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7 Interventional Ultrasound inObstetrics andGynecology
315
imaging technique of PHILIPS iU22 nonlinear
imaging-pulse inversion harmonic technology and
energy modulation technology are used. Firstly,
observe the characteristics of the echo under routine ultrasound. And then switch to the contrast
mode. Observe the lesion under the fundamental
wave state, and select the largest cross-section of
the lesion. Patient’s uterus is displayed at the same
time, and the xed section is enabled with a low
mechanical index contrast double-amplitude mode
(harmonic and fundamental states) and displayed
simultaneously. While bolus injection of contrast
agent, start the timer and store the dynamic image
to 3 min after the injection of contrast agent.
Continue to observe the contrast image and save
the dynamic image on the hard disk.
• Notes
– Let the patient breathe as smoothly as possible dur-
ing the examination and keep the position xed.
– Contraindications: Patients with a history of sig-
nicant allergies; patients with signicant abnormal lung function.
– Images should be analyzed by an experienced
physician.
• Ultrasound diagnosis
– Morphological analysis of CEUS.
Taking ovarian tumors as an example, based
on the observation of perfusion of contrast agent,
according to the distribution of the contrast agent
in the mass, the ovarian mass can be divided into
three types: no enhancement type, no contrast
agent enters into the mass; surrounding type,
contrast agent is only distributed around the
periphery of the mass; extension type, contrast
agent enters and distributes inside the mass.
According to the intensity of the contrast agent of
the mass, it can be divided into three types. For
comparison, if the enhancement intensity is
lower than that of the uterus, it is a low enhancement; if it is close to or equal to the enhancement
intensity of the uterus, it is an equal enhancement; if the enhancement intensity is higher than
that of the uterus, it is high enhancement
(Fig.7.33).
Fig. 7.33 CEUS of ovarian tumors. (a) The patient is 26years old with
a right ovarian mass, which is a kind of no enhancement; (b) The patient
is 46years old, with a left ovarian mass, which is a kind of extension
type and low enhancement; (c) The patient is 43years old with a left
ovarian tumor, which is a kind of extension type and equal enhancement; (d) The patient is 42years old with a pelvic mass, which is a kind
of extension type and high enhancement
316
cd
Fig 7.33 (continued)
H. Luo et al.
a
– Time–intensity curve analysis of CESU.
The obtained dynamic images are analyzed by
Qlab-ROI software. Select the area of the lesion;
then the time–intensity curve (TIC) is obtained.
Select a gamma tting function suitable for bolus
injection to perform gamma curve-tting on the
TIC; obtain contrast perfusion parameters of the
lesion site, including rising time (RT), peak intensity (PI), Area under the curve (AUC), time from
peak to one half (TTH), and time to peak (TTP)
b
(Fig.7.34).
Suggested Reading
Fig. 7.34 Time–intensity curve analysis of CEUS of ovarian tumors.
(a) Under contrast harmonic-fundamental double imaging, select ROI
in the largest longitudinal section of the ovarian tumor; (b) Process
curve tting to the time–intensity curve with gamma tting function
1. 张美琴, 周彩云, 罗红. 纳米级超声造影剂的技术进展, 华西医
学, 2012, 27(10):1585–1587 (无英文摘要).
2. ZHOU Cai-yun, LUO Hong, Ultrasonic contrast’s application
and development in ovarian tumor, Technical Acoustics. 2010,
29(4):476–478.
3. Fan YANG, Tai-zhu YANG, Hong LUO, etal. Diagnostic value of
contrast-enhanced ultrasonography in ovarian tumors. J Sichuan
Univ (Med Sci Edi). 2013;44(003):424–8.
4. Fan YANG, Tai-zhu YANG, Hong LUO, et al. Preliminary
study of contrast-enhanced ultrasonography in the evaluation of
angiogenesis in ovarian tumors. J Sichuan Univ (Med Sci Edi).
2014;45(06):964–9.
Applications of3D Ultrasound
inObstetrics andGynecology
TaizhuYang, JiaoChen, andHouqingPang
8
8.1 Introduction of3D Ultrasound Modes
3D ultrasound, a signicant breakthrough of the ultrasonic
elds, opens an entirely new visual space. 3D ultrasound
technology collects a volume database containing numerous
2D plans, and displays the region of interest (ROI) using
various modes, providing new methods of volume measurement without mathematical simulation formula. 3D ultrasound has a considerable clinical inuence on obstetrics and
gynecology. The advantage of 3D ultrasound is fully reected
because of its increasing popularity.
