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DOI: 10.1148/radiol.2322030504
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(Radiology 2004;232:398-404.)
© RSNA, 2004

Obstetric Imaging

Fetal Anomalies: Comparison of MR Imaging and US for Diagnosis1

Mary C. Frates, MD, Ada J. Kumar, MD2, Carol B. Benson, MD, Valerie L. Ward, MD and Clare M. Tempany, MD

1 From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (M.C.F., A.J.K., C.B.B., C.M.T.); and Department of Radiology, Children’s Hospital, Harvard Medical School, Boston, Mass (V.L.W.). From the 1999 RSNA scientific assembly. Received April 3, 2003; revision requested June 20; revision received November 3; accepted December 9. Address correspondence to M.C.F. (e-mail: mfrates@partners.org).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To compare prenatal ultrasonography (US) and magnetic resonance (MR) imaging for the diagnosis of fetal anomalies.

MATERIALS AND METHODS: Images of 27 fetuses (28 diagnostic cases) with anomalies diagnosed at US were evaluated; in these fetuses, prenatal MR imaging was performed within 15 days of US. Prenatal US and MR imaging findings were compared with postnatal diagnoses. Postnatal evaluation included US, MR imaging, autopsy, surgery, voiding cystourethrography, computed tomography, angiography, and physical examination.

RESULTS: In seven diagnostic cases, US and MR imaging findings were in complete agreement with postnatal diagnoses. MR imaging correctly provided additional information to the US-determined diagnosis in another seven and correctly changed the US diagnosis in three. The MR imaging–determined diagnosis was incorrect and the US diagnosis was correct in four cases. In seven cases, the diagnoses at both US and MR imaging were incorrect when correlated with the postnatal outcome. MR imaging was most valuable in the assessment of anomalies of the central nervous system.

CONCLUSION: MR imaging may have a place as an adjunct to US in evaluation of fetal anomalies, particularly those involving the central nervous system.

© RSNA, 2004

Index terms: Fetus, abnormalities, 856.87 • Fetus, MR, 856.121411 • Fetus, US, 856.1298


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Ultrasonography (US) is the primary imaging modality for the evaluation of the fetus. It is safe for both fetus and mother, is relatively inexpensive, allows real-time imaging, and is readily available. However, US may be limited in cases of oligohydramnios, large maternal body habitus, or complex fetal anomalies, particularly when scanning is performed late in gestation. In these cases, alternative imaging modalities may provide additional information that can improve diagnostic accuracy and facilitate treatment decisions.

Magnetic resonance (MR) imaging has been successfully used to assess the fetus. When fetal MR imaging was initially described in 1983 (1), slow acquisition times and fetal motion artifact substantially degraded image quality and limited the usefulness of the technique (2). The advent of faster sequences has revolutionized the ability of MR imaging to assess the fetus. Image acquisition now occurs during a single maternal breath hold; therefore, fetal motion is much less of a limiting factor (3,4). Since this development, several authors (5,6) have described their experiences with fetal MR imaging. Researchers in several studies (7–10) have demonstrated a positive effect of fetal MR imaging on clinical treatment of the mother and fetus, primarily in terms of pregnancy termination and delivery. We undertook this study to compare prenatal US and MR imaging for the diagnosis of fetal anomalies.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Institutional review board approval was obtained for this study, and informed consent was waived, as patient confidentiality was maintained. Between January 1998 and December 2000, all pregnant patients at Brigham and Women’s Hospital, Boston, Mass, who underwent both second- or third-trimester fetal US and MR imaging within 15 days of each other for a fetal indication were eligible for inclusion in this study. Follow-up was available for 27 fetuses with 28 diagnoses (one fetus had two diagnoses) (Table 1). These 27 fetuses formed our study group.


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  		TABLE 1. Postnatal Evaluation Methods

 
The gestational ages of the fetuses evaluated with MR imaging ranged from 18 to 37 weeks. The time between performance of US and MR imaging ranged from 0 to 15 days. More than half (14 of 27) of the MR imaging studies were performed within 4 days of US studies.

