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  • 1. King Abdul-Aziz University Faculty of Applied Medical Sciences Diagnostic Radiology Department 4D Ultrasound Equipments Diffusion in Jeddah City Research conducted by : Abrar Abdul- Elah Alfattani year medical technologyth 4 Diagnostic Radiology Supervised by : Dr. Njlaa M. Al-Sayed. Mr. Nabeel Mishah. ARABIAJEDDAH - SAUDI 1429/2008
  • 2. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
  • 3. {{‫ثم‬ * ‫طين‬ ‫من‬ ‫سلالة‬ ‫من‬ ‫الإنسان‬ ‫خلقنا‬ ‫ولقد‬ ‫النطفة‬ ‫خلقنا‬ ‫ثم‬ * ‫مكين‬ ‫قرار‬ ‫في‬ ‫نطفة‬ ‫خلقناه‬ ‫المضغة‬ ‫فخلقنا‬ ‫مضغة‬ ‫العلقة‬ ‫فخلقنا‬ ‫علقة‬ ‫انشأنا‬ ‫ثم‬ ‫لحما‬ ‫العظام‬ ‫فكسونا‬ ‫عظاما‬‫ه‬‫خلقا‬ * ‫الخالقين‬ ‫أحسن‬ ‫هللا‬ ‫فتبارك‬ ‫آخر‬}} ...‫العظيم‬ ‫هللا‬ ‫صدق‬ ( ‫آية‬ ..‫المؤمنون‬ ‫سورة‬۲۱–۲١) 4D Ultrasound Equipments Diffusion in Jeddah City
  • 4. By: Abrar Abdul –Elah Alfattani Aprojectsubmitted in partial fulfilment of the requirements for the degree of Bsc. In diagnostic imaging department. Faculty of Applied Medical Science King Abdul Aziz University Jeddah – Saudi Arabia 1429 A.H / June 2008 A.G 4D Ultrasound Equipments Diffusion in Jeddah City
  • 5. By: Abrar Abdul –Elah Alfattani Wecertifythatwehavereadthisproject and thatinouropinion is fully adequate in scope andqualityas a project for the degree of Bsc. Project supervised: Dr.Njlaa M. Al-Sayed. …………. Mr.Nabeel Mishah. ………… 4D Ultrasound Equipments Diffusion in Jeddah City
  • 6. By: Abrar Abdul –Elah Alfattani This project has been approved and accepted in partial fulfilment of the requirements for the degree of Bsc. Dr. Bhaa Aldeen => …………… Examiner. Dr. SeddigJastanniah=> ………….. Head of exam committee. Dr. Sattam Lingawi => ……… Chairman of diagnostic imaging. Dedication
  • 7. I would like to dedicate this research to my dear parents who supported me & guided my thoughts, to my lovely sisters & brothers, to my teachers for their great help , and to all my colleagues & friend who truly helped me making my experience a wonderful one . Acknowledgment
  • 8. ♠ First of all, I would like to thank" Allah" for helping me to reach this level ofeducation & facilitateto methe way to reach to the high degree. ♠ Then I would like to thankmy lovely parents who did a lot for me & gave me full chance to reach to my demand. ♠ At the end, I would like to thank all doctors & supervisors who supported me & helped me to finish my research. Thanks to all radiology staff & all my colleagues who give us this opportunity and chance through which we got a lot of experiences & knowledge , and allow us to deal & communicate with different levels in the community . Thanks a lot for all, and I wish to all my colleagues nice future. Content
  • 9. Titele Page Abstract ……………………………………….……........1 Motivation ………………………………….………...….1 Objective ……………………………………….……..…1 Introduction ……………………………………………...2 The definition of 4D Ultrasound …………………...……3 Equipment ..................................................................…...4 Technique …………………………………………..……4 Clinical use………………………………………….……5 3D & 4D clinical advantages …………………………….6 Benefits of 3D & 4D Ultrasound…………………………6 Photos of the babies taken before & after delivery………7 The main factors that affect the quality of the images…...8 The difference between 2D & 4D Ultrasound …………..9 References ……………………………………………...12
  • 10. Methodology ……………………………………………14 Survey questionnaire……………………………………15 Analysis & Result…………………………………….....18 Discussion ………………………………………………22 Conclusion & recommendation …………………...……26 Appendix (1) ……………………………………………27 Appendix (2) ……………………………………………31 Appendix (3) …………………………………………....34 4D Ultrasound in Arabic ………………………………..39 Abstract Nowadays the science & technology of medical imaging is highly advanced in all diagnostic imaging fields all around the word, every day a new imaging technology & techniques discovered by the scientist in which will enhance the diagnostic accuracy of diseases. For this reason, in my research I will study the diffusion of one of the new technology introduced lately known as 4D ultrasound imaging where we can use it for many clinical applications such as monitoring fetal movement and body parts.
  • 11. This technology is becoming more interesting for pregnant ladies since it can help them to see there baby's facial expressions as live monitoring even before delivery. I think most of us know about 2D & 3D ultrasound, but few of us knows about 4D Ultrasound, so I focus on this advanced technology in order to gain the attention of medical professionals involved in pregnant women healthcare delivery. The aim of my research is to highlight the benefits & clinical advantages of this 4D ultrasound technique over conventional 2D & 3D techniques in Ultrasound. Motivation One of the reasons that motivated me to conduct this research is the introduction of this new technology in the local market lately but it seems that many hospitals within the kingdom of Saudi Arabia did not take the initiative to implement it, it is only found in some advanced hospitals & many medical professionals doesn't know about it. Objective My objective of my research is to highlight the necessity of 4D machine and to measure the diffusion and penetration of this technology among the hospitals within Jeddah city & to identify the obstacles facing the introduction of this technology. Literature review Introduction: In obstetrics, the ultrasound is an essential imaging tool used to clearly visualize the fetus in the uterus.
