Three-dimensional ultrasound experience in obstetrics

Ilan E. Timor-Tritscha and Lawrence D. Plattb

Purpose of review
Three-dimensional (3D) ultrasound is a natural development of
the imaging technology. Fast computers are essential to enable
3D and four-dimensional (4D) ultrasound pictures. A short
review of the technical points and clinical aspects is presented.
Our purpose is to acquaint the reader with the possibilities of
this new technology and to increase awareness of its present
clinical usefulness. A short review of technical information is
provided.
Recent findings
The advantages of 3D and 4D ultrasound in certain areas are
unequivocal. Its use in the workup of fetal anomalies involving
the face, limbs, thorax, spine and the central nervous system are
already applied by most centers.
The use of this technology in applying color Doppler, in guiding
needles for different puncture procedures as well in evaluating
the fetal heart are under close research scrutiny. The bonding
effect between the parents and their future offspring is
becoming evident as 3D ultrasound is used. Consulting
specialists understand fetal pathology better and can better plan
postnatal interventions. 4D or real time 3D ultrasound was
developed and is expected to achieve new meaning with the
planned introduction of electronic transducer multilinear arrays.
Summary
3D ultrasound is an extremely promising imaging tool to image
the fetus. In spite of the scant outcome studies the potential of
3D ultrasound is understood by a large number of obstetricians,
maternal fetal specialists and imaging specialists.
Keywords
3D ultrasound, 4D ultrasound
Curr Opin Obstet Gynecol 14:569575.

2002 Lippincott Williams & Wilkins.

a
Department of Obstetrics and Gynecology, New York University School of Medicine,
New York, New York, USA; bDepartment of Obstetrics and Gynecology, UCLA
School of Medicine, Los Angeles, California, USA

Correspondence to Ilan Timor-Tritsch, Director of OB/GYN Ultrasound, NYU School

of Medicine, New York, NY 10016, USA
Tel: +1 212 263 8610; fax: +1 212 263 8690
Current Opinion in Obstetrics and Gynecology 2002, 14:569575
Abbreviations
4D
3D
2D
ROI

four-dimensional
three-dimensional
two-dimensional
region of interest

# 2002 Lippincott Williams & Wilkins

1040-872X

DOI: 10.1097/01.gco.0000045482.15021.dc

Introduction

We live in a three-dimensional (3D) world. Binocular

vision enables us to add a third dimension to otherwise
two-dimensional (2D) pictures. It is therefore natural
that ultrasound technology started to look at the
possibility of displaying some ultrasound images in a
perceivable 3D reconstruction of an ultrasound image,
which in the 1970s required approximately 24 h calculations on a computer lling a small room. 3D ultrasound
became a reality linked to the tremendous advances of
computer speed, size and memory volume. It is now
clear that in the near future 3D technology will be
present on all (probably even on portable) ultrasound
machines. As far as real-time 3D ultrasound is concerned, at this time this technology has limited availability, but it seems that it will develop and be
increasingly used [13]. Several excellent textbooks are
available describing this promising imaging technology.

Technical information

A short review of the important but basic technical

points will be presented before the clinical aspects are
touched upon.
Acquisition methods

Acquisition of the data points is required to produce a 3D

ultrasound picture. This is done through the entire
volume of interest. Acquisition quality depends upon the
acquisition speed. A slow acquisition speed yields more
scanned slices and more volume data points and are used
in static organs (uterus, motionless fetus, etc.). Fast
acquisition speeds are adequate for moving structures
such as fetal imaging. Ultra-fast acquisition is required by
real-time imaging such as the `four-dimensional (4D)
ultrasound' technique [4]. Acquisition is currently performed using mechanical scanning devices providing
linear, tilt or rotational geometry operated by a motorized
device. This device can be incorporated in the probe
itself or added on externally to move the transducer.
Free-hand aquisition can employ one of two methods: a
position sensor (usually magnetic or the less used
acoustic and articulated area sensors) or a totally freehand method without any knowledge of transducer
position and hence the location of data points. No
measurements can be performed using this last method.
2D electronic array scanning may be commercially
available soon. A 2D array of crystals will scan the
volume by sweeping through it when the transducer is
motionless [59].
569

