PRENATAL DIAGNOSIS

Prenat Diagn 2010; 30: 631–638.

Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pd.2561

30th Anniversary Issue of Prenatal Diagnosis

REVIEW OF CURRENT PRACTICE

Three-dimensional ultrasound in evaluating the fetus

Anna M. Dückelmann and Karim D. Kalache*
Department of Obstetrics, Campus Charité Mitte, Charité University Hospital, Berlin, Germany

In recent years three-dimensional (3D) ultrasound has made a place in clinical practice and has become a
major field of research in obstetrics. In this article we will review the diagnostic performance of the most
widely used 3D ultrasound applications in the assessment of fetal anomalies, explain the technique to gain
correct 3D images and offer some practical advice for their efficient use. Examples are given to demonstrate
the applicability and vividness of 3D in daily routine. Copyright  2010 John Wiley & Sons, Ltd.
KEY WORDS: three-dimensional ultrasound; fetal imaging; ultrasonography; prenatal diagnosis

INTRODUCTION normal fetuses (Lee et al., 2007). According to a recent

In recent years, the field of prenatal diagnosis has
been inundated with three-dimensional (3D) ultrasound
imaging tools for diagnosis in obstetrics. The current
literature is extensive and filled with articles addressing
the application of 3D ultrasound to virtually every
aspect of fetal imaging (Goncalves et al., 2005). The
advantages of 3D outlined here include the enhanced
identification of the nature, size and location of certain
fetal defects (Merz et al., 1995a,b; Platt et al., 1998;
Baba et al., 1999; Dyson et al., 2000; Xu et al., 2002);
the precise measurement of the volumes of organs
with irregular shapes (Kalache et al., 2003b; Ruano
et al., 2005); visualizing structures in reconstructed
planes (Kalache et al., 2006a,b); imaging of the fetal
skeleton (Benoit, 2003); spatial presentation of blood
flow arborization and vessels (Chaoui and Kalache,
2001; Kalache et al., 2003a; Lee et al., 2003b); the
ability to reconstruct a 3D rendered image of the
fetal heart that contains depth and volume which may
provide additional information that is not available
from two-dimensional (2D) ultrasound images (DeVore
et al., 2003); the storage and retrospective analysis (Lee
et al., 2003a; Bergann et al., 2006) and exchange of
data that can be used for second opinions (Nelson
et al., 2001; Vinals et al., 2005); and the facilitation
of maternal–fetal bonding (Ji et al., 2005). Moreover,
a study on the perception of non-pregnant sonographers,
sonologists and undergraduate students on the use of
3D ultrasound technology in fetal medicine showed
that both caregiver and laypersons believe that 3D
ultrasound will play a role in the future, for medical
indications and in reassuring patients who are carrying
*Correspondence to: Karim D. Kalache, Department of Obstet-
rics, Campus Charité Mitte, Charité University Hospital,
Charitéplatz 1, 10117 Berlin, Germany.
E-mail: karim.kalache@charite.de
study, 3D ultrasound is a time-saving method allowing
cost-effective use of equipment and sonographer time
yielding an equally accurate anatomic examination of
the second-trimester fetus in half the time required for
a 2D survey (Benacerraf et al., 2005).
It remains difficult to understand, however, whether
the additional diagnostic information gained from 3D
ultrasound is clinically relevant and has a positive
impact on improved patient care. Despite the fact that
large prospective studies on its clinical importance and
accuracy are lacking, 3D ultrasound has made a place
in clinical practice and has become a major field of
research in obstetrics. The main reason is that the
technology is now cheap, user-friendly and widely
available. This is partly related to rapid technological
improvements implemented at the end of the 1990s. In
this article we will review the diagnostic performance of
the most widely used 3D ultrasound applications in the
assessment of fetal anomalies and offer some practical
advice for their efficient use.
3D ULTRASOUND METHODS
For 3D ultrasound, a set of consecutive 2D ultrasound
slices at a preset angle are acquired using dedicated
mechanical volume probes. Upon activating the 3D
modus, a render box appears on the screen that allows
selection of the scanned volume. The render box may
be modified regarding position and size (height, width
and depth). The speed of the acquisition of a 3D
image depends on the position, height and width of the
render box. There are generally three or four options for
volume resolution. We suggest choosing, on principle,
the highest resolution.
To minimize artifacts that occur with movement,
we ask our patients to hold their breath during the
acquisition of volumes. It may happen of course that