  • 12. Recent advances in fetus imaging have resulted in the introduction of three-dimensional (3D) and four-dimensional (4D) ultrasound. Both used in conjunction with traditional two-dimensional (2D) ultrasound imaging, which has been in practice for more than 25 years, 3D/4D ultrasound provides a higher resolution image in actual or “real” time. Such imaging is especially useful for obstetricians who suspect structural abnormalities and need to see specific surface renderings of a fetus. This 3D & 4D ultrasound ( real time 3D) are becoming a clinical reality only now. (1, 2) 3D/4D ultrasound helps the bonding b/w the parents & their future offspring, and consultants understand fetal pathology better & can plan postnatal intervention better. The volume measurement is better assessed with 3D & we can perform studies that follow growth in order to decide medical or surgical treatment. (3) By this new technology we can observe different expressions and movements of a fetal face during investigation of fetal behavior in the second and the third trimester of normal pregnancies, as a probable manifestation of fetal awareness. (4,5) For more information see appendix (1) Some of these facial expressions & movements include : Yawning Dancing
  • 13. BoxingSucking Thump Before I going in detail to the 4D ultrasound technique & what are the advantages and benefits that we can get from it , first of all we must know : The definition of 4D ultrasound: "4D" is shorthand for "four-dimensional", a technique that allows visualization of the unborn baby moving in real-time. 4D Ultrasound is the latest ultrasound technology. 4D Ultrasound takes multiple 2-dimensional ultrasound images, creates a 3-dimensional image and then does this repeatedly so that, over time, you can see the movements of the fetus in three dimensions. The fourth dimension is time. So you can see live movements of the baby in-utero, like a video. (6, 7, 8) Equipment: used equipments are known as real-time scanners, With which a continues picture of the moving fetus can be depicted on a monitor screen. Very high frequency sound waves of between 3.5 to 7.0 megahertz are generally used for this purpose. (9, 10)
  • 14. Technique: In conventional 2D ultrasound for an abdominal scan, ultrasound gel is applied to the belly then the body is scanned using a movable probe over the surface of the abdomen. This transducer is then used to send sound waves into the body. The image received is made up of thin views or “slices” of an image, only one slice may be seen at a time on the screen. While informative, the image does not always give an adequate view of the structure being studied. In 3D ultrasound, the technologist sweeps a probe over the maternal abdomen. A computer takes multiple images and renders a life-like 3D image. With 4D ultrasound, the computer takes the images as multiple pictures while the technician holds the probe still and simultaneously renders a 3D image in real time on a monitor. The difference between the 3D and 4D is that 4D is real-time imagery. In most cases, the standard 2D ultrasound is taken, and then the 3D/4D scan capability is added if an abnormality is detected or suspected. The 3D/4D is then focused on a specific area, not the whole body, to provide the details needed to assess and diagnose a suspected problem.(1,9,11)
  • 15. There are limitations to adequate visualization of fetal anatomy with 3D/ 4D technologies. If there is inadequate amniotic fluid surrounding the fetus, or if the fetus has its face in the posterior position in the uterus, there will be difficulty visualizing structures and the face. (12) Clinical uses: The clinical use of this technology is an intense area of research activity especially in fetal anomaly scanning, but there are also popular uses that have been shown to improve fetal-maternal bonding. (13, 14, 15, 16, 17, 18) 3D & 4D clinical advantages: The advantages of 3D/4D ultrasound in obstetrics are outlined including: 1) Improved understanding of normal fetal anatomy and fetal anomalies by the parents. 2) Improved maternal-fetal bonding. 3) Enhanced diagnosis of fetal anomalies. 4) Precise identification of the nature, size and location of certain fetal defects.
  • 16. 5) Precise volume measurement of organs with irregular shape. 6) Retrospective analysis, data exchange and education. Some specific advantages of 3D/4D sonography are listed regarding its application in the first trimester, for the diagnosis of fetal anomalies and for fetal growth assessment.(19) Benefits of 3D/4D Ultrasound: You will be able to see amazingly realistic images of the baby and this positive emotional experience will bring love, affection, respect for the miracle of a new life and a sense of security into your family. The expectant father becomes more connected to the child and more emotionally involved in the pregnancy. Seeing the baby will reduce the stress and anxiety for the mother and the rest of the family. It will bring reassurance of the baby’s wellbeing. (20) Photos of the babies taken before & after delivery:
  • 17. Sleeping. Tongue out One mother said:" I really enjoyed my ultrasounds. I can't believe how much she looks like the pictures. What a wonderful keepsake I have for my daughter now. The only shocker was all the hair she has. Our first daughter was blonde and bald. So we still had a big surprise". (21, 22) To look at more testimonials see appendix (2) *There are may be some questions coming in our mind & we want to know the answer of it, so I will offer some of these questions to help us: 1- How safe is 3D/ 4D Ultrasound? 3D and 4D ultrasound use sound waves, just like ordinary 2D ultrasound.
  • 18. Numerous studies over several decades have shown that there is no detrimental effect on the baby of antenatal ultrasound. It uses simple, safe ultrasound waves, which are then processed by high powered computer technology. Then, the images are displayed on a large screen for you to appreciate.(6) (2) How long is the session? 20 minutes is the usual time for the Ultrasound exam. (3) What is the earliest time that my baby’s gender can be determined? The earliest gestational age for gender determination is 16 weeks (4 months). (20) For more detail questions that could be asked directly from the patients please see appendix (3) The main factors that affect the quality of 3D/4D images are: 1-Baby's Face Position: The baby should be looking up or to the side. If the baby is in a difficult position, such as with the spine up or face looking down, it may be difficult to obtain facial views. If this happens, the lady must changing her position, roll on her side, or even have her walk to stimulate her baby to move to a favorable position. 2-Fluid In Front Of Baby's Face: The more amniotic fluid in front of the face, the better the images. If the baby's face is right on the placenta or uterine wall without fluid between them, then the images will be of less quality. Basically anything adjacent to the face, such as cords or hands & Feet can obstruct a clear facial photo. We recommend hydrating yourself by drinking lots of water before your appointment. 3-Gestational Age: The younger the baby, the more skeletal appearance (18-23 weeks). Since the baby is smaller with more amniotic fluid, you will see more of the baby, but