570 General obstetrics

In most commercially available systems the 3D volume

reconstruction is voxel-based (voxel is the smallest 3D
picture unit). This allows for each pixel (the smallest 2D
picture unit) to be placed in its correct position in the 3D
volume. This also makes it possible for the operator to
review the information repeatedly as well as displaying it
in the various rendering modalities. Measuring in the
volume becomes possible using the 3D volume reconstruction. The following companies (among several
others) employ the above technique: Aloka (Japan),
Kretz (Austria), GE (USA), Phillips (USA), Life Imaging
Systems (Canada).
Display modalities

The purpose of the display is to transform a voxel-based

information set and show it on the monitor in a 2D pixelbased data set. There are three basic display methods:
The multiplanar or orthogonal display mode

Once the volume is stored, the rst of several

available options is to display the volume in three
orthogonal planes (by denition, planes that are right
angles to each other), and this is also known as the
multiplanar display. Each plane can be moved at the
command of the operator to scroll through the volume
as needed. The `niche' mode, a subset of the
multiplanar display modes available on some systems
can also be used to scroll and navigate within the
volume and reslice it at will. In this mode, perception
of the planes is obvious and easy to understand. The
point where the three orthogonal planes intersect is
marked by a dot, which can be called the `marker
dot'. That dot marks the same point (technically the
same voxel) within the volume. Using the `marker
dot' one can pinpoint the same exact spot or structure
on the three planes that are being simultaneously
displayed.
The addition of a `third plane' to the examination (the
coronal plane evaluating the uterus, the median plane
evaluating the fetal brain, etc.) considerably increases
the chances of a thorough spatial evaluation.
Surface rendering

One of the most important display modalities is the

surface rendering. This is the feature of 3D ultrasound
that is most recognizable to the layperson and
physicians alike. For achieving `surface effect', the
volume can be rotated in all three cardinal directions.
The light mode of the surface rendering displays the
body surface (in the case of a fetal face rendering) as it
would appear if illuminated by a light source.
Different selections of ltering levels can improve
the quality of this display mode. Various opacity levels
selected by the operator can enhance the clarity of the
picture.

Transparency mode

Another display modality is the transparency mode. Here

the surface mode algorithm was combined with those of
the X-ray mode and the maximum intensity modes. By
combining these software algorithms the strong echoes
are kept and the rest is removed. In this fashion, some
subsurface structures are better displayed whereas some
soft tissue structures are eliminated.
Maximum intensity mode

This `eliminates' the echoes originating in the soft tissues

and prominently displays strong echoes. The bones of the
skeleton can be scrutinized using the display mode.
To summarize, the different display modalities enable
the operator systematically to evaluate the stored volume
by navigating in the orthogonal planes long after the
patient has left the ofce. Using the stored volume, all
the above different display modalities can be used
interchangeably.
Four-dimensional ultrasound

The difference between 3D and 4D ultrasound is the

following: 3D ultrasound is a static display of the various
reformatting techniques based upon the acquisition of a
static volume. 4D ultrasound displays a continuously
updated and newly acquired volume in any rendering
modality, creating the impression of a moving structure.
The following describes the essence of the `4D'
ultrasound examination. The examination starts in the
conventional real-time 2D mode. The user places the
region of interest (ROI) box or volume box over the
structure to be scanned, then touches the appropriate
key to initiate the acquisition mode. Once the object of
interest is displayed on the monitor, the operator holds
the probe still. The transabdominal or transvaginal
transducer automatically performs continuous and repetitive volume scanning by rapidly moving the acoustic
array within the transducer housing. At rst, a real-time
2D imaging appears on the monitor, right alongside the
continuously updated near real-time image. Once the
displayed sequences are deemed satisfactory, the operator can activate a full-screen display of the moving
surface rendering.
Some 3D/4D ultrasound machines operate at acquisition
speeds of approximately four volumes per second. This
speed renders the motion somewhat interrupted. Others
display approximately 16 volumes (or more) per second,
which makes the perceivable transition between images
more uid.
Special features of three/four-dimensional ultrasound
machines

The `cine-loop' feature permits the `play-back' of

numerous, stored consecutive images as a small movie

Three-dimensional ultrasound experience in obstetrics Timor-Tritsch and Platt 571

clip that can be stored as an AVI (Audio Video

Interleave) le. Moreover, the `cine-loop' can be stored
on a CD-ROM disk.
The capabilities of the machines extend to reformatting
the volume on the screen and using the same electronic
editing tools used for any acquired 3D or 4D volume. In
other words, the volume can be rotated, sliced, and
rendered in all the above-mentioned display formats.
The available editing tools include the electronic scalpel
and eraser and harmonic 3D imaging, which reduces
`noise', such as shadowing.

