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4/5/2019

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FUTURE TRENDS IN OBSTETRICAL SONOGRAPHY: LATEST MARKERS & MODALITIES

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUMDept. of Ob/Gyn, Division of MFM, University of Florida

DISCLOSURES

• I have no disclosures

LECTURE OBJECTIVES

By the end of this lecture the viewer should be able to:

• Describe the latest sonographic markers in the second trimester

• Describe the utility and limiations of various technological modalities

Present Advances in Obstetrcial Ultrasound

Latest Markers

Technological Modalities

12W2D

OBJECTIVES

Conus Medullaris

TT Ratio CSP

BCV

Prefrontal Thickness

Talipes

Placental Thickness

Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

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TETHERED SPINAL CORDCLOSED SPINA BIFIDA

www.thenextdds.com/clinicalimages.aspx?catid=612&id=4294970994

CONUS MEDULLARIS

CONUS MEDULLARIS

CM

Hypoechogenic

Traingular In Shape

Shifts cephalad with advancing gestation

Dysraphisms in 2-4/1000

Abnormal in NTD

CONUS MEDULLARIS

CM

CONUS MEDULLARIS CONUS MEDULLARIS

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Hoopman et al. Ultrasound Obstet Gynecol 2011; 38:548-552

Conus Distance (mm) = Femur Length (mm) - 8

CONUS MEDULLARIS

Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

DIGEORGE SYNDROMEANEUPLOIDIES

http://static.memrise.com/uploads/mems/output/1171765-140423151007.png

THYMUS

THYMUS AT 3VV THYMIC THORACIC RATIO

Thymus

Ao

PA

SVC

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MEAN IN DIGEORGE 0.25 TRISOMY 18 0.38, TRISOMY 21 0.40

THYMIC THORACIC RATIO 0.44THYMIC THORACIC RATIO:

TRISOMY 21 Ratio 0.45

THYMIC THORACIC RATIO:TRISOMY 18 Ratio 0.38

PA

AO SVC

THYMUS

THYMIC THORACIC RATIO

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THYMIC THORACIC RATIO:MASS

THYMIC THORACIC RATIO:MEGA THYMUS 0.57

THYMIC THORACIC RATIO:MEGA THYMUS

XRAY COURTESY of LINDA DAOU, MD

RECENTLY…

Chaoui et al. Prenatal Diagnosis 2016; 36: 1-5


FETUS WITH DiGEORGE

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FETUS WITH DiGEORGE

Thymic/Thoracic Ratio 16.3/33.4=0.49

FETUS WITH DiGEORGE

*


Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

TOTAL ANOMALOUSPULMONARY VENOUS RETURN

Wikipedia.org

PULMONARY VEINS LEFT BRACHIOCEPHALIC VEIN

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LBCV 21W6D

BCV

BCV

BCV

LBCV 21W6D

Sinkovskaya et al, Ultrasound Obstet Gynecol 2012; 40: 542-548

LBCV 21W6D

CV

pv

pv

pvpv

*

L

R

L

R

4 CHAMBER VIEW26W3D

Images adapted from Mahmoud et al. ePoster AIUM Annual Convention 2016.Schematics adapted from Abuhamad & Chaoui. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts. 3rd Edition

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L

R

AoLA

Images adapted from Mahmoud et al. ePoster AIUM Annual Convention 2016.

4 CHAMBER VIEW26W3D

*LBCV

LBCV26W3D

Images adapted from Mahmoud et al. ePoster AIUM Annual Convention 2016.Sinkovskaya et al. Ultrasound Obstet Gynecol 2012; 40: 542-548

Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

NORMAL PROFILE 26W2Dd2/d1 0.97 Vs 0.2 FOR TRISOMY 21

d1 D2

D1 Leading edge of skull to skin

D2 Skin to MM Line

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MM

NORMAL & ABNORMAL PROFILE

Normal FetusTrisomy 21

d1

d2

ABNORMAL PROFILECOURTESY OF NABIL HELOU, MD

26w6d

ABNORMAL PROFILELYMPHEDEMA

21w5d

ABNORMAL PROFILE

21w2d Trisomy 21

Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

CLUB FEET

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FOOT

Normal Foot Talipes

FOOT

58

Adapted from ‘A Practical Guide to 3D Ultrasound’. RS Abu-Rustum. CRC Press 2015

FEET

Conus Medullaris

TT Ratio CSP

BCV


Talipes

Placental Thickness

PLACENTAL THICKNESS

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LATESTTECHNOLOGICAL MODALITIES

