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INTRODUCTION

In the past, registration of fetal movements and fetal heart rate

auscultation were the only methods of the follow-up of fetal will being. In the

last few decades, the development of new ultrasound techniques has allowed

direct visualization of the fetus in utero. 4D ultrasound has recently been

introduced in medical practice and complements 2D and 3D examination by

obtaining images in real time. 4D ultrasound allows visualization of embryonic

movements two weeks earlier than 2D ultrasound. In comparison with 2D

ultrasound, 4D ultrasound offers real benefits for fetus's assessment prenatal

condition. The most benefits of 4D ultrasound could be real time assessment of

fetal face, grimacing, breathing movements, swallowing, mouthing, isolated

eye-blinking and reveals the direction of the limbs. In a relatively short period of

time 4D ultrasound stimulated multi centric studies on fetal and even embryonic

behavior with more convincing imaging than conventional 2D ultrasound. A

large spectrum of neurological problems, such as attention-deficit/hyperactivity

disorder, schizophrenia, epilepsy, autism could be result at list in part from

prenatal neurodevelopment problems.

The fetuses with abnormal fetal behavior should be followed at least till

the age of two years when their categorization to disabling or non-disabling

cerebral palsy can be possible. It is well known that fetal movement occurs far

earlier than a mother can register it, at the end of the embryonic period. Pattern

of the movements, its quantity and quality is expanding rapidly during

pregnancy, from gross movements of the whole embryo to organized

movements and facial expressions towards the end of the pregnancy.

Understanding the relationship between fetal behavior and brain developmental

processes in different periods of gestation makes it possible to distinguish

between normal and abnormal central nervous system (CNS) development and

early diagnosis of various structural and functional abnormalities.

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HISTORY OF ULTRASOUND MACHINE (ultrasonography)

Diagnostic ultrasonography is an ultrasound-based diagnostic

imaging technique used for visualizing internal body structures

including tendons, muscels, joints, vessels and internal organs for possible

pathology or lesions. The practice of examining pregnant women using

ultrasound is called obstetric sonography, and is widely used.

In physics, 'ultrasound' refers to sound waves with a frequency too high

for humans to hear. Ultrasound images (sonograms) are made by sending a pulse

of ultrasound into tissue using an ultrasound transducer (probe). The sound

reflects (echoes) from parts of the tissue; these echoes are recorded and

displayed as an image to the operator.

Many different types of images can be formed using ultrasound. The

most well-known type is a B-mode image, which displays the acoustic

impedance of a two-dimensional cross-section of tissue. Other types of image

can display blood flow, motion of tissue over time, the location of blood, the

presence of specific molecules, the stiffness of tissue, or the anatomy of a three-

dimensional region.

Compared to other prominent methods of medical imaging,

ultrasonography has several advantages. It provides images in real-time (rather

than after an acquisition or processing delay), it is portable and can be brought

to a sick patient's bedside, it is substantially lower in cost, and it does not use

harmful ionizing radiation. Drawbacks of ultrasonography include various limits

on its field of view including difficulty imaging structures behind bone and air,

and its relative dependence on a skilled operator.

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WHAT IS AN ULTRASOUND SCAN?

An ultrasound scan sends sound waves through your womb (uterus).

These waves bounce off your baby as echoes. The echoes are then turned into an

image on a screen that shows your baby’s position and movements.

Hard tissues, such as bone, reflect the most sound waves and so make the

biggest echoes. These appear white in the image, and soft tissues appear grey.

Fluids, such as the amniotic fluid surrounding your baby, appear black. This is

because the sound waves go through them with no echoes.

The person performing the scan (sonographer) will look at these different

shades to interpret the images. Your first scan can be very exciting because it

gives you a first glimpse of your baby. Your sonographer may even print out the

image of your baby and give it to you as a keepsake. However, you will need to

ask at the start of your scan, and some hospitals charge for this service.

Although it's great to have that first photo for your baby album, the

purpose of the scan is to check how many babies you're carrying, and whether

they're developing normally. Your first scan won't be able to tell you the sex of

your baby just yet.