  • 19. less details. The older the baby (26-34 weeks), the more fat they have which shows more facial detail. 4-Maternal Body Habitus: The more tissues the ultrasound has to travel, the lower the image quality. We recommend 30-32 wks scan for plus size. sometimes ultrasounds waves are unable to penetrate through the abdominal tissue what causes poor image quality. We recommend for heavyset mothers to have 3D/4D Ultrasound after 28 weeks of pregnancy. (23) The difference between 2D& 4D ultrasound: Conventional ultrasound, usually offered to mothers at 12 and 20 weeks, produces 2D images of the developing fetus. These are very useful for helping doctors to measure and assess the growth of the fetus, but convey very little information about behavior.(24) The regular two dimensional scan (2D) is in black and white and is used to look inside organs, for example we can see the fetus inside the maternal uterus, as well as see the internal organs of the fetus - It produces a slice through the body. The right handed figure is: 3D/4D Ultrasound. The left handed figure is: 2D Ultrasound. The three/four dimensional scan (3D/4D) is in color (sepia) and is called a surface rendering type of scan. This is when only the outer layer of the image is shown. We use this for our bonding scan or to look for any soft tissue anomaly e.g. cleft lip
  • 20. The right handed figure is: 2D Ultrasound. . The left handed figure is: 3D/4D Ultrasound The movement of the fetus is known as the 4th dimension (4D) and movement is seen in real time. (26) Both 2D& 4D methods are required for the assessment of early fetal motor development & motor behavior. Several movement patterns such as sideway bending, hiccup, breathing movements, mouth opening and facial movements could be observed only by 2D USG .(27) Facial activities and different forms of expression are easily recognized by 4D USG. 4D USG is superior to 2D USG in the evaluation of complex facial activity and expression . Among facial activities observed by 4D USG , simultaneous eyelid and mouth movements dominate b/w 30 & 33 weeks of gestation , pure mouth movements such as mouth opening , tongue expulsion , yawning and pouting are present but at a significantly lower
  • 21. incidence . facial expressions such as smiling and scowling can be precisely observed using 4D USG . (28) 4D ultrasound uses the same high frequency sound waves as 2D. The difference is that instead of the sound wave being sent straight down and reflected back, the waves are sent into the body at multiple different angles. The reflected waves are then computer-processed to reconstitute and produce the life-like image complete with movements. If it was bread, you will see the whole loaf! It is awesome. The technology has been there for a number of years now but it is the advent of affordable sophisticated computing power that has made this possible at the consumer level.(7) References : -(1) Less.W .ultrasound imaging in three and four dimensions. 2001(2) (3) ( Timor-Tritsch IE , Han E , Platt LD .Three- dimensional ultrasound experience in obstetric).Curr Opin Obstet Gynecol. 2002 (4)
  • 22. Carrera%20JM%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed _ResultsPanel.Pubmed_RVAbstractPlusDrugs1 (6) au /SUW/3d4d.html-9k (7) - (8) - 5k (10) (11) (12) ( Leung KY , Ngai CSW, Chan BC etal.Three-dimensional extended imaging: a new display modality for Three-dimensional ultrasound examination . Ultrasound Obstet Gynecol. 2005 ) . (13)Benacerraf et al (2005). "Three- and 4-dimensional ultrasound in obstetrics and gynecology: proceedings of the American institute of ultrasound in medicine consensus conference" (14)Benoit B, Chaoui R (2004). "Three-dimensional ultrasound with maximal mode rendering: a novel technique for the diagnosis of bilateral or unilateral absence or hypoplasia of nasal bones in second-trimester screening for Down syndrome" (15)Krakow D, Williams III J, Poehl M, Rimoin DL, Platt LD (2003). "Use of three- dimensional ultrasound imaging in the diagnosis of prenatal-onset skeletal dysplasias" (16)Ji EK et al (473-477). "Effects of ultrasound on maternal-fetal bonding: a comparison of two- and three-dimensional imaging" )19(DimitrovR,Markov D,Dimitrova V , 3D and 4D ultrasonography in obstetric. Akush Ginekol (sofiia) .2007 (20) www.clearimage 4d ultrasound .com /faq.htm - 9k21)) (22) - 25k - 39k(23) (24)
  • 23. (25) Content/ (27) ( Andonotopo W, Medic M, Salihagic-Kadic A etal.The assessment of fetal behavior in early pregnancy : comparison between 2D and 4D sonogrphic scanning .J Perinat Med 2005 ) . (28) ( Kurjak A, Azumendi G , Vecek N etal. Fetal hand movements and facial expression in normal pregnancy studied by four dimensional sonography . J Parinat Med 2003 ). Methodology This study was done in the period from ( 20/4/2008) till ( 2/6/2008).
  • 24. A questionnaire was designed compromising several questions to measure the diffusion & availability of this technology. About 16 hospitals selected for field survey and programmed visits were arranged where I personally visited all hospitals and performed the questionnaire by interviewing the radiologist & sonographers, then the data collected were processed & reviewed. These selected hospitals include: 1) King Abdul Aziz University Hospital (KAAUH). 2) King Fahad Military Hospital (KFMH). 3) Saudi German Hospital (SGH). 4) Dr. Soliman Fakeeh Hospital (DSFH). 5) King Fahad General Hospital (KFGH). 6) Maternity & Children Hospital (MACH). 7) National Guard Hospital (NGH). 8) Doctor Ghassan N. Pharaon Hospital (DGNPH). 9) Dr.Erfan & Bagedo Hospital (DEABH). 10) International Medical Center (IMC). 11) King Faisal Specialist Hospital (KFSH). 12) Bakhsh Hospital (Bakhsh H). 13) Bugshan Hospital (Bugshan H). 14) United Doctors Hospital (UDH). 15) Mental Health Hospital (MHH). 16) AL-Thagher General hospital (Al- Thagher GH). Here is a form of my questionnaire. King Abdul-Aziz University Faculty of Applied Medical Sciences
  • 25. Diagnostic Radiology Department "SURVEY QUESTIONAIR" 4D Ultrasound Equipments Diffusion in Jeddah City [Section A] 1) Did you hear about 4D Obstetric US technology? □ Yes □ No 2) Do you have 4D technology option available in your US machine? □ Yes "if (Yes) please continue section A and /or B" "If (No) please skip to section C"□ No 3) How many ultrasound machines equipped with 4D technology in your department? 1 □ 2 □ 3 □ 4 □ 5□ 4) From which vendor is your machine? ………………………………………………………………………… 5) Is it in use (or) not? " if (No) please skip to section [B]"□Yes □ No 6) What are the major advantages of 4D technique which makes you prefer it on clinical use? ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………. 7) From your experience what are the cases that will benefit mostly from the use of 4D ultrasound? ………………………………………………………………………………………… ……………………………………………………………………………… 8) What is the most recommended stage of pregnancy to do this 4D technique for better fetus position & enhanced accuracy? ……………………………………………………………………………….
