD (Table 11.2, Figures 11.11–11.20), among many oth- addition, it is possible to obtain striking surface-rendered
ers. STIC allows the study of a volume of the beating fetal images of the fetal heart (Table 11.3).
Table 11.3 Steps to Acquiring a 3D Surface-Rendered Image of the Four-Chamber View

Step 1: Obtain a 3D volume of the fetal heart at the level of the four-chamber view using the cardiac presets and display it in the multiplanar
mode (Figure 11.28)
Step 2: Render the volume using surface rendering with a direction of back-to-front for viewing the region of interest (Figure 11.29)
Step 3: Change the size of the render box to optimize the final rendered four-chamber view (Figure 11.30)
Step 4: Select the single-pane display and adjust the threshold and mix (Figure 11.31)
Step 5: Select HDlive surface rendering (Figure 11.32)
Step 6: Adjust the threshold and mix to optimize the texture and appearance of the image (Figure 11.33)
Step 7: Change the direction of the internal light source in order to reversely illuminate the heart (Figure 11.34)
3VV
PA
Figure 11.21 A STIC
volume of a 26w6d heart SVC
acquired from the axial
plane and displayed using
TUI with an interslice
LVOT
distance of 1.5 mm. It is
possible to see the four-
chamber view (4CV), the
left ventricular outflow
tract (LVOT), pulmonary 4CV
artery (PA), three-vessel
view (3VV), and superior
vena cava (SVC).
IVC
RA AoA
SVC
DAo
Figure 11.22 A sagittally acquired STIC volume of the fetus in Figure 11.21 displayed using TUI with
an interslice distance of 0.5 mm. The aortic arch (AoA), descending aorta (DAo), right atrium (RA), and
superior and inferior venae cavae (SVC and IVC) can be seen.
ASD and VSD seen Loss of Normal Off-Set
A B
Figure 11.23 A 3D volume of a 21w2d fetus with an atrioventricular (AV) septal defect. (A) The volume is displayed using TUI at an
interslice thickness of 2 mm and VCI with a slice thickness of 2 mm. The loss of the normal off-set of the AV valves is seen as well as the
atrial (ASD) and ventricular (VSD) components of the defect. (B) The volume is rendered using HDlive, clearly depicting the defect.
CAT
ASD, VSD and HRV Loss of Normal

Off-Set
Left Right
HRV
S
A B
Figure 11.24 A STIC volume of a 22w5d fetus with an atrioventricular (AV) septal defect, a hypoplastic right ven-
tricle (HRV), and a common arterial trunk (CAT). (A) The volume is displayed using TUI at an interslice thickness of 2
mm and VCI with a slice thickness of 2 mm. Normal fetal situs is ascertained by visualizing the fetal stomach (S). The
loss of the normal off-set of the AV valves is seen as well as the ventricular and atrial components of the defect. (B) The
volume is rendered using surface rendering clearly depicting the defect.
VSD
VSD VSD
A
VSD
B C D
Figure 11.25 A series of 2D and 3D images of a second-trimester fetus with an isolated mid-muscular ventricular
septal defect (VSD). (A) A 2D image of the four-chamber view depicting the VSD. (B, C) The location of the VSD is
ascertained using color Doppler. (D) A 3D volume of the fetal heart is now rendered using the inversion mode, clearly
demonstrating the VSD.
Figure 11.27 A 3D
AV
sagittal volume of the
aortic arch and descend-
ing aorta of a 34w0d
fetus with ventricular
FO disproportion. The vol-
AV
ume is rendered using
the inversion mode with
HDlive. This was a case
Figure 11.26 A 3D volume of a 15w3d of coarctation of the aorta
fetus with a univentricular heart rendered further clarified utilizing
using the inversion mode during diastole. Note the inversion mode. Note
the flow across both atrioventricular valves the location of the luminal
(AV) as well as across the foramen ovale (FO). narrowing (*).
Figure 11.28 A 3D volume of the fetal heart at the level of the four-chamber view
obtained using the cardiac preset, and displayed in the multiplanar mode.
Figure 11.29 The volume is rendered using surface rendering with a direction of back-to-
front selected in plane B for viewing the region of interest.
Figure 11.30 The size of the render box is adjusted in order to optimize the final rendered
image of the four-chamber view.
MB
TV
MV
Ao
Figure 11.31 The single-pane display is selected and the Figure 11.32 HDlive surface rendering is then selected,
threshold and mix are adjusted in order to optimize the final with which the final rendered image is displayed. Note the left-
rendered image. sided aorta in cross-section (Ao), the normal off-setting of the
atrioventricular valves (MV, mitral valve; TV, tricuspid valve),
and the thick moderator band (MB) in the right ventricle.
Figure 11.33 The threshold and mix are adjusted further Figure 11.34 The direction of the internal light source is
in order to change the texture and appearance of the image. changed in order to reversely illuminate the heart.
Limitations of Volume Sonography in Practical Pearls

Evaluation of the Fetal Heart
The greatest limitation for the use of volume sonography in
the fetal heart is due to the underlying fetal movement which • Standardization is key for evaluating the fetal
distorts volume imaging, especially in the Y and Z planes. heart
A small angle and the use of STIC can help overcome this • Any number of modalities may be combined
limitation to a certain extent. Due to the complexity of the to best evaluate the area in question
fetal heart, it is easy to get “lost” while navigating through • A 15-degree volume angle is sufficient for
the volume. This is where standardization and the use of the evaluating the second trimester fetal heart
reference dot prove to be of tremendous benefit. • Volume sonography provides the best avenue
for learning the complicated fetal cardiac
anatomy
Conclusion • During the acquisition of a 3D or STIC
volume of the fetal heart, commencing with
Fetal echocardiography remains one of the most difficult the four-chamber view, it is possible to view
areas to perfect as a result of several factors as noted above. the abdominal circumference plane, four-
With the advent of volume sonography, several modalities chamber view, right and left outflow tracts as
are now available to further clarify the area under study and well as the three-vessel view during the sweep
ascertain a diagnosis. This cannot be accomplished without • It is possible to carry out a complete assessment
an optimized 2D image from which the volume is obtained. of the fetal heart from 2 properly acquired
In addition, stored volume datasets of the fetal heart are a STIC volumes: an axial and a sagittal volume
great educational tool for the study of normal anatomy
and cardiac pathology. With the availability of automation
for the second trimester fetal heart on certain sonographic
machines, it is now possible to generate all the required key
cardiac planes necessary for a complete off-line assessment
of the fetal heart out of a standardized stored volume data-
set. Ultimately this may translate into better understanding of
fetal cardiac anatomy and improved prenatal detection rates.
12 Clinical Applicability in the Fetal Chest
Introduction Clinical Utility
The fetal chest is an area that has received much attention The two main areas of utility of volume sonography in the
with 3D sonography, especially with respect to fetal lung fetal chest are first, fetal lung development and the establish-
volume measurements. Pulmonary hypoplasia remains a ment of volume normograms, and second, utilizing the vari-
major source of fetal morbidity and mortality. Pulmonary ous 3D modes to enable more precise diagnoses in fetal lung
hypoplasia may be the result of several maternal and fetal abnormalities.
conditions, oligohydramnios caused by premature rupture of
membranes or renal disease, skeletal dysplasias, chylothorax
(Figure 12.1), pulmonary masses, and fetal diaphragmatic
hernia (Figure 12.2 and 12.3). With the availability of fetal Areas of Utility of Volume
endotracheal occlusion (FETO) for antenatal management Sonography in the Fetal Chest
of fetal diaphragmatic hernia, lung volume assessments 1. Lung development and establishing lung
become critical. Fetal lung volumes are calculated pre- and volume normograms
post-FETO for patient selection and for the determination of 2. Assessing lung abnormalities
procedural impact. This has led to several studies investigat-
ing the role of volume sonography in accurately quantifying
fetal lung volume.
Right
L
A AS
V
V Left
L VS
B C
Figure 12.1 A 3D volume of the fetal chest of a 20w5d fetus with chylothorax. (A) The volume is displayed in the multiplanar mode
using sepia. Note the small fetal lungs (L). (B) The same volume displayed using TUI at an interslice thickness of 3 mm and VCI at a slice
thickness of 3 mm, depicting the extent of the chylothorax. (C) A surface-rendered image of the heart and lungs facilitated by the acoustic
window created by the fluid filling the chest. V, ventricle; VS, ventricular septum; AS, atrial septum.
111
L
S
Figure 12.2 A 16w6d fetus with a left-sided congenital diaphragmatic hernia.