3D ultrasound provides several display modes, including
multiplanes mode, niche mode, surface mode, and transparent mode, etc.
I. Multiplanar mode
Three mutually perpendicular planes, the sagittal
plane, transverse plane, and coronal plane, are simultaneously visualized, which can be shifted and rotated
arbitrarily. It is convenient to continuously observe the
lesion and dene the spatial relationship between the
lesion and the tissues surrounding it.
II. Niche mode
Observe the internal morphology of the organs or
lesions and determine lesion involvement.
III. Surface mode
Visualize the structures surrounded by hypoechoic
or anechoic hierarchically and dimensionally. The surface mode is utilized to demonstrate the features of the
surface organs or tissues.
This chapter was translated by Mingchun Zhi, Miaoqian Wang
Department of Obstetrics and Gynecology, Beijing Hospital, National
Center of Gerontology, Beijing, China
T. Yang (*) · J. Chen · H. Pang
Department of Ultrasonography, West China Second University
Hospital, Sichuan University, Chengdu, China
IV. Transparent mode
There are three different display modes according
to the algorithm of different echo data. Among them,
the maximum mode facilitates the study of the fetal
skeletal system, the minimum mode is mainly used for
the evaluation of vessels and hollow viscera, and the
X-ray mode is utilized for the tumor areas and similarecho structures. Inversion mode inverts the gray-scale
information based on the minimum mode. This mode
transforms original anechoic structures into hyperechoic structures, and vice versa.
V. B-ow mode. A stereoscopic way to display the blood
ow, evaluate the perfusion, and observe the relationship between blood vessels and tissues.
VI. Glass body mode. Highlight the location and distribu-
tion of vascular structure, usually with 3D color or
power Doppler ultrasound.
VII. Tomographic ultrasound imaging (TUI)
TUI, a relatively new 3D ultrasound imaging mode,
obtains multidirectional tomographic images with the
collected volume data, facilitating the study of the
fetal structure from a new perspective. After scanning
with a 3D/4D probe, it generates a 3D database containing multiple continuous 2D plans, allowing for the
simultaneous display of several parallel slices in three
planes that are orthogonal to each other. It is facilitated
to show the structural changes on the same screen by
adjusting the slice distance and image rotating, equivalent to CT and MRI, with relatively convenient
operation.
VIII. Spatiotemporal image correlation (STIC)
STIC is a feature of real-time 3D technology that is
utilized for the fetal heart and great arteries. Volume
datasets for fetal echocardiography, composed of
sequential 2D plans, are acquired with an automated
scan of the volume probe. Combined with time information, the volume datasets of multiple cardiac cycles
can be displayed in the same cardiac cycle.
© Chemical Industry Press 2022
T. Yang, H. Luo (eds.), Practical Ultrasonography in Obstetrics and Gynecology,
https://doi.org/10.1007/978-981-16-4477-1_8
317
318
T. Yang et al.
8.2 Application of3D Ultrasound
inObstetrics
With 3D ultrasound, stereoscopic imaging of the fetal surface and internal structures can be obtained to observe the
overall fetal morphology and structure. 3D ultrasound is utilized to demonstrate the normal and pathological morphology during gestation and improve the prenatal diagnosis rate
of fetal malformations.
I. Embryo and fetal activity
3D ultrasound is used to observe embryos and fetuses
in different gestational weeks. In early pregnancy, the
a b
embryo sac is oval or round, covering chorion. The yolk
sac is usually spherical; the curved embryo is in a “C”
shape, the upper and lower limb buds are spoon-shaped,
and the umbilical cord is linear. During the mid and late
pregnancy, 3D ultrasound shows the intrauterine fetal
movement visually and vividly, including the motion of
the fetal head, mouth, arm, trunk, and lower limbs
(Figs.8.1, 8.2, and, 8.3).
II. Fetal biological measurement
TUI technique, utilizing for the measurement of fetal
nuchal translucency, postnasal triangle, hard palate, and
alveolar bone at 11~14weeks of gestation, has been one
of the hotspots in early detecting of fetal abnormalities.