Imaging and Image Interpretation
Obstetric US was performed with state-of-the-art equipment (XP-128 or Sequoia; Acuson, Mountain View, Calif) by one of seven staff sonologists (including M.C.F. and C.B.B.). All had training in high-risk obstetric US, with a mean number of years of experience of 8 years (range, 3–16 years). MR imaging was performed with a 1.5-T unit (Signa; GE Medical Systems, Milwaukee, Wis) and a pelvic multicoil array. Imaging sequences included a multiplanar single-shot fast spin-echo sequence (repetition time msec/echo time msec, 60,000/99; field of view, 20 x 20 cm; section thickness, 3–8 mm; spacing, 1–2 mm; matrix, 256 x 256) and a T1 fast spin-echo sequence (600/20; field of view, 20 x 20 cm; section thickness, 5–10 mm; spacing, 1–2 mm; matrix, 256 x 128). The anatomic area was mapped, and sequence selection and planes of acquisition were chosen on the basis of the clinical context defined at US by a radiologist (C.M.T.) who supervised the examination. The total acquisition time was approximately 20 seconds per sequence, and examination duration averaged approximately 30 minutes. No sedatives or intravenous gadolinium-based contrast material was used. Pregnant patients were instructed to avoid a high oral sugar intake for 4 hours prior to the examination.

All MR images were interpreted (26 fetuses) or reviewed (one fetus) by one staff radiologist (C.M.T.) with more than 15 years of experience in MR imaging. The results of US were available and known to the MR imaging radiologist at the time of acquisition and at the time the MR images were interpreted. US and MR image interpretations were compared for discrepancies and consistencies. US and MR imaging were categorized as correct or incorrect with respect to the final postnatal diagnosis. In addition, we noted cases in which MR imaging or US provided more information.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
DISCUSSION
 REFERENCES
 
Fetal anomalies involved the central nervous system, the genitourinary system, the thorax, and the face (Table 2).


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  		TABLE 2. Distribution of Anomalies according to Affected Area

 
In 14 (50%) of 28 cases, the diagnoses established by using US and MR imaging were correct when compared with postnatal diagnosis. MR imaging provided more information than did US in seven of the 14 (25% of total) cases but added no information in seven others (Fig 1). There were no cases in which US provided additional information to that provided with MR imaging when both were correct. In seven (25%) of 28 cases, diagnoses with both US and MR imaging were incorrect when compared with postnatal diagnosis (Fig 2).



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  		Figure 1. Schema shows comparison of US and MR imaging findings for cases in which MR imaging added no information and for those in which MR imaging added information to final diagnosis. Findings were confirmed at postnatal final diagnosis.

 


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  		Figure 2. Schema shows comparison of US and MR imaging findings; diagnosis was incorrect with at least one modality when findings were compared with postnatal final diagnosis. Findings that occurred in the same fetus are indicated (*).

 
Discrepancies occurred in seven cases: In four (14%) cases, diagnosis at US was correct and that at MR imaging was incorrect. In three (11%) cases, diagnosis at US was incorrect and that at MR imaging was correct. In both of these categories, the diagnoses were diverse and included fetal abnormalities of the central nervous system, thorax, and genitourinary system; two normal fetuses were also included (Fig 2).

In the majority of cases (16 [57%] of 28) in this study, the central nervous system was involved. In 10 (62%) of 16, the diagnosis established with both modalities was correct when it was compared with postnatal diagnosis, and additional information was provided by using MR imaging in half (five of 10) of the cases with a correct diagnosis. The five cases with complete agreement in regard to the diagnosis included two cases of isolated ventriculomegaly, one case of Dandy-Walker variant (Fig 3), one case of intraventricular hemorrhage and dilated ventricles (Fig 4), and one case of meningomyelocele. The five cases of anomalies of the central nervous system in which MR imaging added additional correct information to the US findings included posterior fossa anomaly (Fig 5), agenesis of the corpus callosum, aneurysm of the vein of Galen, and a small anterior encephalocele in the setting of a large facial cleft. Among three cases of central nervous system anomalies for which diagnoses at both US and MR imaging were incorrect, postnatal imaging results were normal in two. In the third case, tuberous sclerosis was found after delivery. In one case, Dandy-Walker variant that was not found at MR imaging was correctly diagnosed at US. In two cases, MR imaging helped to correctly categorize fetuses as normal after Dandy-Walker variant and agenesis of the corpus callosum were each suggested at US.