A first trimester scan will check that your baby's heart is beating and also

look at the basic anatomy of your baby’s head, abdominal wall and limbs.

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IS ULTRASOUND SAFE?

Ultrasound scans have been used in pregnancy for decades, and nobody

has found them to be harmful, if carried out correctly. To be on the safe side,

there are clear guidelines on the use of scans in pregnancy, which your

sonographer will follow.

Studies have found no link between ultrasound and birth weight,

childhood cancers, dyslexia or hearing.

Even so, most experts agree that scans should only be performed by a

qualified healthcare professional. Even then, scans are only recommended when

there's a clear medical reason, such as checking that your baby's developing

normally. This is why you'll probably only have a few scans during your

pregnancy.

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WHAT IS AN ULTRASOUND SCAN USED FOR?

Depending on your stage of pregnancy, scans can:

• Check that your baby has a heartbeat.

• Say whether you're pregnant with one baby or twins or more.

• Detect an ectopic pregnancy, where the embryo implants outside the

womb, usually in the fallopian tube.

• Find out the cause of any bleeding you may be having.

• Accurately date your pregnancy by measuring your baby.

• Assess your baby's risk of Down's syndrome by measuring fluid at the

back of your baby’s neck at 11 weeks plus two days to 14 weeks plus one

day (nuchal translucency (NT) scan).

• Find out why a blood screening test was abnormal.

• Help with diagnostic tests, such as CVS or amniocentesis, by showing the

position of the baby and placenta.

• Examine your baby to see if all his organs are normal.

• Diagnose most abnormalities, such as spina bifida.

• Assess the amount of amniotic fluid you have and find out where the

placenta lies.

• Measure your baby's rate of growth over several scans.

A scan may show if you are expecting a girl or a boy. But if your baby's

lying in an awkward position, it's not always easy to tell. Plus, some hospitals

have a policy of not revealing the gender of a baby.

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WHO WILL DO THE SCAN?

Sonographers are radiographers or midwives who are trained in

ultrasound. They usually have a postgraduate certificate, diploma or master's

degree in medical ultrasound, and will carry out most of your scans.

If you consent, you may also be scanned by someone who is training in

ultrasound, under the direct supervision of a qualified sonographer. Being

scanned by a trainee can be an interesting experience, as it can let you know

exactly what the sonographer is looking for during your scan.

If you need any additional, special scans, these will be carried out by a

doctor who is trained in ultrasound (fetal medicine specialist).

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HOW IS AN ULTRASOUND CARRIED OUT?

The sonographer will put some gel on your tummy and move a hand-held

device (transducer) over your skin to pick up images of your baby.

If you’re having a scan in early pregnancy, you’ll need to drink a few

glasses of water beforehand. A full bladder helps the ultrasound echoes to reach

your womb, giving the sonographer a good view of your baby.

If your baby's still deep in your pelvis, or if you're overweight, the image

won't be very clear. In this case, your sonographer may suggest a vaginal scan.

This will give a much clearer picture of your baby, especially if you're at an

early stage of pregnancy.

The vaginal transducer is long and narrow to fit comfortably inside your

vagina. The sonographer will use a cover similar to a condom and will lubricate

this with plenty of gel, so it slides in easily. She won't need to go in very deeply,

and it won't harm you or your baby in any way.

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WHEN SCANS USUALLY CARRIED OUT?

During your first trimester, you may have an early scan at about six

weeks or seven weeks. However, this will only happen if you're experiencing

problems, such as pain or vaginal bleeding.

Your first scan is likely to be a dating scan when you're between 11

weeks and 13 weeks plus six days pregnant. This will confirm your due date.

The dating scan is especially important if you're having screening tests

for Down's syndrome. This is because a correct due date is needed to make the

result accurate.

You can have a nuchal translucency (NT) scan between 11 weeks plus

two days and 14 weeks plus one day of your pregnancy, or when your baby

measures between 45mm (1.8in) and 84mm (3.3in). In most cases, this will be

combined with a blood test for increased accuracy.

