UltrasoundObstetGynecol2017;49:671–680Publicatonlinepedatade6Aprilie2017inWileyOnlineLibrary(wileyonlinelibrary.com).DOI:10.1002/uog.17412

GhidurileISUOGdepracticămedicală:utilizareaimagisticiiprinRezonantaMagneticaNuclearaTradusde:Dr.CalomAirescuMarius-Vicea,Dr.TudoracheȘtefania;Editor/Reviewer:Dr.IliescuDominicGabriel

ComitetulpentruStandardeClinice

SocietateaInternaționaladeUltrasonograOieînObstetricășiGinecologie(TheInternationalSocietyofUltrasoundinObstetricsandGynecology-ISUOG)esteoorganizațieștiințiOicăcareîncurajeazăbunapracticămedicalăclinicășiunprocesdeînvățământșicercetaredeînaltăcalitate,îndomeniuldiagnosticuluiimagistic,încadrulîngrijirilordesănătateacordatefemeii.ComitetulISUOGpentruStandardeClinicearecascopelaborareaderecomandărieducaționalesubformădeGhidurideBunăPracticășiDeclarațiideConsensceoferămedicilorposibilitateaabordăriidiagnosticuluiimagisticpebazaconsensuluiexperților.AcesteghidurisuntconceputeastfelîncâtsăreOlecteceeaceISUOGconsiderăceamaibunăpracticălamomentulpublicării.DeșiISUOGfacetoateeforturilepentruaseasiguracăghidurileconțindateexacteînmomentulpublicării,atâtsocietateacâtșiangajațiisaumembriiacesteiaîşideclinăoriceresponsabilitatepentruconsecințeledatelor,opiniilorsauaOirmațiilorinexactesaueronateemisedeComitetulpentruStandardeClinice.DocumenteleemisedeComitetulpentruStandardeClinicealISUOGnusuntdestinatesăstabileascăunstandardlegaldeîngrijiredeoareceinterpretareadovezilorcarestaulabazaghidurilorpotOiinOluențatedecircumstanțeindividuale,deprotocoalelelocaleșideresurseledisponibile.GhidurileaprobatepotOidistribuitegratuitcupermisiuneaISUOG(info@isuog.org).

Acesteghidurisebazeazapeconsensulparticipanţilorînurmaunuistudiuprivindpracticileactuale,realizatdeISUOGin2014(AnexaS1).

INTRODUCEREImagisticafetalaprinrezonantamagneticanucleara(RMN)reprezintauninstumentdiagnosticimportantalaturideecograOie1,maialespentruevaluareadezvoltariicreieruluifetal2.UnstudiurealizatdeISUOGin2014(Anexa1),incareauparticipat60decentredemedicinaperinatalainternationale,aaratatcaRMNfetalserealizeazaincelputinintr-uncentruinpeste27tari.Totusi,calitateaimaginii,secventeleutilizatesiexperientaoperatorilorparsadiferemultintrecentre3.

ImpactulunorasemeneadiferenteartrebuiredusprinelaborareadeghiduricaresadeOineascamaibinerolulRMN-uluifetalinrelatiecuecograOiadiagnosticaprenatala.ScopulacestuidocumentestedeafurnizainformatiimedicaledecelmaiinaltnivelasupraRMNfetal,atatpentruceicarerealizeazacatsipentruclinicieniicareinterpreteazarezultatele.

CareestescopulRMN-uluifetal?ScopulRMN-uluifetalestedeacompletaoexaminareecograOicadenivelinalt4,5,princonOirmareaconcluziilorecograOieisauprinfurnizareadeinformatiiaditionale6.RMNnuesteutilizatinprezentpentruscreeningprimariningrijirileprenatale,desievaluareacompletasistandardizataaanatomieifetaleparefezabila.Figura1prezintaopiniileparticipantilordinaceststudiuprivindindicatiilepentrucareRMNpoatefurnizainformatiiutile.

EsteRMN-ulfetaloprocedurasigura?RMNnuesteasociatcuniciunefectfetaladverscunoscutlaniciunmomentalsarcinii,atuncicandesterealizatfaraadministrareadesubstantadecontrast7.NusuntraportateefecteadverselaefectuareaRMNde1,5Tesla(1,5T)8.Totusi,nusuntstudiilaomaposibilelorefecteadversepentruutilizareaunorcampurimaiputernice,cumarOi3,0T7,9,10,desiinformatiirecentearatacaarputeaOisigurintr-unmodelporcin11.

IncesituatiiartrebuirealizatRMN-ulfetal?ExistaunconsenslargprivindindicatiadeefectuareaRMN-uluifetaldupaoexaminareecograOicadenivelexpertlacarediagnosticuluneianomaliinecesitainformatiisuplimentare.InacestecircumstanteRMN-ulartrebuisafurnizezeinformatiiimportantecarecaresaconOirmesaucompletezedescrierileecograOicesisaoptimizezesaumodiOicemanagementulcazului.