Note the position and axis of the heart now that the abdominal contents have
occupied the left side of the chest, with the stomach bubble clearly visible (S). Note
the compressed right lung (L).
Figure 12.3 The same volume from

the 16w6d fetus in Figure 12.2 displayed
using TUI at an interslice distance of 1.8
mm and a VCI thickness of 1.9 mm. The
reference dot is placed within the fetal
stomach and locates it in all the planes.
Fetal Lung Volume

postmortem lung volumes by water displacement as the gold
There have been numerous studies evaluating the role of vol- standard (Pohls and Rempen 1998; Merz 1998; Bahmaie et
ume sonography in determining fetal lung volume, looking al. 2000; Osada et al. 2002; Kalache et al. 2003; Sabogal et
at both normal and abnormal lungs, up until gestations of al. 2004; Ruano et al. 2004a; Moeglin et al. 2005; Ruano et
34 weeks. Beyond 34 weeks, the evaluation becomes very al. 2005a; Peralta et al. 2006a, 2006b; Ruano et al. 2006;
difficult due to a fetal spine-up position, a much larger mov- Gerards et al. 2006, 2007). Chapter 6 provides a description
ing fetal heart, shadowing, and size limitations (Sabogal et of fetal lung volume calculation in the case of a normal fetus
al. 2004; Pohls and Rempen 1998). These studies have com- (Table 6.2; Figures 6.9–6.12). Fetal lung volume measure-
pared 2D, 3D multiplanar, 3D rotational multiplanar, also ment in the case of a diaphragmatic hernia is illustrated in
known as VOCAL, fetal MRI, and at times have even utilized Table 12.1 and Figures 12.4–12.8.
Table 12.1 Steps to Measuring Fetal Lung Volume in Congenital Diaphragmatic Hernia
Step 1: Obtain an axial section through the anterior fetal chest at the level of the four-chamber view
Step 2: Place the acquisition box around the entire chest, with an angle of acquisition of 55 degrees and a mid to high quality for the volume
Step 4: Select VOCAL and use manual trace at a rotational angle of 30 degrees and hit “next” (Figure 12.5)
Step 5: Point trace the right lung (Figure 12.6) and repeat this step in all six rotational planes
Step 6: Once the right lung has been traced in all six rotational planes, hit “done” and a 3D reconstruction of the lung appears with the volume
calculated (Figure 12.7)
Step 7: The final rendered volume may be displayed as a mesh and rotated along all three axes (Figure 12.8)
Clinical Applicability in the Fetal Chest 113
S
L
Figure 12.4 This is a volume of the

same 16w6d fetus with the left-sided con-
genital diaphragmatic hernia. The volume
is displayed in the three orthogonal planes
in preparation for calculating the right
lung volume.
Figure 12.5 VOCAL is activated with

a rotational axis through the right lung
and a rotational angle of 30 degrees. The
open arrows are placed along the margins
of the right lung.
Figure 12.6 Manual trace is used to

encircle the right lung at a rotational angle
of 30 degrees around the vertical axis.
Figure 12.7 Once all six measurements are obtained, a 3D schematic of the compressed lung is generated and its volume is calculated:
8.429 cm2 in this case.
Figure 12.8 The final rendered schematic may be displayed

in a “mesh” style that can be rotated along any of the three
orthogonal axes.
Clinical Applicability in the Fetal Chest 115
Volume Sonography in Fetal Lung Abnormalities malformation of the lung (CCAM) in fetuses with a hyper-
echogenic lung mass by identifying the feeding vessel. This
Another utility of volume sonography is in its role in is helpful in prenatal counseling and postnatal management
localizing and evaluating the lungs (Figure 12.9), further (Ruano et al. 2005b).
characterizing lung lesions and mapping out their extent,
involvement of adjacent structures, and their vasculature. A
study by Achiron et al. presented an overview of the various
modalities in volume sonography and addressed where to
use which modality to further enhance the diagnostic accu- Clinical Utility OF VOLUME
racy in cases of lung abnormalities (Achiron et al. 2008). SONOGRAPHY IN LUNG ABNORMALITIES
Another report by Ruano et al. on a case of a posterior 1. Localizing chest abnormalities
mediastinal lymphangioma concluded that 3D was helpful 2. Assessing lung abnormalities
in determining the precise location of the mass (Ruano et 3. Differentiating CCAM from pulmonary
al. 2008). Ruano et al. also investigated the role of 3D power sequestration
Doppler and found it to be critical in differentiating pul-
monary sequestration from congenital cystic adenomatoid
L L
Figure 12.9 A 3D coronally displayed volume

of a 16w4d fetus with megacystis. (A) The volume is
displayed in the multiplanar mode with VCI at a slice
thickness of 2 mm. (B) OmniView polyline is acti-
vated, with two lines drawn from the apex to the base
of each lung and a third line across them, generating L
B L
three planes in which the fetal lungs are seen.

the Evaluation of the Fetal Chest
The greatest limitation to using volume sonography in the

fetal chest is bone shadowing. This becomes quite challeng- • VOCAL is a most useful modality for
ing beyond 34 weeks of gestation, especially when attempt- quantifying fetal lung volume
ing to calculate fetal lung volumes. It requires skill and • SonoAVC may be used to quantify the amount
practice, and is further limited by suboptimal volumes, espe- of chylothorax
cially when there is a structural abnormality. • Whenever viewing the heart and lungs from an
axially acquired volume, adjust the direction
of view of the render box to front-to-back for
Conclusion optimal results
• Avoid acquiring any volumes with fetal
In the assessment of fetal lung volume, 3D ultrasound is most extremities covering the fetal chest and use
useful, especially in cases of congenital diaphragmatic her- the smallest acquisition box possible
nia pre- and post-FETO. It may also be utilized to help in the • The 3D techniques are of limited utility
accurate localization of fetal chest masses and quantifying beyond 34 weeks due to bone shadowing
pleural effusions and chylothorax for monitoring the evolu-
tion and progression of pleural effusions and chylothorax. It
is of great benefit in learning the anatomy and enabling off-
line consultation in challenging cases.
13 Clinical Applicability in the
Fetal Gastrointestinal Tract
Introduction in the late second and third trimesters. The main areas of rel-
evance are with respect to quantifying bowel echogenicity,
Gastrointestinal abnormalities tend to be identified in the characterizing abdominal wall defects (Figure 13.1 and 13.2),
late second and early third trimesters of pregnancy except assessing liver volume, and assessing abdominal vasculature,
in cases of abdominal wall defects or hyperechogenic bowel. with isolated reports on other gastrointestinal abnormalities
Similar to the genitourinary tract, the gastrointestinal tract (Figures 13.3–13.5).
contains several fluid-filled structures. As a consequence, the
role of the inversion mode becomes apparent, as does TUI,
enabling serial slices spanning the abdominal cavity and pel- Areas in the Gastrointestinal
vis allowing for the characteriztion and accurate identifica- Tract to be Assessed by
tion of the lesion under suspicion. Volume Sonography
1. Echogenic bowel
2. Abdominal wall defects
Clinical Utility 3. Liver volume
4. Abdominal vasculature
Most reports on describing the use of volume sonography in 5. Other areas in the gastrointestinal tract
evaluating the gastrointestinal tract are limited to case reports
Figure 13.1 A sagittal 3D volume of a 11w6d fetus with an omphalocele displayed using TUI at an
interslice thickness of 1.2 mm. The reference dot is placed in the fetal omphalocele and localizes it in all
the 2D planes.
117
Figure 13.2 A 3D volume of a 14w1d fetus with an omphalocele (*) displayed

using surface rendering. This 3D image helped clarify the abnormality to the family.
H: head.
Figure 13.3 An axial

3D volume of the fetal
abdomen of a 26w1d fetus
displayed using TUI at an
interslice thickness of 1.2
mm. Note the dilated loops
of small bowel, localized by
the reference dot. B: bowel;
S: stomach.
Echogenic Bowel more relevance, whether by 2D or 3D sonography, keeping in

mind its wide variability (Figure 13.6). It is this inherent vari-
Echogenic bowel is a subjective sonographic finding that ability that renders the independent use of echogenic bowel
is affected by the machine settings, such as employment of unpredictable. As such, when isolated, it is not possible to
tissue harmonics. Its presence may have serious implica- predict adverse fetal outcome.
tions since it is a marker for chromosomal aneuploidy, cystic
fibrosis, and viral infections. Khandelwal et al. carried out
a study on 47 fetuses between 15 and 24 weeks in which an Clinical Utility of Volume
attempt was made to objectively score bowel echogenicity Sonography in Evaluating
in comparison to bone and the fetal liver, using 3D volumes Bowel Echogenicity
(Khandelwal et al. 1999). The 3D imaging allowed quanti- 1. Quantification of bowel density in comparison
fication of the density of bowel, liver, and bone, and it was to liver and bone
concluded that comparing bowel to liver echogenicity is of
Clinical Applicability in the Fetal Gastrointestinal Tract 119
Figure 13.4 The same

fetus from Figure 13.3 now
at 27w1d. Again an axial 3D
volume of the fetal abdomen
is obtained and displayed
thickness of 2.1 mm and
VCI with a slice thickness of
5.8 mm. The reference dot
locates the dilated loop in all
the planes.
Figure 13.5 An axial

