Dr. Judy Estroff - Prenatal Diagnosis and the Pediatric Surgeon: State of the Art 2021

7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. These are post-processing things that can be done. We are capable of doing these. We are capable of doing in high school and I was interested in studio art and theaters. I was a painter and a weaver. And I entered the University of Michigan as a theater major. I then switched to dance and art history. And I took anatomy for dance in the medical school with cadavers and liked it. Went on to graduate from the Honors College at Michigan in art history, medieval art history and dance. I went to New York to dance for a year and decided that the competition was very stiff and it was going to be a short career even if I was successful and so I decided to apply to medical school. I spent two years as a post-baccalaureate premed in San Francisco. I worked as a nanny and a tutor. I went to UCSF med school, started in peas and then switched to radiology. During that rotation, in an Oakland Children's Hospital, I met Hushan Tady. I don't know if you have heard of him perhaps by the Rubenstein Tady Syndrome, but he was a pioneer in pediatric radiology. He offered me a job at Oakland Children's Hospital, but he said I needed to go to Boston Children's for my fellowship and so I did. There I met John Kirkpatrick, who was my chief and mentor and one of my heroes and wonderful colleagues Bob Lee Woods, Rita Teal, for Ingriscom, Clip Harris, Bob Wilkinson and all of them were incredible teachers, mentors, and researchers. Bob Lee Woods, when I asked him how it was that he published so many articles, he said some questions will bother you and you will want the answer and so that has proven to be true. I also during my fellowship met my husband, who's a neonatal and pulmonary fellow and didn't end up going back to California. My first job was at Austin Medical Center when I finished my fellowship and then I was offered a faculty position back at Children's one day a week. And at that time there were nine pediatric radiologists, there were no openings. Dr. Kirkpatrick offered me one day a week and I needed to do something the other four days. I was pregnant and during my fetal ultrasound with Ferrell Benastraff, who many of you know, while she was guiding my amus and thesis, she offered me a job. And I didn't know what to do. Dr. Kirkpatrick at that point said take the job. Fetal imaging is the future of pediatric radiology. And so I did. And Ferrell was a wonderful mentor as many of you know, a prolific researcher and an innovator and she taught me that every fetus is abnormal until you prove that it isn't. And also that if you have a great idea, someone else is thinking it as well, so publish quickly. So I worked four days a week with Ferrell in an OBGYN and private practice for five years and then with a similar practice for nine years, still keeping my one day at children. And during that time we did a lot of research without any protected time. And then when the fetal care center opened in 2001, I returned to children's full time shortly thereafter. And since then I've had never one boring day. And my research and clinical focus has been on fetal and neonatal diseases, imaging treatment and outcomes. So these are my heroes. I, for those of you who did get to know Dr. Kirkpatrick, I mean there was no one like him. As people said at his funeral, you know, I'm fortunate to count myself among the two or three hundred closest friends of Dr. Kirkpatrick. He knew everyone in the department including the staff who who who cleaned and you know the names of everybody's children. This is Thorne Griskem, another one of my mentors and then Hush Tady. So John was a pioneer in pediatric radiology and he was the one who described the complex of anomalies that we now know as Tricchio, the South Agile Fisciolo with the South Agile Treesia. And he was the chief from 74 to 92. This picture hangs in the reading room. I had someone go and take a picture so that I could show it to you. They didn't recognize me. I'm short-haired and much younger and the only person left of these people who still works in the department here, that that was in 1992. And this was our small staff, wonderful group of people. And many of you remember Thorne, Griskem and Thorne had a very innovative way of looking at things. And he said, look at the images first before you read the history, the history is valuable but it can sometimes mislead you. So look at the images first, make your observations and come to preliminary opinion and then you can revise it once you've gotten the history. I'm very grateful for my fellow fetal images, Carol Barney-Wolf here, Sukon Ali here and also John Choi. And then for everyone else, the neuro radiologist with whom I work, the imaging researchers, the synographers, technologists, and then the many surgeons and specialists with whom we all work including all of you. And I don't need to lead anyone out. These are department leaders who I've worked with for many, many years and I hope I haven't left anyone's name out but I haven't had a chance to work with all of you in fetal but we're very appreciative of all of you. And we have done a lot of work. These are just a few of the publications that we have been able to produce working together over the years looking at diabetic