InmomentuldefataelementelecareinOluenteazadeciziaderealizareaRMN-uluifetalinclud,faraaselimitala:experienta/echipamenteledisponibilepentruecograOiesiRMN,disponibilitateaRMN-ului,factorimaterni,varstagestationala,aspectelegatedepotentialaafectareasarcinii,considerentelelegaleprivindintrerupereasarcinii(TOP)sioptiuneaexprimatadeparintidupaconsiliereainformata3.10,12,13.

StudiulrealizatdeISUOGaabordatnecesitateaefectuariiRMN-uluipentruindicatiiselectionatesiautilizatunsistemdeierarhizarecu7niveluripentruaevaluaraspunsurileunuisondaj,dela0(totalneindicat)la7(indicatieabsoluta)(Figura1).VariabilitatearaspunsurilorpoateOiexpresiadivergentelordintrespecialitatisiaspectruluidiferitdepatologieexaminatinOiecarecentru.OpiniileparsareOlectedeasemeneanivelediferitedeexperientainrealizareaecograOiilorsiaRMNfetale.

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Figura1RezultatelesondajuluiISUOGprivindindicatiilepentruRMNfetal,ierarhizatepe7niveluridela0(RMNtotalneindicat)la7(RMNcuindicatieabsoluta).*Istoriclaosarcinaanterioarasauinfamilie,cuecograOienormalalasarcinaactuala.STT–sindromtransfuzortransfuzat.VM–ventriculomegalie.

Decelemaimulteori,oecograOierealizataconformrecomandarilorminimepentruscreeningdeanomaliiintrimestrul2/examinareadebazacreierului,dupacumsuntpropusedeISUOG5,esteinsuOicientapentruasolicitaRMNfetal.Imagisticasuplimentara,cumarOiplanuriortogonale,sondecufrecventamaimaresi/sauexaminarevaginalasuntnecesarepentruadetaliaanomaliadepistata14,15.

PracticareaTOPsiaspectelemedico-legalecorespunzatoarepotinOluentautilizareaRMNfetalinuneleinstitutii.IntarileundedeciziaTOPtrebuieluatapanala24saptamani,doarrealizareaRMNanterioracestuimomentpoateajutaanumitecuplurisadecidareferitorlacontinuareasarcinii;totusi,deobicei,RMN-ulfetalestemaidegrabautilmaitarziuintrimestrul2siintrimestrul313.Desidateledisponibilesuntincaneconcludente,indicareaRMNpentrulinistireaparintilorcuprivirelacaracterulizolatalanomalieipoateOirecomandatincazuricuventriculomegalieizolata16,ageneziacorpuluicalos17,absentaseptuluipellucidsianomaliialecerebeluluisauvermisului18.Suplimentar,utilitateainvestigatieiRMNafostdemonstrataincazulsarciniigemelaremonocoriale,dupadecesuliatrogensaunaturalalunuigeaman,pentruaidentiOicamodiOicaripatologicelageamanulsupravietuitor19,20.

LacevarstaasarciniiartrebuirealizatRMNfetal?Deobicei,RMN-ulfetalrealizatinaintede18saptamaninufurnizeazainformatiisuplimentarefatadeceleobtinuteprinexaminareaecograOica.InunelecazuripotOiobtinuteinformatiiaditionaleinaintede22saptamani13,iarulteriorutilitateaRMNcresteodatacuavansareavarsteigestationale.ExempleparticularedepatologiecarepotOievaluateintrimestrul3includ,faraaselimitalaacestesituatii,dezvoltareacorticalasiformatiunilecervicalecepotcompromitecailerespiratorii21.CelemaimulteorganepotOievaluateindetaliuintresaptamanile26si32alesarinii,candaspectelepatologicelegatededezvoltareafetalaanormalasuntmaibineexprimate,insaOiecaresarcinasiOiecarefatvoraveadiferente.DevinemaidiOicilpentrumamasasteainaparatulRMNpemasuraceavanseazasarcinasiesterecomandataseluaprecautiiprinpozitiaindecubitstang.

CineartrebuisarealizezeRMNfetal?Insituatiaincareesteindicat,realizatsiinterpretatcorect,investigatiaRMNcontribuieladiagnosticsipoateOiunelementimportantinalegereastrategieiterapeutice,planiOicareanasteriisiconsiliere.ProfesionistiicareinterpreteazaRMNfetaltrebuiesaOiefamiliarizati/specializatiindiagnosticulantenataldeoarecediferadediagnosticulinaltecategoriidepacienti.Alegereaprotocoalelorsiatehniciideexecutarecorespunzatoarenecesitainstruireextensiva;deaceearealizareaexplorariiRMNfetalartrebuilimitatalaprofesionisticuinstruiresiexpertizaspecializata.Acelasipricipiuseaplicasipentruinterpretareaexamenului.Inmultecentreaceastasepuneinpracticaprinechipemultidisciplinareceincludexpertiindiagnosticulprenatal,perinatologie,neonatologie,neurologiepediatrica,neuroradiologie,geneticasialtespecialitati(Tabel1)pentruaintegradateleclinicesideistoricfamilial,rezultateleecograOieisiRMN-uluisipentruaoptimizaingrijirilepacientilor.ConsultareaunuigeneticiansiaaltorspecialitatipediatricepoateOinecesarapentruafurnizapacientilorcelemaimaibuneconsilierisioptiuniterapeutice.