  • 26. 9) What is the percentage of 4D technique among your daily conventional work load? ……………………………………………………………………………… - If there is any added information that can help me in my project, please write it down. ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………… Section [B] For the hospitals that have the machine but not using this 4D technology 1) How many ultrasound machines equipped with 4D technology? 1 □ 2 □ 3 □ 4 □ 5□ 2) What is the reason behind not using 4D technology? □ Insufficient technicians . □ There is no places to put the machine & work on it . □ Lack of knowledge. □ Lack of patients cases needs this imaging technology . □ Lack of clinical experience . □ Others causes ( mention it please ). …………………………………………………………………………… Section [C] For the hospitals that don’t have this machine: 1) What is the reason for not having this technology? □ No funds.
  • 27. □ No patient flow. □ No experience. □ No economical incentive. □ Others (mention it please) ………………………………………………………. 2) Do you plan to acquire this technology in near future? □ Yes □ No Thank you, ResearchConducted by: year medical technology .thElah Alfattani,4-Abrar Abdul Supervised by: Mr. Nabeel Mishah . sAnalysis & Result Results: First:
  • 28. A) 11 hospitals out of 16 selected hospitals in Jeddah city which were mentioned above have the 4D obstetric ultrasound machine these hospitals are: 1) Saudi German Hospital . (SGH) 2) Dr. Soliman Fakeeh Hospital(DSFH) 3)Maternity & Children Hospital .(MACH) 4) National Guard Hospital .(NGH) 5) Doctor Ghassan N. Pharaon Hospital (DGNPH) 6) Dr.Erfan & Bagedo Hospital.(DEABH) 7) International Medical Center (IMC) 8) King Abdul Aziz University Hospital(KAAUH) 9) Bakhsh Hospital .(Bakhsh H) 10) Bugshan Hospital .(Bugshan H) 11) United Doctors Hospital.(UDH) B) All of these hospitals are using the 4D ultrasound machine except one hospital which is (KAAUH) it has only one machine but not in clinical use & one of the private Hospitals which is (SGH) has 2 machines but only one in clinical use while the other one under repair. C) The rest five hospitals which do not have 4D ultrasound machine are: 1) King Faisal Specialist Hospital (KFSH) 2) King Fahad Military Hospital (KFMH) 3) King Fahad General Hospital (KFGH) 4) Mental Health Hospital (MHH) 5) AL-Thagher General Hospital.(AL-Thagher GH) And this is represented by graphic (NO. 1) N.B. its to be mentioned that the 1st 4D ultrasound done in KSA was at 2001 . Second: Statistic data was analyzed to identify the number of 4D ultrasound machine equipped in each hospital and this is represented on a graph attached (No. 2) "Table: Hospitals names, Number of machines and vendors"
  • 29. Vendor of the machines. Number of 4D US machines. Name of the hospitals. GE, Philips2SGH 3 "GE" , 1 "Philips"4DSFH GE1MACH Philips1 and "2" more will be coming in the way. NGH Philips1NPH GE1DEABH iu22Philips1IMC Philips1KAAUH 2 "Philips"2Bakhsh H Isoate1Bugshan H Philips1UDH Total number: Eighteen "18" (4D ultrasound machines) are availablein these selected hospitals. Graphic ( No.1 ): Number Of hospitals
  • 30. The percentage of 4D Ultrasound Diffusion: Graphic (No. 2): Group 1 Represent the number of hospitals that have 1 (4D machine ) 0 1 2 3 4 5 6 7 8 9 10 hospitals have 4D machine & use it hospital have it but not use it hospitals don’t have it 63% 6% 31% hospitals haveing it and using it hospitals haveing it but not using it hospitals do not have it
  • 31. Group2 Represent the number of hospitals that have 2 ( 4D machine ) Group 3  Represent the hospital that have 3 machines . Group 4 Represent the hospital that have 4 machines. Number Of Hospitals Number of machine Discussion Through this study, it was found that all sonographers & radiologists working in ultrasound field already heard about "4D obstetric Ultrasound Technology". 1 2 3 4 0 1 2 3 4 5 6 7 Group 1 Group2 Group3 Group 4
  • 32. In order to be able to discuss the topic we need to discuss it from three different prospective which are:  The answers that was collected from hospitals that have 4D ultrasound machine & clinically using it.  The answers that was collected from the hospitals that the machine is available but not used clinically.  The answers that was collected from the hospitals that don’t have the machine. For the hospitals that have 4D ultrasound machine& use it: ● The questionnaire started by asking the radiologist and /or ultrasound operators about if they have the 4D machine or not. Then I asked if they use it or not, and what are the advantages that made them to prefer it in clinical use? Some of them stated that it is more informative for congenital anomalies in fetus like in the spine or in face, again more informative & better delineation of gynecological-problems, masses and tumors & its more amazing for pregnant ladies. Another radiologist said: it's easy to diagnose, clear & easy to differentiate veins & arteries and also we can exam the heart in more details by Doppler & Duplex. In addition, this new technology gave entertainment to the pregnant mother, it allowed her to see her baby more clearly better than 2D & she can see the movement as well as the facial expressions of her baby. Also we can see the position of the fetus, this will satisfy the patient and reassure the parents. During my visits to the hospitals, I asked the radiologists according to their experience for the cases that will benefit mostly from the use of the 4D technique, some of them answers it more helpful for the congenital anomaly survey, e.g.: cleft lip, kidney abnormality, abdominal hernia, hydrocephalus, limbs abnormality, spine anomalies like (spina bifida, meningeocele, myelocele) so we can take more accurate measurements by this advanced technique.
