J Obstet Gynecol India Vol. 56, No.
1 : January/February 2006 Pg 22-24
EDITORIAL
3D – 4D Ultrasound in Obstetrics and Gynecology
Three dimensional (3D) ultrasound (USG) and 4D i.e. real
time 3D are a natural development of the imaging technology
and were first demonstrated nearly 15 years ago, but are
becoming a clinical reality only now. Methods for 3D
reconstruction of CT and MRI images have achieved an
advanced state of development. 3D applications in ultrasound
have lagged behind CT and MRI, because ultrasound data is
much more difficult to render in 3D. Only in the past few
years has the computing power of ultrasound equipment
reached a level adequate enough for the complex signal
processing tasks needed to render ultrasound data in three
dimensions. The clinical application of 3D ultrasound is likely
to advance rapidly, as improved 3D rendering technology
becomes more widely available 1.
The advantages of 3D and 4D ultrasound in certain areas
are unequivocal. Most centres already apply its use in the
workup of fetal anomalies involving the face, limbs,
thorax, spine and the central nervous system. The use of
this technology in applying color doppler, in guiding needles
for different puncture procedures as well in evaluating
the fetal heart are currently under close research scrutiny.
3D ultrasound helps the bonding between the parents and
their future offspring, and consultants understand fetal
pathology better and can plan postnatal interventions better.
The multiplanar presentation and niche mode are quite
useful to determine the extension –inside or outside the
organs, of nodules, cysts or tumors. The volume
measurement is better assessed with 3D and we can
perform studies that follow growth in order to decide
medical or surgical treatment. The VOCAL(R) makes it
possible to obtain a proper after-treatment follow-up of
focal disorders in these small organs. Neovascularization
is clearly viewed with 3D USG and probably can suggest
malignant origin of a neoplasm. 3D USG offers a more
comprehensive image of anatomical structures and
pathological conditions and also permits observation of
the exact spatial relationships 1,2.
More studies are needed to demonstrate specificity and
sensitivity of 3D and 4D USG. There are limitations to
adequate visualization of fetal anatomy with 3D/4D
technology. If there is inadequate amniotic fluid surrounding
the fetus, or if the fetus has its face in the posterior position
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The Journal of
Obstetrics and Gynecology
of India
in the uterus, there will be difficulty visualizing structures
and the face. 3D allows a simultaneous display of multiple
sequential parallel planes of the fetal structures, but there is
some uncertainty if an isolated image in one of the multi-
slice images represents the exact level of a fetal structure.
Another problem is the creation of false expectations and
overall the medical value is limited. Pregnant women will
ask for a picture of their fetus like those they have seen in
advertisements and put pressure on the scanning centres.
Such is the demand in the United States that technician
operated 4D ultrasounds are readily available in scanning
booths in shopping malls, enabling parents to purchase a
video of their moving fetus. This creates problems later on
when women, having already had such USG, do not realise
that they need a targeted anomaly scan 3-5.
Endometrial thickness, endometrial pattern, pulsatility index
(PI) and resistance index (RI) of uterine vessels, endometrial
volume, vascularization index (VI), flow index (FI) and
vascularization flow index (VFI) of endometrial and sub-
endometrial regions have been studied by 3D with power
dopplers on the day of oocyte retrieval in patients undergoing
the first IVF cycle. Uterine RI, endometrial VI and VFI were
significantly lower in the pregnant group than in the non-
pregnant group. There was a nonsignificant trend of higher
implantation and pregnancy rates in patients with absent
endometrial or subendometrial blood flow. The number of
embryos replaced and endometrial VI were the only two
predictive factors for pregnancy. Endometrial and sub-
endometrial blood flows measured by 3D power doppler
ultrasound were not good predictors of pregnancy if they
were measured at one time-point during IVF treatment 6,7. A
similar study noted that endometrial volume decreased
significantly after hCG injection in women who conceived,
but not in those who did not.
Along with crown-rump length (CRL), the size (diameter)
of embryonic structures such as gestational sac (GS) and
yolk sac (YS) may have prognostic value for embryonic
development. First trimester volume calculations of these
structures using transvaginal 3D USG technic have been
done. Volumetry of GS proved to be a sensitive predictor
for pregnancy outcome and can be a good supplement to
CRL measurements. However, no statistically significant

difference was found when YS volumes of normal and
abnormal pregnancies were compared. Specificity, sensitivity,
positive and negative predictive values of GS volumes and
CRL were similar. Mean YS/GS ratios also had good
predictive values (P <0.05) 8.