Tabel1Echipamultidisciplinara:participantipropusisirolullorinrealizareaRMNfetalParticipant Rol

Obstetrician,radiolog RealizeazaexaminareaecograOica/neurosonograOia;furnizeazainformatiipacientilorprivindrezultatulsiposibilediagnostice;consiliere;indicatiedeRMNfetal

Radiolog,ostetrician PrezentiintimpulexaminariiRMNpentruachizitiaplanurilorcorespunzatoaresischimbareaprotocoluluidacaestenecesar;consiliere

Echipamultidisciplinara:obstetrician,radiologpediatrusauneuroradiolog,neurologpediatru,genetician,altespecialitatipediatrice,psiholog,asistentfamilial/social

ConsilieresirecomandarifunctiedeneuronosograOie,RMN,rezultategenetice,rezultatedelaborator,si/sauistoricfamilial

Undeartrebuisaseintruiascaunasemeneapractician?DesiinmomentuldefatanucunoastemexistentauneispecializariinRMNfetal,persoanelecarerealizeazaRMNfetalartrebuisaurmezeoinstruirespecializataintr-uncentrueducational,aceastapermitandu-lesarealizezeexameneRMNfetaldenivelinaltdupaunnumarsuOicientdecazuri(ELEMENTDEBUNAPRACTICA;recomandaredebunapracticabazatapeexperientaclinicaagrupuluidedezvoltareaghidului).

Uncentrueducationalesteoinstitutiecapabilasainstruiascastudenti,medicisitehnicieniinrealizareacupricepereaRMN-uluifetal.Cerintelecaretrebuieindeplinitedeunasemeneacentrudeinvatamantinclud:

1. existentaunorspecialistimultidisciplinaricelucreazaindomeniuincluzand,darfaraaselimitala:specialistiinmedicinamaterno-fetala,radiologisiobstetricieni;

2. experientainstitutionalasacuprindacelputin500investigatiiRMNfetaledejarealizatesicelputin2saptamanal;

3. publicareadearticolesaucartidereferintainacestdomeniu(Figura2).

Figura2RezultatelesondajuluiISUOGprivindnumaruldepublicatiiconsideratminimdorituneiinstitutiiindomeniulRMNpentruasecaliOicacasicentrueducational.

RECOMANDARIRealizareaRMN-uluifetalconformcriteriilorstandardizate(Tabel2)vaimbunatatiingrijireasarcinilorcomplicatecumalformatiifetalesaupatologiedobandita(ELEMENTDEBUNAPRACTICA).

Tabel2Pasiinrealizareaexaminariifetalecurezonantamagneticanucleara(RMN)

Indicatie DepindedecalitateaexaminariiecograOiceanterioare,solicitarileclinicesivarstasarcinii

Consilieregravida Explicareaindicatiei,performantei,informatiilorobtinutesiconsecintelorasupraingrijirii,informareacuprivirelaposibilitateaexistenteiunuiinsotitor,discutiireferitoarelacontraindicatii,claustrofobiesiprescrieredesedativelanevoie

NecesareunitatiiRMN Trimiterescriscuindicatiesiintrebarileclinicerelevante,raportecograOiecuimagini(dacaesteposibil),varstagestationalaconOirmata/determinataprinecograOieintrimestrul1

InunitateaRMN ClariOicareaposibilelorcontraindicatii,pozitionareaconfortabilaagravidei(decubitposteriorsaulateral),pozitionareaadecvataabobinei,realizareaexaminariiconfromprotocoluluiadecvat/pertinent

Dupaexaminare Informareapacientuluiasupratermenuluiraportului;incazdeconsecinteimediatedatedeexaminareaRMN,medicultrimitatortrebuieinformatrapidcuprivirelarezultat

Raport,imagistica Stocareaelectronicaaimaginilor,analizaimaginilor,raportstructurat(Tabel3)

CumartrebuirealizatRMNfetal?

PutereacampuluiLamomentulactualcelmaiutilizatcampareoputerede1,5T,furnizandorezolutieacceptabilaincepandcu18saptamani22.Campulde3Tarepotentialuldeafurnizaimaginicurezolutiesiraportsemnal-zgomotmaibunecomparativcu1,5Tcuoacumularedeenergiecomparabilasaumaimica22.Totusi,campurimaiputernicenusuntrecomandateaOiutilizateinimagisticafetalain-vivo10.

Proceduraexaminarii1. ExcludereacontraindicatiilorRMN22.2. Obtinereaconsimtamantuluiinformatdelagravida.3. Notareavarsteigestationale,inmodoptimstabilitaprinecograOiadeprimtrimestru23siainformatiilor

anterioareclinicesiecograOicesemniOicative.4. Optional,administrareadesedativepentrureducereamiscarilorfetalesi/sauaartefactelor,pentru

pacienticuanxietatesauclaustrofobie.5. Pozitionareapacienteiintr-opozitieconfortabilapentruexaminare24.6. Inanumitecazurisiinconformitatecureguliledesigurantadininstitutie,poateOiluataincalcul

prezentaunuiinsotitorincameradeexaminare25.7. Achizitiadesecventetintite.8. Asigurareapozitionariicorecteabobinei,cuorganulprincipaldeinteresincentrulcampuluide

examinare;planiOicareasecventelorurmatoare.9. Evaluareaorganuluiprincipaldeinteres.10. Atuncicandesteindicat,sevarealizaevaluareacompletaafatuluisiastructurilorextrafetale(inclusiv

cordonombilical,placentasicoluterin).11. Informatimedicultrimitatorrapiddacaseobservaaspectecenecesitainterventieimediata(cumarOi

suspiciunededezlipiredeplacentasauafectarecerebralafetalahipoxic-ischemica).