3D volume of the same
fetus in Figure 13.3 and
13.4, displayed using TUI
at an interslice thickness
of 1.2 mm with VCI at a
thickness of 3 mm. The
fetus is now at 37w1d.
Note the massively dilated
small bowel (B).
Abdominal Wall Defects et al. compared the use of 2D to 3D in 12 cases of abdomi-

nal wall defects (Bonilla-Musoles et al. 2001). Although
One of the most investigated areas on the use of volume 2D allowed better visualization of the herniated contents in
sonography in the gastrointestinal tract is in cases of abdomi- the case of an omphalocele, 3D added a great deal of value,
nal wall defects. In 1996 Matsumi et al. reported on the use of especially in the presence of other associated facial anoma-
3D sonography to determine the exact location of abdominal lies. The final consensus was that the two modalities were
wall defects. (Matsumi et al. 1996). In 2001, Bonilla-Musoles complementary, and that the greatest utility for 3D was in
CI
S
EB
Figure 13.6 A sagittal

3D volume of the abdomen
and pelvis in a 17w3d fetus.
Note the echogenic bowel
(EB), which is brighter than
L
B
the fetal liver (L) and simi-
lar in brightness to the fetal
bones (B). CI: cord inser-
tion; S: stomach.
the evaluation of fetal gastroschisis prior to 14 weeks of ges- Liver Volume

tation. In early pregnancy, the defect can be infracentimet-
ric, and in the absence of bowel peristalsis the defect may Laudy et al. assessed liver volume (Table 13.1; Figures 13.7–
be missed altogether. Anandakumar et al. evaluated volume 13.10) in 34 fetuses at 19–39 weeks and found that liver vol-
sonography in a fetus with first-trimester omphalocele and ume doubled in the latter half of gestation. Liver volume may
concluded that 3D was able to better clarify and confirm the play a role in identifying fetuses with intrauterine growth
2D diagnosis (Anandakumar et al. 2002) (Figure 13.1 and restriction (Laudy et al. 1998). Kuno et al. compared 14
13.2). appropriately grown fetuses and 10 growth-restricted fetuses
to evaluate whether liver volume or length might correlate
with intrauterine growth restriction. The study concluded
that liver volume, but not liver length, correlated with growth
Clinical Utility of Volume restriction (Kuno et al. 2002).
Sonography in Evaluating
Abdominal Wall Defects
1. Identification of first-trimester abdominal Clinical Utility of Volume
wall defects Sonography in Evaluating
2. Characterizing the exact location of the lesion Liver Volume
3. Identifying other associated anomalies
1. Calculating liver volume
Table 13.1 Steps to Measuring Liver Volume

Step 1: Obtain an axial section through the upper abdomen at the level of the abdominal circumference plane
Step 2: Place the acquisition box around the entire abdomen, with an angle of acquisition of 55 degrees and a mid to high quality for the volume
Step 4: Select VOCAL and use manual trace at a rotational angle of 30 degrees around a rotational Y axis that bisects the liver (Figure 13.8) and
hit “next”
Step 5: Trace the liver and repeat this step in all six rotational planes (Figure 13.9)
Step 6: Once the liver has been traced in all six rotational planes, hit “done” and a 3D reconstruction of the liver appears with the volume
calculated (Figure 13.10)
S
B
Figure 13.7 An axial 3D volume of the abdomen of a 32w1d fetus displayed in the mul-
tiplanar mode. B: bladder; S: stomach.
S
B
Figure 13.8 VOCAL is now selected with a rotational Y axis bisecting the fetal abdomen.
B: bladder; S: stomach.
S
B
Figure 13.9 Manual trace with a rotational angle of 30 degrees is then selected and the
fetal liver is traced in six consecutive planes. B: bladder; S: stomach.
Figure 13.10 Once all six measurements are obtained, a 3D schematic of the liver is
generated and its volume calculated: 106.54 cm2 in this case. The final rendered schematic
may be rotated along any of the three axes.
Abdominal Vasculature Other Benefits in the Gastrointestinal Tract
One of the first studies on the use of 3D power Doppler for Ramón y Cajal et al. reported on the utility of 3D in differ-
the study of the fetal abdominal vasculature was by Chaoui entiating the duodenal and gastric cavities and visualizing
et al. where the study was able to differentiate the spleen the connecting pyloris in a case of duodenal artesia (Ramón
from the liver and confirm the presence of splenomegaly in a y Cajal et al. 2003). Yagel reported on a case of esophageal
case of cytomegalovirus infection (Chaoui et al. 2002). Paris atresia where 3D facilitated the diagnosis and visualization
et al. mapped out the anatomy of the portal sinus using 3D of the atretic portion of the esophageal pouch (Yagel 2005).
angiography (Paris et al. 2004). Subsequently, Loureiro et Ramon y Cajal et al. reported on visualization of fetal def-
al. utilized 3D power Doppler to study the vasculature of a ecation using 4D sonography (Ramón y Cajal et al. 2005).
congenital abdominal hemangioma and was able to display In cases of fetal ascites, the intra-abdominal fluid provides
the feeding vessel (Loureiro et al. 2008). Sammour et al. a window through which to obtain nice intra-abdominal
diagnosed prenatal volvulus using 3D Doppler, where the 3D images (Figure 13.11 and 13.12).
counterpart to the 2D “whirlpool sign” was described. This
was called the “barber pole” sign (Sammour et al. 2008).
Clinical Utility of Volume Other Clinical Utilities of

Sonography in Mapping Out Volume Sonography in the
Abdominal Vasculature Gastrointestinal Tract
1. Differentiate spleen from liver 1. Diagnose esophageal atresia
2. Map portal sinus angiography 2. Diagnose duodenal atresia
3. Locate the feeding vessel for a hemangioma 3. Document fetal defecation
4. Identify the “barber pole” sign in prenatal
volvulus
PE
Figure 13.11 A 3D volume of 23w2d fetus with ascites displayed using the multiplanar
mode with VCI at a thickness of 2 mm. A: ascitis; B: bowel, L: liver; PE: pleural effusion.
Figure 13.12 The same volume from Figure 13.11 now displayed in TUI at an interslice thickness
of 2 mm and VCI at a slice thickness of 2 mm, showing the small echogenic bowel and the extent of the
ascites. It is possible to use VOCAL in this case to quantify the ascites for follow-up of the progression
with advancing gestation. A: ascitis, B: bowel.

Evaluation of the Gastrointestinal Tract
One of the main limitations for the evaluation of the gastro-
intestinal tract is that most abnormalities are late appearing, • When examining the bowel, turn off
first seen in the late second and early third trimesters. At this harmonics, SRI and CRI, especially when
point in gestation, the 2D scan is more challenging due to evaluating bowel echogenicity
fetal flexion and bone shadowing. Since the quality of the 2D • Volume sonography is most useful in mapping
image remains the cornerstone for an adequate 3D image, out vasculature and identifying feeding
acquisition of an adequate volume with minimal shadowing vessels for any masses in the fetal abdomen
is the greatest limitation. • The reference dot proves to be most helpful
in the evaluation of cystic abdominal/pelvic
lesions while navigating within the volume
Conclusion trying to determine the origin of the lesion
The gastrointestinal tract remains a challenging area to

evaluate, especially in cases of cystic abnormalities. Volume
sonography, through the utilization of the inversion mode,
TUI, surface rendering, and advanced vascular settings, helps
in the clarification of the abnormality present, enhances the
diagnostic accuracy, and subsequently may positively impact
patient management.
14 Clinical Applicability in the
Fetal Genitourinary System
Introduction of gender assignment is beyond determination of fetal sex; it