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  		Figure 3a. Dandy-Walker variant in 18-week fetus. (a) Transverse US image of fetal posterior fossa demonstrates cleft (arrow) between cerebellar hemispheres. (b) Transverse T2-weighted single-shot fast spin-echo MR image of the fetal brain 8 days later shows cleft (arrow) between cerebellar hemispheres and confirms partial absence of the vermis.

 


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  		Figure 3b. Dandy-Walker variant in 18-week fetus. (a) Transverse US image of fetal posterior fossa demonstrates cleft (arrow) between cerebellar hemispheres. (b) Transverse T2-weighted single-shot fast spin-echo MR image of the fetal brain 8 days later shows cleft (arrow) between cerebellar hemispheres and confirms partial absence of the vermis.

 


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  		Figure 4a. Intracranial hemorrhage in 28-week fetus. (a) Transverse US image of fetal head shows mild ventriculomegaly (calipers) with echogenic material (arrows); findings were consistent with clot in dependent left lateral ventricle and adjacent parietal lobe. Nondependent ventricle is obscured by shadowing from fetal skull. (b) Transverse T2-weighted single-shot fast spin-echo MR image of fetal head obtained later the same day confirms presence of hemorrhage (arrows) in left cerebral parenchyma. Intraventricular clot was also confirmed on other images. (c) Postnatal sagittal US image of left lateral ventricle demonstrates porencephalic cyst (arrows) and irregularity of ventricular wall. (d) Postnatal transverse T2-weighted single-shot fast spin-echo MR image of brain shows focal dilatation of dependent left lateral ventricle, as well as hemosiderin deposition (arrows) along lateral aspect of ventricle.

 


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  		Figure 4b. Intracranial hemorrhage in 28-week fetus. (a) Transverse US image of fetal head shows mild ventriculomegaly (calipers) with echogenic material (arrows); findings were consistent with clot in dependent left lateral ventricle and adjacent parietal lobe. Nondependent ventricle is obscured by shadowing from fetal skull. (b) Transverse T2-weighted single-shot fast spin-echo MR image of fetal head obtained later the same day confirms presence of hemorrhage (arrows) in left cerebral parenchyma. Intraventricular clot was also confirmed on other images. (c) Postnatal sagittal US image of left lateral ventricle demonstrates porencephalic cyst (arrows) and irregularity of ventricular wall. (d) Postnatal transverse T2-weighted single-shot fast spin-echo MR image of brain shows focal dilatation of dependent left lateral ventricle, as well as hemosiderin deposition (arrows) along lateral aspect of ventricle.

 


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  		Figure 4c. Intracranial hemorrhage in 28-week fetus. (a) Transverse US image of fetal head shows mild ventriculomegaly (calipers) with echogenic material (arrows); findings were consistent with clot in dependent left lateral ventricle and adjacent parietal lobe. Nondependent ventricle is obscured by shadowing from fetal skull. (b) Transverse T2-weighted single-shot fast spin-echo MR image of fetal head obtained later the same day confirms presence of hemorrhage (arrows) in left cerebral parenchyma. Intraventricular clot was also confirmed on other images. (c) Postnatal sagittal US image of left lateral ventricle demonstrates porencephalic cyst (arrows) and irregularity of ventricular wall. (d) Postnatal transverse T2-weighted single-shot fast spin-echo MR image of brain shows focal dilatation of dependent left lateral ventricle, as well as hemosiderin deposition (arrows) along lateral aspect of ventricle.

