Three- and 4-Dimensional Ultrasound

in Obstetrics and Gynecology

Proceedings of the American Institute of Ultrasound
in Medicine Consensus Conference
Beryl R. Benacerraf, MD, Carol B. Benson, MD, Alfred Z. Abuhamad, MD,
Joshua A. Copel, MD, Jacques S. Abramowicz, MD, Greggory R. DeVore, MD,
Peter M. Doubilet, MD, PhD, Wesley Lee, MD, Anna S. Lev-Toaff, MD,
Eberhard Merz, MD, Thomas R. Nelson, PhD, Mary Jane ONeill, MD,
Anna K. Parsons, MD, Lawrence D. Platt, MD, Dolores H. Pretorius, MD,
Ilan E. Timor-Tritsch, MD
Received September 6, 2005, from the Departments
of Radiology and Obstetrics and Gynecology,
Harvard Medical School, Brigham and Womens
Hospital, Boston, Massachusetts USA (B.R.B., C.B.B.,
P.M.D.); Department of Obstetrics and Gynecology,
Eastern Virginia Medical School, Norfolk, Virginia
USA (A.A.); Department of Obstetrics, Gynecology,
and Reproductive Sciences, Yale University School of
Medicine, New Haven, Connecticut USA (J.C.);
Department of Obstetrics and Gynecology, Rush
University, Chicago, Illinois USA (J.A.); Fetal
Diagnostic Center, Pasadena, California USA
(G.R.D.); Department of Obstetrics and Gynecology,
William Beaumont Hospital, Royal Oak, Michigan
USA (W.L.); Department of Radiology, Thomas
Jefferson Medical Center, Philadelphia, Pennsylvania
USA (A.L.-T.); Department of Obstetrics and
Gynecology, Krankenhaus Nordwest, Frankfurt am
Main, Germany (E.M.); Department of Radiology,
University of California, San Diego, San Diego,
California USA (T.N., D.P.); Department of Radiology,
Massachusetts General Hospital, Boston,
Massachusetts USA (M.J.O.); Department of
Obstetrics and Gynecology, University of South
Florida, Tampa, Florida USA (A.P.); Center for Fetal
Medicine and Womens Ultrasound, Los Angeles,
California USA (L.P.); and Department of Obstetrics
and Gynecology, New York University, New York,
New York USA (I.E.T.T.). Manuscript accepted for
publication September 8, 2005.
Address correspondence to Beryl R. Benacerraf,
MD, 333 Longwood Ave, Suite 400, Boston, MA
02115 USA.
Abbreviations
ACOG, American College of Obstetricians and
Gynecologists; ACR, American College of Radiology;
AIUM, American Institute of Ultrasound in Medicine; CT,
computed tomography; DICOM, Digital Imaging and
Communications in Medicine; 4D, 4-dimensional; MRI,
magnetic resonance imaging; PACS, picture archiving
and communications system; 3D, 3-dimensional; 2D,
2-dimensional
The American Institute of Ultrasound in Medicine convened a panel
of physicians and scientists with interest and expertise in 3-dimen-
sional (3D) ultrasound in obstetrics and gynecology to discuss the
current diagnostic benefits and technical limitations in obstetrics and
gynecology and consider the utility and role of this type of imaging
in clinical practice now and in the future. This conference was held
in Orlando, Florida, June 16 and 17, 2005. Discussions considered
state-of-the-art applications of 3D ultrasound, specific clinical situa-
tions in which it has been found to be helpful, the role of 3D volume
acquisition for improving diagnostic efficiency and patient through-
put, and recommendations for future investigations related to the
utility of volume sonography in obstetrics and gynecology. Key
words: fetal ultrasound; gynecologic ultrasound; obstetric ultra-
sound; 3-dimensional ultrasound; ultrasound technology.
hree-dimensional (3D) ultrasound has the poten-
tial to be a considerable advance in the armamen-
tarium of medical sonography. The qualitative
and quantitative assessment of sonographic vol-
ume data is now possible with the use of several analysis
tools, such as multiplanar imaging, surface and volume
rendering, and semiautomated volume calculation using
a technique known as virtual organ computer-aided
analysis (VOCAL).