One has to remember that faster acquisition speeds are

usually used for moving objects (for example, in
scanning the fetus), whereas slower acquisition speeds
are suitable for scanning a motionless fetus or a
gynecological patient. Choosing the slower scanning
mode allows the operator to capture more tomograms or
slices, therefore enabling a better resolution of the
picture. Ultrafast acquisition is necessary for moving
structures and constantly to `update' the volume in
`near-real-time' (4D) rendering of the target structure.

Once the volume is transferred to a CD-ROM disk, the

volume can be manipulated with the aid of powerful
software programs, which by the use of a desktop or a
laptop computer duplicate all the functions available on
the main platforms of the ultrasound machines.

After the volume is in the memory the process of

reviewing the volume data begins. This is done after the
patient leaves the ofce. The volume is resliced,
rendered in the desired modality and displayed. The
different enhancing and editing tools can then be
applied to maximize the diagnostic value of the
examination.

Transducers

Advantages of three- and four-dimensional ultrasound

Most stand alone 3D/4D models accommodate all the

standard 2D probes as well as a range of dedicated 4D
transducers: abdominal (curved array 48 MHz for
obstetrics/gynecology, 25 MHz for general abdominal),
small-parts (linear array 612 MHz), transvaginal (5
9 MHz), endo-anal (610 MHz).
Finally, most 3D equipment digital imaging and
communication in medicine is compatible as required
for all ultrasound (and other medical) equipment
manufactured after the year 2000.

Clinical objectives of three-dimensional

ultrasound

The three objectives of 3D imaging are: (1) to obtain a

set of data points and store them as a volume for later
display in a multiplanar fashion; (2) to elucidate spatial
relationships between the scanned structures; and (3) to
enable linear and volumetric measurements. The end
result is an image that in certain display modes (e.g.
rendered mode) looks more like a photograph than it
does a typical 2D ultrasound image.
Clinical techniques of three-dimensional ultrasound

Beginning a 3D ultrasound examination is not unlike

the start of a conventional 2D scan. After selecting
the ROI using the volume box in the 2D image, the
user activates the volume scan. The patient should
hold her breath during the acquisition process. The
transducer sweeps the area of interest. The data set is
then stored in the machine's random access memory.
The volume is acquired by one sweep of the
transducer, and is made up of a large number of
consecutive slices placed in the machine's memory.
Usually several volumes are acquired and the best
ones are stored and archived.

It is difcult to evaluate the net effect of 3D ultrasound

on obstetric practice and on outcome. Such studies are
hard to come by and it will be some time until they are
available. However, it can be said that the pertinent
literature makes a clear promise as to the future value of
this relatively new scanning modality. Based on the
literature, the clinical applications of 3D and 4D
ultrasound can be empirically classied into three
categories: (1) 3D and 4D have proved validity for use;
(2) 3D and 4D have less convincing data or promise for
its use; (3) areas of research and data based upon a
subjective impression.
Fetal anomaly scans

Several authors compared the performance of 3D versus

2D ultrasound in detecting anomalies. A diagnostic
advantage of 3D ultrasound was found in 5164% of
cases [1041]. 3D ultrasound was found to be helpful in
detecting or signicantly adding to the detection of a wide
range of anomalies, some of which are discussed below:
Three-dimensional ultrasound in the first trimester

Some articles explored the usefulness of 3D ultrasound

over that of 2D ultrasound in obtaining a better view of
the embryo/fetus and enabling a better crownrump
length and other measurements such as measurements
of the nuchal translucency to be made. This is possible
by rotating the volume (i.e. the fetus) into the right
position for the measurements to be made [4245].
Nuchal translucency can be measured better by 3D
ultrasound than by 2D ultrasound because of the better
positioning of the fetus [46].
The central nervous system

At this time no comparative studies are available to

support the superiority of 3D ultrasound compared with

572 General obstetrics

Among the most important diagnosis that relies heavily

on 3D ultrasound is the agenesis of corpus callosum
[47,48]. 3D ultrasound enables a reconstruction of the
median plane to be made, without which the above
diagnosis with its subsets is extremely hard to make.
The other diagnosis that is or should rely on 3D
ultrasound is spina bida. Not only can the diagnosis
itself probably be made more reliably than with 2D
ultrasound, but the level of the lesion can be pinpointed
with greater precision. Although not tested yet, 4D
ultrasound may be important in the neurological assessment of lower limb mobility. Cephaloceles have been
located and described better than by 2D ultrasound [17].
The cranial sutures and fontanelles were also successfully evaluated using 3D ultrasound [18].