Alegereasecventelor1. ContrastulT2-inponderatieesteprincipalulutilizatinRMNfetalsiesteobtinutdeobiceiprinachizitie

cusecventerapida(turbo)Spin-Echo(SE)sausteady-statefree-precession(SSFP).SecventeleSErapide(turbo)cutimpdeecou(echo-time,TE)lungartrebuiutilizateinexaminareacreieruluifetal(Figura3).UnTEmaiscurtfurnizeazauncontrastmaibunincorpulfatului(Figura4).SecventeleSSFPfurnizeazainformatiiT2lafetiiinmiscaresipermit,deexemplu,diferentiereaintrevaseledesangesitesuturilesolide26.

2. ContrastulT1-inponderatieesteobtinutprinutilizareasecventelordegradient-echo(GRE)bidimensionalla1,5T.Cuoduratamediede15secundesepoaterealizaintimpuluneiapneimaterne,ceeacefavorizeazaobtinereadeimaginifaraartefactedemiscare27.ContrastulT1-inponderatieidentiOicamethemoglobinainhemoragiilesubacute,calciOicarile,glandelesimeconiul27(Figura5a,b)

3. Secventelesingle-shothigh-resolution(SSH)GREecho-planar(EP)suntutilizatepentruvizualizareastructurilorosoase,calciOicarilorsiprodusilordedegradareaihemoglobinei,cumarOiprezentadeoxihemoglobinei-caresugereazahemoragierecenta,sauahemosiderinei-careindicaohemoragiemaiveche28(Figura5c-e)

4. Secventeoptionaleinclud:secventadedifuzie(diffusion-weightedimaging),secventadediffusiontensorimaging,secventedynamicSSFPsiSSHdecolangiopancreatograOieprinrezonantamagnetica,cugenerareadeimaginicvasi-tridimensionale(Figura5f,g)

Intoatesituatiilecampuldeexaminareartrebuiajustatperegiuneadeinteres.Ogrosimedeachizitiede3-5mmcuintervaldesuprapunerede10-15%estepotrivitaincelemaimultecazuri.Examinareaartrebuisa

includacelputininformatiiT2in3planuriortogonalealecreieruluisicorpuluifetalprecumsisecventeT1siGRE-EPinunulsau2planuri,preferabilfrontalsisagital.

Acestprotocol“minim”esterealizabilinmaiputinde30deminute,permitandchiarmiscarifetalesirepetareasecventelor.DoarexaminarileRMNrealizateconformacestuiprotocolartrebuiconsideratedenivelinalt(ELEMENTDEBUNAPRACTICA).

Figura3Secventerapid(turbo)spin-echoT2-inponderatie(cutimpdeecoulung)inplanurilecoronal,axialsisagital(delastangaladreapta)alecreieruluifetalnormalla21+0,28+1si31+1saptamani.

Figura4Secventarapid(turbo)spin-echoT2inponderatielaunfatnormalde39+4saptamaniaratacumuntimpdeecou(echo-time,TE)maiscurtfurnizeazadetaliimaibunelacorpulfetal:(a)TE=80ms;(b)TE=140ms.

Figura5ContrastulsecventeiT2inponderatieesteprincipalulutilizatinRMNfetal.AltesecventeincludRMNT1inponderatie(a,b),utilizataicilafetinormalide27+1(a)si38+3(b)saptamani,aratandhipersemnalalglandeitiroidesiansecumeconiu;secventesigle-shothigh-resolutiongradientechoechoplanar,observateaiciinplanurilecoronal(c),axial(d)sisagital(e)launfat22+6saptamanicuhemoragiecerebrala,aratandhiposemnalulprodusilordedegradareaihemoglobinei;secventacolangiopancreatograOieiRMN(grosime40mm),folositaaicilaunfatde24saptamani+4zile,cumalformatiecardiaca(ne-prezentatainOiguri)(f)silaunfatde20saptamani+1zilecuanomalieaarticulatieigenunchiului(genurecurvatum),pentruapermiteobservareaproportieisipozitieipicioarelorsimainilor.

Figura6ImagineRMNT2inponderatiesagitalalaunfat21saptamani+5zile,aratandproOilulcupalatulintact

Planuristandardizatepentruexaminareacreieruluifetal1. Sectiunisagitalealecraniului,incluzandunamedio-sagitalacepuneinevidentacorpulcalos,apeductul

siglandapituitara.2. Sectiunicoronaleparalelecubulbulrahidiancuvizualizareasimetricaastructurilorurechiiinterne.3. Sectiuniaxiale,perpendicularepecelesagitale,paralelecutraiectulcorpuluicalos(saucubazacraniului

inabsentacorpuluicalos),cusimetrielateralaajustatainfunctiedesectiunilecoronale.

