Foetal facial clefts: prenatal evaluation of lip and primary palate by 2D and 3D ultrasound

Cleft Lip and Palate Antenatal Diagnosis: A Swiss University Center Performance Analysis

Precision of cleft lip and/or palate antenatal diagnosis plays a significant role in counselling, neonatal care, surgical strategies and psychological support of the family. This study aims to measure the accuracy of antenatal diagnosis in our institution and the detection rate of cleft lip and/or palate on routine morphologic ultrasonography. In this retrospective observational study, we compared antenatal and postnatal diagnosis of 233 patients followed in our unit. We classified our patients according to the Kernahan and Stark's classification system: Group 1: facial cleft including labial and labio-maxillary clefts; Group 2: facial cleft including total, subtotal and submucous palatal clefts; Group 3: labio-maxillary-palatal clefts. Out of 233 patients, 104 were antenatally diagnosed with a facial cleft, i.e., an overall detection rate of 44.6%. The diagnosis was confirmed at birth in 65 of these patients, i.e., an overall accuracy of 62.5%. Of the 67 children (29.2%) in Group 1, the screening detection rate was 58.2% with an antenatal diagnostic accuracy of 48.7%. Of the 97 children (41.6%) in Group 2, the screening detection rate was 2% with an antenatal diagnostic accuracy of 50%. Of the 69 children (29.6%) in Group 3, the screening detection rate was 91.3% with an antenatal diagnostic accuracy of 71.4%. Our study demonstrates a relatively poor diagnostic accuracy in prenatal ultrasound, where the diagnosis was inaccurate in one third to one half of patients. It showed great variability in the screening detection rate depending on the diagnostic group observed, as well as a low rate of detection of palatal clefts.

Diagnostic Accuracy of Prenatal Fetal Ultrasound to Detect Cleft Palate in High-Risk Fetuses: A Systematic Review and Meta-Analysis

OBJECTIVES

This systematic review and meta-analysis investigated the accuracy of prenatal fetal ultrasound (US) to detect cleft palate during the second and third trimester (12-36 weeks) of pregnancy in high-risk fetuses.

METHODS

Pubmed and Embase databases were searched for studies that performed prenatal fetal US (comparator) and postnatal examination (reference standard) in fetuses at high risk for orofacial clefts. Risk of bias among included studies was assessed using the QUADAS-2. Area under the summary receiver operating characteristic (SROC) curve and pooled sensitivity and specificity were calculated.

RESULTS

This meta-analysis included 7 studies involving 663 high-risk fetuses. The individual studies showed that prenatal fetal US accurately predicted the possibility of cleft palate in these fetuses. Pooled sensitivity was 87% (95% CI 71%-95%), pooled specificity was 98% (95%CI 90%-100%), and the area under the SROC curve was 0.98 (95% CI 0.97-0.99).

CONCLUSION

Second and third trimester fetal US has excellent sensitivity and specificity for the detection of cleft palate in high-risk pregnancies.

Prenatal diagnosis of isolated lateral facial cleft by ultrasonography and three-dimensional printing: A case report

BACKGROUND

Lateral facial clefts are atypical with a low incidence in the facial cleft spectrum. With the development of ultrasonography (US) prenatal screening, such facial malformations can be detected and diagnosed prenatally rather than at birth. Although three-dimensional US (3DUS) can render the fetus' face via 3D reconstruction, the 3D images are displayed on two-dimensional screens without field depth, which impedes the understanding of untrained individuals. In contrast, a 3D-printed model of the fetus' face helps both parents and doctors develop a more comprehensive understanding of the facial malformation by creating more interactive aspects. Herein, we present an isolated lateral facial cleft case that was diagnosed via US combined with a 3D-printed model.

