Medical imaging in pregnancy
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Medical imaging in pregnancy may be
indicated In medicine, an indication is a valid reason to use a certain test, medication, procedure, or surgery. There can be multiple indications to use a procedure or medication. An indication can commonly be confused with the term diagnosis. A diagnosis ...
because of
pregnancy complications Complications of pregnancy are health problems that are related to pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal di ...
, intercurrent diseases or routine
prenatal care Prenatal care, also known as antenatal care, is a type of preventive healthcare. It is provided in the form of medical checkups, consisting of recommendations on managing a healthy lifestyle and the provision of medical information such as materna ...
.


Options

Options for
medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
in
pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...
include the following: *
Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI) without
MRI contrast agent MRI contrast agents are contrast agents used to improve the visibility of internal body structures in magnetic resonance imaging (MRI). The most commonly used compounds for contrast enhancement are gadolinium-based. Such MRI contrast agents shorten ...
s as well as
obstetric ultrasonography Obstetric ultrasonography, or prenatal ultrasound, is the use of medical ultrasonography in pregnancy, in which sound waves are used to create real-time visual images of the developing embryo or fetus in the uterus (womb). The procedure is a stan ...
are not associated with any risk for the mother or the fetus and are the imaging techniques of choice for pregnant women. February 2016 *
Projectional radiography Projectional radiography, also known as conventional radiography, is a form of radiography and medical imaging that produces two-dimensional images by x-ray radiation. The image acquisition is generally performed by radiographers, and the images ...
,
X-ray computed tomography An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30  ...
and
nuclear medicine Nuclear medicine or nucleology is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease. Nuclear imaging, in a sense, is "radiology done inside out" because it records radiation emitting ...
result in some degree of
ionizing radiation Ionizing radiation (or ionising radiation), including nuclear radiation, consists of subatomic particles or electromagnetic waves that have sufficient energy to ionize atoms or molecules by detaching electrons from them. Some particles can travel ...
exposure but have with a few exceptions much lower radiation doses than what is associated with fetal harm. They are indicated when ultrasonography or MRI is not readily available or not feasible for the diagnostic question at hand. :*
Radiocontrast agent Radiocontrast agents are substances used to enhance the visibility of internal structures in X-ray-based imaging techniques such as computed tomography (contrast CT), projectional radiography, and fluoroscopy. Radiocontrast agents are typically io ...
s, when orally administered, are harmless.
Intravenous administration Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...
of iodinated radiocontrast agents can cross the
placenta The placenta is a temporary embryonic and later fetal organ that begins developing from the blastocyst shortly after implantation. It plays critical roles in facilitating nutrient, gas and waste exchange between the physically separate mater ...
and enter the
fetal circulation In humans, the circulatory system is different before and after birth.  The fetal circulation is composed of the placenta, umbilical blood vessels encapsulated by the umbilical cord, heart and systemic blood vessels. A major difference between the ...
, but animal studies have reported no
teratogenic Teratology is the study of abnormalities of physiological development in organisms during their life span. It is a sub-discipline in medical genetics which focuses on the classification of congenital abnormalities in dysmorphology. The related t ...
or
mutagenic In genetics, a mutagen is a physical or chemical agent that permanently changes genetic material, usually DNA, in an organism and thus increases the frequency of mutations above the natural background level. As many mutations can cause cancer in ...
effects from its use. There have been theoretical concerns about the potential harm of free iodide on the fetal
thyroid gland The thyroid, or thyroid gland, is an endocrine gland in vertebrates. In humans it is in the neck and consists of two connected lobe (anatomy), lobes. The lower two thirds of the lobes are connected by a thin band of Connective tissue, tissue cal ...
, but multiple studies have shown that a single dose of intravenously administered iodinated contrast medium to a pregnant mother has no effect on neonatal thyroid function. Nevertheless, it generally is recommended that radiocontrast only be used if required to obtain additional diagnostic information that will improve the care of the fetus or mother.


Magnetic resonance imaging (MRI)

Magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wave ...
(MRI), without
MRI contrast agent MRI contrast agents are contrast agents used to improve the visibility of internal body structures in magnetic resonance imaging (MRI). The most commonly used compounds for contrast enhancement are gadolinium-based. Such MRI contrast agents shorten ...
s, is not associated with any risk for the mother or the fetus, and together with
medical ultrasonography Medical ultrasound includes diagnostic techniques (mainly medical imaging, imaging techniques) using ultrasound, as well as therapeutic ultrasound, therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal ...
, it is the technique of choice for medical imaging in pregnancy.


Safety

For the first trimester, no known literature has documented specific adverse effects in
human embryo Human embryonic development, or human embryogenesis, is the development and formation of the human embryo. It is characterised by the processes of cell division and cellular differentiation of the embryo that occurs during the early stages of de ...
s or fetuses exposed to non-contrast MRI during the
first trimester Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...
. During the second and third trimesters, there is some evidence to support the absence of risk, including a retrospective study of 1737 prenatally exposed children, showing no significant difference in hearing,
motor skills A motor skill is a function that involves specific movements of the body's muscles to perform a certain task. These tasks could include walking, running, or riding a bike. In order to perform this skill, the body's nervous system, muscles, and br ...
, or functional measures after a mean follow-up time of 2 years.
Gadolinium contrast MRI contrast agents are contrast agents used to improve the visibility of internal body structures in magnetic resonance imaging (MRI). The most commonly used compounds for contrast enhancement are gadolinium-based. Such MRI contrast agents shorte ...
agents in the first trimester are associated with a slightly increased risk of a childhood diagnosis of several forms of
rheumatism Rheumatism or rheumatic disorders are conditions causing chronic, often intermittent pain affecting the joints or connective tissue. Rheumatism does not designate any specific disorder, but covers at least 200 different conditions, including art ...
,
inflammatory disorders Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...
, or infiltrative
skin condition A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this sy ...
s, according to a retrospective study including 397 infants prenatally exposed to gadolinium contrast. In the second and third trimesters, gadolinium contrast is associated with a slightly increased risk of stillbirth or neonatal death, by the same study. Hence, is recommended that gadolinium contrast in MRI should be limited, and should only be used when it significantly improves diagnostic performance and is expected to improve fetal or maternal outcomes.