involves sparing the parents an early CVS in certain X-linked
The primary role for volume sonography in the fetal geni- disorders, as well as trying to relieve the stress and serious
tourinary system has been gender assignment, renal pelvis implications when ambiguous genitalia are suspected. One
volumetry, urine production, and characterizing other geni- of the earliest studies on the use of volume sonography for
tourinary abnormalities. fetal gender assignment was by Hata et al. where 3D sonog-
raphy was utilized for examining the genitalia in the second
and third trimesters (Hata et al. 1998a). A limiting factor
Clinical Utility in the volumes evaluated in this study was the inability to
rotate them, a factor to which the suboptimal results of 3D
As with the gastrointestinal tract, volume sonography plays in comparison to 2D in determining fetal sex may be attrib-
an important role in the evaluation of the genitourinary tract, uted. Merz et al. reported on a case in which 3D enabled
especially in the fluid-filled structures, utilizing inversion as visualization of ambiguous genitalia that were missed on 2D
well as other 3D modalities. evaluation (Merz et al. 1999). Several studies (Naylor et al.
2001; Cafici and Iglesias 2002; Verwoerd-Dikkeboom et al.
2008; Abu-Rustum and Chaaban 2009) have looked at the
role of 3D sonography in cases of ambiguous genitalia. The
Areas in the Genitourinary
consensus is that 3D is not diagnostic in cases of ambigu-
Tract that may be Evaluated
ous genitalia but it does help in clarification to the family.
by Volume Sonography
Having a multiplanar volume available enables detailed off-
1. Gender assignment line re-evaluation (Abu-Rustum and Chaaban 2009), looking
2. Renal pelvis volumetry for certain signs such as the tulip sign (Figure 14.3 and 14.4),
3. Fetal urine production which is diagnostic in cases of hypospadias. Two recent stud-
4. Other areas in the genitourinary system ies have looked at 3D planes and modes of display to enhance
the diagnostic ability of gender assignment. Lev-Toaff et al.
reported on using 3D to obtain a true mid-sagittal plane from
stored volumes. The true mid-sagittal plane generated was
Gender Assignment subsequently used to see whether the penis was pointing in
a caudal (male) or rostral (female) direction between 10 and
Fetal gender assignment (Figure 14.1 and 14.2) may prove to 24 weeks (Lev-Toaff et al. 2000). Jouannic et al. reported on
be difficult especially in the first trimester. The importance utilizing VCI while looking at the pelvis of 38 female fetuses
Figure 14.1 3D examina-

tion of external genitalia. (A)
A 3D volume of the external
genitalia of a 33w4d female
fetus rendered using surface
rendering. The labia majora
can be depicted with great
clarity. (B) A similar volume
of a 21w3d fetus displayed
using HDlive. A B
125
A B
Figure 14.2 3D examination of the external genitalia. (A) A 3D volume of the external genitalia of
a 27w0d male fetus rendered using surface rendering. The scrotum and penis can be depicted with great
clarity. (B) The volume is now displayed using HDlive.
EG
A B
Figure 14.3 3D examination of ambiguous external fetal genitalia (EG). (A) A 3D volume of the exter-
nal genitalia of a 34w5d fetus displayed using surface rendering with HDlive. The 2D image in plane A
depicts the “tulip” sign described in hypospadius. The 3D surface-rendered image was highly suggestive
of swollen labia in a female fetus. (B) A close-up of the external genitalia. This fetus was a live born male
with hypospadias.
EG
A B
Figure 14.4 A 22w3d fetus with multiple anomalies. (A) A 3D volume of ambiguous external genitalia
(EG) is acquired and displayed using surface rendering. (B) The Volume is manipulated by adjusting the
size of the render box and rotating along the three axes. Surface rendering is used, depicting seemingly
female external genitalia. However, postmortem this was a male fetus with hypospadias and a bifid scrotum.
Clinical Applicability in the Fetal Genitourinary System 127
at 20–22 and 32–34 weeks in an attempt to further enhance Fetal Urine Production
the endometrial visualization. The VCI mode clarified the
distinction between the uterus and rectum (Jouannic et al. The amniotic fluid index may be measured in several ways,
2005). and the importance of quantifying the amniotic fluid lies in
its ability to indicate adequate fetal vascularization, in the
absence of fetal hypoxia, reflected by good urine production.
Utility of Volume Sonography in However, the amniotic fluid is not made up entirely of urine,
the Evaluation of Fetal Gender and there have been various attempts at quantifying the
1. Clarifying ambiguous genitalia amount of fetal urine production more accurately, an area in
2. Utilizing the mid-sagittal plane for first- which volume sonography has played a role. Lee et al. exam-
trimester sex determination ined 154 fetuses, between 24 and 40 weeks, and employed
3. Utilizing VCI for the clarification of the VOCAL in order to measure the fetal bladder volume two
endometrial stripe to three times within a 5–10 minute period. The mean fetal
bladder volume was plotted against the gestational age. This
may be an alternative method for quantifying the amniotic
fluid index, and it may aid in signaling fetal hypoxia (Lee
Renal Pelvis et al. 2007). Similarly, Yamamato et al. looked at fetal urine
production using VOCAL in 106 twin-to-twin-transfusion
Hydronephrosis (Figure 14.5) is a marker for chromosomal syndrome cases, pre- and post-laser, to determine how it cor-
aberrations and exists in a continuum of gradations. It may be related with umbilical venous volume flow. The conclusion
benign or it may signal underlying renal disease, from uret- was that urine production is a useful tool in assessing the
ropelvic junction obstruction in its varying degrees, to reflux. severity of twin-to-twin-transfusion syndrome (Yamamato et
Measuring the anteroposterior diameter of the renal pelvis al. 2007).
has been the gold standard, but with the advent of volume
sonography, the volume of the renal pelvis can now be mea-
sured. Duin et al. succeeded in measuring the volume of the
fetal renal pelvis in 15 fetuses and found it feasible and repro- Utility of Volume Sonography
ducible, but in need of comparison to the standard antero- in the Evaluation of Fetal
posterior measurement to determine its clinical utility (Duin Urine Production
et al. 2008). In addition, the inversion mode may be of great 1. Quantifying urine production
use in mapping out the entire pelvis and calyceal system in
cases of hydronephrosis (Table 14.1; Figures 14.6–14.8) and
in creating a true cast of the calyceal system.
Utility of Volume Sonography in

the Evaluation of the Renal Pelvis
1. Calculating the volume of the renal pelvis
2. Mapping the architecture using inversion * P
mode
Figure 14.5 A 3D volume of the left kidney of a 34w1d fetus

with hydronephrosis. Using the inversion mode and adjusting the *
threshold, it is possible to generate a “cast” of the renal pelvis (P)
*
and calyceal system (*). It would be possible to utilize VOCAL as
well for volume calculation.
Table 14.1 Steps to Mapping the Fetal Renal Calyceal System

Step 1: Obtain a volume of the fetal kidneys starting from an axial plane with an angle of acquisition of at least 30 degrees
Step 2: Optimize the volume in planes A and B by rotating along the 3 axes to optimize the views of the renal pelvis (Figure 14.6)
Step 3: Select the two-pane view and render the volume using surface rendering
Step 4: Adjust the threshold to create the optimal inverted image (Figure 14.7)
Step 5: The volume may also be rendered using HDlive inversion (Figure 14.8)
*
*
*
Figure 14.6 A 3D volume of the left
kidney of a 31w4d fetus with hydrone-
phrosis (*). The volume is acquired with
an angle of acquisition of 55 degrees and
displayed in the three orthogonal planes.
Figure 14.7 This is the same volume

from Figure 14.6. Now the two-pane
* view is selected and rotation is carried
*
out along the three axes, with the region
of interest concentrated around the
kidney to be examined. The volume is
then rendered using the inversion mode
in surface rendering, as seen in panel B.
Renal pelvis (*).
Figure 14.8 The same

volume as in Figure 14.6
and 14.7. (A) The volume
is displayed using HDlive
* inversion mode. (B) The
volume is viewed in the
single-pane view, and
using MagiCut, all excess
* material obscuring the
kidney is removed for an
optimal final “cast” of
the calyceal system under
A B evaluation. Renal pelvis (*).
Clinical Applicability in the Fetal Genitourinary System 129
H
C
Figure 14.9 A 3D volume of a 15w4d

fetus with megacystis displayed using
the multiplanar mode with VCI at a slice
thickness of 2 mm. B: bladder C: chest; H:
head; S: spine.
Figure 14.10 This is the same volume