CASE SUMMARY

A 31-year-old G2P1 patient presented for routine prenatal screening at the 22^nd wk of gestation. The coronal nostril-lip section of two-dimensional US (2DUS) demonstrated that the fetus' bilateral oral commissures were asymmetrical, and left oral commissure was abnormally wide. The left oblique-coronal section showed a cleft at the left oral commissure which extended to the left cheek. The results of 3DUS confirmed the cleft. Furthermore, we created a model of the fetal face using 3D printing technology, which clearly presented facial malformations. The fetus was diagnosed with a left lateral facial cleft, which was categorized as a No. 7 facial cleft according to the Tessier facial cleft classification. The parents terminated the pregnancy at the 24^th wk of gestation after parental counseling.

CONCLUSION

In the diagnostic course of the current case, in addition to the traditional application of 2D and 3DUS, we created a 3D-printed model of the fetus, which enhanced diagnostic evidence, benefited the education of junior doctors, improved parental counseling, and had the potential to guide surgical planning.

Advantages of 3D ultrasound in the assessment of fetal abnormalities

Three-/four-dimensional (3D/4D) imaging enables a more detailed survey of the embryo and the fetus compared to two-dimensional (2D) ultrasound. The availability of several display modes and standardized examinations permits the demonstration of both the normal and abnormal fetal anatomy in controlled planes and rendered images from different angles. This allows the demonstration of even subtle fetal defects in an ideal sectional plane in a precisely rendered surface or transparent image viewed from an optimal angle. When counseling the parents, the rendered images can help them understand the severity of an existing malformation or, conversely, ensure them of the absence of any fetal abnormality. This is particularly useful in cases with an increased recurrence risk of a specific fetal malformation.

Integrating 3D Sonography With Targeted MRI in the Prenatal Diagnosis of Posterior Cleft Palate Plus Cleft Lip

Cleft lip and cleft palate are among the more common congenital abnormalities, present in 1.82 per 1000 live births. Although high-quality antenatal 2D sonography can diagnose clefts of the lips and the alveolar ridge, 3D may enhance detection by examining the fetal face in the frontal plane followed by a secondary rotation through 180 degrees on the vertical axis to examine the secondary palate, which has been called the “reverse face” view. Sonographically 3D targeted ultrafast magnetic resonance imaging (MRI) has been shown to improve the diagnostic accuracy of facial cleft by identifying whether a cleft in the primary palate extends to the secondary palate. Further investigation may confirm the ability of MRI to define the extent of the cleft to the secondary palate at a less advanced gestational age (18-23 weeks), where either fetal development or movements could reduce the accuracy of the technique.

Three-dimensional ultrasound of the fetus: how does it help?

Three-dimensional ultrasonography (3-D US) was introduced to the field of fetal imaging in the early 1990s. Since then several publications have described potential applications for the diagnosis of congenital malformations as well as organ volumetry. This article reviews basic principles of 3-D US as well as its clinical applicability to prenatal diagnosis of abnormalities involving the face, spine and skeletal system, as well as potential applications of 3-D US for fetal cardiovascular and neuroimaging. Limitations related to motion artifacts, acoustic shadowing and barriers to clinical implementation of 3-D US in clinical practice are addressed.

Current Role of 3D/4D Sonography in Obstetrics and Gynecology

Modern 3D/4D sonography provides a routine method not only for storing single image planes as in 2D ultrasound but also for storing complete sets of volume data in the computer memory. Once acquisition is completed, all volumes can be accessed from the memory and normal and abnormal findings in both obstetrics and gynecology can be demonstrated in different display modes. Furthermore digital storage of volumes permits virtual examinations by reloading of volumes and navigating through them in the absence of the patient.

This review article would like to give an illustration of the latest technologies in 3D/4D ultrasound in obstetrics and gynecology.

How to cite this article

Merz E, Pashaj S. Current Role of 3D/ 4D Sonography in Obstetrics and Gynecology. Donald School J Ultrasound Obstet Gynecol 2013;7(4):400-408.

Detection of lip, alveolar ridge and hard palate abnormalities using two-dimensional ultrasound enhanced with the three-dimensional reverse-face view

OBJECTIVE

The aim of this study was to assess conventional two-dimensional (2D) ultrasound enhanced with a three-dimensional (3D) ultrasound technique, the 'reverse-face' view (3D-RF) in prenatal evaluation of the involvement of the lips, alveolar ridge and secondary palate in suspected isolated orofacial clefting.