As far as the extremities are concerned, 3D ultrasound

is almost the ideal tool to evaluate the hands and feet.
3D ultrasound performed better than 2D ultrasound in
evaluating fetal digits (74 versus 53%) [39]. Again,
rotation of the volume was the technique that made
the difference. It is expected that real-time 3D will be
able to evaluate the function of the hand, i.e. opening
and closing of the st [38]. Ploeckinger-Ulm et al. [39]
and Budorick et al. [40] published convincing studies
of the upper as well as the lower extremities. A
problem expressed by the two studies was an inability
to study the hands and feet because of their fast
movement. 4D ultrasound may be the answer to this
concern. Lee et al. [41] reported on diagnosing
phocomelia using 3D ultrasound. Skeletal dysplasia
has also been the subject of several reports [34,41]. In
the following, the use of 3D and 4D ultrasound have
provided less convincing clinical data than 2D ultrasound.

The fetal face

The genito-urinary system

its 2D counterpart; however, it is now clear that in

correctly and expeditiously diagnosing several brain
anomalies 3D ultrasound is instrumental.

This part of the fetal body was and still is the most
documented structure in 3D ultrasound. If an adequate
picture of the face is obtained, its study can be enhanced
by rotating the reconstructed 3D image from side to side
using the `cine-loop' feature. It is estimated that starting
from the 20th to the 22nd week the fetal face can be
imaged in 7580% of cases [19,20]. A substantial amount
of literature has been published on this subject [1927].
Even though the lip and the palate are considered to be
part of the face, special consideration has been given to
these structures [11,17,19,20,22,2831]. Placing the face
in a perfect median plane using the multiplanar view or
the on-screen rotation of the reconstructed 3D face will
avoid misdiagnosis as opposed to 2D ultrasound [17]. On
a median view of the face a more precise diagnosis of
micrognathia is possible.
A diagnosis of a cleft of the palate and lip are at times
hard to make using 2D ultrasound. Using multiplanar
imaging the simultaneously evaluated orthogonal planes
will enable the hard-to-image axial planes to be seen and
in other planes the alveolar ridge and upper lip appear at
the same time.
The fetal skeleton and extremities

Using the above-described rendering features of the Xray mode and the maximum mode the bony structures
such as bones and extremities can be visualized.
Developmental anomalies of the skeleton are identied
with a high degree of reliability [15,3237]. The
vertebrae, ribs, and clavicle can be demonstrated as well
as the general appearance of the fetal body. 3D
ultrasound was instrumental in detecting a spina bida
at 10 postmenstrual weeks [37].

Merz et al. [11] reported only a small improvement in

diagnosing genito-urinary anomalies. The diagnosis of
bladder exstrophy was assisted by 3D ultrasound [20]. It
is possible to assess the volume of the fetal urinary
bladder [49]. Fetal sex can be assessed by 3D ultrasound
[50], therefore diagnosing anomalies of the genitalia is a
real possibility.
Color Doppler imaging and three-dimensional ultrasound

Although in its infancy, the use of color and power

Doppler in studies in obstetrics have concentrated upon
the placenta [5155] and to a lesser degree upon fetal
vasculature [50]. The advantage of looking at vessels
with 3D ultrasound is the possibility of observing these
vessels in their original site in the body using the
volume-rendered image as the background.
The uterine cervix in pregnancy recently became a
focus of 3D ultrasound. The logic behind this evaluation is that the cervix can be rotated in a convenient
position to evaluate its shape, length and eventual
cervical suture [5658]. 3D and 4D ultrasound have
shown promise, but insufcient good data are available
to assess fully their additional clinical advantages in the
following, although early indications are that their use is
promising.
The bonding effect

No matter how critical we may become, we must face

the reality that the most impressive feature of 3D
ultrasound is the ability of patients, their families, and
obstetricians to look at the fetal body (specically the
face). This has also given rise to some misconceptions
about the diagnostic power of 3D ultrasound, which
must change by educating users as well as patients.