Fig. 8.1 Embryo and fetal activity. (a) Six weeks pregnancies. The elliptic gestational sac and the spherical yolk sac are identiable. (b) Ten
weeks pregnancies. The bending embryo in the gestational sac is in a “c” shape
Fig. 8.3 Image of a normal fetal spine
Fig. 8.2 Image of normal fetal lower limb
8 Applications of3D Ultrasound inObstetrics andGynecology
319
3D ultrasound is used to accurately measure fetal
growth indexes, including the diameter of the fetal head,
length of the long bones, and the volume of the brain,
internal organs and limbs, for the evaluation of fetal
development (Figs. 8.4 and 8.5). As 3D technology
develops, it is facilitated to observe the structure of fetal
corpus callosum, cerebellar vermis, hard palate, and so
on. The volume of fetal organs, such as cerebellomedullary cistern, cerebellum, corpus callosum, lung, thyroid,
stomach bubble, bladder, are measured accurately.
Moreover, 3D is utilized to evaluate the stomach bubble
development and the fetal urine production rate, etc.
III. 3D ultrasound diagnosis of fetal malformation
• Fetal facial abnormalities
3D ultrasound facilitates to show the full view of
the fetal face, providing a stereo image to explore
facial anomaly. Cleft lip, cleft palate, arhinia, proboscis, collapsed nose bridge, cyclopia, low ears, micrognathia are the most frequently observed abnormalities
(Figs.8.6 and 8.7).
• Fetal skeletal malformation
The transparent mode of 3D ultrasound is the best
way to illustrate the appearance of the fetal skeleton
from different angles, especially for evaluating spine
development. It contributes to the diagnosis of hemivertebra, scoliosis, spina bida, and other spinal
deformities. 3D ultrasound has an integral role in the
diagnosis of local fetal limb deformities, such as the
absence of radius, wrist varus, wrist eversion, acheiria nger absence, cleft hand, cleft foot, apodia, and
clubfoot (Figs.8.8 and 8.9).
• Malformation of fetal central nervous system
3D ultrasound was used to diagnose Dandy–
Walker syndrome, corpus callosum dysplasia, and
meningocele, etc. 3D color Doppler ultrasound has a
signicant impact on the diagnosis of vascular mal-
Fig. 8.4 3D Image of normal fetal internal organs
Fig. 8.5 3D color Doppler sonography demonstrates normal fetal liver
blood vessels
Fig. 8.6 Image of normal fetal face
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T. Yang et al.
Fig. 8.7 Fetal bilateral exophthalmos image
formation by visualizing the circle of Willis intuitively (Figs.8.10 and 8.11).
• Fetal Abdominal Wall Defect and Abdominal Organ
Malformation
The three orthogonal plans of 3D ultrasound facilitate to simultaneously observe the continuity of the
abdominal wall and the spatial relationship of the
attached part of the umbilical cord from all angles,
which is helpful for the differential diagnosis of
umbilical hernia, omphalocele, gastroschisis, and
other malformations. Besides, it can quantitatively
evaluate the volume of the sac, providing more efcient clinical information (Figs.8.12 and 8.13).
• Fetal heart and blood vessels
STIC technology can visually display the spatial
structure of the fetal heart and great arteries and
obtain plans that are challenging to be acquired or
observed in 2D imaging. STIC has signicant advantages in the diagnosis of complex congenital cardiac
malformations. 3Dtechnology, an objective method
for fetal cardiac function measurement, can accurately calculate the fetal cardiac volume, ejection
Fig. 8.8 Image of fetal phocomelia
Fig. 8.9 Fetal overlapping nger of the right hand
fraction, and cardiac movement. With the use of
STIC, volume datasets of the fetal heart are acquired
with a single quick sweep of the probe, effectively
and time-saving.
8 Applications of3D Ultrasound inObstetrics andGynecology
Fig. 8.10 Image of anencephaly
321
Fig. 8.12 Image of normal fetal ventral wall
Fig. 8.11 Image of fetal spina bida
• Urogenital system
The 3D multiplanar mode can clearly show the
polycystic kidney, renal dysplasia, and other diseases.
B-ow imaging facilitates the display of renal vascular abnormalities, the diagnosis of congenital renal
artery stenosis, and the evaluation of renal blood
perfusion. The 3D morphology of the fetal external
genitalia, which is of great value for the diagnosis of
hermaphroditism and hypospadias, is intuitively displayed with the surface mode (Fig.8.14).