churnial lung volumes and at anomalies that are associated with fetuses with esophageal atreasia. Different methods for finding esophageal atreasia which still remains a very difficult diagnosis and then very specific entities such as Beckwith Weedermen syndrome. And in the good old days, I think Craig will remember. We were fellows at the same time and I don't remember Craig what time the daily review was but you would come and I will say invade our reading room. I think maybe it was five o'clock but that seems kind of early for a surgeon to be talking at the end of the day but the whole group would come to radiology and sit down and at that point we had alternators with films and you know everyone would sit around and we would we would join you and listen to the review of the interesting cases. In the good old days I would call Steve if I had a baby who had some sort of a lump and I would say you know Steve I'm doing this ultrasound because you come down and tell me what you think it is and he would come down and I remember he would he would feel it he would look at it and he would say you know this is you know this is a like one but this is a venous malformation and likewise I would call Craig if I found some lump, bump, hernia, mass and he would come down but you know packs really changed everything I remember when it was about to be introduced and it was a sea change at that point everyone was able to look at images and they sort of stopped coming down to radiology and I do I do miss that we're always happy to have you come down but so much has changed since then I just wanted to give you an example so this was a case from about two weeks ago of a fetus referred to us at 13 weeks where the diagnosis was sought to be in and definitely so here's the ultrasound and on trans abdominally we could see the body but not the head very well so we did a trans vaginal ultrasound and you can see here the amnion and the fluid in the amnionic sac and the fetal head this is the maxilla this is the mandible this is the nasal bone and then you can see here that the cranium is not present this is brain tissue that's without a bony covering and this is a coronal view of that sort of shower cap of brain tissue we went on to do a fetal MR at 13 weeks of gestation and that showed us even better to advantage this very terrible anomaly where the upper part of the spine did not fuse as it should have at six weeks and you can see it sort of extends definitely where all the brain tissue is exteriorized without a bony covering but I show you this to show you that we can actually see fetal anatomy exceptionally well at 13 weeks on MR and on ultrasound but you can see the fetal liver the stomach the extremities the heart the lung so I'm going to go through a very brief history fetal imaging at Boston Children's talk to you about fetal ultrasound versus MR a little bit about MR sequences without going into great detail and then some examples of fetal imaging from head to toe and some future directions so the fetal care center has been in existence for about 20 years in the first year we had about 48 referrals in 2017 about 2620 almost 5,000 referrals we now do 15 fetal MRs a week and we often add on additional slots we see all anomalies and as you know the goal is seamless care from fetal life through childhood and we partner with a step caregivers in the city the area the country and the world so just for instance yesterday we had a family flying in from Oklahoma with an an occipital and cephalyseal so the volume I won't go into great detail but suffice it to say that our numbers continue to increase our projected volume for 2021 is that we'll see about a 20% year over year increase in in referrals and we do see a lot of volume just for fetal echocardium rim but the volume for non cardiac referrals continues to go up we had a 32% increase over the past year and even given COVID so you've some of you may have seen these slides before but fetal imaging actually began in at Boston Children's in the 60s with thorn cliffharris and then Frank Fregoletto who was the chief of obstetrics at the Brigham and Women's Hospital and these are techniques from the past photography, amniography and paratinography and this is an example of photography at the time when there was a Boston line in hospital and our pediatric radiologist would go every morning to read radiographs on the newborns this is a maternal radiograph showing the hyper extended fetal head so this is the spine and ribs and the fetal back of the fetal skull is arched backwards and this was a orapherengial teratoma that was seen in utero and was able to be diagnosed by mainly thorn griskin at that time and he wrote articles this is from pdf radiology in 1970 and he wrote an article about the internal radiographic anatomy of the fetus remember there was not ultrasound at this time and he said diagnostic radiology of the fetus will find increasingly wide application as intrauterine therapeutic techniques continue to develop and surgery in the intrauterine fetus is already being practiced in a limited way so this was prescient in 1970 here there's a radiograph maternal pelvis but you can see the feels fine here that is quite disorganized and then the specimen radiograph after birth that matches the multiple segmentation anomalies of the spine there was also