4 Boyutlu Ultrasonografi

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4 Boyutlu Ultrasonografi

• Serdar H. Ural, M.D., F.A.C.O.G.
• Director, Division of Maternal Fetal Medicine
• Director, Labor and Delivery Unit
• Director, Fellowship Training Program
• Director, Obstetrical Ultrasound Suite
• Professor of Obstetrics Gynecology and
  Radiology
• Penn State University College of Medicine, U.S.A.

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3D/4D Ultrason

• 2D 2 boyutlu
• 3D 3 boyutlu
• 4D 3 boyutlu canli (zamanli) real-time goruntu

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4D Ultrason

• 2D ultrason gebelik tetkikinde kullanilan belki
  de en onemli metottur
• 3D/4D ultrasonun yayginlasmasi, gebelik
  takibinde gerekli olup olmadiginin tartismasini
  yaratmistir
• 3D/4D ultrason, bilhassa 2D ile yapilan tetkikte
  tespit edilmis bazi anomalilerin daha iyi analiz
  edilmesinde faydali oldugu gorulmustur
• Fetal vucutta protruzyon yapan anomalilerin
  tetkikinde onemlidir- noral tup defekti,
  omfalosel, gastroskisis
• Cardiac
• American Institute of Ultrasound in medicine.
  Acoustic output measurement standards for
  diagnostic ultrasound equipment. Laurel (MD)
  AIUM 1998
• .

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4D Ultrason

• Ultrasonun guvenilirligi uzun zamandan beri
  bilinmektedir
• Insan calismalarinda yan etki gorulmemistir
• Bazi hayvan deneylerinde yani etki gorulmusse de
  bu calismalar baskalari tarafindan
  tekrarlandiginda ayni sonuclar elde edilmemistir
• Bilhassa 3D/4D ultrasonda termal endeks ve de
  mekanik endeks otomatik olarak kontrol edilmekte,
  ultrason muayenesi sirasinda dokuya yayilan
  enerji miktari minimumda tutulmaktadir
• Stark CR et al. Short and long term risks after
  exposure to diagnostic ultrasound in utero.
  Obstet Gynecol 1984 63 194-200

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3D/4D Ultrason

• 3D popularitesi artmakta
• iU22 (Phillips), Prosound Alfa-10 (Aloka),
  Voluson 730 Expert (GE)
• Ortalama muayene suresi 21 dakika
• 2D mean termal indeks (TI) - 0.28, mekanik indeks
  (MI) 1.12
• 3D mean TI - 0.27, MI 0.89
• 4D mean TI - 0.24
• 3D/4D muayenesi 2.5 dakika ek
• Akustik seviye, enerji seviyesi yaklasik ayni
• Sheiner E et al. A comparison between acoustic
  output indices in 2D and 3D/4D ultrasound in
  obstetrics. Ultrasound Obstet Gynecol 2007, 29
  (3) 326-8

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2D/3D/4D Ultrason

• 2D ultrason ve fetal fizyolojik cevap
• 100 hasta
• 18-24 gebelik haftasi,
• Fetal kalp atis hizi
• AF dikey olcumu
• Umbilical arter Doppler
• Muayene suresi
• Amniyotik sivi da azalma- Istatistiki fark ()
• Fetal kalp hizinda artis- Istatistiki fark (-)
• Doppler, sure- Istatistiki fark (-)
• Akut fetal hemodinamik degisiklikler
• Ural SH, Repke J et al. Does 2nd trimester
  ultrasound effect normal fetal physiology.
• Oral Presentation, International Society of
  Ultrasound in Obstetrics and Gynecology
• Chicago, USA, Agustos 2008

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How Useful Is 3D and 4D Ultrasound in Perinatal
Medicine

• 3D/4D hakkinda tip literaturunde su ana kadar
  yayinlanmis 575 makale/calisma var, 438 tanesi
  sirf 3D/4D hakkinda
• Yuz anomalileri
• Noral tup defektleri
• Iskelet anomalileri
• Konjenital kalp defektleri
• Intrakraniyel anomaliler
• Davranis
• Kurjak A et al. How useful is d and 4D
  ultrasound in perinatal medicine. J Perinat Med
  2007, 35 (1) 10-27