as in Figure 14.9, now being evaluated
using SonoAVC with automatic genera-
tion of the volume of the fetal bladder of
47.51 cm2.
Other Uses in the Genitourinary Tract al. used 4D sonography in a case of fetal lower urinary tract
obstruction as a guide to percutaneous cystoscopy, and this
Schild et al. reported on the use of 3D in a case of fetal meso- was the first fetal cystoscopy under 4D guidance (Ruano et al.
blastic nephroma that was initially diagnosed as a Wilms’ 2009). Volume sonography may also help in the evaluation of
tumor. The 3D imaging allowed volume calculation and a reli- the fetus with megacystis (Figures 14.9–14.11).
able estimation of the size of the mass as well as characteriza-
tion of the borders of the mass (Schild et al. 2000). Dulay et
al. reported on the use of 3D in a case of vesicorectal fistula in
cloacal dysgenesis. The 3D imaging was key in identifying the
Other Uses of Volume
bladder with the umbilical arteries, as demonstrated by color
Sonography in the Evaluation
Doppler, and in finding the connection between the bladder
of the Genitourinary Tract
and bowel by scrolling through the volume (Dulay et al. 2006).
Hsu et al. found 3D power Doppler helpful in localizing an 1. In the evaluation of tumors
aberrant renal artery arising from the iliac artery and feed- 2. In the evaluation of a fistula
ing the kidney’s inferior pole. Aberrant renal arteries may be a 3. In the evaluation of an ectopic kidney
normal variant and may arise from the aorta. In this case, com- 4. In guidance during fetal cystoscopy
bining 2D and 3D power angiography allowed the diagnosis of 5. In the evaluation of megacystis
a horseshoe kidney (Hsu et al. 2007). Most recently, Ruano et
H
C
Figure 14.11 This is the same volume from Figure 14.9. The volume is now displayed using TUI with
an interslice thickness of 3.8 mm and a VCI thickness of 2 mm, with the reference dot in the fetal bladder.
B: bladder; C: chest; H: head.
Limitations of Volume Sonography in the sonography, utilizing inversion mode as well as VOCAL,
Evaluation of the Genitourinary System aids in evaluating the fetal calyceal system in cases of hydro-
nephrosis, and may help in quantifying urine production.
The major limitation with volume sonography in the geni-
tourinary system is false diagnoses, especially in cases
of ambiguous genitalia. Therefore the examiner needs Practical Pearls
to carry out a meticulous evaluation, relying on internal
as well as external 2D findings, prior to announcing the
fetal gender to the family based solely on a 3D surface-
• In order to visualize the kidneys, OmniView
rendered image.
may be utilized commencing with an axial
plane in order to generate coronal or sagittal
views of the kidneys
Conclusion
• Inversion mode is most useful in mapping out
the fetal calyceal system
Volume sonography has several key roles in the evaluation of
• VCI is helpful in the evaluation of fetal
the fetal genitourinary system. Surface rendering aids in visu-
hydronephrosis
alizing the external genitalia; however, navigating through a
• Minimum and inversion modes are helpful in
volume, looking for other signs such as the tulip sign and the
the evaluation of the kidneys and bladder
distance between the bladder and rectum (Glanc et al. 2007),
provides more conclusive information. In addition, volume
15 3D Applications in Obstetrics
Introduction Placenta and Cord
In addition to what has already been discussed, there are con- Volume sonography can be an added benefit in several areas,
stantly emerging studies pertaining to the various applica- including evaluation of placental masses, placental localiza-
tions of volume sonography in obstetrics. The focus of this tion for suspected placenta previa (Figure 15.1), and whenever
chapter is therefore on other clinical applications of 3D ultra- there may be retained products of conception (Figure 15.2).
sound in obstetrics. Volume sonography is also helpful in ascertaining the num-
ber of cord loops (Figure 15.3) or true knots in the cord
(Figure 15.4) whenever these abnormalities are suspected.
Other Applications of Volume
Sonography in Obstetrics
1. Placenta and cord
Role of Volume Sonography in the
2. Fetal weight estimation
Evaluation of the Placenta and Cord
3. Fetal behavior
4. Review of topographic anatomy 1. Placental masses
5. Intrapartum role 2. Placental localization
3. Retained products of conception
4. Nuchal cord
5. True knot in the cord
Clinical Utility
The utility of volume sonography in various aspects of obstet-

rical sonography is now discussed, keeping in mind that new
roles are constantly undergoing assessment and evaluation.
*
Cx
A B
Figure 15.1 A 12w6d intrauterine pregnancy with a suspected placenta previa. (A) Transvaginal evaluation reveals a central previa com-
pletely covering the internal cervical os (Cx). (B) A 3D transvaginal volume of the uterus is displayed utilizing TUI at an interslice distance
of 0.8 mm, further ascertaining the central location of the placenta previa (*).
131
* *
*
*
* *
*
*
*
A B
Figure 15.2 A 3D transvaginally acquired volume of a postpartum uterus with retained products of conception (*). (A) The volume is
displayed in the multiplanar mode, clearly depicting retained placental products. (B) Surface rendering is utilized to display the volume.
The threshold and mix are adjusted to highlight the retained placental products, which are often challenging to depict with conventional 2D
sonography.
Figure 15.3 A 3D volume of a suspected entangled cord at Figure 15.4 A 3D volume of a 27w3d intrauterine pregnancy
35w6d utilizing color Doppler. Glass-body mode is used, highlight- with a true knot in the cord. The volume is displayed in the 3D CFM
ing the vascular structures and clarifying the entangled cord. mode, which highlights the vascular structure, illustrating the knot
in the cord.
3D Applications in Obstetrics 133
Estimation of Fetal Weight approach on how to calculate fetal weight from the fetal thigh
is described in Table 15.1. In a recent study by Pagani et al.,
A novel application for volume sonography, which has been its use in fetal weight estimation in mothers with gestational
studied by Lee et al. (2001b, 2009), is the use of fetal arm diabetes mellitus was found to be of comparable sensitiv-
and leg volumes to assist in the accurate estimation of fetal ity but of superior specificity in fetal weight estimation at
weight. This application has been developed into a software 34w0d–36w6d when compared to the conventional Hadlock
program currently available on certain machines. A stepwise formula for predicting fetal macrosomia (Pagani et al. 2014).
Table 15.1 Steps to Utilizing Fractional Limb Volume

Step 1: Obtain a good 2D image of the fetal thigh
Step 2: Acquire a 3D volume utilizing the surface-rendering machine preset and place the reference dot centrally along the femur (Figure 15.5)
Step 3: Select the FLV option (Figure 15.6)
Step 4: Trace the cross-sections of the fetal thigh sequentially as prompted by the program (Figure 15.7)
Step 5: Once all tracings are complete, a thigh volume (TVol) will be obtained from which the fetal weight is automatically generated (Figure
15.8)
A B
Figure 15.5 A 3D volume of a fetal thigh at 31w3d displayed in a single pane (plane of acquisition plane A) of the multiplanar mode. (A)
The original volume with the arrow pointing to the reference dot. (B) The reference dot (arrow) has now been moved to a central position
along the midpoint of the fetal femur.
Figure 15.6 The fractional limb volume

software has now been activated generating five
axial slices of the fetal thigh in order to calculate
the limb volume.
Figure 15.7 Using the area trace, the circumference of the fetal thigh is encircled sequentially in each of the five
generated volumes.
Figure 15.8 Once all five tracings are complete, the system displays the tracings in a single view with an auto-
matically generated fractional limb volume from which the fetal weight is generated.
Fetal Behavior al. 2010), attempting to identify fetuses with abnormal in

utero neurologic function. The authors employed the Kurjak
The role of volume sonography for the evaluation of the Antenatal Neurodevelopmental Test in which 4D ultrasound
fetal surface, specifically for the visualization of facial gri- was employed to score fetuses based on the presence of var-
maces and detailed limb movements, has been evaluated ious facial grimaces and movements (Figures 15.9–15.13).
by Kurjak et al. to assess fetal neurobehavior (Kurjak et
Figure 15.9 A 3D surface-rendered image of a 29w0d fetal face

with the fetal tongue sticking out.
Figure 15.10 A 3D surface-rendered image of a 21w5d fetus Figure 15.11 A 3D surface-rendered image of a 23w5d fetus
sucking his thumb. hiding its face behind both hands.
Figure 15.12 A 3D surface-rendered image of a 24w0d fetus

scratching its head.
A B
Figure 15.13 A 3D surface-rendered volume of a 30w1d fetus with open eyes. Note artifact (*) generated by fetal movement. (A) The
volume is displayed in the multiplanar mode with surface rendering. (B) The volume is rendered with HDlive.
Review of Topographic Anatomy Intrapartum Role
The role of volume sonography in the review of topographic The role of volume sonography in assessing the position
anatomy has been assessed, and it was found to be useful of the fetal head during labor has been studied by several
in the evaluation of first trimester losses. For instance, in a experts, at the forefront of which is Pilu’s group, leading to
case of a missed abortion, 3D ultrasound identified the pres- the development of the SonoVCADlabor software to monitor
ence of conjoined twins, otherwise missed by conventional fetal head progression in the birth canal during labor (Ghi et
2D ultrasound, at a challenging early point in gestation where al. 2010). It has recently been shown that there is a good cor-
the patient had presented with fetal demise (Abu-Rustum and relation between 2D and 3D sonography in the evaluation of
Adra 2007) (Figure 15.14). In addition, a study by Bromley the head-to-symphysis distance (Youssef 2013).
et al. found it to be of benefit in the evaluation of fetuses pre-
senting with first trimester demise as it helped clarify various
external structural abnormalities that were otherwise missed Limitations of Volume Sonography in Obstetrics
by 2D ultrasound (Bromley et al. 2010).
The major limitation to utilizing these various applica-
tions of 3D ultrasound in obstetrics remains the steep
learning curve, in addition to added cost of some of the
software mentioned.
Figure 15.14 A transvaginally acquired 3D surface-rendered volume of a missed abortion at