amniography so this shows contrast in the amniotic fluid showing the the meningomile seal this is the fetal buttock and then this is the meningomile seal in a fetus was fine a and thorn, thread and cliffhairs wrote these articles in 1970s in the 1970s and they did 28 fetuses 14 to 22 weeks looking for meningomile seals and were able to make that diagnosis and then parotonography this is what ultrasound looked like in 1980 showing if this is the maternal skin this is the amniotic fluid this is the fetus the this is fetal bowel and this is the sighties and this is a fetus that had our age and compatibility and they used to opacify the amniotic cavity with contrast so this is an example of the fetal liver surrounded by fluid that has been opacified so they didn't just do it once this is a series that that was published in 1981 of 365 fetuses who had our age and compatibility and they were under under x-ray and fluoroscopy the last 35 fetuses were done under ultrasound but this they did infreudern transfusions using radiography in these techniques of the past and radiology at childrens has a venerable tradition this is a history that was written by Thorene Griskin and Rita Teal who's who many of you remember who subsequently moved to New Zealand and the history of pediatric ultrasound was also seminal fever at children's Rita Teal was given the opportunity to begin to begin pediatric ultrasound and she did so at that time but between 1980 and 1999 all of fetal imaging was done at adult hospital the only fetal imaging we did at childrens was pregnant teenagers and fetal MR was introduced in the early 80s it was very slow the images were low in resolution and at that time we sedated the fetus and sometimes the mother as well because we couldn't give images if anybody moved and this is a slide from Carol Barney Walt showing the change in sequence length over time so in the 80s it took 10 to 15 minutes to make one image and now we can make images in milliseconds many like 25 images within just a second these are some early fetal MR images courtesy of Ed Yang in 1984 this is this is the maternal spine and this is the uterus with a fetus and a can't see too well this is 94 we could see a little bit better and in 93 the fetal brain was seen fairly well and in 97 we could start to see more detailed anatomy but now I pull this out because you know I love to show the surgeons and to go over what we can now see on fetal MR so this is a case from last week showing maconium in the normal fetal colon here and the liver lights up here and also we can see the hepatic vasculature here and maconium here in the fetal stomach so we do need fetal MR to add to fetal ultrasound but you can never stop doing fetal ultrasound we do the two studies the same day and the same image you're actually does both of them and the principles that we must place the mother carefully in the MR scanner cover the entire uterus and then we make orthogonal slices to the fetus over and over and over again and so this is the scout view where we have you can see here this is the placenta here this is the cervix and the fetus is in vertex position so we begin this way and then we make slices through the fetus of whatever part it is that we want to see we begin with T2 weighted images images and then we go on to other sequences and we cover the organ in three planes I won't go into great detail but suffice it to say that T2 weighted imaging is what we mainly use we do use a trufus or fiesta imaging for fluid filled organs T1 images for blood fat calcium maconium liver defusion weighted images are good for functional perfusion and then echoplane are imaging for cartilage bone and it's a very motion resistant sequence so for instance this is a these are a couple of T2 weighted images in a fetus here who has a collico anomaly here where we see fluid in the bladder and a different signal intensity of fluid behind it in an obstructed vagina here we see the vast signature of a fetal normal fetal lung tissue and this is T2 weighted imaging this is trufus or fiesta type imaging it highlights the differences between soft tissue and bone and you can see here the terminates of the nasal cavity the lomer and the palatal shelves and the orbits of the eyes and again the T1 technique to show us a hemorrhage calcium maconium these take a bit longer and the resolution is less than the T2 weighted imaging we also can do defusuated imaging on the brain and tractography here showing the different tracks within the fetal brain and echoplane are imaging is one of the fastest techniques and we can watch the fetus move in real time and these are just a few epi images so here is a T2 weighted image I'm not sure if you can see my mouse but here we can see the brain very well but the vessels that are in the separate acne space we can see those much better with epi and also we can see the vessels within the the brain here and these are the areas where we can have a fetal stroke and these are seen to advantage with epi so the established local applications of fetal MR definitely for brain and spinal cord everyone agrees about that we have pioneered using MR in addition to ultrasound for craniofacial malformations and for chest masses a diaphragm edicarnia and to evaluate the airway when it's compromised by any of these things but also keratonas and and vestlimatic