 


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  		Figure 4d. Intracranial hemorrhage in 28-week fetus. (a) Transverse US image of fetal head shows mild ventriculomegaly (calipers) with echogenic material (arrows); findings were consistent with clot in dependent left lateral ventricle and adjacent parietal lobe. Nondependent ventricle is obscured by shadowing from fetal skull. (b) Transverse T2-weighted single-shot fast spin-echo MR image of fetal head obtained later the same day confirms presence of hemorrhage (arrows) in left cerebral parenchyma. Intraventricular clot was also confirmed on other images. (c) Postnatal sagittal US image of left lateral ventricle demonstrates porencephalic cyst (arrows) and irregularity of ventricular wall. (d) Postnatal transverse T2-weighted single-shot fast spin-echo MR image of brain shows focal dilatation of dependent left lateral ventricle, as well as hemosiderin deposition (arrows) along lateral aspect of ventricle.

 


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  		Figure 5a. Degenerative disease of posterior fossa in 34-week fetus. (a) Transverse US image of fetal head. Shadowing (S) from fetal skull obscures most of the intracranial anatomy, and late gestational age caused decrease in image quality. Posterior fossa, including the cerebellum (arrowheads) and cisterna magna (*), appears grossly normal. (b) Sagittal T2-weighted single-shot fast spin-echo MR image of fetal brain. Fetal face is to the right. Cerebellum (arrow) and brainstem (arrowheads) are markedly hypoplastic, and these findings are consistent with pontine cerebellar degeneration.

 


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  		Figure 5b. Degenerative disease of posterior fossa in 34-week fetus. (a) Transverse US image of fetal head. Shadowing (S) from fetal skull obscures most of the intracranial anatomy, and late gestational age caused decrease in image quality. Posterior fossa, including the cerebellum (arrowheads) and cisterna magna (*), appears grossly normal. (b) Sagittal T2-weighted single-shot fast spin-echo MR image of fetal brain. Fetal face is to the right. Cerebellum (arrow) and brainstem (arrowheads) are markedly hypoplastic, and these findings are consistent with pontine cerebellar degeneration.

 
Four fetuses were evaluated for thoracic abnormalities, and the diagnosis was incorrect at both US and MR imaging for three (75%) of the four. In two of these fetuses, diaphragmatic hernias were correctly diagnosed prenatally; however, unsuspected intrathoracic liver was found at postnatal surgery in one neonate, and associated sequestration was found postnatally in the other. A third fetus with tracheal atresia and bronchoesophageal fistula died in the delivery room; neither condition was found prenatally. In the fourth fetus with a thoracic abnormality, sequestration was diagnosed correctly at both US and MR imaging; however, the associated diaphragmatic hernia was identified only at US.

Four fetuses were evaluated for five genitourinary abnormalities. In two, diagnoses were correct at both US and MR imaging; one fetus had posterior urethral valves, and the other had bilateral multicystic dysplastic kidney. One fetus with bilateral renal agenesis was incorrectly thought to have a single small kidney at both MR imaging and US. In the fourth fetus, reflux into a duplicated collecting system was correctly diagnosed at US, but multicystic dysplastic kidney was diagnosed at MR imaging. This fetus was also believed to have a separate cystic pelvic mass at US, but none was found at MR imaging or at postnatal examination.

When all cases (27 fetuses with 28 diagnoses) in this study are considered, there was complete agreement between US, MR imaging, and postnatal findings in seven (25%) of 28 cases. MR imaging provided additional information to that from US in another seven (25%) cases (Fig 6) and helped to change the US diagnosis in an additional three (11%). In other words, the addition of MR imaging to the prenatal evaluation provided valuable information in 10 (36%) of 28 cases. In seven of these 10 cases, central nervous system anomalies were involved. Diagnosis at MR imaging was correct at final diagnosis comparison in 17 (61%) of 28 cases.