  • 33. ● One of the technicians in private hospital was asked about the cases that she faced during her work & could require 4D ultrasound, she said: I didn’t face any abnormality until now for any patient that coming to me which needed further evaluation by 4D ultrasound and she added that: In fact the rate of the pregnant ladies that asked for this technique was very little, and also some of these patients didn’t have any idea about this new technology. In addition we don't have good experience in 4D technology, and we didn’t take enough courses for training. ● Among this research it was found that the most recommended stage of pregnancy to do this 4D technique for better fetus position rang between 2nd & 3rd trimester ( actually from 6 to 7 month ) for adequate liquid amnii & with the fetus in sagittal position . One of the doctors said that we can catch the congenital anomalies & see it clearly actually at 2nd trimester, and for face surface rendering will be from (32 to 35 weeks). ● About the frequency of using 4D ultrasound machines it was found that it is in the low percentage approximately around (5-10 %) for all hospitals except 2 hospitals it was around 20% but it still in low percentage. For the hospital that having the machine but not using it: ● Only one hospital from total number of hospitals included in my research, The reasons for not using it are: because its time consuming & also the technician not have well clinical experience and no body learn them, so they were not trained on it and of course this technology need practice. For the hospitals that don’t having the machine:
  • 34. 5 out of 16 hospitals included in the research. One of the hospitals , have only 3D in the machine and again not use it& when I asked about the reason for that, their answer was the image not appear clearly with 3D so we concern only on 2D . Also we are don’t have enough technicians in the department only 2 available & this is small hospital no need for this & I think it is only used in premier and large hospital. In one of the famous hospitals, the reason for that the machine is not available, but they did the training on demo machine. One of the technicians said: From my opinion it is important to acquire one machine because it helps in the detection of some abnormalities. In one of the semi-private & very well known hospitals, when asked the radiologist why you are not using this advanced technology in such advanced hospital? He said: we are only have 3D machine, and this service is not important for us & we concerning for diagnostic issue & no need for this imaging option, and it is not in our future plane to use it, but if we need this facility to any reason in the future then we will reconsider it , otherwise no need to have it as of yet. Other hospitals included in my research stated that they have the future intention to acquire this 4D ultrasound technology. I noticed in one of the hospitals in our list, that there is no obstetric ultrasound department at all. So they are not in need to use 4D obstetric ultrasound option. ● However, I think that 4D technology needs the technicians to practice on it & get experience. Unfortunately During my tour to the hospitals, I found most of technicians don’t have enough experience on this technology & they were trained by them selves, no body learned them.
  • 35. One of the doctors told me her opinion about this subject and said "I think that 4D ultrasound machine is essential and should be available in any hospital providing care to ante-natal". Another doctor said about the same subject "We are not using it for routine cases, we use 2D only. But in case that the parents requested this service and wanted to see the movement of their baby, facial expression we do offer this optional service. recommendationConclusion & The 4D obstetric ultrasound is an advanced technology, and it can be used for detecting abnormality of the fetus but it is still considered as optional feature in ultrasound machine.
  • 36. It was noticed that there was a wrong impression, that 4D ultrasound is available & used in all large and well-equipped hospitals, but from my research, I found that even in some premier hospitals they don’t have the technology or the machine to do 4D techniques. Although this recent technology was applied in most hospitals but not considered as a promising technique for other hospitals that don’t have it. They think that it is not for that necessity to be there in the hospital. Other hospitals that have the machine think that 2D and 3D USG may be enough for diagnosis & 4D has only limited role in the diagnosis of selected cases . However, always keep in mind that an elective 4D ultrasound should only be used to complement the diagnostic ultrasounds prescribed by the physician, so its not separate technique & we can't do it until we do 2D USG first. Elective 4D ultrasounds should never be used as a replacement for ante-natal care. I think this advanced technology is made for commercial use & to satisfy parents but not of clinical importance other than fetal abnormalities, it only gives the doctors the re-assurance & makes them happy when they can demonstrate babies in normal pattern for the parents, to satisfy their entertainment need.
  • 37. (A) The potential of four-dimensional (4D) ultrasonography in the assessment of fetal awareness: AIM: The aim of the study was to observe different expressions and movements of a fetal face during investigation of fetal
  • 38. behavior in the second and the third trimester of normal pregnancies, as a probable manifestation of fetal awareness. SUBJECTS AND METHODS: Over a 6-month period a study was conducted in three centers in Zagreb, Croatia and in Barcelona and Malaga, Spain. Women with singleton pregnancies (16-33 weeks) who were referred for ultrasound check-up for determination of gestational age, suspicious fetal malformations, polyhydramnios, and/or the assessment of biophysical profile or other possible pathology, were assigned to the study. After regular two-dimensional (2D) ultrasound assessment at an antenatal clinic, pregnant women were offered the possibility of undergoing 4D ultrasound examination if the fetus and the mother were considered "normal", i.e., if ultrasound and clinical assessment were uneventful. If the newborn delivered at term had 1- and 5- min Agar scores of 7 and 10, respectively, and if the newborn was considered "term and normal" (normal spontaneous activity, normal posture and tone, and presence of some primitive reflexes) at the first and subsequent regular check-ups, the inclusion criteria were deemed to have been met. Out of 119 patients, 99 fulfilled the inclusion criteria, 40 of whom were in the second, and 59 in the third trimester of pregnancy. A Voluson 730 Expert system with a transabdominal 5-MHz transducer was used for 4D ultrasonography. After regular 2D scanning, the 4D mode was switched on, and a live 3D image was reconstructed by selecting ideal 2D mid-sagittal images of the face (the region of interest). The volume was automatically scanned every 2 s while the surface- rendered mode was switched on, and 4D images were displayed on the screen and recorded on videotape during a 30-min observation period. Movements of the following fetal face structures were analyzed: forehead, brows, nasal soft tissue and nasolabial folds, upper lip, oral cavity and tongue, lower lip and chin, eyelids and eyes, mouth and mouth angles, and facial expression. 4D
  • 39. ultrasonography allowed in utero observations of fetal facial expressions such as smiling, yawning, and swallowing. RESULTS: The quality of 4D depiction of fetal facial expressions increased with gestational age. The frequency of fetal facial expressions such as yawning ranged from 1 and 6 with a median of 1.5 per 30-min observation period; smiling ranged from 2 and 8 with the median of 2; tongue expulsion ranged from 2 to 6, median 3; mouth and eye squeezing ranged from 5 to 10, median 6; scowling ranged from 1 to 3, median 0.5; and isolated eye blinking ranged from 4 to 12 with a median of 5. CONCLUSIONS: Our study shows the ability of 4D sonography to depict different facial expressions and movements, which might represent fetal awareness. Nevertheless, long, precise and thorough observation of fetal faces by 4D sonography was hampered as the images were only near real-time. Thus, we were only able to study the quality and not the quantity of facial movement patterns. By :Azumendi G,Stanojevic M,Kurjak A(2005) Medical School University Zagreb, Zagreb, Croatia. (B) Four-dimensional sonographic assessment of fetal facial expression early in the third trimester:
  • 40. OBJECTIVE: To evaluate the characteristic patterns of facial expression in fetuses aged from 28 to 34 weeks using 4- dimensional (4-D) ultrasonography. METHODS: The faces of 10 healthy fetuses aged from 28 to 34 weeks were recorded continuously for 15 min with a 4-D ultrasonographic machine performing up to 25 frames per second. The occurrence rates of blinking, mouthing, yawning, tongue expulsion, smiling, scowling, and sucking were evaluated. RESULTS: Mouthing was the most frequent facial expression (median, 6.5; range, 2-19) whereas the least frequent were scowling (median, 1; range, 0-9) and sucking (median, 1; range, 0-2). Mouthing was evident in all fetuses and significantly more frequent than any other movement (P<.05). Yawning (median, 3; range, 0-6), smiling (median, 2; range, 0-9), and blinking (median, 1.5; range, 0-6) were observed in most cases. Tongue expulsion (median, 1.5; range, 0-5), scowling, and sucking were each observed in 6 cases. CONCLUSION: 4-D sonography provides a means of evaluating fetal facial expression early in the third trimester. It may be a key to predicting fetal brain function and well-being and an important modality in future fetal neurophysiologic research. By :Yan F, Dai SY, Akther N, Kuno A, Yanagihara T, Hata T (2006) Department of Perinatology and Gynecology, Kagawa University School of Medicine, Miki, Kagawa, Japan.