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3D/4D Ultrason

• 3472 fetal anatomik tarama, 2D ve 3D
• 906 tanesinde 1-5 anomali
• 2D ile karsilastirildiginda 3D - multiplanar
  tomografik inceleme
• 70 daha avantajli
• Defektin ciddiyetinin ve de normalitenin
  degerlendirilmesinde 2Dden daha mi iyi

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3D/4D Ultrason

• 99 fetus, once 3D/4D, sonrasinda 2D
• 2D 54 fetus normal, 45 fetusta 82 anomali
• 2D ve 3D/4D arasinda anomali tanisinda anlasma
  orani 90, intraclass correlation coefficient,
  0.834 95 CI, 0.774-0.879
• 3D/4D 2Dden 6 eksik anomali teshis etmis
• VSD (2)
• IVC blokaji
• Tetralogy of Fallot
• Bobrek
• Cystic adenmatoid malformasyon
• Dogum sonrasi tani ile karsilastirma,
  sensitivite/spesifisite
• 2D 96 - 73
• 3D/4D 92 - 76
• Istatistiki olarak ciddi fark yok

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3D/4D Ultrason

• 13-34 gebelik haftalarinda
• 3D/4D ile kalp fonksyon tesbiti
• Tomografik real-time 3D
• Sistolik/diyastolik, atriyal/ventrikuler
  hemodinamik tesbit
• Anatomik anomali gorulmese de kalp anomalilerine
  bagli degisiklikler
• Hata T et al. 4D ultrasound in spatiotemporal
  image correlation for fetal heart visualization.
  J Clin Ultrasound Mayis 2008364204-7.

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3D/4D Ultrason

• The effects on maternal anxiety of 2D vs. plus
  3D/4D ultrasound in pregnancies at risk of fetal
  abnormalities A randomized study
• 4D ultrason uygulanan annelerin 80i, 2D ile
  karsilastirildiginda, bebegin normal oldugunun
  daha inandirici oldugunu
• Fakat anksiyetenin istatistiki olarak daha dusuk
  olmadigi

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3D/4D Ultrason

• 2D ve 3D/4D ultrason kullanildiginda annenin
  bebegine psikolojik bagi
• Yayinlanmis bazi calismalarda bu bagin ultrasonla
  guclendigi, ve de uzun vadede anne ve bebegin
  daha az hastaliga yakalanmasina sebep olabilecegi
  varsayilmistir
• 3D/4D ultrason daha mi etkili
• Penn State Universitesinde calisma
• Rados C. FDA cautions against ultrasound keepsake
  images. FDA Consum 2004 38 (1) 12-6

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Ultrasound Research Symposium

• Nisan, 2010
• Philadelphia
• Best Research Prize

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Does Ultrasound Influence the Bond between Mother
and Fetus? Serdar Ural, MD, and MFM Team Penn
State University, College of Medicine
Figures

• Results
• The data from the entire study population (Group
  A, 100 patients) was analyzed based on 21
  questions while the data of 35 patients (Group B)
  was analyzed based on 25 questions.
• Group A and Group B both resulted in a p value
  lt.0001 indicating that the difference in MFA
  scores before and after the ultrasound is
  statistically significant.
• Questions 22-25, assessing prenatal care, were
  analyzed individually. Question 23 was
  statistically significant with a p value of
  .0156.
• Conclusions
• The ultrasound experience is one of many major
  events that occur during pregnancy. It becomes a
  lasting memory, especially if it is the first
  pregnancy.
• This study determined that 2D ultrasound
  significantly increases the bond between mother
  and fetus in addition to 3D and 4D imaging.
• The fact that ultrasound has such a profound
  impact on the thoughts of mothers suggests that
  it can be a stepping stone to incorporate other
  aspects of prenatal care into the appointment.
• Confounding variables multiple ultrasound
  technicians and less than ideal results of
  anatomical survey.
• Future research fathers reaction to ultrasound
  experience, the effect of other patients having
  an ultrasound on the MFA, the use of ultrasound
  to prevent maternal use of alcohol and tobacco.