Conceptually, the acquisition of sonographic volumes
rather than single tomographic slices provides the ability
to display information in any plane and in any orienta-
tion. This ability to image in any plane, not just the acqui-
sition plane, in real time or simultaneously in several
different planes has enormous potential for medical
diagnosis with ultrasound. Until recently, ultrasound has
lacked the capability to reconstruct images rapidly and
with high resolution, which other types of cross-sectional
2005 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2005; 24:15871597 0278-4297/05/$3.50
T
Special Report
imaging, such as computed tomography (CT)
and magnetic resonance imaging (MRI), have
enjoyed. With current clinically available equip-
ment, 3D sonographic reconstruction is fast with
high resolution, giving ultrasound the ability not
only to image in real time, which MRI and CT
cannot do, but also to be displayed in standard-
ized uniform protocols as in MRI and CT.
The American Institute of Ultrasound in
Medicine (AIUM) convened a panel of physi-
cians and scientists with interest and expertise in
3D ultrasound in obstetrics and gynecology to
discuss the current state of the art for 3D ultra-
sound and to evaluate the clinical potential of
these new capabilities.
Setting and Conference Participants
The day and a half conference was held immedi-
ately before the 2005 Annual Convention of the
AIUM, in Orlando, Florida, June 16 and 17. Four
program directors (B.R.B., C.B.B., A.Z.A., and J.A.C.)
and 10 discussants constituted the panel. Also in
attendance in the audience were representatives
from invited professional societies, including the
AIUM, American College of Obstetricians and
Gynecologists (ACOG), Society for Maternal-Fetal
Medicine, American College of Radiology (ACR),
Society of Diagnostic Medical Sonography, Society
of Radiologists in Ultrasound, World Federation
for Ultrasound in Medicine and Biology, and
American Board of Obstetrics and Gynecology, and
from commercial companies, including GE
Healthcare, Medison America, Siemens Medical
Solutions, Philips Medical Systems, and SonoSite.
The first day of the conference was devoted to
scheduled presentations from panelists about a
variety of state-of-the-art applications of 3D
ultrasound in obstetric and gynecologic ultra-
sound. Discussion periods were interspersed.
During the evening between the first and second
days, the panelists drafted a summary of the first
days discussion and outlined areas for further
discussion. During the second day, the summary
was discussed, and statements were modified on
the basis of the consensus of the panelists.
Where Are We Today? State-of-the-Art
3- and 4-Dimensional Ultrasound:
Reports From the Panelists
The literature contains many articles addressing
the use of 3D ultrasound in obstetrics and gyne-
cology.
183
Some articles have shown that, in
certain situations, volume sonography adds
diagnostic value to standard 2-dimensional
(2D) ultrasound.
49,1641,6466,79,83
Three-dimen-
sional ultrasound can also provide accurate
measurements in 3 planes with acceptable
interobserver reliability.
1014,4250
Still other arti-
cles have focused on acquiring volumes for sub-
sequent review and interpretation, in addition
to improving practice efficiency and patient
throughput.
14,15
Most articles, however, are
descriptive of new techniques for acquiring and
reconstructing 3D volumes or are presentations
of the appearances of a variety of conditions
with 3D multiplanar reconstruction and surface
and volume rendering.
1633
Although more sci-
entific studies are in progress, it remains diffi-
cult to compare 2D and 3D ultrasound because
2D imaging, by necessity, always precedes the
3D volume acquisition. Furthermore, sonogra-
phy is an operator-dependent imaging modality.
Consequently, it may be difficult to generalize
some of the results obtained by experts or
researchers to other health care providers who
use 3D diagnostic ultrasound in their clinical
practices.
To date, studies focusing on the added value of
3D capabilities to 2D ultrasound have shown that
3D volume sonography provides important diag-
nostic information for gynecologic evaluation of
uterine duplication anomalies
4,9
and for optimal
evaluation of the uterine cavity.
5
In the assess-
ment of fetal anomalies, 3D ultrasound can
enhance the prenatal characterization of con-
genital defects, such as facial and skeletal
anomalies.
7,22,23,33,79,83
These rendered images
may be especially helpful for assisting health care
providers who counsel parents about the nature,
prognosis, and postnatal management of con-
genital abnormalities.
