TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn...
Transcript of TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn...
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Fetal Imaging
TRONDHEIM
National Centerfor Fetal Medicine
Dept Ob & Gyn
Trondheim - Norway
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Outline of presentation• Basic imaging technique• Normal sonoembryological and fetal development in 2D and 3D imaging
• The routine fetal examination at 18 weeks
• Fetal medicine
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?Those were the days ..
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Traditional obstetric communication with the fetus has changed
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Sound• Infrasound (0 - 20 Hz)
• Audible sound (20 - 20kHz)
• Ultrasound > 20kHz• Diagnostic ultrasound (1 - 20 MHz)
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Bats need ultrasound .....
Sound produced bybats is reflected fromthe walls of their cave.The echo patterns are picked up by the bat’s ears enabling them to avoid obstacles in the dark
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Voltageimpulse
VoltageBurst
Ultrasoundpulse
Ultrasoundpulse
Sending
Receiving
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Linear array
Weldner
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1990
Technical developmentUltrasound imaging of the fetal head
19951970
1960
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Fetal sections
Frontal section Sagittal section Horizontal section
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The technical developmentwill go on -Smaller objects will be imaged betterend earlier
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Embryology of Norwegians
At 9 weeks The Norwegian usually has mono-skis
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A Norwegian at the routine 18 week scan
Fully developed Norwegian
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What makes the embryospecial?Small size
5 weeks 10 weeks
2 610 13
2030 mm
Constantly changing of appearance
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The implantation
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4 1/2 weeks
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The sagital folding
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6 weeks, CRL 4 mm
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b
c
d
a b c
d
H
H
Rh
Rh MD
H H
Lennart Nilsson 7 weeks, CRL 12 mm
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9 weeks, CRL 22 mm
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The heart is relatively large compared to the body of the young embryo
0
5
10
15
20
25
30
0 10 20 30 40 50 60 70CRL
Hea
rt s
ize
%of
CR
L
CRL 6 mm
CRL 11 mm
CRL 29 mm
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Size of embryonic/fetal heart
01234
6789
10
0 10 20 30 40 50 60 70CRL (mm)
5
at 9 weeks2.6–4.8 mm
Blaas et al. 1995
+
++
+
Meandiameter(mm)
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HeartTrondheim, 2001
61/2 weeks, CRL 6 mm
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9 weeks; CRL 23 mm
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Early diagnosis10 weeks
• Acrania, anencephaly, encephalocele• Myelomeningocele• Large facial defects• Limb defects; poly-, oligodactyly• Gross body wall defects (LBWC,
gastroschisis, epigastric omphalocele)• Major heart defects (AV-commune)
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Fetus 13 weeks (CRL 65 mm)
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3D scan-conversion
Regular volumeUS data
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For the evaluation of the small embryo by 3Dcertain demands have to be made to the ultrasound equipment
CRL 17 mm
Ultrasoundtomograms
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d e
a b c
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Embryonic development from 7 - 10 weeks(Blaas et al. The Lancet 1999)
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The shape
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The evolution of aNorwegian -
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Contours
Surface
Originalscan
CRL 29 mm9 weeks 6 days
Geometryvisualization
3D visualization modes
Volume
Segmentation
Anyplane slicing
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3D - Still limited resolution
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• Assessment of gestational age
• Location of the placenta• Detection of multiple
pregnancies• Detection of
developmental disorders
The fetal examination - 18 weeks
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Invasiveprocedures
• Blood sampling• Blood transfusion• Acute drainage of fluid• Cronic drainage of fluid• Laser surgery
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Fetal blood sampling
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Fetal blood transfusions
• Direct intravascular• Umbilical vein, placental insertion• Infusion of packed cells, Hct ≥ 80%• Computer calculation of volume to be transfused• Infused volume up to 50% of fetoplacental
volume• Tranfusion velocity approx. 5 ml/min
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Fetal blood transfusion
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Conclusion
• Fetal blood transfusion forfetal Rh-disease has over 30years been developed toperfection using ultrasound
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Drainage of fluid infetal / amniotic cavities
• Single or repeated aspirations• Application of pig-tail catheter
HydrothoraxPericardial fluidThoracic tumors (CCALM)Ovarian / mesenteric cyst(Urinary tract obstruction)
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CCALM type I
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Chylothorax
2 catheters inserted. 22 weeks
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CCALM Type I
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Chylothorax
35 weeks
Polyhydramnion
Slight upper body edema
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Drainage of fetal chylothorax at 35 weeks
Needle tipAspiration of 115 mlcompleted
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2000 challenge
Twin - twin transfusion
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Laser ablation
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The perinatal team
ObstetricianPediatriccardiologist Midwife
NeurosurgeonPathologist
PregnantcouplePediatrician Pediatric
surgeonNeonatologist
Geneticist Technician
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The fetal examination
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- some conditions where antenatal diagnosis may decide between life and death
• Sacrococcygeal teratoma• Cystic hygroma of the neck• Diaphragmatic hernia• Ductus dependent CHD• Abdominal wall defects• Cystic adenomatoid malformation of
the lung
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Sacro coccygeal teratoma
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Future obstetricsMaternal transport of afetus rather than a sick neonate
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Epigastric omphaloceleabdominal wall
liverascites
umbilical cord
amnion
Wharton’s jelly
peritoneum
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Gastroschisisabdominal wall
bowel
umbilical cord
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Gastroschisis
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Cystic hygroma
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”EXIT”-procedure
EX utero Intrapartum
Treatment procedure
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EXIT-procedure
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So far - so good
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Amniotic rupture sequence
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Fetal medicine• Primarily take care of the fetal
condition, be a ”fetal doctor”• Act as the fetus’ advocate
but
• Have respect for the parents’choice
• Not ”sorting” of human beings
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Fetal medicine•Will remain controversial
•Balance between obviously ”good”and ”bad”
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The development of ultrasound
Based on cooperation between technician and clinician
Technician Clinician
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Where are we going?
• Where new technology is taking us
• Where we are taking new technology
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Åbødalen - my favorite mountains
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