• Introduction
• Maternal-fetal attachment (MFA) is a new concept
  that encompasses the behaviors mothers evoke
  toward their babies.
• A handful of studies have been conducted to
  determine if fetal ultrasounds are a means for
  increasing or even inducing a mothers attachment
  towards her unborn child.
• Many studies have compared the effects of 3D and
  4D ultrasounds on MFA, however, few have
  investigated the influence of the basic 2D
  ultrasound, considering it is the most common
  type of scan used in practice.
• It is hypothesized that the ultrasound experience
  will have a positive impact on a mothers
  feelings for her fetus by increasing her
  attachment to the fetus.
• Methods
• 100 women obtaining a routine ultrasound scan at
  the Department of Maternal-Fetal Medicine at
  Hershey Medical Center were recruited.
• The 25-question survey given before and after the
  ultrasound was based on the MFA questionnaire
  developed by Cranley with additional statements
  addressing prenatal care.
• Group A (64 patients) completed a 21-question
  survey. Group B (35 patients) completed a
  25-question survey, which included 4 questions on
  prenatal care.
• The difference between the pre-ultrasound mean
  and post-ultrasound mean was analyzed by a
  nonparametric 1-sample Wilcoxon signed ranks test.

Table 1 Analysis of Group A maternal-fetal
attachment scores (Q1-Q21)
Observations 100
Mean 0.130
Std Deviation 0.182
Wilcoxon Signed Rank Statistic 1469.5
p value lt.0001
Table 2 Analysis of Group B maternal-fetal
attachment scores (Q1-Q25)
Observations 35
Mean 0.181
Std Deviation 0.208
Wilcoxon Signed Rank Statistic 198
p value lt.0001
Table 3 Analysis of prenatal care questions 22-25
Wilcoxon Statistic p value
Question 22 3 0.25
Question 23 14 0.0156
Question 24 1.5 0.5
Question 25 -1 1.0
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4D Ultrason

• Prenatal invaziv tani ve tedavisi icin 4D, 93
  fetus
• Amniosentez, amnioinfuzyon, CVS, kordosentez
• Prosedur mean 5 dakika, 100 basari
• Oligohidramniyoz, ince plasenta, ince kord
• Zaman, komplikasyon riski daha dusuk
• Kim S et al. 4D ultrasound guidance of prenatal
  invasive procedures. Ultrasound Obstet Gynecol
  2005, 26 (6) 663-5

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Maternal Obezite ve Fetal Anomali Taramasi2D

• Fetal anatomy ultrasound screening
• American Institute of Ultrasound in Medicine
  (AIUM)
• Over 25 structures
• 18-22 weeks of gestation
• Variable sensitivity
• 34-60
• Decreases with increased BMI
• Absence of markers, 80 reduction in Down
  syndrome risk
• Experience
• Standardization

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Obezite2D

• Significant ultrasound impairment
• Visualization decreases
• Mostly cardiac and spine others
• Suboptimal visualization
• Obezite 17

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Maternal Obezite ve Fetal Anomali Taramasi3D/4D

• 18-24 hafta
• 11,000 vaka
• Body mass index (BMI) gt25
• BMI gt25, gt30, gt40
• Sensitivite 66dan 49, 25lere inmis
• 3D/4D yarari?
• Dashe et al. Obstetrics/Gynecology, Mayis, 2009.