10w3d in which a round mass was seen next to the fetal head. 3D was of tremendous value in this
case of first trimester fetal demise, as it demonstrated a case of conjoined twins as seen in the
final-rendered image. H: fetal head.
The role of volume sonography has encompassed every

aspect of obstetrics including fetal organ system assessment, • When uncertain about placental location,
the study of in utero fetal behavior, placental assessment, obtain a volume and scroll through it or utilize
fetal weight estimation, topographic evaluation in the case of TUI to ascertain the distance of the placental
fetal demise, and monitoring fetal head progression during edge from the internal os
labor. The future will undoubtedly bring more applications • When in doubt concerning a knot in the cord,
integrating the benefits of volume sonography together with a volume with color Doppler may help clarify
automation. The optimized acquired 2D image remains the whether or not it is present
basis for a good 3D volume. Volume sonography will never • Even in the case of a first trimester fetal
replace conventional 2D ultrasound, but it plays an important demise, obtaining a 3D volume may prove to
complementary role. be of utility in providing an explanation as to
the cause of the demise
16 3D Applications in Gynecology
Introduction the volume using Abuhamad’s Z technique (Abuhamad et al.
2006) (Table 16.1) to obtain the perfect coronal view. This has
Traditionally, we have been limited in how we evaluate the gained momentum as an effective, cost-containing, invaluable
pelvic organs by the available transabdominal and transvagi- modality in the diagnosis of müllerian anomalies (Bocca et al.
nal routes and the angles from which we can visualize them. 2012; Bocca and Abuhamad 2013; Sakhel et al. 2013).
Using traditional 2D approaches, there are several questions
that can be posed and the two most relevant are:
1. Are the angles used to acquire the 2D images optimal? Clinical Utility
2. How feasible is it to obtain a true coronal view of the uterus?
The answers to the above questions were elegantly dis- There are many benefits to utilizing volume sonography in the
cussed by Benacerraf in her lecture “Viewing the Dark Side field of gynecology.
of the Moon” (oral communication International Society of
Ultrasound in Obstetrics and Gynecology World Congress
2004), in which she addressed these issues and how with Clinical Utility of Volume
volume sonography we may now gain access to these organs Sonography in Gynecology
through never-before-used image planes that more accurately
1. Characterizing uterine pathology
depict pelvic anatomy. The benefits of volume sonography
2. Visualizing the mid-coronal plane of the
in gynecology extend far beyond the uterus; they encompass
uterus
evaluation of the adnexa in polycystic ovaries, evaluation of
3. Counting follicles in assisted reproduction
follicles in assisted reproduction, characterization of benign
4. Differentiating ovarian from tubal pathology
ovarian cysts (Figure 16.1), differentiation of hydrosalpinx
5. Characterizing gynecologic tumors
from an ovarian cyst, evaluation of tuboovarian abscesses,
6. Enhancing the visualization in
paraovarian cysts, and gynecologic tumors. Additional infor-
sonohysterography
mation can be obtained with volume sonography when per-
7. Other utilities
forming saline infusion sonohysterography (Figure 16.2) and
hysterosalpingo-contrast-sonography (Benacerraf et al. 2005;
Bocca et al. 2012; Bocca and Abuhamad 2013; Sakhel et al.
2013). Because motion and motion artifacts are not a con- Uterine Pathology
cern, gynecological volumes can be acquired with the highest
quality, generating images with superb resolution, which are Volume sonography can provide a great deal of detail when
further enhanced when utilizing high-frequency transvaginal evaluating the endometrium and the uterus for the presence
probes. of uterine fibroids (Figure 16.3). It facilitates determining the
With volume sonography, we may also standardize the extent of their intramural extension and enables better typing
acquisition of a uterine volume and subsequently manipulate and management.
Figure 16.1 A trans-

vaginal 3D volume of a
hemorrhagic ovarian cyst is
obtained. (A) The volume is
displayed in the multiplanar
mode with surface render-
ing. (B) The final rendered
volume using HDlive is
displayed where the fibrous
mesh within the cyst is
clearly depicted. A B
139
A B
C D
Figure 16.2 A transvaginal sonohysterography with saline infusion. (A) 2D sagittal image of
the fluid-filled endometrial cavity is obtained. (B) Volume of the uterus is now acquired and is
displayed in the three orthogonal planes. (C) Rotation along the X, Y, and Z axes has been carried
out, and the single pane has been chosen. Note the catheter tip (arrow). (D) The volume is now
displayed using TUI at an interslice distance of 1.5 mm, allowing for a more comprehensive evalu-
ation of the normal endometrial cavity.
Mid-Coronal Plane of the Uterus
The mid-coronal plane of the uterus is of utmost impor-

tance, and it is inaccessible using traditional 2D sonogra-
phy. With volume sonography, the acquisition of this plane
becomes a possibility and facilitates evaluation of several
key constituents in gynecology, primarily in the evalu-
ation of müllerian anomalies. There is ample evidence
today in support of the reliable, cost-effective, safe, and
well-tolerated use of 3D ultrasound in comparison to hys-
terosalpingography in the evaluation of müllerian abnor-
malities. Utilizing Abuhamad’s Z technique (Table 16.1;
Figures 16.4–16.9) (Abuhamad et al. 2006), Bocca et al.
were able to demonstrate that 3D ultrasound is effective
and accurate when compared to hysterosalpingography, at
less cost and morbidity to the patient, for the evaluation of
müllerian anomalies (Bocca et al. 2012).
Main advantages of the mid-

coronal plane of the uterus
1. Evaluating the serosal fundus
Figure 16.3 A transabdominal 3D volume of a 10w1d intrauter- 2. Evaluating the endometrial fundus
ine pregnancy displayed using surface rendering, with a leiomyoma 3. Evaluating the lower segment
(arrows) seen abutting the gestational sac.
3D Applications in Gynecology 141
Table 16.1 Steps to Utilizing the Z Technique to Obtain the Mid-Coronal View of the Uterus
Step 1: Obtain a 3D volume of the uterus starting from the sagittal plane (Figure 16.4)
Step 3: Place the reference dot in the center of the endometrial stripe in plane A (Figure 16.6)
Step 4: Align the sagittal plane to depict the endometrial stripe as horizontally as possible in plane A by rotating along the Z axis (Figure 16.7)
Step 5: Select plane B and rotate along the Z axis in order to align the endometrial stripe horizontally (Figure 16.8)
Step 6: The mid-coronal plane will be automatically displayed in plane C and may be optimized by rotation along the Z axis (Figure 16.9)
Cx
Figure 16.4 The first step for employing the Z technique is to

obtain a transvaginal 3D volume of the uterus, commencing with
the sagittal plane. In this volume, VCI was used at a slice thickness
of 1 mm. Cx: cervix; E: endometrium.
Cx
Figure 16.5 The volume is then dis-

E
played in the multiplanar mode. Note the
position of the reference dot, which shall
be key in the subsequent steps. Cx: cervix;
E: endometrium.
Cx
Figure 16.6 The reference dot is E

then placed centrally along the endo-
metrial stripe in plane A. Cx: cervix; E:
endometrium.
Cx
E
E
Figure 16.7 Rotation along the Z axis
is then carried out in plane A to align the
endometrial stripe in as horizontal a lie as
possible. Cx: cervix; E: endometrium.
Cx
E
Figure 16.8 Plane B is then selected

E
and Z rotation is carried out to align the
endometrial stripe horizontally. This
automatically generates the coronal view
of the endometrial cavity in plane C. Cx:
cervix; E: endometrium.
A B C
Figure 16.9 Coronal view of the uterus. (A,B,C) Plane C is selected and rotation along the Z axis is then carried out to
orient the endometrial cavity in its normal anatomical position. The image threshold, transparency, and color are adjusted to
optimize the depiction of the coronal view of the uterine cavity.
Assisted Reproduction Adnexal/Gynecological Pathology
One of the greatest roles for volume sonography has been Volume sonography provides clarification of the characteris-
in assisted reproduction, particularly in tracking ovar- tics of all gynecological tumors to help differentiate benign
ian follicles. This has been facilitated through the use of from malignant tumors. By utilizing the various rendering
SonoAVC. Obtaining a 3D volume of an ovary and activat- techniques, it is possible to visualize hair within mature tera-
ing SonoAVC makes it possible to automatically color-code, tomas (Figure 16.10), excrescences (Figure 16.11), and obtain
count, and calculate the volume of all the follicles within 3D renderings to study complex vascularity. In addition, eval-
an ovary, thus facilitating optimal management of patients uating tubal pathology and differentiating tubal (Figure 16.12)
undergoing ovarian stimulation and properly timing oocyte from ovarian pathology (Figure 16.13) is greatly facilitated.
retrieval. The steps for using inversion on a cystic ovary and
SonoAVC to calculate follicular number and volume were
covered in Chapters 4 and 6 (Tables 4.2 and 6.3; Figure 4.12
and Figures 6.13–6.15).
Figure 16.10 A trans-

abdominal 3D volume of a
mature teratoma. (A) The
volume is displayed in the
multiplanar mode. Note the
hair filaments in plane A
(arrow). (B) The volume is
rendered depicting the mixed
nature of the constituents of
the cyst, with visible hair fil-
aments now having a thicker
appearance (arrow). A B
*
*
A B
Figure 16.11 A transvaginal 3D volume of an ovarian tumor is obtained. (A) The volume is displayed in the multiplanar mode. (B) The
volume is rendered using surface rendering, depicting the solid nature of the mass with excrescences (*).
*
*
O
O
A C
Figure 16.12 A transvaginal 3D volume of the right adnexa.