malformations evolving applications for GI and abdominal wall defects GU especially when there's not enough amniotic fluid and then cardiovascular and cardiovascular anomalies and then the placenta so I won't go into great detail but suffice it to say that we have switched from 1.5 tesla magnetic imaging to three tesla and we were amongst the first fetal images to do so and we did that because we were getting rid of our 1.5 machines and we kind of had to and a reminder that it's not fetal ultrasound versus MRI it's fetal ultrasound and MRI and here's a case that illustrates that of a woman referred at 20 weeks and two days for microchranathia complex heart disease and club feet and this is the ultrasound showing the orbits which are widely spaced and have an abnormal sort of oval configuration the fetus has severe microchranathia you can see here the nose the upper lip and then the very are retarded chin and the again here's the lenses of the eyes and there was congenital heart disease the 3D images show low set ears with little skin tags and on MR we could see the microchia the microchranathia the microchranathia with a cleft vote to a cleft secondary palate with gloss octosis so this fetus will have airway difficulties and then we could see the the bilateral severe club feet we don't need MR for that but I show that it to you here and the final diagnosis for this fetus was trisomy 22 a very rare entity but all of these things are a part of that there are a lot of studies looking at fetal MR how useful it is there are very few studies that directly compare ultrasound to MR and even fewer studies that look at same-day ultrasound in MR so for instance at children's hospital Philadelphia you know not a slaggy place the the the MRs are read if it's a neuro indication it's read by a neuro and there's a body consult after that here we we we combine our studies on every fetus there's a double read a body and a neuro read on both of our MRs every day and the benefits of an accurate diagnosis I don't need to tell you it leads to accurate counseling informs the parents so they can make thoughtful decisions and it allows all of us to get ready for the safe delivery and appropriate treatment of a fetus with an anomaly and hopefully leads to better outcomes so that we can deliver fetuses who need to be close to us with cardiac anomalies or diaphragmetic herniath retina airway it's best to have an accurate diagnosis ahead of time there are some studies looking at when MR at value and discussions happening in many places about whether fetal MR should be performed for all fetal anomalies there are very few anomalies that we don't do MR for but they include gastroes thesis and club feet but the risk of having multiple anomalies is always there and so we don't want to miss that there was an editorial in the International Society of Ultrasen and as Tetris and Gynecology by Rich Bard who's a pediatric radiologist at Stanford and Denise Pugach who practices in Vancouver and basically Denise said we can't afford to spend the money on MR and Rich Bard said we can't afford to miss anomalies and so that debate continues but we feel strongly that fetal MR does add value. Few studies have looked at the contribution of MR after ultrasound and have found that it added things and changed the diagnosis and changed management and other studies looking at ultrasound and MR together again showing the same thing some things were more sensitive on MR and it did affect prognosis and counseling in many cases. In our own institution I've worked with John Mulligan one of my mentors and heroes on fetal cleft lip and palate and using the combination of ultrasound and MR we were accurate in the characterization of the lip at 99.5% and of the palate in 94% and the reason we're able to do that is the imaging but also because he teaches us what he needs to know so that we can make the diagnosis like a surgeon and that's what we learn from you as well. So MR is used for all kinds of things and I will show you some examples of that now and we have made our own efforts to get the information out there looking at the new techniques for fetal MR and using the differences between 1, 5 and 3 Tesla imaging. Ellen Grant has helped us to show that 3 Tesla imaging is safe to do and many places have moved on to show that they can do fetal MR at 3 Tesla that it's not dangerous. And the reason we go to a higher magnet is that we have better imaging. There's increased signal compared to noise and we can get thinner slices and see tiny structures better. So as an example here's an 18 week fetus with an abnormal brain and you can see here the clifting full thickness clifting in this fetus who has schismcephaly and that's an 18 weeks and then look at this 13 and a half week fetus where the fetal brain has not yet fully developed but we know from embryology that this is normal and this is what it should look like at 13 and a half weeks and at that time we can see the diaphragm, the lungs, the kidneys and a lot of important anatomy. One of the disadvantages of MR at 3 Tesla is that there's a lot of artifact when there's polyhydrammias. So sometimes Terry you give me a wonderful example of a recent sacripoxigil chiroatoma and I looked in images were terrible because there was polyhydrammias and the fetus was not, we couldn't see the fetus very well