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3D/4D Ultrason

• 4D 3 boyutlu canli (zamanli) real-time goruntu
• 4D tomografik ultrason incelemesi
• Hacim olcumu icin ideal
• Operatif prosedurlerde daha guvenilir
• Hasta/fetuse yan etki kaniti yok
• 3D/4D yayinlanmis calisma sayisi az
• 2D 3D/4D su anda en faydali yontem
• Tek basina 3D/4D muayene icin yeterli veri yok

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4D Ultrason Davranis

• Bugune kadar yapilan deney ve calismalarda fetal
  davranis bicimlerinin ultrason ile incelenmesi
  sonucu fetal saglik hakkinda bilgi verip
  veremeyecegi yonundedir
• Bu calismalarda fetal davranis dendiginde el kol
  hareketlerinden tutun yuz ifade degisikligine
  kadar bircok hareket edebilen bolge ele
  alinmaktadir
• Fetal davranis incelenmesinin en iyi bilineni ve
  standart yontemi olan biyofizik profildir (BPP)
• Burda el, kol, govde gibi hareket edebilen
  bolgelerin incelenmesi sonucu evet fetus
  saglikli, ya da hayir fetus saglikli degil,
  dogurmak gerekir gibi sonuclara ulasmaktayiz

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BPP

• Fetal hareket 2
• Fetal tonus 2
• Solunum 2
• Amniyotik sivi 2
• NST 2
• Toplam 10/10

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4D Ultrason Davranis

• 14 hareket 4D ile incelenebilir
• Goz kapagi
• Agiz
• Dil
• Dudak bukme
• Gulumseme
• Somurtma
• Esneme
• Elin basa
• Elin yuze (goz, kulak, agiz)
• Bas antefleksyon/retrofleksyon
• Emme
• Yutkunma

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4D Ultrason Davranis

• Neonatal donemdeki yuz ifadeleri incelendiginde
  fetal surecte 4D ile gorulenlerle ayni oldugu
  tespit edilmis
• Dogum sonrasi streste olan bebegin yuz
  ifadeleri, fetal donemde streste olan bebegin
  ifadeleriyle benzerlik gostermekte
• Fetal noral gelisim hakkinda bilgi vermekte
• Santral sinir sisteminin gelisimi direk olarak bu
  davranislara yansir
• Spesifik hareket duzeni (SMP) mevcuttur

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4D Ultrason Davranis

• Fetal davranisin dinamik analizi, santral sinir
  sisteminin maturasyonu ve gelismesi ile direk
  baglantilidir
• Norolojik hastaliklarin erken teshisi

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4D Ultrason Davranis

• Cok az data
• Arastirma ve dergi yayin kalitesi?
• Standart olusturmak icin cok erken
• Tekrarlanabilir sonuclar gormek sart
• Ornegin BPP
• Yani konumuz cok yeni ve henuz gelismekte olup
  literaturde temsili az

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4D Ultrason

• Yani fetal davranis sadece tibbi bilgi vermekle
  kalmayip psikolojik ve emosyonel yani da var

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4D Ultrason Davranis

• Intrauterin gelisme geriligi (IUGR) oldugu
  bilinen fetuslerde fetal yuz ifadesi ve de
  vucut hareket kalitesinde degisikler oldugu
  tespit edilmis
• Bu da acaba beyin gelisiminde aksakliktan oturu
  olabilecegi teorisini gelistirmis
• Yani IUGR olan fetuslerde oksijenlenme aksakligi
  beyni etkileyip indirek yolla fetal davranisi da
  etkileyebilmektemidir?
• Bu da bize davranissal tanida yardimci olabilirmi
  sorusunu sordurtmaktadir

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Fetal Behaviour of IUGR Fetuses by 4D USG

• Fetal yuz ifadesi, vucut hareket kalitesi
• Beyin gelisiminde aksaklik?
• 50 IUGR, 50 kontrol
• Hareket duzeni tamamen farkli, hareketlerde
  farklilik
• IUGR azalmis hareket, sayi, bicim, duzen
• Elin basa hareketi
• Elin yuze hareketi
• Bas retrofleksyon
• Andonotopo W et al. The assessment of fetal
  behaviour of growth restricted fetuses by 4D
  ultraound. J Perinatol Med 2006, 34 (6)471-8