PlanuristandardizatepentruexaminareacorpuluifetalAcesteasuntmaidiOicildeobtinutdeoarecefatulseaOladeobiceiintr-opozitiecarenuvapermiteopozitionarestrictortogonalaaplanurilor.

1. SectiunilesagitalepotOiobtinuteplasandplanulmedianprincoloanatoracicasiinsertiacordonuluiombilical.

2. Sectiunilecoronaletrebuiescajustateconformtraiectuluicoloanei(paralelcucoloanalaniveltoracicsicupereteleanteriorlanivelabdominal).

3. SectiunileaxialeartrebuisaOieperpendicularepeaxullungalcoloaneidelanivelulzoneideinteres.PentruarealizavolumetriapulmonaraplanurileaxialetrebuiesaOieperpendicularepecoloanatoracica.

Figura7RMNdetoracefetal(a,b)siabdomenfetal(c,d).(a)RMNaxialT2inponderatieintr-unfat34+2saptamani,aratanduntoracenormalconformatsiplamanicusemnalnormalpantruvasrsta;(b)RMNcoronalT2inponderatielaunfat35+3saptamani,aratandinplusportiunidinOicat,suprarenalasirinichipeparteadreapta.(c)RMNcoronalT2inponderatieintr-unfetus32+2saptamani,aratandstomacsianseintestinalecucontinutlichidian;(d)imaginesagitalasteady-statefree-precessionlaunfat35+6saptamani,aratandinplusvezicaurinaraculichid.Denotathiperintensitateacardiacain(d),incontrastcuimaginileT2inponderatie(c).

Figura8ImaginiRMNsagital(a)siaxial(b)T2-inponderatielaunfatnormalfenotipfemininde31+1saptamani,careprezintaorganelegenitaleexterne.Imaginisagitale(c)siaxiale(d)steady-statefree-precessinglaunfatfenotipmasculinde35+1saptamani,aratandtesticolecoboratesihidrocel,inacestcazoconsecintaauneitumorihepatice.

Figura9ImagineRMNT2-inponderatiesagittalprinabdomenulmatern,careprezintacoluterinnormalla33saptamanivarstagestationala

InanumitecazurimasurareaanumitorstructurilaexaminareaRMNpoateOibeneOica,chiardacamasuratorileuzualeaufostdejaefectuateecograOic12.TrebuietinutcontcamasuratorileRMNalestructurilorcucontinutlichidiansuntdeobiceicu10%maimaridecatmasuratorileecograOice.Involumetriapulmonara,masuratorileRMNnormalepentruvarstagestationalasecoreleazacuvolumulfetal29sisuntconsideratepredictivepentruprognosticulcazurilorcupatologiepulmonara30.

StocareaimaginilorRMNIntreagaexaminareartrebuistocataconformprotocoalelorlocale,preferabilinformatelectronic.CD-uricuexaminareapotOifurnizatepacientuluipentruafacilitaevaluari/opiniisuplimentare(second-opinion)(ELEMENTDEBUNAPRACTICA).

RaportulDouatipurideexaminaretrebuiediferentiateclarsiprecizatinraport:

1. Examinareatintita,carestudiazadoaroanumitacategoriedeanomaliifetale.InacestscopesteevaluatdoarunanumitorgansausaOiefurnizateinformatiile/rasunsuluneiintrebarispeciOicesinuevaluattotfatul.

2. Examinareadetaliata,ceincludeoevaluarestandardizataaintregiianatomiifetaleintr-omanierasimilaracuceadescrisainghidurileISUOG5pentruecograOiadintrimestrul2(saualteghidurilocale)(Tabel3).AceastaexaminarepoatecuprindesistructurimaiputinaccesibileevaluariiRMNdecatecograOic,deexemplustructurilecardiace.Structurileextrafetale,cumarOicordonulombilical,placenta,coluluterinsilichidulamniotic(cantitatesiintensitateasemnalului),trebuiedescriseatuncicandesteindicatclinic.Structurileneevaluatederutinainacesteexaminaritrebuieprecizateclarinraportuldeexaminare.

RapoartelestandardizateartrebuisaurmezestructurilesugerateinTabelul3(ELEMENTDEBUNAPRACTICA).