METHODS

One hundred and twenty-four cases of suspected orofacial clefting diagnosed by a routine 2D ultrasound scan were referred for specialist ultrasound at 20-34 weeks' gestation for a detailed assessment of the lips and palate using both 2D and 3D ultrasound. For the 3D examination the lips and alveolar ridges were examined both in profile and in the frontal plane. The palate was then assessed in the reverse coronal view by rotating the face through 180° on the vertical axis to produce the 3D-RF view. Antenatal diagnoses were compared with postnatal findings. Left and right lip and alveolar ridge defects were counted separately according to the Kernohan 'striped Y' classification.

RESULTS

Of 124 patients, 110 had isolated facial clefts and were available for follow-up; in 10, 3D-RF views were not successfully obtained, leaving 100 cases for assessment. The sensitivity of the 2D enhanced with 3D-RF technique for the diagnosis of cleft of the lip was 116/122 (95%), false-positive rate (FPR) 7.7%; for alveolar ridge was 87/103 (84.5%), FPR 7.2%; and for hard palate was 61/68 (89.7%), FPR 15.6%.

CONCLUSION

The data reported represent the largest series of orofacial abnormalities diagnosed by 2D ultrasound and enhanced with 3D imaging to refine the detection of clefts of the hard palate. The technique is feasible in 90% of patients in whom almost 90% have a correct classification of clefts of the lip, alveolar ridge and palate.

Anatomy and Growth of the Fetal Soft Palate: A Cadaveric Study to Improve Its Ultrasonographic Observation

Objective:

To determine the anatomy of the soft and hard palate during fetal growth in order to improve its ultrasonographic prenatal visualization.

Design:

Anatomic study in human formalin-fixed fetus.

Methods:

The heads of 18 second and third trimester fetuses were studied in the median sagittal plan. Measurements of the soft palate, the velopharynx, the root of the tongue, and the oral floor were taken. The hard palate/soft palate angle and the anterior cranial base/soft palate angle were measured.

Results:

The growth of the hard palate was linear, and the growth of the soft palate was polynomial (second order) during the period studied. The hard palate/soft palate angle was 150.33° ± 7.62 and 150.20° ± 6.67 in the second and third trimester, respectively. The anterior position of the soft palate in relation to the anterior cranial base was 48.8° ± 3.13 in the second trimester and 52.26° ± 3.31 in the third trimester. Its posterior position was 89.66° ± 5.51 in the second trimester and 92.97° ± 4.01 in the third trimester. Throughout the fetal period, the soft palate moved downward relative to the clivus and cervical spine.

Conclusions:

Despite the nonlinear growth and downward displacement of the soft palate during fetal life, its position remains stable. These results may be useful to explore the fetal soft palate using 2D and 3D ultrasonography and to improve the prenatal diagnosis of isolated cleft palate.

Three-dimensional ultrasound in prenatal diagnosis

PURPOSE OF REVIEW

Several technological advances have greatly improved three-dimensional sonography, which have improved acquisition and display capabilities. This review describes these technical changes as well as current applications of 3D sonography in prenatal diagnosis.

RECENT FINDINGS

Recently published papers have emphasized the potential of getting a precise 'any plane of choice' from a three-dimensional volume, as a new way of scanning, based on the off-line analysis of a volume dataset. Surface mode has been used to demonstrate malformations and genetic diseases. The maximum rendering mode, which highlights bones, has great potential for imaging the nasal bones and the frontal bones with the metopic suture. Organ volume can be measured, but the utility of this in clinical practice remains to be determined. Three-dimensional ultrasound needs to be standardized.

SUMMARY

Three-dimensional ultrasonography is the most rapidly developing technique in fetal imaging. New features will permit the transition from the era of 'sonography in two-dimensional planes' to 'volume ultrasound'.

Prenatal evaluation of facial clefts by three-dimensional extended imaging

OBJECTIVES

To determine the prenatal diagnostic accuracy of two-dimensional ultrasound (2DUS) alone versus 2DUS in conjunction with three-dimensional ultrasonography (3DUS) including orthogonal display (OGD) and three-dimensional extended Imaging for cleft lip and primary palate.

