4D 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.
3D/4D Ultrason
 2D = 2 boyutlu
 3D = 3 boyutlu
 4D= 3 boyutlu canli (zamanli) real-time
goruntu
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 onemlidirnoral tup defekti, omfalosel, gastroskisis
 Cardiac
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American Institute of Ultrasound in medicine. Acoustic output measurement standards for diagnostic ultrasound equipment. Laurel (MD):
AIUM; 1998
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
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Stark CR et al. Short and long term risks after exposure to diagnostic ultrasound in utero. Obstet Gynecol 1984; 63; 194-200
3D/4D Ultrason
 3D popularitesi artmakta
 iU22 (Phillips), Prosound Alfa-10 (Aloka), Voluson 730 Expert (GE)
 Ortalama muayene suresi 21 dakika
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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
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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
2D/3D/4D Ultrason
 2D ultrason ve fetal fizyolojik cevap
 100 hasta
 18-24 gebelik haftasi,
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Fetal kalp atis hizi
AF dikey olcumu
Umbilical arter Doppler
Muayene suresi
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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
How Useful Is 4D Ultrasound
in Perinatal Medicine
 4D hakkinda tip literaturunde 2000 senesinden beri su ana kadar
yayinlanmis 200 makale/calisma var
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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
Martin J et al. Births; final data for 2002. Natl Vital Stat rep 2003, 52 (10):1-113
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 2D’den
daha mi iyi
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Long G et al. A comparative study of routine vs. selective fetal anomaly scanning. J Med Screen 1998; 5; 6-10
3D/4D Ultrason
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99 fetus, once 3D/4D, sonrasinda 2D
2D 54 fetus normal, 45 fetus’ta 82 anomali
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2D ve 3D/4D arasinda anomali tanisinda anlasma orani %90, intraclass correlation
coefficient, 0.834; %95 CI, 0.774-0.879
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3D/4D 2D’den 6 eksik anomali teshis etmis
 VSD (2)
 IVC blokaji
 Tetralogy of Fallot
 Bobrek
 Cystic adenmatoid malformasyon
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Dogum sonrasi tani ile karsilastirma, sensitivite/spesifisite
2D
%96 - %73
3D/4D %92 - %76
Istatistiki olarak ciddi fark yok
Goncalves L et al. What does 2 dimensional imaging add to 3D/4D obstetric ultrsound. J Ultrasound Med 2006, 25 (6); 691-9
Long G et al. A comparative study of routine vs. selecyive fetal anomaly scanning. J Med Screen 1998; 5; 6-10
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 anomalilerinde
degisiklikler
 Hata T et al. 4D ultrasound in spatiotemporal image correlation for
fetal heart visualization. J Clin Ultrasound Mayis 2008;36;4;204-7.
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 %80’i, 2D ile
karsilastirildiginda, bebegin normal oldugunun daha
inandirici oldugunu
 Fakat anksiyetenin istatistiki olarak daha dusuk olmadigi
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2014 Mart yeni yayin
Fetal Behaviour of IUGR Fetuses by 4D USG
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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
 El’in bas’a hareketi
 El’in yuz’e hareketi
 Bas retrofleksyon
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Dogum oncesi bilgi icin yararli
Fakat tedavi yoksa, gebeligin takibi degismeyecekse , yarari?
Iyi fizyolojik bilgi
4D 3D’nin canli gosterimidir, 2D’ye gore daha mi iyi?
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Andonotopo W et al. The assessment of fetal behaviour of growth restricted fetuses by 4D ultraound. J Perinatol Med 2006, 34 (6);471-8
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
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Rados C. FDA cautions against ultrasound keepsake images. FDA Consum 2004; 38 (1); 12-6
Ultrasound Research Symposium
 Nisan, 2011
 Philadelphia
 Best Research Prize
Does Ultrasound Influence the Bond between Mother and Fetus?
Serdar Ural, MD, and MFM Team
Penn State University, College of Medicine
Introduction
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.
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 mother’s
attachment towards her unborn child.
Group A and Group B both resulted in a p value
<.0001 indicating that the difference in MFA
scores before and after the ultrasound is
statistically significant.