In your second trimester you will be offered an anomaly scan at about 20

weeks. This is to check that your baby is developing normally.

The anomaly scan may need to be repeated at 23 weeks if the

sonographer hasn't been able to see everything she needs to assess your baby's

health. This may be if you're overweight, or if your baby was in an awkward

position at your first scan.

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In your third trimester, your doctor or midwife may recommend that you

have a growth scan between 28 weeks and 40 weeks. This will be if you

previously gave birth to a small baby are having twins have other complications,

such as diabetes or high blood pressure are pregnant with a baby who measures

smaller than expected are measuring larger than expected and your midwife

suspects that there's too much fluid around your baby

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DOES AN ULTRASOUND HURT?

An abdominal scan is usually painless except for the mild discomfort of

the transducer pressing on your tummy if you have a very full bladder. If you

are in pain, tell the sonographer. She may ask you to half empty your bladder,

which will make the examination more comfortable.

You shouldn't be asked to fill your bladder for scans in the third

trimester. At this stage, your baby is much bigger and the amniotic fluid around

him will help conduct the echoes to create the image on the screen.

Some women prefer a vaginal scan, as it's best done with an empty

bladder. There's no need to feel embarrassed, as the sonographer does these

scans every day. She’ll cover you with a sheet, and if you relax your muscles to

allow the transducer to slide in easily, it shouldn't be uncomfortable.

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DO I HAVE TO HAVE AN ULTRASOUND?

Most women in the UK have at least one scan during pregnancy, but you

don't have to have one. Scans give useful information about your pregnancy, and

most women find them reassuring. However, many abnormalities can’t be seen

on a scan, and sometimes the scan findings can cause mums to worry

unnecessarily.

If your midwife recommends a scan and you'd rather not have one, ask

her to explain her reasons. The final decision will always rest with you.

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WHAT IF THE SCAN SHOWS A PROBLEM?

It's natural to be worried if your scan suggests that there's a problem with

your baby. Sometimes a clear diagnosis can be made from the scan, such as for

spina bifida. Or the scan may show minor changes (markers) which are usually

nothing to worry about. Occasionally, though, these can be a sign of something

more serious, such as Down's syndrome.

If the sonographer finds anything unusual during the scan, she should

refer you to a doctor within 24 hours. If necessary, you'll be seen by a fetal

medicine specialist, usually within 72 hours.

Once you've been referred, the doctor may offer to carry out a further

test, such as CVS or amniocentesis. These can give you a definitive answer as to

whether or not your baby has a chromosomal abnormality such as Down's

syndrome. However, they do carry a small risk of miscarriage, which is why an

ultrasound is always done first.

If a scan reveals a serious problem, you should be given plenty of support

to guide you through all the options. Although such serious problems are rare,

some families are faced with the most difficult decision of all: whether to end

the pregnancy.

Other problems may mean a baby needs surgery, either after birth or

while in the womb. Or you may need to prepare for the possibility of your baby

needing special care when he's born. There will be a whole range of people to

support you through it, including midwives, obstetricians, pediatricians,

physiotherapists, and the hospital chaplain.

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ADVANTAGES

3D and 4D ultrasounds use sound waves to create an image of your baby

in your womb. What's different is that 3D ultrasounds create a three-

dimensional image of your baby, while 4D ultrasounds create a live video

effect, like a movie -- you can watch your baby smile or yawn.

4D scans have also been found to pick up on congenital heart diseases

more accurately.

3D scans show still pictures of your baby in three dimensions. 4D scans

show moving 3D images of your baby, with time being the fourth

dimension.

With 3D and 4D scans, you see your baby's skin rather than her insides.

You may see the shape of your baby's mouth and nose, or be able to spot

her yawning or sticking her tongue out.

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DISADVANTAGE

Not all doctors have access to 3D or 4D ultrasounds. Also, your

insurance may not cover the cost.