Three-dimensional imaging of the fetal face,
either with multiplanar reconstruction or surface
rendering, is a complementary technique to 2D
sonography. For example, a single volume acqui-
sition of the fetal face can be used to reconstruct
a true midline sagittal plane, often not possible
with 2D ultrasound alone. This particular view is
important for optimal evaluation of the fetal
nasal bone or for suspected cases of microg-
nathia. Multiplanar and surface-rendered views
from volume data of the fetal face can help fur-
ther delineate a suspected cleft lip and palate or
possible orbital and mental abnormalities.
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Fetal echocardiography, using 3D ultrasound,
is practiced by some experts in fetal imaging.
These experts have used volume acquisitions to
reconstruct images of the fetal heart to show nor-
mal cardiac structures.
3440
From a sonographic
volume of the fetal heart, standardized planes of
reconstruction can be displayed. In addition,
automation can be used to display these stan-
dardized planes, diminishing operator depen-
dence. Fetal heart volumes can also be acquired
in real time and, with the use of gated technolo-
gy, can be stored as a cine loop of the cardiac
cycle. Thus, any reconstructed plane or surface-
rendered image can be displayed as a cine loop
of the cardiac cycle. Automated sequences are
now being developed to reduce operator depen-
dence for achieving these standardized cardiac
views.
3942
Three-dimensional color and power Doppler
sonography can also be used for the assessment of
extracardiac vasculature.
43
These techniques can
provide images of the placental cord insertion site,
vascular anastomoses involving fetuses with twin-
to-twin transfusion, abnormal vessels from pul-
monary sequestration, and aberrations of the
central venous system such as an interrupted
inferior vena cava with azygous venous return.
Another important role of 3D ultrasound
relates to the ability to store volume data that can
be manipulated long after the patient has left the
examination room.
78
The acquisition of sono-
graphic volumes rather than single tomographic
or 2D images allows for storage of information
that can be reconstructed in any plane or orien-
tation for interpretation. Storage of a single vol-
ume of data is quick, yet the stored volume
permits interpretation of the scanned region in
multiple planes. This obviates the need to take
multiple images of an organ in 2 different planes.
Rather, a single volume of that organ can be
saved and later reviewed in any plane at any
level, leading to improved patient throughput
and a more efficient ultrasound practice.
15
Sonographic volumes can also be transmitted
electronically from a remote site for full interpre-
tation and evaluation elsewhere, making telera-
diology ultrasound image interpretation easier
and less operator-dependent.
14,15
This capability
has the potential to increase the use of ultra-
sound in remote locations where an ultrasound
expert is not present. Furthermore, volume scan-
ning may permit standardization of image dis-
play planes in a way similar to other types of
cross-sectional imaging modalities, such as CT
and MRI.
The model of volume scanning with subse-
quent review has been tested in 2 centers. In the
first, obstetric scans were performed using vol-
ume acquisitions for the fetal structural survey.
In less than 2 minutes, 5 volumes of the fetus
were obtained. Subsequent review of the vol-
umes yielded complete fetal surveys in 90% of
cases.
15
Another site replaced static 2D image
acquisition with volume scanning, reducing
scanning time from an average of 15 minutes to
4 minutes, improving efficiency such that 20%
more patients could be scanned in a day. In
addition, less hands-on scanning was required
of interpreting physicians because the physi-
cians had full volumes of information, allowing
them to do virtual sweeps through the entire
volume, if needed (M. ONeill, personal commu-
nication).
Three-dimensional ultrasound can improve
the accuracy of length, area, and volume mea-
surements.
43
Various strategies have been used,
from full manual outlining of structures to semi-
automatic and fully automatic algorithms that
segment organs and structures for analysis.
Currently, there is still a need for improved auto-
mated segmentation algorithms for such mea-
surements to be clinically useful. Ultrasound
poses challenges in developing robust algo-
rithms; however, advances in image processing
should improve the situation in the future.
Three-dimensional ultrasound has been used to
measure bladder volume,
44,45
the endometrium,
and masses
4752
and to estimate the weight of
fetal organs (eg, brain, lungs, and liver).
Some studies suggest that patients who are
undergoing volume sonography and viewing the
3D and 4-dimensional (4D) images report
enhanced bonding with their fetuses and more
positive feelings about the experience than do
patients having 2D sonography, although the
overall satisfaction from the ultrasound exami-
nation remains high with both 2D and 3D/4D
imaging.