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  		Figure 6a. Sacrococcygeal teratoma in 25.5-week fetus. (a) Sagittal US image of sacral spine demonstrates large heterogeneous mass (arrowheads) that protrudes from base of spine, consistent with sacrococcygeal teratoma. There were no sonographic signs of hydrops. (b) Oblique T2-weighted single-shot fast spin-echo MR image obtained earlier the same day shows heterogeneous teratoma (arrowheads). Subcutaneous fluid (arrows) is seen as high-signal-intensity area under skin of fetal chest, back, and abdomen; this finding indicates early hydrops. Five days after these images were acquired, fetal demise occurred.

 


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  		Figure 6b. Sacrococcygeal teratoma in 25.5-week fetus. (a) Sagittal US image of sacral spine demonstrates large heterogeneous mass (arrowheads) that protrudes from base of spine, consistent with sacrococcygeal teratoma. There were no sonographic signs of hydrops. (b) Oblique T2-weighted single-shot fast spin-echo MR image obtained earlier the same day shows heterogeneous teratoma (arrowheads). Subcutaneous fluid (arrows) is seen as high-signal-intensity area under skin of fetal chest, back, and abdomen; this finding indicates early hydrops. Five days after these images were acquired, fetal demise occurred.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
REFERENCES
 
The utility of MR imaging for fetal evaluation has evolved considerably in recent years. In the past, fetal motion and longer acquisition times limited the role of fetal MR imaging. With the advent of shorter acquisition times, fetal MR imaging has become more valuable, and its role is still expanding (11). While researchers in many studies have demonstrated that MR imaging is a useful adjunct to US in the evaluation of complex fetal anomalies (12–19), most have compared findings at prenatal US with those at prenatal MR imaging. Levine et al (9) found that MR imaging provided additional information in both the central nervous system in 10 (55%) of 18 fetuses, which affected pregnancy care in seven (39%) mothers, and the thorax in 28 (38%) of 74 fetuses, which affected pregnancy care in six (8%) mothers (20). Postnatal imaging correlation was available in many but not all of the neonates in these two series, and prenatal MR imaging was considered the reference standard. In another comparison of prenatal MR imaging and US, MR imaging added information in 12 of 24 cases, which contributed to alteration in treatment in four (17%) (7). However, no postnatal correlation was reported, and MR imaging was again used as the reference standard. In our study, postnatal evaluation with imaging, surgery, or autopsy was a criterion for study inclusion. When one attempts to evaluate the role of an imaging technique, the technique itself cannot be used as the end point. In this study, we sought to define a role for fetal MR imaging in a high-risk obstetric US center by comparing prenatal findings of both imaging modalities with the confirmed postnatal diagnosis.

In our limited study, we found that MR imaging was accurate in 61% of cases and that it can sometimes provide valuable information about the fetus above and beyond that obtained at prenatal US, particularly in the evaluation of anomalies of the brain. The corpus callosum and vermis can be difficult to image in the second trimester with US, yet these structures are often clearly visualized with MR imaging. MR imaging has also proved to be useful in the evaluation of the cerebral cortex for ischemic changes (21).

In seven cases, diagnoses at both US and MR imaging were incorrect when they were compared with the postnatal results. In one case, the periventricular lesions of tuberous sclerosis were not identified prenatally with either imaging modality. In another case, mild unilateral ventriculomegaly was identified at both MR imaging and US, but results at postnatal US 8 weeks later were normal. The time between pre- and postnatal imaging may account for this discrepancy. Evolution of the diaphragmatic hernias in two neonates may help explain the presence of liver above the diaphragm at surgery in the first neonate and the missed sequestration in the second neonate.

Despite the well-known advantages of US, including multiplanar imaging and real-time evaluation, the potential advantages of fetal MR imaging as an adjunct to US are many. Fetal anatomy is well visualized at MR imaging, in part because of large amounts of amniotic fluid, as well as fluid within the fetal lungs, gastrointestinal tract, kidneys, bladder, and gallbladder (22,23). The multiplanar abilities of MR imaging may help determine the origin and extent of an abnormality. MR imaging is not limited by fetal position or maternal body habitus to the same degree as is US, particularly in the third trimester. MR imaging, however, is limited by fetal motion and, as is US, by severe oligohydramnios. In our study, severe oligohydramnios contributed to misdiagnosis with both modalities in a fetus with bilateral renal agenesis. With both fetal MR imaging and obstetric US, interpretive expertise is beneficial.