because of the signal in the extra-miotic fluid. So you can see here that's a very vague image of the fetus. We can see the placenta, well I won't go into detail but we can see on this scout view this is the placenta we can see where the cord inserts into the placenta centrally which is good this is the cervix long and closed we can tell if the placenta has a vasoprevia or central previa whether it's invasive and you can see here that the placenta can land almost anywhere in the uterus and can invade partially or full thickness into the myometrial wall. Here's an example of an ultrasound where we couldn't tell where the placenta was except that it was near the cervix. On MR we see that it completely covers the cervix this is the cervical oss this is the placenta so a complete placenta previa. On ultrasound we can see cervix here and then that the placenta comes right up to it on MR we see that placenta covering the cervix and this is an invasive placenta, placenta acrita or on ultrasound we can't quite see where the placenta ends and the wall of the uterus begins and here we can see complete invasion of the placenta here and this is something everyone wants to know about in case and everyone needs to be ready to do grab its hysterectomy at delivery so even though this doesn't something that affects you I just wanted you to see what it is that we can see on on Cigula MR. So this is an example of an ultrasound that 20 weeks showing the chest here's the lungs this is a an abnormal ecogenic mass within the ventricle of the heart and on ultrasound this is one of the ventricles of the brain the other side we couldn't see that well and we implied that there was some mass occupying a portion of the brain we went on to MR here we have the fetus invertex position and could immediately see what we couldn't see on ultrasound which is this very large tumor in a fetus with so a cardiac mass and a brain mass so this is a fetus who has tuberous fllerosis these are postnatal imaging views of the same fetus after birth showing a giant cell astrocytoma and the multiple sub-economal nodules that are associated with tuberous fllerosis we can also see the brain better this is the skull we can see that one of the ventricles is enlarged but we can't really say too much about the brain on ultrasound and then we go on to MR and we were stunned to see how markedly abnormal this brain is the quote is colosum is missing the posterior fossa is abnormal and there is both listencephaly and polymicrogiria in a fetus with a very severe brain abnormality that really we couldn't see on ultrasound the baby once born was having seizures during imaging but the postnatal imaging matched the fetal imaging for head and neck as you know we can see or a pharyngeal masses lip eye and ear abnormality this is a fetus who on 3D imaging has something abnormal between the eyes on ultrasound this is the surface rendering on MR we could see that there was a mass that was between the orbits and we could see it here on the sagittal MR and then once the infant was born you can see that it was actually a glioma and it was coming through this hole in the skull and the postnatal MR is here and here and then that was repaired a cleft of the pynipalate this is somewhat older 3D view of a very wide unilateral cleft lip and then an infant after birth showing that there can be both complete and incomplete cleft lip here is a bilateral incomplete cleft lip and then the palate is cleft and we have been taught by our preneofacial surgeons what information they want so John Mulligan has taught us the vo classification for cleft palate and the Y diagram which segments all of the clefts and so this is the information that we give him on all of our clefts and we use as I said the combination of ultrasound for the lip and alveolus and then MR for the secondary palate so this is an ultrasound showing us the cupid's bow of a lip this is the vermilion border here in the the upper lip we can see a beautiful normal lip and nose when there's no cleft this is a view of the teeth the tooth buds on ultrasound and the upper lip we can see the palate on MR so three different planes sagittal, coronal and axial we can see the vomer and the palatal shelves here and a fetus who has a cleft lip we see that there's no secondary palate you can see the vomer comes down there's a palate on the palatal shelf on the right but not on the left and here's the break in the teeth for mychic natia as you know the risk is of a posteriorly displaced chin and tongue that can block the airway and that it can be associated with many syndromes so working with Cory Resnick and Carolyn Rogers which done a lot of work on mychic natia where the chin looks a little bit small the palate is not cleft the chin is moderately small the palate is cleft but the airway is still open and then there's a severe mychic natia where the chin is minuscule the tongue blocks the airway and this fetus will definitely need help at birth here's an example at 24 weeks of gestation of a fetus with mychic natia low-set ears hybrids tend to thumb and a cleft palate so three d imaging shows a very abnormal fetal face with low-set ears and a tiny chin a big thumb and a cleft secondary palate and this was fight for syndrome i realized that i can't go through every single thing that we we use fetal imaging for with you