Copyright  2010 John Wiley & Sons, Ltd. Received: 22 February 2010
Revised: 27 April 2010
Accepted: 27 April 2010
632 A. M. DÜCKELMANN AND K. D. KALACHE
the acquisition of a high-quality image is impossible
due to a very active fetus. The acquired volume can
be displayed either in three perpendicular planes that
are displayed simultaneously on the screen (multiplanar
mode) or as a rendered image through the application of
various algorithms.
The multiplanar mode allows exact orientation by syn-
chronous viewing of the longitudinal, transverse and
coronal planes. Each of these three planes can be rotated
around the x , y and z axes. It is also possible to better
understand the spatial relationship of complex anatomi-
cal structures by moving a cursor representing the com-
mon intersection point referencing the three multiplanar
images to each other in each of these planes. Basically,
any ultrasound section can be obtained from the 3D
block, and clinical applications as an adjunct to 2D ultra-
sound are innumerable. However, it is important to know
that every deviation from the initial acquisition plane
is associated with a loss of image quality. The experi-
enced examiner will try to start from an optimal initial
plane requiring minimal adjustments once the volume is
acquired. Another very important issue is that the same
artifacts related to acoustic shadow may occur with 3D
ultrasound as with 2D scanning. Yet, 3D ultrasound is
operator dependent, and factors such as fetal position and
overlaying bone can limit the examination. Thus, spe-
cific acquisition techniques should be used for different
regions of interest avoiding the disadvantages inherent in
the two techniques. Most commercially available ultra-
sound systems offer two rendering modes: the surface
(skin) and the maximum (skeletal) rendering modes. In
the surface mode, the limits between the surface of the
fetal body and the amniotic fluid are scanned, and a
sculpture-like representation of the fetus is obtained.
The viewing direction in the 3D scan is shown by a
render line. After that, the region of interest is fixed.
Thus, the render line disappears and the volume can be
worked on with any desired method (by zoom, rotation
or electronic scalpel). The image can then be rotated
in any direction, offering a perspective from different
angles. In the surface mode it is necessary to have
a depot of amniotic fluid around the examined struc-
ture. Structures that occlude the region of interest can
be removed using the electronic scalpel function while
rotating the volume around its three axes. Optimal results
are achieved when these structures do not lie directly on
the region of interest, and they do not throw shadows
onto it.
The maximum rendering mode, which highlights
bony structures, has also great potential for imaging
cranial sutures. Again, it is important to know that
every deviation of the render line from its initial
position causes a loss of image quality. The well-
trained sonographer is able to obtain an optimal initial
setup without further need to move the render line.
Disturbances, like particles in the amniotic fluid, can
be removed with the use of a threshold.
In addition to static 3D ultrasound, it is possible to
perform updates at a frame rate of up to 25 volumes per
second to obtain the impression of a live 3D ultrasound
(also known as 4D ultrasound). This results in a movie
that allows the real-time observation of fetal movements
Copyright  2010 John Wiley & Sons, Ltd.
and other dynamic processes. The advantage of real-time
3D scanning is the ability to get a quick idea of expected
results while scanning. It is also possible to set up and
adjust the gain while acquiring the volumes. This allows
the sonographer to react immediately and optimally to
changes in fetal position. However, there is a trade-off
in imaging quality in real time compared to static modes
of 3D ultrasound. In our experience, it is advisable to
start with real-time 3D ultrasound and then continue with
static 3D ultrasound under good conditions (visibility,
position).
EVIDENCE-BASED ROLE OF 3D ULTRASOUND
IN EVALUATING THE FETUS
The authors of a recent study from Germany concluded
that 3D ultrasound is not only a useful tool in appreci-
ating the severity of a fetal defect, but has also a better
specificity in regard to the confirmation of normality
than conventional 2D ultrasound in cases with increased
risk of a recurrent surface malformation (Merz and Wel-
ter, 2005). However, in this study on the accuracy of
3D ultrasound in prenatal diagnosis, like in many others,
the 3D examiner was not blinded to the 2D ultrasound
examination. Another study from the NIH Perinatology
Research Branch in Detroit, USA compared the abil-
ity of 2D and 3D ultrasound to diagnose congenital
malformations (Goncalves et al., 2006b). In this study,
the examiner began with 3D ultrasound and added 2D
ultrasound only later. In 91% of the cases, there was
agreement between the two techniques. The authors con-
cluded that both the techniques are interchangeable for
screening for fetal anomalies in the second trimester.
However, according to another study, 3D ultrasound as
a primary examination was insufficient to study fetuses
at high risk for anomalies (Benacerraf, 2006). Even for
2D ultrasound there is a wide range of reported detec-
tion rates, which is dependent on the type of anomaly,
gestational age at time of the study, the skill of the
sonographer and whether the population is at high or
low risk for congenital anomalies (Li et al., 1988; Levi
et al., 1989; Lys et al., 1989; Saari-Kemppainen et al.,
1990; Chitty et al., 1991; Shirley et al., 1992; Ewigman
et al., 1993; LeFevre et al., 1993; Crane et al., 1994;
VanDorsten et al., 1998; Vintzileos et al., 2000)
SPECIFIC APPLICATIONS OF 3D ULTRASOUND
First trimester
The small size of the fetus in the first trimester allows
it to be encompassed in a single 3D ultrasound sweep.
Furthermore, amniotic fluid is invariably present in the
first trimester, allowing the obtention of a surface-
rendered 3D ultrasound mode reconstruction without the
difficulties inherent to the second and third trimesters.
Additionally, the visualization of structure within the
volume is good, with minimal acoustic shadows from
the bones. It has been shown that by employing a single
Prenat Diagn 2010; 30: 631–638.
DOI: 10.1002/pd
 3D ULTRASOUND IN EVALUATING THE FETUS 633