Tabel3RaportstructuratpentruexaminareadetaliatafetalaRMNMetoda Conditiideexaminare(ex.:afectatademiscarifetale,obezitatematerna,terminareaneprogramataa

examinarii),putereacampului,bobina,secvente,planuri

Cap ProOil,palatosossimoale(Figura6),craniu,masuratorioculare

Creier Giratiasisulcatiacorelatecuvastagestationala,laminatia/stratiOicareaparenchimuluicerebral(dupa30saptamanimielinizareasipremielinizarea),sistemventricular,cerebel,structurilelinieimedianesilargimeaspatiilorlichiduluicefalo-rahidian(Figura3)

Torace Formatoracelui,semnalelepulmonare,elementeleinimiiinmarenormale(nuseexamineazaindetaliu)(Figura7a,b)

Abdomen Situsfetal,stomacsivezicabiliara(umplerelichidiana),semnalelichidienesimeconialeintestinale(Figura7c,d),rinichi,vezicaurinara(umplerelichidiana);lacerereorganegenitaleexternefenotipfeminin/masculin(coborareatesticulelor)(Figura8)

Structuriextrafetale Cordonombilical(numarulvaselor),cantitateadelichidamniotic,pozitiasicaracteristicileplacentei,lungimeacoluluiuterindoardacaestescurtatsemniOicativ(Figura9)

Schelet(candesteexaminat) Pozitiasiintegritateacoloaneivertebrale,forma,pozitiasidimensiunileoaselor,degetelemembrelorsuperioaresiinferioare(nuintotdeaunaposibildeexaminat,maialesinsituatiiculichidamnioticputin,precumlaovarstagestationaladepeste32-35saptamani)

DeoareceRMN-ulnureprezintaoexaminarefetaladeprimaintentie,ciunacomplementara,indicatacaurmareauneiecograOiidintrimestrul2sau331,examinareasiraportulartrebuisapunaaccentpestructuricaresuntmaidiOicildeexaminatecograOic.OexaminaredetaliataanatomicapoateOiefectuatalacerere.

AUTORIIGHIDULUID.Prayer*,DivisionofNeuroradiologyandMusculoskeletalRadiology,DepartmentofRadiology,MedicalUniversityofVienna,Vienna,AustriaG.Malinger*,DivisionofUltrasoundinObstetrics&Gynecology,LisMaternityHospital,SouraskyMedicalCenterandSacklerFacultyofMedicine,TelAvivUniversity,TelAviv,IsraelP.C.Brugger,DivisionofAnatomy,CenterforAnatomyandCellBiology,MedicalUniversityofVienna,Vienna,AustriaC.Cassady,TexasChildren’sHospitalandFetalCenter,Houston,TX,USAL.DeCatte,DepartmentofObstetrics&Gynecology,UniversityHospitalsLeuven,Leuven,BelgiumB.DeKeersmaecker,DepartmentofObstetrics&Gynecology,UniversityHospitalsLeuven,Leuven,BelgiumG.L.Fernandes,FetalMedicineUnit,DepartmentofObstetrics,ABCMedicineUniversity,SantoAndre,Brazil

P.Glanc,DepartmentsofRadiologyandObstetrics&Gynecology,UniversityofTorontoandSunnybrookResearchInstitute,ObstetricalUltrasoundCenter,DepartmentofMedicalImaging,BodyDivision,SunnybrookHealthSciencesCentre,Toronto,CanadaL.F.Goncalves,FetalImaging,WilliamBeaumontHospital,RoyalOakandOaklandUniversityWilliamBeaumontSchoolofMedicine,Rochester,MI,USAG.M.Gruber,DivisionofAnatomy,CenterforAnatomyandCellBiology,MedicalUniversityofVienna,Vienna,AustriaS.Laifer-Narin,DivisionofUltrasoundandFetalMRI,ColumbiaUniversityMedicalCenter-NewYorkPresbyterianHospital,NewYork,NY,USAW.Lee,DepartmentofObstetricsandGynecology,BaylorCollegeofMedicineandTexasChildren’sPavilionforWomen,Houston,TX,USAA.-E.Millischer,RadiodiagnosticsDepartment,HopitalNecker-EnfantsMalades,AssistancePublique-HopitauxdeParis,UniversiteParisDescartes,Paris,FranceM.Molho,DiagnostiqueAnteNatal,ServicedeNeuroradiologie,CHUSudReunion,StPierre,LaReunion,FranceJ.Neelavalli,DepartmentofRadiology,WayneStateUniversitySchoolofMedicine,Detroit,MI,USAL.Platt,DepartmentofObstetricsandGynecology,DavidGeffenSchoolofMedicine,LosAngeles,CA,USAD.Pugash,DepartmentofRadiology,UniversityofBritishColumbiaandDepartmentofObstetricsandGynecology,BCWomen’sHospital,Vancouver,CanadaP.Ramaekers,PrenatalDiagnosis,DepartmentofObstetricsandGynecology,GhentUniversityHospital,Ghent,BelgiumL.J.Salomon,DepartmentofObstetrics,HopitalNecker-EnfantsMalades,AssistancePublique-HopitauxdeParis,UniversiteParisDescartes,Paris,FranceM.Sanz,DepartmentofObstetricsandGynecology,BaylorCollegeofMedicineandTexasChildren’sPavilionforWomen,Houston,TX,USAI.E.Timor-Tritsch,DivisionofObstetrical&GynecologicalUltrasound,NYUSchoolofMedicine,NewYork,NY,USAB.Tutschek,DepartmentofObstetrics&Gynecology,MedicalFaculty,HeinrichHeineUniversity,Dusseldorf,GermanyandPrenatalZurich,Zurich,SwitzerlandD.Twickler,UniversityofTexasSouthwesternMedicalCenter,Dallas,TX,USAM.Weber,DivisionofNeuroradiologyandMusculoskeletalRadiology,DepartmentofRadiology,MedicalUniversityofVienna,Vienna,AustriaR.Ximenes,FetalMedicineFoundationLatinAmerica,Centrus,Campinas,BrazilN.Raine-Fenning,DepartmentofChildHealth,Obstetrics&Gynaecology,SchoolofMedicine,UniversityofNottinghamandNurtureFertility,TheFertilityPartnership,Nottingham,UK*D.P.andG.M.contributedequallytothisarticle.

