TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn...

70
Fetal Imaging TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn Trondheim - Norway

Transcript of TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn...

Page 1: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetal Imaging

TRONDHEIM

National Centerfor Fetal Medicine

Dept Ob & Gyn

Trondheim - Norway

Page 2: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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

Page 3: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

?Those were the days ..

Page 4: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Traditional obstetric communication with the fetus has changed

Page 5: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Sound• Infrasound (0 - 20 Hz)

• Audible sound (20 - 20kHz)

• Ultrasound > 20kHz• Diagnostic ultrasound (1 - 20 MHz)

Page 6: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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

Page 7: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Voltageimpulse

VoltageBurst

Ultrasoundpulse

Ultrasoundpulse

Sending

Receiving

Page 8: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Linear array

Weldner

Page 9: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

1990

Technical developmentUltrasound imaging of the fetal head

19951970

1960

Page 10: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetal sections

Frontal section Sagittal section Horizontal section

Page 11: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The technical developmentwill go on -Smaller objects will be imaged betterend earlier

Page 12: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Embryology of Norwegians

At 9 weeks The Norwegian usually has mono-skis

Page 13: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

A Norwegian at the routine 18 week scan

Fully developed Norwegian

Page 14: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

What makes the embryospecial?Small size

5 weeks 10 weeks

2 610 13

2030 mm

Constantly changing of appearance

Page 15: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The implantation

QuickTime™ og en-dekomprimerer

kreves for å se dette bildet.

QuickTime™ og en-dekomprimerer

kreves for å se dette bildet.

Page 16: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

4 1/2 weeks

Page 17: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The sagital folding

QuickTime™ og en-dekomprimerer

kreves for å se dette bildet.

QuickTime™ og en-dekomprimerer

kreves for å se dette bildet.

Page 18: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

6 weeks, CRL 4 mm

Page 19: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

b

c

d

a b c

d

H

H

Rh

Rh MD

H H

Lennart Nilsson 7 weeks, CRL 12 mm

Page 20: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

9 weeks, CRL 22 mm

Page 21: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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

Page 22: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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)

Page 23: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

HeartTrondheim, 2001

61/2 weeks, CRL 6 mm

Page 24: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

9 weeks; CRL 23 mm

Page 25: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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)

Page 26: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetus 13 weeks (CRL 65 mm)

QuickTime™ og enAnimation-dekomprimerer

kreves for å se dette bildet.

Page 27: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

3D scan-conversion

Regular volumeUS data

Page 28: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

For the evaluation of the small embryo by 3Dcertain demands have to be made to the ultrasound equipment

CRL 17 mm

Ultrasoundtomograms

Page 29: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

d e

a b c

Page 30: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Embryonic development from 7 - 10 weeks(Blaas et al. The Lancet 1999)

Page 31: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

QuickTime™ og enMicrosoft Video 1-dekomprimerer

kreves for å se dette bildet.

QuickTime™ og enMicrosoft Video 1-dekomprimerer

kreves for å se dette bildet.

The shape

Page 32: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The evolution of aNorwegian -

QuickTime™ og enMicrosoft Video 1-dekomprimerer

kreves for å se dette bildet.

Page 33: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Contours

Surface

Originalscan

CRL 29 mm9 weeks 6 days

Geometryvisualization

3D visualization modes

Volume

Segmentation

Anyplane slicing

Page 34: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

3D - Still limited resolution

Page 35: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

• Assessment of gestational age

• Location of the placenta• Detection of multiple

pregnancies• Detection of

developmental disorders

The fetal examination - 18 weeks

Page 36: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Invasiveprocedures

• Blood sampling• Blood transfusion• Acute drainage of fluid• Cronic drainage of fluid• Laser surgery

Page 37: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetal blood sampling

QuickTime™ og enAnimation-dekomprimerer

kreves for å se dette bildet.

Page 38: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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

Page 39: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetal blood transfusion

QuickTime™ og enAnimation-dekomprimerer

kreves for å se dette bildet.

Page 40: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Conclusion

• Fetal blood transfusion forfetal Rh-disease has over 30years been developed toperfection using ultrasound

Page 41: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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)

Page 42: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

CCALM type I

Page 43: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Chylothorax

2 catheters inserted. 22 weeks

Page 44: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

CCALM Type I

Page 45: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Chylothorax

35 weeks

Polyhydramnion

Slight upper body edema

Page 46: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Drainage of fetal chylothorax at 35 weeks

Needle tipAspiration of 115 mlcompleted

Page 47: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

2000 challenge

Twin - twin transfusion

Page 48: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Laser ablation

QuickTime™ og enAnimation-dekomprimerer

kreves for å se dette bildet.

QuickTime™ og enAnimation-dekomprimerer

kreves for å se dette bildet.

Page 49: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The perinatal team

ObstetricianPediatriccardiologist Midwife

NeurosurgeonPathologist

PregnantcouplePediatrician Pediatric

surgeonNeonatologist

Geneticist Technician

Page 50: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The fetal examination

Page 51: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

- 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

Page 52: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Sacro coccygeal teratoma

Page 53: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5
Page 54: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Future obstetricsMaternal transport of afetus rather than a sick neonate

Page 55: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Epigastric omphaloceleabdominal wall

liverascites

umbilical cord

amnion

Wharton’s jelly

peritoneum

Page 56: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Gastroschisisabdominal wall

bowel

umbilical cord

Page 57: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Gastroschisis

Page 58: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Cystic hygroma

Page 59: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

”EXIT”-procedure

EX utero Intrapartum

Treatment procedure

Page 60: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

EXIT-procedure

Page 61: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5
Page 62: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5
Page 63: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

So far - so good

Page 64: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Amniotic rupture sequence

Page 65: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

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

Page 66: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Fetal medicine•Will remain controversial

•Balance between obviously ”good”and ”bad”

Page 67: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

The development of ultrasound

Based on cooperation between technician and clinician

Technician Clinician

Page 68: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Where are we going?

• Where new technology is taking us

• Where we are taking new technology

Page 69: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5

Åbødalen - my favorite mountains

Page 70: TRONDHEIM National Center for Fetal Medicine Dept Ob & Gyn ...folk.ntnu.no/htorp/Undervisning/MEDT8002/notater/... · Trondheim - Norway. Outline of presentation ... Small size 5