  • 41. 3D & 4D Ultrasound Testimonials: (1) My husband and I enjoyed both visits to Storks view Ultrasound to see the 3D/4D images of our precious little girl, I felt so much at home.
  • 42. We are so ecstatic at how much she looks like us, from her cute little nose, to her chubby cheeks. It's so awesome! We can't believe the technology of sonograms now, and to have been able to participate and actually have them done is the greatest experience ever. To see what our daughter looks like before she is born amazes us. Thank you for this life changing experience, we will always look back on this and smile. All of our family and friends are surprised to see what our baby looks like, and some wish they could have done 3D/4D sonograms with their children as well. We recommend this to everyone we talk to. Thank you so much for this experience, and for bringing us that much closer to our precious baby girl." David and Alicia Q. (2) This is clearly something you don't want to miss; it's a once in a life time experience that you can never get back again. I had the 4-D ultrasound done twice once at 20 wks & another at 31wks both times where awesome! & I'm very glad I had both experiences because at 20 wks she was tiny but just right to get her whole body in the picture, you can clearly she her hands, feet, mouth & so on….Awesome! Second time was very much awesome because you can see pretty much exactly what your child will look like when he or she arrives & not just that but I also saw my child smiling, yawing & my husband & I noticed that when she was sleeping she slept with her one hand under her head & that is exactly the way her big sister sleeps also. Ladies take my advice & don't miss out on this once in a life time experience!! Stephaney K. (3) "Our experience at Storksview Ultrasound was really amazing! We had no idea that the pictures we would see of our soon-to-be daughter would be as revealing and eye-opening as they were. During our visit, we actually got to see our daughter open her eyes, which was totally beyond belief. Having our ultrasound session on DVD is a lifetime keepsake. All of
  • 43. our friends and family were shocked at how much you can really see. The whole experience was awesome! I would definitely recommend Storksview Ultrasound to anyone who is pregnant and wants a once-in-a lifetime opportunity at seeing your child in a way I never thought possible." It was always hard to imagine it was a baby inside of me. I could feel it kick and move. The only thing I could picture was the "slice" image of the black and white Ultrasound. I could see its spine and the inside of its skull and know it was a baby inside of me. When I had my 3D/4D Ultrasound, my heart skipped a beat. He's not a shadow, he's not a skeleton. He is my son. He has his sister's nose and chubby cheeks. He's real. And he's inside of me growing. My son is beautiful. The whole family loved the pictures and the tape. Julie R.
  • 44. 1)Do I need to have a diagnostic, 2D ultrasound performed by my prenatal care provider before coming in for a little sprout imaging session?
  • 45. Yes, little sprout imaging requires that all clients have a normal diagnostic medical ultrasound (fetal survey) before coming in for a little sprout scan. These are typically performed during weeks 18-22 of your pregnancy. little sprout imaging provides reassuring ultrasound images of your baby. These are not performed as a diagnostic medical ultrasound of your baby. Our service should not be considered a substitute for any ultrasounds that may have been recommended by your doctor. 2)How long is the session? 20 minutes is the usual time for the Ultrasound exam, however we could exceed this time in case of medical necessity during Diagnostic Ultrasound tests. Please arrive 10 minutes prior to your appointment time to fill out the paperwork. Unfortunately, we would have to reschedule your appointment if you are more than 10 minutes late in order to keep our schedule running. 3)Is the 3D/4D ultrasound covered by my insurance? No. 3D/4D Fetal Ultrasound is categorized as an "Elective" service because it is not medically required. This is the reason why most insurance do not cover it because it is NOT deemed as a medical necessity. Most people get these services simply to have an opportunity to view their unborn baby in its most natural environment, creating a bonding experience for the families. 4) Does this replace my ultrasound exam with my gynecologist? Absolutely Not! 5) What if my doctor does not sign the prenatal verification form?
  • 46. The purpose of getting the prenatal verification form signed is for your healthcare provider to verify your prenatal care. However, If your pregnancy is being monitored for a particular medical conditions or if you have any concerns for the baby depending on the severity of your condition, we encourage you to engage in a conversation with your physician. If your physician is concerned for you or the baby's well being then entertainment should always take a second place to you or your baby's safety. Some doctor's may not sign the prenatal verification form simply because they don't believe in doing Ultrasound for Non-Diagnostic reasons. If this is the case, please ask your physician if they see any concerns for you or the child. Again, please use your best judgment. We reserve the right to deny our services to anybody who may try to misrepresent their physician's views or fail to provide proper proof of prenatal care. Please get your physician's input if you are a high risk pregnancy or being monitored for a certain medical condition. 6)What is a report of limited Medical Ultrasound? The report of limited Medical Ultrasound, performed during our 3D/4D session, include very limited diagnosis to confirm heartbeat, the number of babies in the pregnancy, the position of the baby, and the placenta location. Please note, at no time is this exam to be used in place of a complete diagnostic ultrasound ordered by your physician. Any questions or concerns relating to the well being of the baby needs to be directed to your obstetrician. 7) Are there any special preparations for a 3D/4D ultrasound? Please have a meal 90 minutes prior to your exam. Have a bottle of your favorite juice drink and wear comfortable clothing. Full bladder is not required for this ultrasound. Please be sure to bring your proof of prenatal care.