Drawbacks of ultrasonography include various limits on its field of view

including difficulty imaging structures behind bone and air, and its

relative dependence on a skilled operator.

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4D Ultrasound 15

4D ULTRASOUND MACHINES

(Ultrasonography)

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CLINICAL USES

3D

Imaging during surgery, radiotherapy planning

Find instruments with respect to structures in the body

Looking at structures / sections of larger structures

o eg: fetal screening, breast biopsy, carotid artery, intestine, eye,

intravascular, rectal, gynaecological

4D

Fetal screening

Echocardiography

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MATERIAL AND METHOD

The study is a prospective longitudinal study conducted in the department

of Obstetrics and Gynecology Hospital Elias for a three years period (January

2008 - December 2010). The study involved the follow-up of the fetal behavior

throughout the pregnancy for normal fetuses derived from single pregnancies.

We assessed qualitatively and quantitatively 8 types of movements during the

first trimester and 14 types of fetal movements and facial expressions during the

second trimester for 15-20 minutes. At the end of the examination we noticed a

fetal behavior according to the gestational age.

Inclusion criteria:

The study included 144 healthy pregnant women with single pregnancies

between 7-38 weeks of gestation.

The fetuses and mothers were considered "normal" after the 2D examination.

Exclusion criteria:

We excluded from the study the pregnancies with high maternal or fetal

risk (hypertension, gestational diabetes, intrauterine growth restriction (IUGR),

threatened preterm delivery, polyhydramnios, chromosomal abnormalities).

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CONCLUSION

Behaviour is closely related to fetal development and maturation

processes of the central nervous system. Widespread assessment of the fetal

movements can diagnose early many neurological diseases that have their

origins more in peri- and postnatal periods than during intrauterine period.

The identification of neurological problems during fetal life is based on

evaluation of opening of the eyes, variety of facial expression, primary reflexes

(rhythmical burst in the sucking pattern) and quality of general movements. The

identification of dynamic and static patterns of the symptoms may be helpful to

date precisely the time when the insult occurs.

The major problem in studying fetal behavior is that it requires a

significant amount of time and it has not become an ultrasound exam routine.

The bias in examination can be eliminated by use of ultrasound recordings.

Frequent use of the kanet score would bring a series of benefits and

would solve situations in which obstetricians are considered accountable for

neurological injury in the neonatal period.

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FUTURE WORK

HD Ultrasounds: 4D Imaging of Your Unborn Child is the Future

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REFERENCES

Salihagic - Kadic A, Medic M, Kurja , et al. 4D sonography in the

assessment of fetal functional neurodevelopment and behavioural paterns.

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Kurjak A, Pooh R, Tikvica A, et al. Assesment of Fetal Neurobehavior

by 3D/4D Ultasound. Fetal Neurology. 2009:222–250.

Kurjak A, Chervenak FA. Textbook of Perinatal Medicine, 2nd Edition.

2006:568–575.

Goto S, Kato Tk. Levski RA, Moreley P. Pergamon Press; Oxford-New

York: 1983. Early movements are useful for estimating the gestational

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Kurjak A, Andonotopo W, Stanojevic M, et al. Longitudinal study of

fetal behavior by 4D sonography. Ultrasound Rev Obstet Gynecol.

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Kurjak A, Azumendi G. The Fetus in Three Dimensions: Imaging,

Embryology and Fetoscopy. Informa Healthcare. 2007:375–395.

Kurjak A, Chervenak FA, Donald School Textbook of Ultrasound

Obstetrics & Gynecology by Asim Kurjak 2004. 450–462.462

Carrera JM, Chervenak FA, Kurjak A. Controversies in Perinatal

Medicine: the Fetus as a Patient. 2003

Kurjak A, Azumendi G, Vecek N, et al. Fetal hand movements and facial

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De Vries JIP, Visser GHA, Prechtl HFR. The emergence of fetal

behavior. Individual differencies and consistencies. Dev. 1988;16:85–

103. [PubMed]

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COMMENTS

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COMMENTS

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