Common uses

MRI is commonly used in pregnant women with acute
abdominal pain Abdominal pain, also known as a stomach ache, is a symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than ...
and/or
pelvic pain Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis. Common causes in include ...
, or in suspected
neurological disorder A neurological disorder is any disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms. Examples of symptoms include paralysis, muscle weakn ...
s, placental diseases,
tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
s,
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
s, and/or
cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, h ...
s. Appropriate use criteria by the
American College of Radiology The American College of Radiology (ACR), founded in 1923, is a professional medical society representing nearly 40,000 diagnostic radiologists, radiation oncologists, interventional radiologists, nuclear medicine physicians and medical physicists. ...
give a rating of ≥7 (usually appropriate) for non-contrast MRI for the following conditions: *Acute non-localized pain in the right upper quadrant or right lower quadrant (in concurrent fever and
leukocytosis Leukocytosis is a condition in which the white cell (leukocyte count) is above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, but may also occur following certain parasi ...
) *Acute
pelvic pain Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis. Common causes in include ...
when a non-gynecological cause is suspected *Suspected
biliary disease Biliary diseases include gallbladder disease and biliary tract diseases. In 2013 they resulted in 106,000 deaths up from 81,000 deaths in 1990. __TOC__ Types * malignant neoplasm of the gallbladder * malignant neoplasm of other parts of biliary tr ...
such as
jaundice Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and sclera due to high bilirubin levels. Jaundice in adults is typically a sign indicating the presence of underlying diseases involving abnormal heme meta ...
*Suspected
pancreatic disease Pancreatic diseases are diseases that affect the pancreas, an organ in most vertebrates and in humans and other mammals located in the abdomen. The pancreas plays a role in the digestive and endocrine system, producing enzymes which aid the digesti ...
*New‐onset severe
headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a result ...
*Newly diagnosed
cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...


Radiography and nuclear medicine


Fetal effects by radiation dosage

Health effects of radiation may be grouped in two general categories: *stochastic effects, i.e.,
radiation-induced cancer Exposure to ionizing radiation is known to increase the future incidence of cancer, particularly leukemia. The mechanism by which this occurs is well understood, but quantitative models predicting the level of risk remain controversial. The most wi ...
and heritable effects involving either cancer development in exposed individuals owing to mutation of somatic cells or heritable disease in their offspring owing to mutation of reproductive (germ) cells.Paragraph 55
of Ann. ICRP 37 (2-4)
The risk for developing radiation-induced cancer at some point in life is greater when exposing a fetus than an adult, both because the cells are more vulnerable when they are growing, and because there is much longer lifespan after the dose to develop cancer. *deterministic effects (harmful tissue reactions) due in large part to the killing/ malfunction of cells following high doses. The determinstistic effects have been studied at for example survivors of the
atomic bombings of Hiroshima and Nagasaki The United States detonated two atomic bombs over the Japanese cities of Hiroshima and Nagasaki on 6 and 9 August 1945, respectively. The two bombings killed between 129,000 and 226,000 people, most of whom were civilians, and remain the onl ...
and cases of where
radiation therapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...
has been necessary during pregnancy: The intellectual deficit has been estimated to be about 25 IQ-points per 1,000 mGy at 10 to 17 weeks of gestational age.


Fetal radiation dosages by imaging method


Radiation-induced breast cancer

The risk for the mother of later acquiring radiation-induced
breast cancer Breast cancer is cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a re ...
seems to be particularly high for radiation doses during pregnancy. This is an important factor when for example determining whether a
ventilation/perfusion scan A ventilation/perfusion lung scan, also called a V/Q lung scan, or ventilation/perfusion scintigraphy, is a type of medical imaging using scintigraphy and medical isotopes to evaluate the circulation of air and blood within a patient's lungs, in ...
(V/Q scan) or a
CT pulmonary angiogram A CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism (PE). It is a preferred choice of imaging i ...
(CTPA) is the optimal investigation in pregnant women with suspected
pulmonary embolism Pulmonary embolism (PE) is a blockage of an pulmonary artery, artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include dyspnea, shortness of breath, chest pain p ...
. A V/Q scan confers a higher radiation dose to the fetus, while a CTPA confers a much higher radiation dose to the mother's breasts. A review from the
United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Europe, off the north-western coast of the continental mainland. It comprises England, Scotland, Wales and North ...
in 2005 considered CTPA to be generally preferable in suspected pulmonary embolism in pregnancy because of higher
sensitivity and specificity ''Sensitivity'' and ''specificity'' mathematically describe the accuracy of a test which reports the presence or absence of a condition. Individuals for which the condition is satisfied are considered "positive" and those for which it is not are ...
as well as a relatively modest cost.


See also

*
Radiobiology Radiobiology (also known as radiation biology, and uncommonly as actinobiology) is a field of clinical and basic medical sciences that involves the study of the action of ionizing radiation on living things, especially health effects of radiation. ...


References

{{reflist Human pregnancy Medical imaging