  • 47. 8)Is it better to come in later in the pregnancy to get a 3D/4D Ultrasound? No. The best time to come in for a 3D/4D ultrasound is between your sixth and seventh month (5-6 months for multiple pregnancies!). Once the mother is well into her third trimester, the amniotic fluids get lesser because the size of the baby gets larger. The maternal fluids, also known as the Amniotic fluids, are the most helpful aspect of this Ultrasound, since the ultrasound waves pass through the fluids to create a picture. More fluids will allow for clearer picture and better fetal movements. Lesser fluids are a sign that the size of the baby has become too large which making it difficult to view the baby with clarity. Another important factor that affects the picture quality is the orientation, or positioning, of the baby. Later in the pregnancy, the head of the baby descends deeper into the pelvic area to prepare for the birthing process. The fluids around the face will get lesser, making it difficult to capture better images of the baby's face. 9)When is the best time to have these services done? Whether you wish to come in for gender determination, a full 3D/4D scan or expecting twins, following are the recommended times for these services: For Gender Determination: 18-34 weeks For Single Pregnancy: 26-32 weeks. For Multiple pregnancies (twins or more): 20-26 weeks. Usually by these times, a mother still has retained enough amniotic fluid to be able to observe fetal movements.
  • 48. 10)Is 3D/4D ultrasound available to anyone? 3D/4D appointments are recommended after the mother has completed her second trimester diagnostic ultrasound. 11)Will I always get a clear view of my baby? Mostly but not always! Sometimes if the baby is persistently looking face down, i.e. towards your spine it may be difficult to see the baby's face. Every baby scans differently, depending on its gestational age, position, amount of fluid, and mother's condition. We make no promises that the images will be similar to those you might have seen elsewhere or even from our clinic, or that we can always meet everyone's expectations. 12)In case we do not get a clear view of the baby, is it possible to have a repeat scan? Please note that no one can ever guarantee a perfect shot of the baby's face. You pay for a chance to see your baby, not a guarantee! The idea is to get a glimpse into your child's most natural environment to watch them do whatever they would: yawn, smile, kick, punch, play or just sleeping comfortably facing the mother's back!