Three-dimensional ultrasound experience in obstetrics Timor-Tritsch and Platt 573

Whereas some regard the bonding issue with a degree of

skepticism, certainly the sight of a moving and
irrefutably `real' baby on the screen makes a powerful
impression on both the parents-to-be and those viewing
it with them. We certainly will have to change our
attitude towards the patient needs in relating to the
moving baby on the monitor screen [59,60].
Fetal anatomy is understood much better when 3D
ultrasound pictures of normal anatomy or pathology are
shown to patients who do not comprehend well a 2D
ultrasound image. Using 3D ultrasound pictures (and the
newly introduced 4D ultrasound images) bonding sometimes seems to be spectacular if judged by the bedside
reaction of the entire family. Increased bonding may
even help patients quit abusive materials and smoking
[10,61].
Three-dimensional ultrasound and consulting specialists

In addition to a better understanding of anatomy as well as

of anomalies by the patient and her family, there is an
additional advantage of 3D ultrasound. Showing the
anomaly to a consulting specialist such as a pediatric
neurologist (brain anomaly), a urologist (distended bladder), a surgeon (gastroschisis), a plastic surgeon (cleft lip/
palate) led to more focused and objective counselling of
the pregnant mother-to-be. Specialists can better convey
management when they can rely on 3D ultrasound images
(I.E. Timor-Tritsch, personal communication).
Other three-dimensional ultrasound evaluations

Several articles have evaluated the measurements of

distance, volume and weight using 3D ultrasound
[43,58,6268]. Most of these articles claim that measurements based on 3D ultrasound are more accurate than
those obtained by 2D ultrasound.

Research

The use of 3D ultrasound techniques by Blaas and

colleagues [44,45] has added signicantly to the research
into embryos, which would not have been possible using
only 2D ultrasound.
Real-time three-dimensional ultrasound

Also called 4D ultrasound, this technology enables the

user to see fetal motion in almost real time. The time
vector (the fourth dimension) makes it possible to
perceive a rapid update of the successive individual
images displayed on the monitor at very short intervals.
This creates the impression of real-time measurement.
The larger the number of pictures per unit time that can
be seen, the more uent the movements appear.
Clinical applications of four-dimensional ultrasound

The clinical usefulness and the potential applications of

real-time 3D or 4D ultrasound have not yet been fully

established, therefore no published material is available

at this time. Several applications may, however, become
important. Fetal behavior can be studied by observing
the various body movements. Previously, the study of
behavior-focused fetal physiology was the purview of
electronic methods, such as heart rate recordings,
tocodynametric registrations of movements, and realtime 2D ultrasound. These will almost certainly be
studied anew and will prove to be more accurately
dened using the real-time 3D ultrasound method.
Looking at and recording the opening and closing of the
fetal hand as well as observing fetal tone as the building
blocks of the biophysical prole will probably now be
possible. Evaluating lower limb mobility in real time in
cases of spina bida may also be on the list of future
studies.
Near real-time 3D or 4D ultrasound will undoubtedly
enable an even closer look at various fetal anomalies in
which motion plays a signicant part. In addition, as the
acquisition of the scan or images becomes faster, it is
only a matter of time before true real-time 3D evaluation
of the fetal heart motion and anatomy will become a
reality; a subject that some researchers are already
working on.

Accurate needle placement for different

puncture procedures

For minimally invasive procedures such as biopsies,

ultrasound is a widely used method to visualize and
guide the needle during puncture. The advantage over
other imaging methods is the real-time display, quick
availability, and easy access to any desired region of the
patient. It is expected that breast biopsies will be guided
in a more precise fashion by real-time 3D guidance. New
therapy techniques such as thermal radio frequency
ablation or cryogenic procedures are increasingly being
performed in radiological practice. For all of these
applications, the accurate placement of the needle is
the most important precondition. Answering this need,
the real-time biopsy allows for real-time control of the
biopsy needle in 3D multiplanar display during the
puncture. The user will be able to see the ROI in three
perpendicular planes (coronal, sagittal and axial sections)
in real time and be able to guide the biopsy needle
accurately into the center of the lesion.

Conclusion

3D ultrasound is an extremely promising tool in imaging

the fetus. It is too early to expect well-designed outcome
studies as to its clinical effectiveness. In spite of this
shortcoming, imaging specialists in leading academic
institutions have expressed a clear interest in exploring
the advantages or disadvantages (if any) of this imaging
technique.

574 General obstetrics

It seems that in every category it presents a fair and clear

addition to classic 2D ultrasound imaging. Outcome
studies are yet to be published.
As experience with its use increases and the technology
itself evolves, it can be expected that it will nd its due
place in enhancing the efciency and accuracy of 2D
ultrasound in fetal diagnosis.
As said with the constant growth of computers, speed
and computing power, and the imminent development
of 2D array transducer technology, real-time 3D ultrasound is only a step away. Careful observations and
optimistic expectations are mandatory.

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