suffice it to say that we see a lot of lung masses thumbtleral effusions and a lot of diaphragmatic hernias this is an example of a very very large lung mass where we can see the abnormal part but also the the normal lung that's compressed superiorly and that the fetus does have hydrops for the chest we start with ultrasound we look at the heart where it is what it looks like what the lungs look like we look at the airway assess the diaphragmatic integrity and contour i know when we when we're counseling our surgeons will always say well is the diaphragm still convex is it flattened is it inverted and so these are the things that we look at and we try to provide you with the information that you need sonography as i said we always do that to help characterize the mass and to see that the fetus is doing well in general as you know fetal lung masses have a good outcome the fetus often out grows the lesion and hydrops often responds to steroids and fetal surgeries the last resort so here's an example of a somewhat small lesion the the usual ones are small and wedge-shaped and the larger ones are larger and more complex it's not always a a c-pan it can be other entities like neuroblastoma or even esophageal atreja where there's a a esophagus that looks like a mass but we try very hard not to make mistakes in determining these things as you know we no longer use the stalker classification for lung masses we have a unifying theory of maldevelopment where we think almost all of the lung masses are part of the bronchial atreja spectrum including interlobar extra low bar sequestrations c-panes and overinflation and we care much less what the lesion looks like and care more about how it behaves what is it due to the heart, median strina and it does it cause hydrops and we try to determine which lobes are involved and to determine the amount of residual lung tissue because of course hopefully the lung mass is going to be something that you will take out but we really care about what else is left there and usually we can stay the course in utero and not do anything however and we we know from some of our work here that lung masses follow a predictable pattern of increasing in size and then the fetus outgrows lesion after about 28 weeks so here is a lesion on ultrasound that has a big feeding vessel and so at least part of it is a sequestration part of it is probably a c-pan and we can see here on MR that there's normal lung to the scene this fetus as we looked at before is in trouble we use the CVR the chestnut volume ratio to try to predict which fetuses will develop hydrops and which ones will not. We and others have used steroids to try to shrink these masses and have had very good success in getting masses to diminish and to even to clear up hydrops and in general they have a good prognosis the fetus outgrows them and fetal surgeries the last result. A few other entities I hope we're not going to run out of time but the suffigilatrice is one of the diagnoses that continues to give us trouble we often make the diagnosis but we also miss it it can be implied that there is a suffigilatrice if the stomach is small or absent if there's polyhydrammias but the the golden ring is to see the esophageal pouch or a distended hypoference and that is very difficult and we do know that it's associated with other anomalies so this is some work that Terry Buckmiller and Ophir Ben Ashe had done with us when he was here looking at the distended fetal hypoference so this is what a normal hypoference with the piriform sinuses should look like and the subglotic trachea and when there's an obstruction from esophageal trhesia it balloons out like this and it's higher up than the pouch itself but both of these this is hard to see this is a little bit easier so in this view we have the piriform sinuses and then ballooning of the fetal hypoference as a secondary sign of esophageal trhesia and here in this fetus with difficulty we can see the pouch itself so here's a fetus at 32 weeks with a very small stomach and polyhydrammias and an MR where you know if I tell you it took the entire 40 minutes to get this one image here where we finally filled the esophageal pouch but it's intermittent and it's hard to see so here's the trachea which we see well and then a little bit of the obstructed esophagus so still a difficult diagnosis things that are easy to diagnose are due to an allotretia so here's the dilated stomach and do adenum on ultrasound and on MR a very easy diagnosis and we can see reflux up the esophagus on the MR here we don't use MR often for abdominal wall defects except for umphalusial and more complicated lesions so here's a 12 week fetus with a liver containing umphalusial and a older an older fetus with liver and bowel in the umphalusial we know that umphalusels can be associated with other anomalies including Beck with Weedemann syndrome although counterintuitively in Beck with it's usually usually but not always just the bowel that's out and not liver imperfect edis is a very difficult diagnosis I know Craig had a case this week with suconally that was beautiful still in utero but we think that that's what it is um we can see the macombium in the um in the bowel here in a normal fetus and in a fetus with imperferdainus here and here is mixing of the urine and stool and these little fecaleths that are