Fig. 8.13 Fetal visceral herniation
• Umbilical cord and placenta
With 3D ultrasound, it is benecial to show the
number of umbilical arteries and veins, the twisting
direction of the cord, the number of the cord around
the neck, and true knots in the cord (Figs.8.15 and
8.16). The 3D power image contributes to evaluate
the placental vascular bed, quantitatively calculate
the placental blood ow, and monitor the placental
blood perfusion. 3D B-ow imaging is suitable for
assessing the placental infarction, twin-twin transfusion, and circumvallate placenta, etc. 3D ultrasound
facilitates to distinguish the chorionicity by evaluating the intervening membrane in the second and third
trimesters, with high sensitivity, specicity, and
accuracy.
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T. Yang et al.
Fig. 8.14 Urogenital system.
(a) Fetal external genitalia
(female) (b) Fetal external
genitalia (male)
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Fig. 8.15 3D B-ow image of fetal umbilical cord
8.3 Application of3D Ultrasound
inGynecology
3D ultrasound, showing the longitudinal, transverse, and
coronal views of the uterus simultaneously, reveals a new
technique and provides more accurate information, which
makes it possible to simulate the preoperative surgical path.
3D ultrasound is the optimal noninvasive method for allaround observation of the uterus and adnexa, accurate diagnosis, timely treatment, and prognosis evaluation of diseases
(Fig.8.17).
Fig. 8.16 3D image of placental hemangioma
I. Uterine diseases
3D ultrasound can acquire the true coronal view of
the uterus that cannot be obtained using 2D ultrasound.
By parallel shifting and spinning the anatomic planes of
the 3D ultrasound, make a comprehensive analysis of
the interested structures, such as uterine malformation,
endometrial polyps, and submucous myoma, etc.
• Uterine malformation
By freely rotating planes, a standard 3D plan can
be obtained to measure the depth of the uterine fundal
indentation and the length of the intrauterine septum.
It is often recommended for denitive diagnosis of the
8 Applications of3D Ultrasound inObstetrics andGynecology
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Fig. 8.17 (a) Longitudinal view of normal uterus; (b) coronal view of normal uterus
323
Fig. 8.18 Uterine
malformation. (a) Partial
septate uterus; (b) Complete
septate uterus
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arcuate uterus, septate uterus, and bicornuate uterus,
with high sensitivity and specicity (Fig.8.18).
• Uterine myoma
3D ultrasound facilitates to accurately measure the
size of uterine myoma and distinguish the positional
relation with the endometrium, which is conducive to
the follow-up (Fig.8.19).
• Endometrial lesion
3D ultrasound is utilized to denitively measure
the endometrial volume, which can predict and diagnose endometrial cancer. The intrauterine cavernous
changes of hydropic chorionic villi and abnormal rich
blood ow in hydatidiform mole lesions are
stereoscopically demonstrated using 3D ultrasound
(Fig.8.20).
• Intrauterine Space-Occupying Disease
3D ultrasound can provide the optimal view to
show the uterine cavity, evaluate the size, number,
and position of the space-occupying lesion.
The availability of 3D ultrasound combined with
sonohysterography has a positive impact on the differential diagnosis of intrauterine residues, endometrial polyp, and other lesions (Fig.8.21).
• Cervical disease
In cervical cancer cases, the rich cervical blood
ow is reworks-like displayed. 3D B-ow imaging
provides more detailed information for the overall
estimation of the cervical cancerous lesion and extent
(Fig.8.22).
II. Intrauterine device (IUD)
With the availability of 3D ultrasound, the shape,
size, and type of the IUD are visually displayed. It is
possible to precisely ascertain the location of IUD for
the detection of slipped IUD using 3D ultrasound
(Fig.8.23).
III. Monitoring follicular development
3D ultrasound can more clearly observe.
The delineation and maturity level of the follicle is
visible by 3D ultrasound.
It is utilized to accurately measure the volume of the
ovary and follicle for further follicular monitoring, guiding clinical medication, and infertility treatment.
IV. Ovarian diseases
3D ultrasound can intuitively show the spatial relation between the pelvic space-occupying lesion and
adjacent organs, such as uterus, ovary, bladder and rec-
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Fig. 8.19 Uterine myoma. (a) Submucosal myoma; (b) Uterine myoma in middle pregnancy
T. Yang et al.
Fig. 8.20 Hydatidiform mole. (a) 3D image of hydatidiform mole; (b) 3D B-ow imaging of hydatidiform mole
Fig. 8.21 Intrauterine
space-occupying lesion. (a)
Intrauterine residues after
abortion; (b) Endometrial
polyp