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4D Ultrason Davranis

• Anensefalik fetuste motor hareketlerde
  anormallikler
• IUGRda benzer hareket degisiklikleri

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Fetal Behaviour of IUGR Fetuses by 4D

• Dogum oncesi bilgi icin
• Iyi fizyolojik bilgi
• 4D 3Dnin canli gosterimidir, 2Dye gore daha
  iyi?
• Standart henuz yok

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4D Ultrason Davranis

• Eger tedavisi olan bir risk ise bilhassa
  biyofizik profil ile davranissal degisiklikler
  takip edilerek fetuste duzelme olup olmadigi
  gorulebilir
• Fakat bunun standart olarak kullanilmasi henuz
  erkendir
• Daha fazlaca sayida kaliteli yayin gerekmektedir
• Cok merkezli calismalara acilen ihtiyac vardir
• Bu sayede fetal norodavranis ve cocuk gelisimsel
  sonuclari normativ data elde edilerek,
  aralarindaki prediktebilite teyit edilmelidir

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3D/4D Ultrason

• 4D 3 boyutlu canli (zamanli) real-time goruntu
• 4D tomografik ultrason incelemesi
• Hacim olcumu icin ideal
• Operatif prosedurlerde daha guvenilir
• Hasta/fetuse yan etki kaniti yok
• 3D/4D yayinlanmis calisma sayisi az
• 2D 3D/4D su anda en faydali yontem
• Tek basina 3D/4D muayene icin yeterli veri yok

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Sonuc

• 2D 3D/4D rutin kullanilmasi gebelikte en
  faydali yaklasim
• Guvenilir, yan etki yok
• Anne-bebek bagi ve anne anksiyete
• 3D/4D belli anomalilerin incelenmesinde daha
  faydali
• Yumusak doku, protuzyon, kalp

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Sonuc

• 4Dden elde edilen tomografik goruntuler
  bilgisayar araciligiyle anatomik
  reconstructiondan gecip 2D ve 3Dye gore
  organlar/olcumler daha net goruntu verecek
• 4D muayenesi hasta icin cok kisalacak
• Anomali ve de normal teshislerin dogruluk orani
  100e yaklasacak

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Referans

• American Institute of Ultrasound in medicine.
  Acoustic output measurement standards for
  diagnostic ultrasound equipment. Laurel (MD)
  AIUM 1998
• Stark CR et al. Short and long term risks after
  exposure to diagnostic ultrasound in utero.
  Obstet Gynecol 1984 63 194-200
• Rados C. FDA cautions against ultrasound keepsake
  images. FDA Consum 2004 38 (1) 12-6
• Martin J et al. Births final data for 2002. Natl
  Vital Stat rep 2003, 52 (10)1-113
• Long G et al. A comparative study of routine vs.
  selecyive fetal anomaly scanning. J Med Screen
  1998 5 6-10
• Ewigman B et al. Effect of prenatal ultrasound
  screening on perinatal outcome. RADIUS study
  froup. N Engl J Med 1993 329 821-7
• Kurjak A et al. How useful is d and 4D
  ultrasound in perinatal medicine. J Perinat Med
  2007, 35 (1) 10-27
• Sheiner E et al. A comparison between acoustic
  output indices in 2D and 3D/4D ultrasound in
  obstetrics. Ultrasound Obstet Gynecol 2007, 29
  (3) 326-8
• Goncalves L et al. What does 2 dimensional
  imaging add to 3D/4D obstetric ultrsound. J
  Ultrasound Med 2006, 25 (6) 691-9
• Kim S et al. 4D ultrasound guidance of prenatal
  invasive procedures. Ultrasound Obstet Gynecol
  2005, 26 (6) 663-5
• Leung et al. The effects on maternal anxiety of
  2D vs. plus 3D/4D ultrasound in pregnancies at
  risk of fetal abnormalities A randomized study.
  Ultrasound Obstet Gynecol 2006, 28 (3) 249-54

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