visible in the fetal abdomen here I won't go into great detail about musculoskeletal anomalies but we can see them here's a fetus with a very short spine and a sort of crab life appearance of the ribs on MR we can see a very short trunk and this fetus ended up having a darker 11 syndrome this is an x-ray showing how all of the little ribs come out of that very short spine and then the unusual position of the baby due to the spine abnormalities. Sacred oxygenate heratoma diagnosis is difficult when the component is pre-sacral and doesn't it's not visible to us the large ones like this one are easy it's like the fetus is sitting on an exercise you know ball here but this part I always say we care a little bit about but it's the part that is internal that we care more about and you know here we here's the handoff to you for a sacri-caxigil heratoma we care whether it's solid or cystic and the growth rate of these multiple anomalies I'll just deal with briefly here is a fetus who on MR we saw that there was a right aortic arch so here's the trapea right arch sort of an unusual flat face and spine abnormalities microethalmia and this ended up being charge syndrome we make this diagnosis all the time just last week we found a fetus with with charge syndrome based on unilateral cloning allotrygia and then abnormal internal urinatomy charge syndrome as you know has colobumida and many other abnormalities so near in the end some future directions earlier fetal MR better 3D imaging new strategies to deal with fetal motion moving from purely anatomic imaging to more functional fetal imaging using cardiac gating and also looking at how well the fetus is doing we have done this is an example of a gated cardiac MR and the early fetal MR I'll just show you some examples it started when a referring MFM asked us if we could find revand sequence in a 13 week fetus given that the patient had a prior pregnancy with this problem so this was the prior pregnancy ultrasound and MR this was the fetus that the index case we couldn't really tell on trans abdominal imaging we did transvaginal imaging and we could see that there was microethanthia and at 13 weeks we could see there was all zoom this in a cleft palate and this fetus at 13 weeks had revand sequence so we then went on to do more imaging there was another patient who had fetus with arthrogryposis you can see here the abnormal positioning of the hands she became pregnant again and we could see that there were abnormalities I warned you now there's some graphic images here this is a a turidium in the elbow and this fetus and this is what we ended up seeing in a fetus with multiple turidium syndrome which we were able to diagnose very early on MR so then she became pregnant again wanted to know whether this next fetus had the abnormality it's said with 11 weeks we tried fetal MR you can see that we see the fetus fairly well we can see that there is microethanthia and a cleft palate you can see that there are these jugular ervenous sacs and then abnormal positioning with the arms held in an abnormal position at 11 weeks we did ultrasound and we could see after the MR we could see that this fetus was also affected so 20 weeks 12 weeks 2016 2018 so I it's a difficult thing to do but it helps the patient not to have to wait an additional two months for the diagnosis of these terrible things so that's been an innovation we did 11 cases over the next 15 months of all different things and we have done now 60 cases of fetal MR under 15 weeks of gestation we've also seen fetuses with lung masses where we decided we were trying to decide whether it was a diaphragm and a kernea this was not this was a CPM and so in conclusion we think that fetal MR is going to be very helpful earlier I didn't want to leave out the placenta that one grant has an NIH grant for looking at the placenta and has a lot of innovations using placental imaging I mentioned Werner and his 3D images Ali Golupor one of our electrical engineers who works in radiology has made an atlas of brain growth in the fetus using motion correction and segmenting the brain beautifully diffusion tensor imaging again showing the tracks of the brain in the fetus and so the future direction I think is is limitless practically pediatric radiologists really have established themselves as fetal images and pushing the envelope for fetal MR at all of the obstetric centers in children's hospitals and you the pediatric specialist with your depth and breadth of experience in diagnosing and treating these anomalies that's the future and then the maternal fecal medicine specialists have become interested in doing fetal MR I actually took this course that was offered for MFMs at a meeting in Vienna but I think that pretty securely imaging is in the hands of pediatric images at the moment so in summary ultrasound is ubiquitous but MR is increasing MR adds a lot of information but the two entities are complementary not competitive fetal MR fetal ultrasound will remain the first line modality and MR use will continue to grow in final summary feel imaging as a team sport and we're so happy to play with you we learn from each other and I thank you very much for your attention looks like this fetus is put in their hands over their ears because they finally had enough well Judy I don't think anybody's going to have enough from