8W3D

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation


TV RIC 6-12: ADVANTAGES

Resolution3D Capabilities

TV AT 11W3D USING RIC 6-12

TV RIC 6-12: LIMITATIONS

TV RouteIn Need of Technical SkillCost

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation


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TA LINEAR 9 MHz: ADVANTAGES

ResolutionAbdominalLow CostVirtual Convex Available

LINEAR 9 MHz PROBEKIDNEY: WITHOUT AND WITH

31w1d

33w3d

LINEAR 9 MHz PROBESPINE: WITHOUT AND WITH

31w0d

LINEAR 9 MHz PROBECEREVELLUM: WITHOUT AND WITH

LINEAR 9 MHz PROBE13W1D HEART

LINEAR 9 MHz PROBE32W1D ORBITS

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LINEAR 9 MHz PROBE32W1D HEART

TA LINEAR 9 MHz: LIMITATIONS

PenetrationProbe Width

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation


76

SURFACE MODE

77


SURFACE MODE

HDlive 7W2D HDlive 8W3D HDlive 8W3D

SURFACE MODE

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SURFACE MODE


SURFACE MODE

SURFACE MODE SURFACE MODE


SURFACE MODE


SURFACE MODE

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85


SURFACE MODE

86


SURFACE MODE

87


SURFACE MODE

88


89

SKELETAL MODE

90


SKELETAL MODE

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91


SKELETAL MODE

92


SKELETAL MODE

93

OMNI VIEW

94


OMNI VIEW

95

INVERSION VERSION

96

*

*

**

*


INVERSION VERSION

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97


INVERSION VERSION

98

COMBINATION: FETAL HEART

99

HDlive/VCI

Ao

MBTV

MV

Ao

MB

MV

TV


100

INVERSION MODE

RVLV

LVOT


101

AoA

*


INVERSION MODE

102


INVERSION MODE

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103


INVERSION MODE SURFACE/TUI/VCI

Loss of normal off-setASD and VSD and HRV

CAT

Left Right

HRV


Loss of normal off-setASD and VSD seen


SURFACE/TUI/VCI LATESTTECHNOLOGICAL MODALITIES

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation

107

MINIMAL MODE


108


MINIMAL MODE

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109

MCA

MCA


MINIMAL MODE

RARA

UAUA

MINIMAL MODE

111


MINIMAL MODE

112


MINIMAL MODE

RECENTLY… SILOHUETTE

Adapted from B. Benoit ISUOG World Congress 2016

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HDlive STUDIO

Adapted from B. Benoit ISUOG World Congress 2016

AMBIGUOUS GENITALIA

Abu-Rustum, Chaaban J Ultrasound Med 2009 28: 95

Technique of Glanc J Ultrasound Med 2007 26: 563

LIMITATIONS 3D LIMITATIONS 3D

LIMITATIONS 3D

Abu-Rustums, Daou

LIMITATIONS 3D

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Cost/ReimbursementSteep Learning CurveMay Provide False ReassuranceGood 2D Remains the Gold Standard

LIMITATIONS 3D

TV 6-12 MHz

Linear 9L

3DVascular Modes

Automation


AUTOMATION IN 2D SONOGRAPHY

1- FT Automation: NT, IT

2- Automated Biometry: BPD, HC, AC and FL

•Automation1- Fetal Heart

2- Volume NT

3- EFW from Fractional Limb Volume

4- Progress in Labor

5- Future: FT Anatomic/biometric evaluation

•Automation

AUTOMATION IN 2D SONOGRAPHY

ABUHAMAD’S AUTOMATION

• Acquired volume of a structure contains all the anatomical 2D planes for a complete evaluation of this structure

• For every organ, 2D anatomical planes that are needed for a complete evaluation are organized in a constant anatomic relationship to each other.

J Ultrasound Med 2005 24: 397 J Ultrasound Med 2007 26: 501UOG 2008 31: 30

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MAIN CONCEPT

Computerized program to automatically display all2D planes that are required for a complete evaluation

of this particular organ

Obtain a volume of an organ

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AUTOMATION: FETAL HEARTVCAD ACTIVATION


AUTOMATION: FETAL HEARTVCAD ALIGNMENT


AUTOMATION: FETAL HEARTVCAD ALIGNMENT


130

LVOT

AUTOMATION: FETAL HEARTCARDIAC 1


RVOT



Stomach



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RA

SVCIVC



DAo

DA



135

S

DAo

AoA



AUTOMATION: LIMITATIONS

Machine DependentSteep Learning CurveLimited by Fetal Size, Position and Maternal BMIIntroduces a 3rd Dimension of Error

CONCLUSIONS

We are at a most exciting time in prenatal diagnosis

This is a direct result of all the technological advances

Enables us to diagnose earlier and with more certainty

There is so much to learn and stay abreast with

Tremendous need for in-depth provider and patient education

Great caution must be exercised with the introduction of allthese new modalities

THANK YOU!


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I THANK YOU FOR YOUR ATTENTION…

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