4D was successfully used to perform amniocentesis, CVS,
cordocentesis, and intrauterine transfusion. Using 4D USG
guidance, most procedures were performed within 5 minutes
and with a 100% success rate, even in cases involving severe
oligohydramnios, thin placenta and narrow umbilical veins.
Moreover, there were no serious complications during or
after any procedure. This appeared to contribute to the
accuracy of needle placement by eliminating the lateralization
phenomenon when a fixed needle guide attachment was used.
Needle tip visualization was seen in each orthogonal plane in
most freehand 4D amniocentesis cases 9,10.
Presently, both 2D and 4D methods are required for the
assessment of early fetal motor development and motor
behaviour. Several movement patterns, such as sideway
bending, hiccup, breathing movements, mouth opening and
facial movements could be observed only by 2D USG 11.
Isolated hand movement and subtypes of hand movements
were easily recognized by 4D USG. All subtypes of hand to
head movement can be seen from 13 weeks of gestation
with fluctuating incidence. Facial activities and different
forms of expression are easily recognized. 4D USG is superior
over real time 2D USG for qualitative, but inferior for
quantitative analysis of hand movements. 4D USG makes it
possible to determine the exact direction of the fetal hand,
but the exact number of each type of hand movements can
still not be determined.4D USG is superior to 2D USG in the
evaluation of complex facial activity and expression. Among
facial activities observed by 4D USG, simultaneous eyelid
and mouth movements dominate between 30 and 33 weeks
of gestation. Pure mouth movements such as mouth opening,
tongue expulsion, yawning and pouting are present, but at a
significantly lower incidence. Facial expressions such as
smiling and scowling can be precisely observed using 4D
USG 12. There were no movements observed in fetal life that
were not present in neonatal life; the Moro reflex was present
only in neonates 13.
Inclusion of 3D and 4D ultrasound imaging in the examination
of cleft lip and/or palate, allows easier and more rapid
screening and more precise evaluation of the different cleft
constituents 14. 3D USG can be a reliable technic for
visualizing most fetal cranial sutures and fontanels. By
performing a sagittal and a transverse scan, most of the
sutures and fontanels can be made visible during the second
half of pregnancy. Visualization depends on gestational age
15
. Gray-scale and color doppler dynamic 3D displays and
Editorial
multiplanar views used to assess cardiac gating and cardiac
morphology demonstrate clinically useful 4D images of the
fetal heart. The reconstruction of 3D and multiplanar views
provided additional views not obtainable by 2D imaging 16.
3D echocardiography can provide estimates of ventricular
volume and function and may in future be used for evaluation
of fetuses with congenital heart disease and cardiac
dysfunction 17 . Spatio-temporal image correlation in
combination with color doppler USG is a promising new
tool for multiplanar and 3D/4D rendering of the fetal heart.
Limitations may be found later in gestation in fetuses with
large hearts and early in gestation as a result of low
discrimination of signals. In addition, insonation perpendicular
to the structure of interest does not image color doppler
signals and should be avoided during acquisition 18. There is
a potential value of 3D power doppler in prenatal diagnosis
and monitoring of pregnancies complicated by large,
vascularized placental chorioangioma 19. No significant
differences are shown between 2D and 4D ultrasound
placental scanning 20.
3D power doppler ultrasound provides a useful tool to
investigate intratumor vascularization and volume of cervical
cancer 21. Alterations of 3D USG derived vascular indices
were found in patients with cervical cancer and some
vascular indices proved to be associated with tumor size 22.
In a small group of pelvic masses that appear malignant on
B-mode USG, the use of 3D quantification of tumor
vascularity yields a diagnostic accuracy that is similar to
that of subjective evaluation of vascularity 23. 3D power-
doppler imaging does not have a better diagnostic
performance than 2D power doppler imaging in the
discrimination of benign from malignant complex adnexal
masses 24. Endometrial volume and thickness measurements
by 3D and 2D USG, in patients with postmenopausal
bleeding, show good reproducibility but the reproducibility
of 3D ultrasound is better 25. Rectovaginal septal defects are
readily identified on translabial 3D USG as a herniation of
rectal wall and its contents into the vagina. Approximately
one third of clinical rectoceles do not show a sonographic
defect, and the presence of a defect is associated with age,
not parity 26. While 3D pelvic floor imaging is a field that is
still in its infancy, it is already clear that the method has
opened up entirely new opportunities for the observation of
functional anatomy.
The exact applicability of 3D and 4D USG is yet to be
ascertained. The American Institute of Ultrasound in Medicine
has convened a panel of physicians and scientists with interest
and expertise in 3D USG to discuss the current diagnostic
benefits and technical limitations in obstetrics and gynecology
and to consider the utility and role of this type of imaging in
clinical practice now and in the future 27.
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