hearing from you and I thank you so much for educating us over and over and over I'm one of the few people on the screen who who was here when that photo was taken John Carpetrick's department and there were so many friends and mentors of the mine that photo as well and I missed them I learned some things not only about fetal imaging but about you that didn't know and I don't know there's time to explain how you dance with a cadaver but that's not certainly intriguing I knew you were a dancer but I didn't take that to that length obviously we're we're working to continue to support your efforts and those for all the families faced with fetal challenges and we continue tirelessly to do so I am repetitively an awe of what you can see and what you can find and the detail and the and the counseling and when I or I think all of us go to see the patient in the NFC see the first thing we do is stop in the imaging room and you teach us everything we need to know and we just go tell the family that often with your personal guidance so the family and I think that's incredibly holistic care not only the family but of us so you can make us sound smart when we walk in so I can't tell you how much we appreciate your incredible leadership friendship and partnership and I'll just time for others to ask questions I'm sure we'll be at others to comment thank you if this is a terrier want to echo dr. freshman's comments uh jd you and your colleagues have just been spectacular in in guiding us so that we can provide the most accurate counseling I think on the planet wonder if you could and I appreciate sharing the history as a reminder of the logarithmic advances in the last few years when you look at ultrasound and the MR techniques could you share with us during the COVID era being at home you've trained your radiology technicians for image acquisition and I would say that when you're looking yourself for vasophagella triusia you sit with the ultrasound probe for a half an hour just waiting for that baby to swallow and then you do it again it's very time intensive so what have we learned from that process and then my other question is when you provide us with these numbers whether or not their percent predicted lung volume for CDH or CBR you're doing that methodically by hand if you will where do we stand with potential automation and standardization and those techniques so those are those are our good questions so um you know we're we're hoping to be back on site soon there just isn't room for us I know that all of you who would come down and sit with us in in our little reading room which we share with cardiology know that there was absolutely no room for us but um I think we've lost something of course by the by the radiologist not not scanning after the synographer and uh we send them back in over and over again you know get me a coronal view of the aorta and turn color on and use this setting but you know I think we will be back uh we will be back doing that soon and there's no you know there's no substitute for lane hands on um and um as far I know I I understand your question I think it is possible to automate a lot of these um these calculations um and the trouble is that some of our seminal articles were done by hand and so we haven't proven that automation can match that especially in you know an expert's hand but I think we need to move towards that um the trouble is you need a set of eyes that can distinguish what's diaphragmatic content and what is the lung and so it's you know if there is some um thoughtfulness that that artificial intelligence can't provide I think you Anyway I also wanted to say that we learned so much from from you I remember seeing what I thought was a sequestration one of the early ones in the setting of a diaphragmatic churri and I was like how can that be you know that would be so unusual and I remember talking to Jay and he was like bad to see them all the time that you know there they are we see them all the time so you know then then we learned that that is an association that you know about that we didn't at that time know that Dude this is rusty just want to say thank you oh you're absolutely amazing it's so interesting to see how far we've come in 20 years and when we started the AFCC it was all about rare problems and there was so much headwind so much conflict and now it's generating careers and all these rare problems become common because there's so few places to go to the end of going to some place a few places like here and chop and also the volume comes up and you get the deep understanding and you work with the clinicians and you can figure out treatments and it's just a positive feedback loop and I am so impressed how far this has come great job amazing work thank you rusty I think the hour has come I think everybody can appreciate the incredible incredible I worked with them yes more space is coming I have confirmation of that from our new CEO and we we continue to to be an obvious ability to read through the skin and all you taught us and for those who don't know our field of energy is really top in class in the world and I think you can all see why it's the dedication and skill of Judy and her colleagues who made that happen so Judy thank you so much for giving us your hour this morning and educating us as always thank you Steve thanks everyone