(A) The volume is displayed in the multiplanar mode. (B) The
* volume is displayed using TUI at an interslice distance of 1
mm, clearly demonstrating that the cystic tubular structure (*)
O is separate from the ovary (O). (C) The volume is rendered using
the minimum mode. All the above 3D modalities, together with
rotation along the three orthogonal planes, depict a tubular
structure, separate from the ovary, and thus help confirm the
B
diagnosis of a hydrosalpinx.
Figure 16.13 A transvaginal 3D volume of the adnexa displayed using inversion mode,
depicting multiple follicles in a patient with hyperstimulation syndrome.
Sonohysterography
The availability of volume sonography coupled with sonohys-

terography has had a positive impact on the evaluation of the
endometrium, and on localizing and characterizing endome-
trial polyps (Figure 16.14). The proper utilization of these two
modalities may save the patient having to undergo other more
costly procedures such as a hysterosalpingography.
Other Uses Figure 16.14 A

transvaginal 3D vol-
Localizing intrauterine devices has always been a challenge ume of the coronal
with 2D sonography and other imaging modalities are fre- view of the endome-
quently needed to determine whether an intrauterine device trial cavity displayed
has slipped or is properly placed. This is especially applica- using VCI at a slice
ble in cases of unexplained pelvic pain. However, with the thickness of 4 mm,
availability of volume sonography and proper use of the Z depicting a hyperecho-
technique, it is possible to properly ascertain the intrauterine genic central area,
device’s location using ultrasound as a single imaging modal- an endometrial polyp
ity (Figures 16.15–16.17) (Sakhel et al. 2013). (arrows).
* *
*
A B C
Figure 16.15 A transvaginal 3D volume of the endometrial cavity from two patients displayed in the coronal view, illustrating a per-
fectly placed intrauterine device (IUD) (*). (A) Final surface-rendered coronal plane of patient 1. (B) Volume of patient 2 displayed in the
three orthogonal planes and rendered with the minimum mode. (C) Final rendered image of patient 2 using minimum mode where the color
settings have been adjusted, clearly displaying the proper placement and the shape of the Cu-T 380A IUD.
*
*
Figure 16.16 Transvaginal coronal *

view of the endometrial cavity for local-
ization of an intrauterine device (IUD)
(*). (A) A slipped intrauterine device
shown using the Z technique. (B) Another
slipped intrauterine device displayed uti-
lizing VCI at a thickness of 4 mm. A B
S
*
* S
* *
A B
Figure 16.17 Transvaginal coronal view of the endometrial cavity for the localization of an intrauter-
ine device (IUD) (*). (A) Utilizing the Z technique demonstrates a uterine septum with the IUD to the left
of the septum. (B) Employing TUI at an interslice thickness of 3.1 mm and VCI at a slice thickness of 3.4
mm generates a clear depiction of the endometrial cavity, the septum (S), and the location of the IUD.
Limitations of Volume Sonography in Gynecology Practical Pearls
As described by Nelson et al., artifacts are as apparent in

volume sonography as in 2D ultrasound, and the presence of • The key to a good 3D image is a good 2D
the third dimension may compound the artifact (Nelson et al. image
2000). This is why the basic gold standard to a good 3D image • Since motion artifacts are not a concern,
remains an underlying good 2D image. Nonetheless, it must use maximal quality and a wide angle when
be kept in mind that there are limiting factors to the utility acquiring a volume of the uterus and adnexa
of volume sonography in gynecology as summarized below. • In gynecology, penetration mode, CRI (com-
pound resolution imaging), and harmonics
may be helpful
Limiting Factors to Volume • In order to surface-render the endometrium,
Sonography in Gynecology the reference box should be minimized along
1. Inability to determine uterine orientation the desired area of the endometrium and then
2. Poor rotation may show pathology in cases of surface-rendered in any of several modes
a normal uterus • For the best endometrial assessment, scan
3. An off-center tilt may also show pathology in during the secretory phase, day 14–28
cases of a normal uterus (Benacerraf oral communication 2007)
4. Often times, the cervix and uterus may not be • For performing a sonohysterography, scan
in the same plane prior to ovulation, day 5–12 (Benacerraf oral
communication 2007)
• For evaluating the postmenopausal endome-
trium, scan any time (Benacerraf oral com-
Conclusion munication 2007)
• For inversion of a fluid-filled area, such as in
The role of 3D ultrasound in gynecology has not been uti- sonohysterography or in the case of a hydro-
lized to its maximal potential, and with proper training it salpinx, optimize contrast resolution and use
is an invaluable diagnostic tool to the practicing gynecolo- the transparency mode for best image quality
gist and anyone involved in gynecological imaging. Over the
past few years, several reports have provided ample evidence
in support of its utility as a first-line modality for the diag-
nosis of uterine anomalies. Global governing bodies, at the
forefront of which is the American Institute of Ultrasound
Medicine, are advocating its use by raising awareness and
providing proper guidance and training to caregivers.
17 Coding and Entertainment Ultrasound
Introduction Coding in 3D Sonography
Volume sonography requires time and dedication to develop Although CPT codes for 3D ultrasound have been intro-
the necessary skill and to employ the various 3D modalities duced, reimbursement remains minimal and there is a con-
available. However, 2D ultrasound remains the “gold stan- sensus among global organizations such as the American
dard,” where in experienced hands its use is sufficient to Institute of Ultrasound in Medicine (AIUM) (http://www.
arrive at the most complicated diagnoses. Because of this, aium.org), the Society for Maternal-Fetal Medicine (SMFM)
billing and third-party coverage for 3D ultrasound continue (http://www.smfm.org), and the American Congress of
to face major limitations. Although the practitioner may bill Obstetricians and Gynecologists (ACOG) (http://www.acog.
for a 3D sonographic examination, reimbursement, unless for org) in North America that unless medically indicated, there
specific indications, remains minimal. should be no billing for a 3D scan. The physician may still
choose to obtain 3D images for the patient at no additional
cost. However, for certain indications where there is suffi-
Coding cient evidence of the added benefits of 3D ultrasound, it may
be possible to bill using the 3D ultrasound-specific codes
Performing a 3D examination requires costly sonographic (Table 17.3) (APS Medical Billing 2013).
equipment in addition to a steep learning curve for the prac- There are many resources available pertaining to coding in
titioner. It also requires time allocation during the examina- obstetrics and gynecology, and recent comprehensive online
tion and additional time is required for off-line analysis after
completion of the examination. With limited reimbursement,
this is a major challenge hindering the widespread use of 3D
ultrasound in obstetrics and gynecology (Ob/Gyn). Table 17.2 Various CPT Codes in Obstetrical
Sonography
CPT 76801 Transabdominal first trimester (<14w0d) fetal and
maternal evaluation of a single or first gestation. Use
Indications for Potential CPT +76802 for each additional gestation
Reimbursement in 3D Sonography CPT 76805 Transabdominal fetal and maternal evaluation (>
14w0d) of a single or first gestation. Use CPT +76810
1. Skeletal abnormalities for each additional gestation
2. Facial anomalies CPT 76811 An indication-based examination not for routine use in
3. Uterine anomalies all pregnancies. To be used once per pregnancy. Use
CPT +76812 for each additional gestation
CPT 76813 Transabdominal or transvaginal evaluation with nuchal
translucency measurement for a single or first gestation.
Coding in Ob/Gyn Sonography Use CPT +76814 for each additional gestation
CPR 76815 Limited evaluation of the fetal heartbeat, placental
There are various codes that may be used in Ob/Gyn sonog- location, fetal position, and amniotic fluid index on 1 or
raphy. Tables 17.1 and 17.2 list the major codes with their more fetuses
requirements (GE Healthcare 2011; United Healthcare 2013; CPT 76816 If 76811 did not allow a full evaluation, a focused
AIUM 2014) for the United States. reassessment may be planned and code 76816 may be
used for the follow-up examination
CPT 76817 Transvaginal evaluation with image documentation
CPT 76820 Fetal and umbilical artery Doppler velocimetry
Table 17.1 Various CPT Codes in Gynecological
CPT 76821 Fetal middle cerebral artery velocimetry
Sonography CPT 76825 Echocardiography (2D) with or without M-mode
CPT 76856 Complete pelvic, nonobstetric, real-time examination recording
with image documentation CPT 76826 Follow up or repeat to CPT 76825
CPT 76857 Limited or follow-up pelvic, nonobstetric, real-time CPT 76827 Complete Doppler echocardiography
examination with image documentation (for instance, for CPT 76828 Follow up to CPT 76827
follicular monitoring)
147
resources are available through the AIUM and other organi- Conclusion
zations (GE Healthcare 2011; United Healthcare 2013; APS
Medical Billing 2013; AIUM 2014). Despite the role of 3D ultrasound in clarifying various fetal
structural defects and its role in the evaluation of the uterine
cavity, reimbursement for an examination that requires cost-
Table 17.3 Various CPT Codes in 3D Sonography lier machines, more operator skill, and more time allocation
CPT 76376 3D rendering with post-processing interpretation; remains the greatest challenge. The practitioner must acquire
however, not requiring post-processing on a separate the needed skills during daily practice and by attending
workstation structured hands-on workshops whenever possible, in addi-
CPT 76377 3D rendering with post-processing interpretation; tion to using off-line software to gain more skill in volume
however, requiring post-processing on a separate manipulation. Various global organizations, at the forefront
workstation of which is the AIUM, through such initiatives as Ultrasound
First (http://www.ultrasoundfirst.org), are raising awareness
as to the tremendous role of ultrasound in general as a first-
line imaging modality, and to 3D ultrasound in particular as
“Entertainment Ultrasound” an indispensible diagnostic tool in gynecology. Awareness
will lead to better utilization and provide further clinical evi-
At the conclusion of this guide on volume sonography, hav- dence, ultimately leading to better reimbursement. Volume
ing discussed all the basic aspects of the various techniques sonography is here to stay despite all the obstacles. It is time
and where and how to utilize them, there must be a brief clos- to confidently incorporate it into daily clinical practice as a
ing discussion on “entertainment ultrasound.” This nonmedi- complementary modality to properly performed 2D sonog-
cal use of ultrasound, also known as “keepsake” imaging, raphy, and to maximize its potential role as an invaluable
has tainted the image of volume sonography. As the practi- tool in helping the clinicians and families better appreciate
tioner commences on incorporating volume sonography into complicated fetal anomalies. This will facilitate planning
daily clinical practice, it is critical to maintain focus on the antepartum, intrapartum, and postpartum care. Caution must
key constituents of a thorough obstetrical evaluation without be exercised against its use for non-medical purposes. This
losing sight of what is important, by misusing resources for novel method, when properly utilized, enhances the physi-
the sake of “pretty” images and perhaps falsely reassuring cian–patient relationship as well as patient-fetal bonding,
patients about the health and well-being of their fetuses. while providing reassurance and valuable information as to
Several press releases and position statements have been the health and well-being of our future generations.
issued by leading professional organizations cautioning
against the nonmedical use of ultrasound, at the forefront of
which are the AIUM and ACOG (AIUM 2002, 2004, 2005a,
2005b, 2005c, 2012; ACOG 2004). In addition, an article by Practical Pearls
Greene et al. attests to the false reassurance resulting from
keepsake imaging and presents the case of a patient whose
fetus was affected by trisomy 18 with seven key sonographic
markers present, none of which were detected by the keep- • Even though reimbursement is limited, the
sake scanner. The conflicting findings between the “enter- practitioner should practice his 3D skills at
tainment” and the “medical” sonograms were confusing for every opportunity
the family and hindered their acceptance of the fetal con- • One must be very familiar with coding and
dition (Greene and Platt 2005). Nonetheless, the consensus the indications
is that 3D sonography may serve to enhance the physician- • Caution is warranted against the non-medical
patient relationship. Therefore it may be a consideration, after use of ultrasound
the performance of a thorough obstetrical scan, to provide the • If possible, after a proper obstetrical exami-
family with nice keepsake images at the physician’s office, nation, keep-sake images of the fetus help
time and fetal position permitting, at no additional cost to the enhance the patient–physician relationship as
family, but this should be in accordance with proper medi- well as patient–fetal bonding
cal practice, while enhancing physician–patient bonding and
ensuring patient satisfaction.
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OBSTETRICS & GYNECOLOGY
This highly illustrated practical guide to 3D ultrasound covers all the