53
In some nonmedical settings, 3D
ultrasound is used to provide keepsake images of
the developing fetus for the parents.
Bioeffects must also be considered for volume
sonography. Ultrasound is a form of energy. It
has 2 major effects in tissues it traverses: heating
and mechanical bioeffects. Such effects have
been shown in vitro and in animals at intensities
equivalent to those used in clinical situations.
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Benacerraf et al
Epidemiologic studies have not shown harmful
effects of 2D ultrasound in humans with the use
of indicated diagnostic ultrasound. Because 3D
and 4D ultrasound uses computer reconstruc-
tions of 2D images obtained through sweeps
across the organ of interest, the level of energy is
not higher than in 2D scanning. Manipulations of
the volumes obtained are performed offline or on
the ultrasound machine after the patients scan is
completed, therefore resulting in no additional
exposure to ultrasound. The studies evaluating
volume acquisitions for subsequent interpreta-
tion suggest that this new scanning method has
the potential to decrease scanning time, which is
likely to decrease exposure. Conversely, constant
scanning, such as might occur with 4D scanning
to observe fetal movement over time, could
potentially return exposure to 2D levels or more.
As with 2D ultrasound, adherence to the ALARA
(as low as reasonably achievable) principle
should be respected with 3D and 4D ultrasound.
76
Panel Discussion
I. Definitions and Summary Statements
The panelists thought it was important to list
some definitions and statements related to 3D
ultrasound in obstetrics and gynecology. They
are as follows:
1. Three-dimensional ultrasound, or volume
sonography, is an imaging technology that
involves acquisition of a series of 2D images
covering a volume from a patient that may be
displayed in different orientations after the
acquisition.
2. Three-dimensional ultrasound, or volume
sonography, may be acquired and displayed
over time. This is variously known as 4D
ultrasound, real-time 3D ultrasound, and live
3D ultrasound.
3. When used in conjunction with 2D ultra-
sound, 3D ultrasound has added diagnostic
and clinical value for select indications and
circumstances in obstetric and gynecologic
ultrasound.
4. Volumetric acquisition of sonographic data
with subsequent offline review and interpre-
tation has the potential to improve patient
throughput, efficiency of clinical practice,
and teleimaging interpretation.
II. Examples of Clinical Utility of 3D and 4D
Ultrasound
Panelists agreed that 3D ultrasound is not yet
widely used on a routine basis. It has been shown
to be a problem-solving tool in selected circum-
stances and may well become a part of many
obstetric and gynecologic ultrasound examina-
tions in the future. The role of 3D ultrasound is
still being evaluated in many areas. Panelists
thought that it was important to list examples of
some areas in which members of the panel have
found 3D ultrasound to be helpful.
5475,79,83
This
list in no way is intended to be all-inclusive or
exclusive, nor is it a current standard of care in
the conditions listed:
I. Gynecology
1. Assessment for congenital anomalies of
the uterus;
2. Evaluation of the endometrium and uter-
ine cavity with or without saline infusion
sonohysterography;
3. Mapping of myomata for planning
myomectomy;
4. Cornual ectopic pregnancies;
5. Intrauterine device location and type;
6. Imaging of adnexal lesions, to distinguish
ovarian from tubal origin and ovarian
from uterine origin;
7. Abscess drainage in the pelvis and abdomen;
8. Three-dimensional guidance in interven-
tional procedures for infertility; and
9. Evaluation and monitoring of patients
with infertility, including patients with
polycystic ovaries and tubal occlusion.
II. Obstetrics
1. Facial anomalies (eg, cleft lip and palate,
micrognathia, abnormal midline profile,
and genetic syndromes);
2. Nasal bone;
3. Ears;
4. Central nervous system (eg, agenesis of
the corpus callosum and Dandy-Walker
malformation);
5. Cranial sutures;
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6. Thorax (eg, rib evaluation, intrathoracic
masses, and lung volumes);
7. Spine (eg, level of neural tube defect and
vertebral abnormalities);
8. Extremities (eg, clubfeet, amputation
defects, and skeletal dysplasia);
9. Heart (eg, conotruncal anomalies and
evaluation of normal anatomy);
10. Placenta (eg, vasa previa) such as to deter-
mine the relationship of the vessel to the
internal os;
11. Visual depiction for reassurance or
demonstration of an abnormality for con-
sulting clinicians and patients;
12. Extent of anomalies, such as cystic hygro-
ma;
13. Multiple gestations (eg, conjoined twins
and vascular mapping for twin-twin
transfusion); and
14. Umbilical cord (eg, cord insertion sites or
cord knots).