CITAREAcesteghiduritrebuiecitateca:‘PrayerD,MalingerG,BruggerPC,CassadyC,DeCatteL,DeKeersmaeckerB,FernandesGL,GlancP,GoncalvesLF,GruberGM,Laifer-NarinS,LeeW,MillischerA-E,MolhoM,NeelavalliJ,PlattL,PugashD,RamaekersP,SalomonLJ,SanzM,Timor-TritschIE,TutschekB,TwicklerD,WeberM,XimenesR,Raine-FenningN.ISUOGPracticeGuidelines:performanceoffetalmagneticresonanceimaging.UltrasoundObstetGynecol2017;49:671–680.’

BIBLIOGRAFIE1.HedrickHL,FlakeAW,CrombleholmeTM,HowellLJ,JohnsonMP,WilsonRD,AdzickNS.Historyoffetaldiagnosisandtherapy:Children’sHospitalofPhiladelphiaexperience.FetalDiagnTher2003;18:65–82.2.JokhiRP,WhitbyEH.Magneticresonanceimagingofthefetus.DevMedChildNeurol2011;53:18–28.3.MalingerG,LevD,Lerman-SagieT.Isfetalmagneticresonanceimagingsuperiortoneurosonographyfordetectionofbrainanomalies?UltrasoundObstetGynecol2002;20:317–321.4.Sonographicexaminationofthefetalcentralnervoussystem:guidelinesforperformingthe‘basicexamination’andthe‘fetalneurosonogram’.UltrasoundObstetGynecol2007;29:109–116.5.SalomonLJ,AlOirevicZ,BerghellaV,BilardoC,Hernandez-AndradeE,JohnsenSL,KalacheK,LeungKY,MalingerG,MunozH,PrefumoF,ToiA,LeeW.Practiceguidelinesforperformanceoftheroutinemid-trimesterfetalultrasoundscan.UltrasoundObstetGynecol2011;37:116–126.6.JakabA,PogledicI,SchwartzE,GruberG,MitterC,BruggerPC,LangsG,SchopfV,KasprianG,PrayerD.Fetalcerebralmagneticresonanceimagingbeyondmorphology.SeminUltrasoundCTMR2015;36:465–475.7.RayJG,VermeulenMJ,BharathaA,MontaneraWJ,ParkAL.AssociationbetweenMRIexposureduringpregnancyandfetalandchildhoodoutcomes.JAMA2016;316:952–961.8.Bouyssi-KobarM,duPlessisAJ,RobertsonRL,LimperopoulosC.Fetalmagneticresonanceimaging:exposuretimesandfunctionaloutcomesatpreschoolage.PediatrRadiol2015;45:1823–1830.9.VictoriaT,JaramilloD,RobertsTP,ZarnowD,JohnsonAM,DelgadoJ,RubesovaE,VossoughA.Fetalmagneticresonanceimaging:jumpingfrom1.5to3tesla(preliminaryexperience).PediatrRadiol2014;44:376–386;quiz373–375.10.PatenaudeY,PugashD,LimK,MorinL,BlyS,ButtK,CargillY,DaviesG,DenisN,HazlittG,NaudK,OuelletA,SalemS.Theuseofmagneticresonanceimagingintheobstetricpatient.JObstetGynaecolCan2014;36:349–363.11.CannieMM,KeyzerFD,LaereSV,LeusA,deMeyJ,FourneauC,RidderFD,CauterenTV,WillekensI,JaniJC.Potentialheatingeffectinthegraviduterusbyusing3-TMRimagingprotocols:Experimentalstudyinminiaturepigs.Radiology2016;279:754–761.