basic technical aspects necessary to incorporate it into daily clinical
practice. The text contains over 350 ultrasound images and covers basic
technical modalities and tools; it also discusses clinical applications for
various fetal anatomical structures and systems, covering both normal
and abnormal fetal development. The guide is filled with easy-to-learn
instructions for the various techniques which are presented in step-
by-step tables and corresponding images. In addition, each chapter
concludes with a table of helpful practical tips.
Reem S. Abu-Rustum, MD, FACOG, FACS, Director, Center For Advanced

Fetal Care, Tripoli, Lebanon
Reem S. Abu-Rustum
K21746
ISBN: 978-1-4822-1433-8
90000
9 781482 214338
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A Practical Guide To 3D Ultrasound

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OBSTETRICS & GYNECOLOGY

This highly illustrated practical guide to 3D ultrasound covers all the

Reem S. Abu-Rustum, MD, FACOG, FACS, Director, Center For Advanced

K21746_Cover_mech.indd All Pages 11/4/14 2:21 PM

No claim to original U.S. Government works

International Standard Book Number-13: 978-1-4822-1434-5 (eBook - PDF)

Chapter 1 Terminology and Basics........................................................................................................................................... 1

Chapter 2 Volume Acquisition.................................................................................................................................................. 9

Chapter 3 Volume Manipulation............................................................................................................................................. 13

Chapter 4 Volume Display...................................................................................................................................................... 25

Chapter 5 Spatiotemporal Image Correlation......................................................................................................................... 33

Chapter 7 Clinical Applicability in the First Trimester.......................................................................................................... 49

Chapter 8 Clinical Applicability in the Fetal Face................................................................................................................. 59

Chapter 9 Clinical Applicability in the Fetal Central Nervous System.................................................................................. 73

Chapter 10 Clinical Applicability in the Fetal Skeleton........................................................................................................... 85

Chapter 11 Clinical Applicability in the Fetal Cardiovascular System.................................................................................... 95

Chapter 12 Clinical Applicability in the Fetal Chest..............................................................................................................111

Chapter 13 Clinical Applicability in the Fetal Gastrointestinal Tract.....................................................................................117

Chapter 14 Clinical Applicability in the Fetal Genitourinary System................................................................................... 125

Chapter 15 3D Applications in Obstetrics...............................................................................................................................131

Chapter 16 3D Applications in Gynecology........................................................................................................................... 139

Chapter 17 Coding and Entertainment Ultrasound.................................................................................................................147

6W0D 8W1D 10W0D 12W4D

15W0D 18W1D 20W0D 23W0D

23W0D 33W0D B-Day!

By: Reem S. Abu-Rustum

Basic Concepts in Volume Advantages of Volume Sonography

Figure 1.2 A 3D volume of the

Figure 1.3 A 3D volume of a

with experts and over the web. With volume sonography, it

Figure 1.7 Samples of 3D sur-

Figure 1.8 A 3D volume of a 15w3d fetus displayed in skeletal mode. This

interpreted as pathology. In addition, artifacts may be a result

Pitfalls in Volume Sonography Conclusion

Figure 1.10 A 3D vol-

Figure 1.11 A 3D ren-

Figure 1.12 A 3D volume of a 27w1d fetus from which the mid-

•• Understand the main concepts of volume

Figure 1.13 A transvaginal volume of the uterus during the

Principles of Volume Acquisition

1. The target area in question in order to set the

Each of the above three prerequisites plays a factor in the

Figure 2.2 Once the volume is displayed in the multiplanar

Table 2.2 Steps to Acquiring a Volume of the Fetal Face

Conclusion Practical Pearls

The key to the success in volume sonography is in an opti-

Figure 3.1 A 3D volume of the fetal

Rotation along the X, Y, and Z Axes Scrolling through the Volume

Basic Concepts in Rotating Around Basic Concepts For Scrolling

Reference Dot Reference Dot

Size and Direction of the Region of Interest

Figure 3.13 3D volume

Figure 3.14 3D volume

Figure 3.15 This is the

Figure 3.17 3D volume of the heart of a 21w6d fetus is acquired and

Figure 3.19 Scrolling cephalad from the four-chamber view in

Figure 3.20 Commencing

Figure 3.21 Returning to the three-vessel view, the reference dot is

Figure 3.22 “Spinning”