MR imaging can be considered safe for fetal evaluation after the first trimester, but its use should be limited to cases in which complex anomalies are suspected and the US results are equivocal or incomplete. No teratogenic effects on the developing fetus have been seen when a clinical-strength magnet (1.5 T) is used (24–26). The Food and Drug Administration, however, has not yet approved MR imaging as a primary imaging modality for the fetus. At our institution, use of MR imaging is restricted to the second and third trimesters, because of theoretical risks to the younger fetus during organogenesis. At this time, intravenous administration of gadolinium-based contrast material is contraindicated in pregnancy, as gadolinium chelates cross the placenta with uncertain effects on the fetus (27).

Although MR imaging provided valuable information for some fetuses in this study, it should not replace US for routine screening of the fetus or for the diagnosis of all fetal anomalies. MR imaging is limited in the evaluation of cardiac disease because of motion from the rapid fetal heartbeat. Unlike US, MR imaging cannot be used to evaluate fetal movement, which is clinically important and a component of the biophysical profile. In this study, MR imaging was used as an adjunct to US for problem solving, and the MR imaging examination was tailored to evaluation of a specific anomaly.

Limitations of this study included a selection bias, as only fetuses with possible or definite anomalies identified by a skilled obstetric sonographer were referred for MR imaging. This, however, is the population that probably benefits most from advanced imaging. Another limitation of our study was that the results of US were available at the time of MR image interpretation, and this availability introduced bias in favor of MR imaging. The lag time between prenatal imaging and postnatal evaluation also limited the comparisons used for this study. As is well known by sonologists, growth and development often alter the appearance of the fetal organs, and anomalies may become more or less visible over the course of gestation. Continued reevaluation of the fetus is critical. Despite these limitations, fetal MR imaging provided additional information in selected cases. In a recent large series of cases involving MR imaging of fetal central nervous system abnormalities (10), investigators found that additional information provided by MR imaging helped to change the treatment in 27 of 145 study patients.

It is clear from the results of the present study, however, that the information provided at MR imaging should not replace US results but be used as an adjunct to them. MR imaging is finding a growing niche as fetal surgery emerges as a new field (28). Preoperative planning with fetal MR imaging, specifically for central nervous system malformations and neck masses (16,29,30), may greatly enhance treatment for these selected life-threatening anomalies. Research continues into the possible role for three-dimensional reconstruction of the fetal brain from two-dimensional MR images (31). In addition, there may be a role for MR imaging in the evaluation of fetal lung volume (32,33) and possible pulmonary hypoplasia (34).

In conclusion, MR imaging as an adjunct to prenatal US may provide valuable information that could add to the prenatal evaluation and treatment of some fetal anomalies, particularly those involving the central nervous system. At present, we believe MR imaging should be considered in fetuses with anomalies for additional evaluation of structures that are suboptimally visualized at US but about which information is critical.


   FOOTNOTES
 
2 Current address: Department of Radiology, Evanston Hospital, Ill. Back

Author contributions: Guarantors of integrity of entire study, M.C.F., C.B.B., C.M.T.; study concepts, M.C.F., C.B.B., C.M.T.; study design, M.C.F., A.J.K., C.B.B., C.M.T.; literature research, M.C.F., A.J.K., V.L.W.; clinical studies, M.C.F., C.B.B., C.M.T.; data acquisition, M.C.F., C.B.B., V.L.W., C.M.T.; data analysis/interpretation, M.C.F., A.J.K., C.B.B.; manuscript preparation, M.C.F., A.J.K.; manuscript definition of intellectual content and final version approval, M.C.F., C.B.B., V.L.W.; manuscript editing, A.J.K., C.B.B., C.M.T.; manuscript revision/review, M.C.F., C.B.B., V.L.W., C.M.T.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 

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