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 mother’s feelings
for her fetus by increasing her attachment to the
fetus.
Questions 22-25, assessing prenatal care, were
analyzed individually. Question 23 was
statistically significant with a p value of .0156.
Conclusions
Table 1: Analysis of Group A maternal-fetal attachment scores (Q1-Q21)
Observations
100
Methods
Mean
0.130
100 women obtaining a routine ultrasound scan
at the Department of Maternal-Fetal Medicine at
Hershey Medical Center were recruited.
Std Deviation
0.182
Wilcoxon Signed Rank Statistic
1469.5
p value
<.0001
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 25question 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.
This study determined that 2D ultrasound
significantly increases the bond between
mother and fetus in addition to 3D and 4D
imaging.
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
<.0001
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.
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.
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
Future research: father’s 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.
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
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Kim S et al. 4D ultrasound guidance of prenatal invasive procedures. Ultrasound Obstet Gynecol 2005, 26 (6); 663-5
Maternal Obezite ve Fetal Anomali Taramasi
2D
 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
Obezite
2D
 Significant ultrasound impairment
 Visualization decreases
 Mostly cardiac and spine + others
 Suboptimal visualization
 Obezite 17%
Maternal Obezite ve Fetal Anomali Taramasi
3D/4D
 18-24 hafta
 11,000+ vaka
 Body mass index (BMI) >25
 BMI >25, >30, >40
 Sensitivite %66’dan %49, %25’lere inmis
 3D/4D yarari?
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Dashe et al. Obstetrics/Gynecology, Mayis, 2009.
3D/4D Ultrason
 4D = 3 boyutlu canli (zamanli) real-time goruntu
 4D = tomografik ultrason incelemesi
 Hacim olcumu icin ideal
 Operatif prosedurlerde daha guvenilir
 Hasta/fetus’e 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
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

Mart 2014
BPP
 Fetal hareket
=2
 Fetal tonus
=2
 Solunum
=2
 Amniyotik sivi = 2
 NST
 Toplam 10/10
=2
4D Ultrason & Davranis
 14 hareket 4D ile incelenebilir;
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Goz kapagi
Agiz
Dil
Dudak bukme
Gulumseme
Somurtma
Esneme
El’in bas’a
El’in yuze (goz, kulak, agiz)
Bas antefleksyon/retrofleksyon
Emme
Yutkunma
4D Ultrason & Davranis
 Neonatal donemdeki yuz ifadeleri incelendiginde fetal surecte 4D ile
gorulenlerle ayni oldugu tespit edilmis
 Dogum sonrasi stres’te olan bebegin yuz ifadeleri, fetal donemde
stres’te 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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Mart 2014
4D Ultrason & Davranis
 Fetal davranisin dinamik analizi, santral sinir sisteminin
maturasyonu ve gelismesi ile direk baglantilidir
 Norolojik hastaliklarin erken teshisi
4D Ultrason & Davranis
 Cok az data
 Arastirma ve dergi yayin kalitesi?
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Standart olusturmak icin cok erken
Tekrarlanabilir sonuclar gormek sart
Ornegin BPP
Yani fetal davranis sadece tibbi bilgi vermekle kalmayip psikolojik ve
emosyonel yani da var
 Yani konumuz cok yeni ve henuz gelismekte olup
literaturde temsili az
4D Ultrason
 2015
 Transvajinal 4D ile fetal kalpte trunkus arteriyosuz tanisi
 Hata T, Ultrasound Obstet Gynecol, Nisan 2015
 4D ve NT
 Kozarov, Med Preg, Nisan 2015
 Standard error, mean value, 0.027’den 0.016’a dusus
 Daha da erken ve dogru teshis
Sonuc
 4D’den elde edilen tomografik goruntuler bilgisayar
araciligiyle anatomik reconstruction’dan gecip 2D ve
3D’ye gore organlar/olcumler daha net goruntu verecek
 4D muayenesi hasta icin cok kisalacak
 Anomali ve de normal teshislerin dogruluk orani %100’e
yaklasacak
Referans
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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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Serdar Ural