  • 49. "‫االبعاد‬ ‫رباعي‬ ‫صوتيه‬ ‫الفوق‬ ‫الموجات‬ ‫جهاز‬ ‫عن‬ ‫مختصرة‬ ‫"نبذة‬ ‫؟‬ ‫الرابع‬ ‫البعد‬ ‫هو‬ ‫وما‬ ‫؟‬ ‫الثالثية‬ ‫األبعاد‬ ‫هي‬ ‫ما‬ ‫نعنةل‬ ‫لةن‬ ‫نةل‬ ‫نةنحن‬ ‫الثالثيةة‬ ‫األبعاد‬ ‫عن‬ ‫نتحدث‬ ‫عندما‬,‫الطةو‬,‫والعةض‬‫وو‬ ‫والعمة‬,‫االرتفةا‬ ‫الثالثةة‬ ‫األبعةاد‬ ‫المجسةم‬ ‫يعطةل‬ ‫والةذ‬ ‫الزمنل‬ ‫البعد‬ ‫نهو‬ ‫الضابع‬ ‫البعد‬ ‫وما‬ ‫المجسم‬ ‫يتشكل‬ ‫وبذلن‬ .‫الحيةاة‬‫نجهةا‬‫التةوتية‬ ‫نةوق‬ ‫الموجةا‬‫ةدو‬‫ة‬‫ت‬ ‫نةل‬ ‫المعةالو‬ ‫الطبيةا‬ ‫لجهةد‬ ‫يحتةاه‬ ‫ةاد‬‫ة‬‫األبع‬ ‫الثالثةل‬‫يض‬ ‫جها‬ ‫وما‬ ‫الوقت‬ ‫بعض‬ ‫يستغضق‬ ‫وهذا‬ ‫الثالث‬ ‫البعد‬ ‫ألخذ‬ ‫الملتقطة‬ ‫التورة‬‫التوتية‬ ‫نوق‬ ‫الموجا‬ ‫ثالثةل‬ ‫بجهةا‬ ‫ا‬‫سةمل‬ ‫لةذلن‬ ‫المحةدد‬ ‫بالوقةت‬ ‫الثالةث‬ ‫البعد‬ ‫بإعطاء‬ ‫بنفسه‬ ‫الجها‬ ‫نيقوم‬ ‫األبعاد‬ ‫رباعل‬ . ‫الحل‬ ‫األبعاد‬ ‫الرباعية‬ ‫األبعاد‬ ‫جهاز‬‫يكتسب‬:‫منها‬ ‫عظيمة‬ ‫ميزات‬ 1-‫ي‬ ‫ة‬‫ة‬‫للتش‬ ‫يؤهلةه‬ ‫الةذ‬ ‫األمةض‬ ‫مةاملة‬ ‫مجسةمة‬ ‫صةورة‬ ‫علة‬ ,‫الحتةو‬ ‫مةن‬ ‫المعةالو‬ ‫الطبيةا‬ ‫تمكةن‬ ‫دورا‬ ‫لعةا‬ ‫وهةذا‬ ‫الثالثيةة‬ ‫بهبعادهةا‬ ‫البشةض‬ ‫الجسةم‬ ‫داخةل‬ ‫الحيةة‬ ‫الحضكةا‬ ‫متابعة‬ ‫إمكانية‬ ‫مع‬ ، ‫الدقي‬ ‫وخةةةةةةةةةةذ‬ ,‫ةةةةةةةةةةضا‬ ‫و‬ ‫نةةةةةةةةةةل‬ ‫رئيسةةةةةةةةةةيا‬‫زعةةةةةةةةةةا‬ ‫ال‬.‫الجسةةةةةةةةةةم‬ ‫نةةةةةةةةةةل‬ ‫القسةةةةةةةةةةطضا‬ ,‫إدخةةةةةةةةةةا‬ ‫وو‬ 2-‫قضية‬ ‫عةن‬ ‫التةور‬ ‫ةزين‬ ‫ت‬ ‫إمكانية‬‫الةذ‬ ‫الوقةت‬ ‫مةن‬ ‫اختتةض‬ ‫قةا‬ ‫ال‬ ‫مقاقعهةا‬ ‫ودراسةة‬ ‫الكمبيةوتض‬ ‫آخض‬ ‫وختائل‬ ‫استشارة‬ ‫من‬ ‫المعالو‬ ‫الطبيا‬ ‫ا‬ ‫ر‬ ‫ما‬ ‫ا‬ ‫إ‬ ‫الضو‬ ,‫مجا‬ ‫ووسع‬ ‫الثانل‬ ‫الفح‬ ‫يستغضقه‬ . ‫تفتةةةةةةةةةةةةةةةيال‬ ‫ةةةةةةةةةةةةةةض‬‫ة‬‫وكث‬ ‫ةةةةةةةةةةةةةةورة‬‫ة‬‫بت‬ ‫ةةةةةةةةةةةةةةاقع‬‫ة‬‫المق‬ ‫ةةةةةةةةةةةةةةة‬‫ة‬‫بدراس‬ ‫ةةةةةةةةةةةةةةه‬‫ة‬‫نفس‬ ‫ةةةةةةةةةةةةةةو‬‫ة‬‫ه‬ ‫ةةةةةةةةةةةةةةا‬‫ة‬ ‫ر‬ ‫وو‬ 3-‫يتكبةد‬ ‫ومةا‬ ‫العةاله‬ ‫قضية‬ ‫تتةض‬ ‫ي‬ ‫األجهةزة‬ ‫هةذ‬ ‫تحققه‬ ‫الذ‬ ‫الدقي‬ ‫ي‬ ‫التش‬‫نفسةل‬ ‫غةغن‬ ‫مةن‬ ‫ماديةةةةةةةةةةةةةة‬ ‫ةةةةةةةةةةةةة‬‫ة‬‫وكلف‬ ‫ةةةةةةةةةةةةد‬‫ة‬‫وجه‬. ‫واالنتضاغةةةةةةةةةةةةةا‬ ‫ةةةةةةةةةةةةية‬‫ة‬‫يت‬ ‫التش‬ ‫بطةةةةةةةةةةةةةا‬ ‫الت‬ ‫ةةةةةةةةةةةةار‬‫ة‬‫باختت‬ 4-.‫ةةةةةة‬‫ة‬‫منتظم‬ ‫ةةةةةض‬‫ة‬‫ي‬ ,‫ةةةةةكا‬‫ة‬‫وم‬ ‫ا‬ ‫ةةةةةت‬‫ة‬‫كان‬ ‫وان‬ ‫الداخليةةةةةة‬ ‫ةةةةةاء‬‫ة‬‫األعك‬ ‫ةةةةةام‬‫ة‬‫ج‬ ‫أل‬ ‫ةةةةةة‬‫ة‬‫الدقيق‬ ‫القياسةةةةةا‬ ‫التطور‬ ‫عجلة‬ ‫دنع‬ ‫عل‬ ‫العالم‬ ‫وجبض‬ ‫التل‬ ‫هل‬ ‫التسعينا‬ ‫وواخض‬ ‫بها‬ ‫خض‬ ‫والتل‬ ‫الميزا‬ ‫هذ‬ ‫كل‬ ‫ع‬ ‫علمية‬ ‫ثورا‬ ‫داث‬ ‫وإ‬‫وجهزة‬ ‫ل‬‫التوتية‬ ‫نوق‬ ‫الموجا‬‫األبعةاد‬ ‫ثنائية‬‫مةن‬ ‫تحققةه‬ ‫مةا‬ ‫م‬ ‫بةض‬ ‫والتةل‬ ‫وكشة‬ ‫النتةائو‬ ‫وعظةم‬ ‫إلعطةاء‬ ‫التطويض‬ ‫من‬ ,‫النو‬ ‫لهذا‬ ‫بحاجة‬ ‫كانت‬ ‫ونها‬ ‫إال‬ ‫ي‬ ‫التش‬ ‫نل‬ ‫جيدة‬ ‫نتائو‬ .‫التفاصيل‬ ‫ودق‬ ‫عن‬ ‫الستار‬ ‫الضباعية‬ ‫باألبعاد‬ ‫الجنين‬ ‫نح‬ ‫عند‬4D: ‫من‬ ‫يمكننا‬ ‫لن‬ ‫نان‬ 1-‫الجنين‬ ‫رؤية‬‫ويم‬ ‫نمه‬ ‫ويفتح‬ ‫وقدميه‬ ‫ويديه‬ ‫مفتيه‬ ‫يحضك‬ ‫وهو‬ ‫الثالثية‬ ‫باألبعاد‬‫إصةبعه‬ )‫ومبامض‬ ‫ل‬ ‫تتويض‬ (. 2-" ‫واقعيه‬ ‫مالمح‬ " ‫الجنين‬ ‫لوجه‬ ‫وملونه‬ ‫مجسمه‬ ‫صور‬ ‫عل‬ ,‫الحتو‬. 3-‫مةن‬ ‫والسةابع‬ ‫السةادو‬ ‫الشةهض‬ ‫بين‬ ‫ما‬ ‫واألنكل‬ ‫الحمل‬ ,‫خال‬ ‫وقت‬ ‫و‬ ‫نل‬ ‫الفح‬ ‫إجضاء‬ ‫نو‬ ‫موجا‬ ‫وإنما‬ ‫بهمعة‬ ‫ليس‬ ‫نهو‬ ‫الحمل‬‫لألم‬ ‫غضرا‬ ‫وو‬ ‫ولما‬ ‫يسا‬ ‫وال‬ ‫اعتيادية‬ ‫صوتيه‬ ‫ق‬ . ‫الجنين‬ ‫وو‬ 4-( ‫نيديو‬ ‫مضين‬ ‫عل‬ ‫الفح‬ ‫كامل‬ ‫تسجيل‬‫كبيض‬ ‫مضين‬‫وو‬ )CD(‫ليزر‬ ‫قضص‬).
  • 50. ‫يعتبض‬ ‫ال‬ ‫األبعاد‬ ‫رباعية‬‫التوتية‬ ‫نوق‬ ‫بالموجا‬ ‫الجنين‬ ‫نح‬ ‫ون‬ ‫االعتبار‬ ‫عين‬ ‫نل‬ ‫يبق‬ ‫ولكن‬ ‫عن‬ ‫االستغناء‬ ‫يمكن‬ ‫ال‬ ‫انه‬ ‫إ‬ ‫بذاته‬ ‫مستقال‬ ‫نحتا‬‫ثنائل‬ ‫التوتية‬ ‫نوق‬ ‫بالموجا‬ ,‫األو‬ ‫الفح‬ . ‫مكمال‬ ‫نحتا‬ ‫يعتبض‬ ‫األبعاد‬ ‫الضباعل‬ ‫الفح‬ ‫نهذا‬ ‫األبعاد‬