12.GarelC.MRIoftheFetalBrain:NormalDevelopmentandCerebralPathologies.Springer:Berlin,Heidelberg,2004.13.ReddyUM,AbuhamadAZ,LevineD,SaadeGR.Fetalimaging:ExecutivesummaryofaJointEuniceKennedyShriverNationalInstituteofChildHealthandHumanDevelopment,SocietyforMaternal-FetalMedicine,AmericanInstituteofUltrasoundinMedicine,AmericanCollegeofObstetriciansandGynecologists,AmericanCollegeofRadiology,SocietyforPediatricRadiology,andSocietyofRadiologistsinUltrasoundFetalImagingWorkshop.AmJObstetGynecol2014;210:387–397.14.MalingerG,Ben-SiraL,LevD,Ben-AroyaZ,KidronD,Lerman-SagieT.Fetalbrainimaging:acomparisonbetweenmagneticresonanceimaginganddedicatedneurosonography.UltrasoundObstetGynecol2004;23:333–340.15.MalingerG,KidronD,SchreiberL,Ben-SiraL,HoffmannC,LevD,Lerman-SagieT.Prenataldiagnosisofmalformationsofcorticaldevelopmentbydedicatedneurosonography.UltrasoundObstetGynecol2007;29:178–191.16.MelchiorreK,BhideA,GikaAD,PiluG,PapageorghiouAT.Counselinginisolatedmildfetalventriculomegaly.UltrasoundObstetGynecol2009;34:212–224.17.MoutardML,KiefferV,FeingoldJ,LewinF,BaronJM,AdamsbaumC,GelotA,IsapofA,KiefferF,deVillemeurTB.Isolatedcorpuscallosumagenesis:aten-yearfollow-upafterprenataldiagnosis(howarethechildrenwithoutcorpuscallosumat10yearsofage?).PrenatDiagn2012;32:277–283.18.GuibaudL,LarroqueA,VilleD,SanlavilleD,TillM,GaucherandP,PracrosJP,desPortesV.Prenataldiagnosisof‘isolated’Dandy–Walkermalformation:imagingOindingsandprenatalcounselling.PrenatDiagn2012;32:185–193.19.GrifOithsPD,SharrackS,ChanKL,BamfoJ,WilliamsF,KilbyMD.FetalbraininjuryinsurvivorsoftwinpregnanciescomplicatedbydemiseofonetwinasassessedbyinuteroMRimaging.PrenatDiagn2015;35:583–591.20.JatzkoB,Rittenschober-BohmJ,Mailath-PokornyM,WordaC,PrayerD,KasprianG,WordaK.Cerebrallesionsatfetalmagneticresonanceimagingandneurologicoutcomeaftersinglefetaldeathinmonochorionictwins.TwinResHumGenet2015;18:606–612.21.TwicklerDM,MageeKP,CaireJ,ZaretskyM,FleckensteinJL,RamusRM.Second-opinionmagneticresonanceimagingforsuspectedfetalcentralnervoussystemabnormalities.AmJObstetGynecol2003;188:492–496.22.ShellockFG,CruesJV.MRprocedures:biologiceffects,safety,andpatientcare.Radiology2004;232:635–652.23.SalomonLJ,AlOirevicZ,BilardoCM,ChalouhiGE,GhiT,KaganKO,LauTK,PapageorghiouAT,Raine-FenningNJ,StirnemannJ,SureshS,TaborA,Timor-TritschIE,ToiA,YeoG.ISUOGpracticeguidelines:performanceofOirst-trimesterfetalultrasoundscan.UltrasoundObstetGynecol2013;41:102–113.24.KienzlD,Berger-KulemannV,KasprianG,BruggerPC,WeberM,BettelheimD,PuschF,PrayerD.RiskofinferiorvenacavacompressionsyndromeduringfetalMRIinthesupineposition-aretrospectiveanalysis.JPerinatMed2014;42:301–306.25.LeithnerK,PrayerD,PorstnerE,KapustaND,Stammler-SafarM,Krampl-BettelheimE,HilgerE.Psychologicalreactionsrelatedtofetalmagneticresonanceimaging:afollow-upstudy.JPerinatMed2013;41:273–276.26.BruggerPC,StuhrF,LindnerC,PrayerD.MethodsoffetalMR:beyondT2-weightedimaging.EurJRadiol2006;57:172–181.27.AsenbaumU,BruggerPC,WoitekR,FurtnerJ,PrayerD.[Indicationsandtechniqueoffetalmagneticresonanceimaging].Radiologe2013;53:109–115.28.PrayerD,BruggerPC,KasprianG,WitzaniL,HelmerH,DietrichW,EppelW,LangerM.MRIoffetalacquiredbrainlesions.EurJRadiol2006;57:233–249.29.WeidnerM,HagelsteinC,DebusA,WalleyoA,WeissC,SchoenbergSO,SchaibleT,BusingKA,KehlS,NeffKW.MRI-basedratiooffetallungvolumetofetalbodyvolumeasanewprognosticmarkerincongenitaldiaphragmatichernia.AJRAmJRoentgenol2014;202:1330–1336.30.ZamoraIJ,SheikhF,CassadyCI,OlutoyeOO,Mehollin-RayAR,RuanoR,LeeTC,WeltySE,BelfortMA,EthunCG,KimME,CassDL.FetalMRIlungvolumesarepredictiveofperinataloutcomesinfetuseswithcongenitallungmasses.JPediatrSurg2014;49:853–858;discussion858.31.YagelS,CohenSM,PoratS,DaumH,LipschuetzM,AmsalemH,MessingB,ValskyDV.DetailedtransabdominalfetalanatomicscanninginthelateOirsttrimesterversustheearlysecondtrimesterofpregnancy.JUltrasoundMed2015;34:143–149.

INFORMATIISUPLIMENTAREPEINTERNETUrmatoareleinformatiisuplimentarepotOigasiteinversiuneaonlineaacestuiarticol:

AnexaS1SondajrealizatdeGrupulSpecialdeInteresinRMNFetalalSocietatiiInternationaledeUltrasonograOieinObstetricasiGinecologiein2014