MATERIALS AND METHOD

Fetuses being suspected of having a facial cleft by previous ultrasound examination or family history were examined sequentially with 2DUS and then 3DUS.

RESULTS

Of a total of 30 infants, 22 had cleft lip and nine also had cleft palate at birth. The use of 2DUS with or without 3DUS correctly identified all cases of cleft lips prenatally. However, the use of 2DUS in conjunction with 3DUS correctly identified more cleft primary palate than 2DUS alone (88.9% vs 22.2%, P < 0.01). Cleft primary palate was well demonstrated in both the multi-slice view (MSV) and OGD modes. In one case, a cleft palate was shown in the MSV mode but not in the Oblique view (OBV) mode. All the unaffected fetuses were reported as no cleft palate with the use of MSV mode.

CONCLUSIONS

Combined approach of 2DUS and 3DUS with both OGD and MSV modes significantly improved the prenatal detection rate for a cleft palate compared with 2DUS alone (88.9% vs 22.2%) without decreasing the specificity.

Prenatal screening for fetal face and clefting in a prospective study on low-risk population: can 3- and 4-dimensional ultrasound enhance visualization and detection rate?

A study of 1856 second trimester low-risk pregnancies was conducted over a period of 12 months to evaluate the detection rate of cleft lip and palate by 3- and 4-dimensional (3D, 4D) ultrasonography. To image the fetal face and profile, a protocol regarding the use of external or internal hand stimulation or a repeated scan was followed, and the time taken to perform 3D scan was compared to that of a conventional 2D ultrasound. One case of unilateral right cleft lip and a cleft lip plus cleft palate were both identified, giving a prevalence of 1.1 per 1000 live births and a prenatal detection rate of 100%. The average imaging time for fetal face/profile view was significantly less with 3D when compared to 2D (5.33 vs 6.2 seconds, P < .001) and diagnosis at first scan without external or internal hand stimulation was feasible in 78% by 2D versus 87% by 3D technique (P < .0001). Cleft lip and palate were isolated prenatal findings and newborn karyotyping showed normal chromosomal maps in both cases. With the use of this standardized protocol, we were able to image the fetal face and profile view in all cases. We underline the critical role of sonographic expertise in screening for these anomalies and the great enhancement in imaging soft tissues and bone lesions by using 3D ultrasound. We advocate that screening for cleft lip and palate be included in future standard ultrasound examination in the second trimester of pregnancy.

Three- and 4-dimensional ultrasound in obstetric practice: does it help?

OBJECTIVE

The purpose of this article was to review the published literature on 3-dimensional ultrasound (3DUS) and 4-dimensional ultrasound (4DUS) in obstetrics and determine whether 3DUS adds diagnostic information to what is currently provided by 2-dimensional ultrasound (2DUS) and, if so, in what areas.

METHODS

A PubMed search was conducted for articles reporting on the use of 3DUS or 4DUS in obstetrics. Seven-hundred six articles were identified, and among those, 525 were actually related to the subject of this review. Articles describing technical developments, clinical studies, reviews, editorials, and studies on fetal behavior or maternal-fetal bonding were reviewed.

RESULTS

Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, especially facial clefts. There is also evidence that 3DUS provides additional diagnostic information in neural tube defects and skeletal malformations. Large studies comparing 2DUS and 3DUS for the diagnosis of congenital anomalies have not provided conclusive results. Preliminary evidence suggests that sonographic tomography may decrease the examination time of the obstetric ultrasound examination, with minimal impact on the visualization rates of anatomic structures.

CONCLUSIONS

Three-dimensional ultrasound provides additional diagnostic information for the diagnosis of facial anomalies, evaluation of neural tube defects, and skeletal malformations. Additional research is needed to determine the clinical role of 3DUS and 4DUS for the diagnosis of congenital heart disease and central nervous system anomalies. Future studies should determine whether the information contained in the volume data set, by itself, is sufficient to evaluate fetal biometric measurements and diagnose congenital anomalies.