A B C D

Figure 1—Sirenomelia in an 11-week-old fetus (D). A single lower limb is obvious on surface-rendered 3D images (B, C), whereas it was
unrecognizable on the 2D ultrasound image (A). Bilateral radial aplasia in this case was suspected on real-time 3D ultrasound and confirmed in
the postmortem examination

A B C D

Figure 2—Megavesica from an urethral atresia in a 10-week-old fetus (D, ultrasound 2D image: A). On surface-rendered 3D images the fetus
was found to have bilateral lower limb amputation (B, C)

transabdominal sweep beginning from a mid-sagittal
plane of the fetus with 3D ultrasound during a regular
nuchal translucency (NT) screening examination at 11
to 13 weeks 6 days of gestation, a volume dataset could
be acquired that allows appropriate views of the fetus
for evaluation of both anatomy and NT in the vast
majority of cases (Fauchon et al., 2008). Another recent
study showed that the first-trimester 3D ultrasound was
efficient for assessment of the head, abdominal wall,
stomach, limbs and vertebral alignment (Bhaduri et al.,
2010). However, it was less effective in evaluating
the heart and excluding spinal defects. Figures 1 and 2
show two examples of anomalies identified in the first
trimester by 3D ultrasound.
Imaging of the fetal face
(Figure 3), tumors such as cervical teratomas extend-
ing to the face (Figure 4), facial clefts and markers of
trisomy 21 (Lee et al., 2003a; Bergann et al., 2006).
Diagnosis of abnormalities of the hard and soft sec-
ondary palate is amenable to prenatal diagnosis by
means of 3D ultrasound (Benacerraf et al., 2006; Faure
et al., 2007a). Several techniques have been developed
to explore these structures including the ‘reverse-face’
view (Campbell et al., 2005), the ‘flipped-face’ view
(Platt et al., 2006) as well as other methods derived from
these techniques (Faure et al., 2007b, Pilu and Segata,
2007; Ten et al., 2009). Accurate visualization of the
palate, however, requires volumes in which the head is
slightly deflected during acquisition. Furthermore, better
results are obtained when those volumes are obtained
during fetal swallowing with a rim of fluid between the
fetal tongue and palate.

Congenital facial dysmorphic feature can be detected

in prenatal 2D scans. Although usually easily suspected
with conventional 2D ultrasound, 3D ultrasound has
the potential to visualize several structures in the same
image, thus improving the comprehension of spatial rela-
tionship and recognition of abnormal features. Abnor-
malities that can be most reliably diagnosed by 3D
ultrasound include distinctive facies such as microg-
nathia as part of the spectrum of genetic disorders
Fetal skeleton
The use of 3D ultrasound has proved to be useful in the
assessment of limb extremities malformation especially
in case of position anomalies and flexion deformity of
the fingers (Figure 5). 2D ultrasound plays a major role
in prenatal diagnosis of major anomalies of the fetal
skeletal system. However, small neural tube defects are

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2010; 30: 631–638.
DOI: 10.1002/pd
634 A. M. DÜCKELMANN AND K. D. KALACHE

Figure 3—3D ultrasound images of a fetal face at 21 weeks’ gestation suggestive of a micrognathia

A B C

Figure 4—2D ultrasound and surface-rendered 3D ultrasound images of a large neck teratoma in a 26-week fetus (A). 2D ultrasound axial images
demonstrate the facial mass (arrow). It is, however, easier to appreciate the degree of facial involvement from surface-rendered 3D ultrasound
images (B, C)

A B

Figure 5—2D ultrasound images suggesting that the 19-week-old fetus is affected with hand flexion deformities (A). The surface-rendered 3D
ultrasound images assisted in the prenatal diagnosis of camptodactyly (B)

sometimes difficult to visualize (Figure 6). 3D ultra-
sound localizes fetal neural tube defects with more accu-
racy and helps in demonstrating the extent of neural tube
defects (Lee et al., 2002). Furthermore, 3D ultrasound
has been applied to diagnose rib anomalies (Esser et al.,
2006) and abnormal cranial sutures (Esser et al., 2005).
Cranial bones may also be displayed, allowing the con-
firmation of a small encephalocele (Figure 7). In some
instances, 3D ultrasound will provide a clearer image of
the fetus allowing the examiner to understand an abnor-
mal spine curvature (Figure 8).
Neurosonography
3D ultrasound technology has been intensely applied
to study the fetal central nervous system (Monteagudo
et al., 2000; Pilu et al., 2007; Monteagudo and Timor-
Tritsch, 2009). The mid-sagittal view is the most