III. Telemedicine and Offline Image Review
1. Storing of volumes for subsequent review
and interpretation;
2. Central monitoring of data for quality and
accuracy in remote clinical sites and in
multicenter research studies; and
3. Telemedicine and offline image review on
an independent workstation.
IV. Education
1. Teaching standardized views and post-
processing techniques for training; and
2. Teaching normal and abnormal anatomy
using volumes as simulated scans.
Where Do We Go Next?
Panelists thought that it is important to educate
and train the medical community on the utility
and functionality of 3D ultrasound as part of
working toward general acceptance of 3D ultra-
sound as a component of the imaging arma-
mentarium in obstetrics and gynecology.
How Do We Get There?
The panelists outlined key steps toward improv-
ing and promoting the clinical acceptance of 3D
ultrasound for diagnostic applications in obstet-
rics and gynecology. These points are as follows:
Encourage those who perform gynecologic
ultrasound examinations to incorporate 3D
ultrasound into their ultrasound practices.
Encourage those who perform obstetric
ultrasound examinations to incorporate 3D
ultrasound into their ultrasound practices.
Achieve acceptance of 3D ultrasound as a
valuable tool in medical imaging by provid-
ing education, training courses, publica-
tions, simulators, online training, and
multimedia tools.
Optimize ultrasound volume displays and
tomographic analysis by using experience
gained from CT and MRI and integrate these
into picture archiving and communications
systems (PACS).
Continue to develop quantitative applica-
tions for 3D ultrasound.
Develop indications and protocols for 3D
ultrasound.
Standardize terminology for volume sonog-
raphy so that it is universal and avoids pro-
prietary terminology.
Set standardized display algorithms to per-
mit reproducibility and automation.
Define the role of the sonographer because
some of the offline reconstruction of images
may well be performed by sonographers in
the future and may replace some hands-on
scanning time.
Advancement Strategy
To advance the use of 3D ultrasound, work is
necessary on a number of fronts, including (1)
technological advances, (2) standardization, (3)
education and training, and (4) research and
clinical investigation.
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Technological advances to improve the ease of
use of 3D ultrasound are key to general accep-
tance. Potential obstacles for its widespread
clinical use are the time and effort required to
learn how to use the new technology. The tech-
nology must become easier, faster, and more
intuitive, and the user interface must be simple.
Otherwise, only power users with special
expertise in gynecologic and obstetric ultra-
sound will learn these new features and incor-
porate them into their imaging practices. In
addition, the image resolution of the 3D volume
probes must be improved. Even when the basic
resolution of the probe is adequate, resolution is
diminished in reconstructed images. In particu-
lar, the reconstructed planes are degraded in
resolution compared with the acquisition
plane. Therefore, 3D images can have image
resolution that is inferior to conventional 2D
sonography.
Standardization is required at multiple levels
for 3D ultrasound to gain widespread use. First,
the equipment needs to be standardized across
manufacturers with respect to terminology of
functions and the display on the ultrasound sys-
tem. This includes the incorporation of anatom-
ic markers into the 3D volumes so that there is no
confusion about right versus left or cranial versus
caudal for a given patient. These markers must
be maintained with the volume data so they are
not lost on reconstructed planes.
Standardization is also needed for methods of
electronic transmission, display, and storage of
volume data. This includes adopting or develop-
ing Digital Imaging and Communications in
Medicine (DICOM) standards for 3D and 4D vol-
ume data sets that are compatible with current
image storage systems (PACS). The ability to store
volume data on PACS and PACS-based basic
image reconstruction algorithms is needed to
enhance penetration of 3D technology in gener-
al practice. This will facilitate multimodality
imaging evaluation and comparison. The ability
to manipulate the volume from the PACS system
is crucial also for evaluating specific types of fetal
anomalies. For example, algorithms to view fetal
bony structures will permit evaluation of bony
anomalies. Image orientation must also be stan-
dardized by using algorithms to display anatom-
ic reference points within multiplanar displays
and rendered reconstructed images.