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2010; 30: 631–638.
DOI: 10.1002/pd
 3D ULTRASOUND IN EVALUATING THE FETUS 635

A B C

Figure 6—2D ultrasound (A) of a pathologic spine at 19 weeks (C). Abnormally splayed posterior elements (arrow) are easily appreciated on
3D maximum-rendered image at the level of the defect (first lumbar vertebra) (B). Note the localization of last thoracic body on the rendered
image as indicated by the 12th rib

A B C

Figure 7—2D ultrasound image of the fetal skull in a 21-week fetus suggesting a small occipital encephalocele (A). The 3D maximum-rendered
image clearly displays the bony defect (arrow) below the posterior fontanel (B). Occipital bone with sagittal and lambdoidal sutures in a normal
fetus (C)

A B

Figure 8—Conventional 2D ultrasound view of a fetus at 18 weeks’ gestation suggesting hyperextension of the fetal head (A). The 3D
maximum-rendered image shows that there is an extreme extension of the cervical spine (B)

Copyright  2010 John Wiley & Sons, Ltd. Prenat Diagn 2010; 30: 631–638.
DOI: 10.1002/pd
636 A. M. DÜCKELMANN AND K. D. KALACHE
Figure 9—Multiplanar display of a 3D sonographic dataset of a normal fetal brain at 26 weeks with the three mutually related orthogonal planes
at 90◦ to one another: (A) the sagittal plane; (B) the coronal plane and (C) the axial plane. Thick slice rendering (green box) may be used for
enhanced soft tissue display. The corpus callosum (open arrow) as well as the vermis cerebelli (closed arrow) is better visualized in the resultant
lower right image (D)
important complement to the three standard axial views
that are required during a routine 2D examination of
the central nervous system. However, obtaining the cor-
rect plane using conventional 2D ultrasound may be
challenging. Fetal brain imaging takes maximum advan-
tages of 3D ultrasound capabilities to look at midline
brain structures by allowing the physician to orient the
fetal brain in any direction. The main advantage of 3D
ultrasound is the easy obtention of a true sagittal view,
allowing detailed investigation of the corpus callosum
and the posterior fossa. However, the best results are
obtained when the volume is acquired either through the
frontal suture or the anterior fontanelle. Thick slice 3D
ultrasound rendering is able to demonstrate more details
than conventional 2D ultrasound through the superim-
position of several layers of tissue (Figure 9).
Spatio-temporal image correlation
Another 3D/4D technique that is taking long steps
into the future of routine use is 4D fetal echocardio-
graphy. This new technique relies on spatio-temporal
image correlation (STIC), which is an indirect, motion-
gated, offline scanning mode. Once a volume is acquired
the information can be used to display multiplanar
images that allow the visualization of any given plane
within the heart. The information in the volume can
also be used to reconstruct a rendered image of an
examiner-defined region of interest. Some of the ren-
dering modes that are useful for visualizing the heart
include surface mode, minimum mode, inversion mode
and glass body mode in combination with color or power
Doppler. 3D fetal echocardiography with STIC allows an
accurate prenatal characterization of aortic arch abnor-
malities to a degree that was typically only attain-
able previously with postpartum imaging (Goncalves
et al., 2006a). However, the technique when used by
Copyright  2010 John Wiley & Sons, Ltd.
general obstetricians was found to be marginally clin-
ically effective when compared to 2D fetal echocar-
diography scanning by experts (Wanitpongpan et al.,
2008). STIC offers the opportunity to reconstruct diverse
planes, but cannot be used as a tool to expand a
fetal cardiac screening program (Wanitpongpan et al.,
2008).
CONCLUSION
In the last years, the use of 3D ultrasound has extended
greatly and provides additional information in selected
indications. The main advantage is the possibility of
obtaining an infinite number of different scanning planes
starting from a single volume acquisition. Although 3D
ultrasound allows several alternative viewing modalities,
the extent to which a given structure can be demon-
strated in a given reconstructed section is entirely depen-
dent on the quality of the initial 2D image as well as
on fetal position. Thus, expertise is not only mandatory
during the manipulation and interpretation processes but
also while acquiring the volumes. At the moment the
technique is always used as a complementary tool to the
2D ultrasound examination that still remains the gold
standard to detect congenital anomalies.
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