The practitioners, both sonographers and
physicians, need to set protocols for volume
acquisitions for various types of 3D ultrasound
examinations. After that, there need to be stan-
dards for display. In particular, image orientation
must be defined.
Education and training are required for
widespread dissemination of information about
when to use 3D ultrasound, as well as how to use
and how to interpret 3D sonographic volumes.
Practitioners will need to learn the appearances
of normal structures, as well as various patholog-
ic conditions. A solid understanding of sono-
graphic artifacts resulting from use of 3D
ultrasound will also be essential.
Last, research and clinical investigations must
be performed to show the utility of 3D ultra-
sound through peer-reviewed scientific publica-
tions. Studies assessing the effect of volume
acquisitions on practice efficiency are needed.
Because early studies suggested increased
patient throughput, further investigations are
needed to determine methods for optimizing the
efficiency of volume acquisitions and interpreta-
tions without compromising the diagnostic
yield. Clinical studies are also needed to compare
3D ultrasound with MRI and other imaging
modalities. It is understood that these compar-
isons will be made against a background of
rapidly emerging technology as volume probes
with improved resolution become available.
Recommendations
To achieve the goal of widespread acceptance
of 3D and 4D ultrasound in obstetrics and
gynecology, the panel provided a number of
recommendations:
Encourage manufacturers, experts, and soci-
eties to make it easier to learn how to per-
form 3D ultrasound examinations with more
accessible educational opportunities such as
online and hands-on courses.
Encourage manufacturers to make 3D ultra-
sound machines easier to use.
Encourage manufacturers to make 3D ultra-
sound systems faster and completely real time.
Encourage manufacturers to include offline
software with basic postprocessing tools with
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the purchase of an ultrasound system to pro-
mote penetration of the technology.
Develop innovative software tools to analyze
ultrasound volumes quantitatively, for
example, fractional volume and cardiac out-
put, including improved automated seg-
mentation algorithms to improve analysis
time.
Encourage manufacturers to develop new
ways to tag volumes as to right/left, anteri-
or/posterior, and cranial/caudal to stan-
dardize orientation and minimize confusion.
Encourage governmental agencies, profes-
sional societies, and industry to support sci-
entific studies and further development of
3D ultrasound. Diagnostic benefits and tech-
nical limitations should be compared with
other imaging modalities, such as 2D sonog-
raphy, MRI, and CT. The cost-effectiveness of
this emerging technology should also be
examined.
Integrate 3D sonographic volume assess-
ment into PACS systems, including the
development of DICOM standards for 3D
ultrasound.
Urge the ACR, AIUM, and ACOG to develop
collaborative guidelines for performance of
3D ultrasound examinations in gynecologic
and obstetric ultrasound.
Encourage the ACR, AIUM, and ACOG to dis-
cuss the importance of 3D sonography with
third-party payers and include it in future
reimbursement policies.
Set up a task force or committee to define 3D
ultrasound terminology and standardiza-
tion. (This is in process in the AIUM Clinical
Standards Committee.)
Set up a task force or committee including
experts and representatives from manufac-
turing to evaluate methods for educating
health care professionals.
Recommend studies to evaluate exposure
and potential bioeffects resulting from vol-
ume sonography.
Encourage manufacturers to ensure that
image quality and resolution of the 3D image
are comparable with those of 2D imaging in
all planes.
Summary
Three-dimensional ultrasound is becoming an
important part of state-of-the-art sonographic
imaging in obstetrics and gynecology. It is a
problem-solving tool in selected circumstances.
It has the potential to improve practice efficiency
and patient throughput without jeopardizing
diagnostic capabilities. To become widely
accepted, however, work must be done by sever-
al groups, including manufacturers, to make the
3D ultrasound systems faster and more user-
friendly. Additionally, standards must be estab-
lished for transmission and storage of volume
data; educational efforts should be expanded for
teaching practitioners how to use and interpret
these results; and medical societies and industry
need to reach a consensus about how to best
standardize imaging protocols and display. The
panel proposed several recommendations to
encourage the use of 3D ultrasound for clinical
care, teaching, and research in obstetric and
gynecologic ultrasound.
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