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This second, revised edition of “Radiological Imaging of the Neonatal Chest” provides a It is written primarily from the point of view of the paediatric radiologist but will be of particular interest to all Medicine Radiology · Diagnostic Imaging.
Table of contents

Guidelines for Diagnostic Imaging During Pregnancy and Lactation - ACOG

Diagnostic Imaging of Neonatal Pneumonia. Antenatal Imaging of Chest Malformations. Postnatal Imaging of Chest Malformations. Congenital Anomalies of the Neonatal Upper Airway. Computed Tomography of the Central and Peripheral Airways. Ultrasound of the Neonatal Thorax. Ultrasound in Congenital Heart Disease. Chest Radiography in Congenital Heart Disease. Computed Tomography in Congenital Heart Disease. Back Matter Pages In animal studies, gadolinium agents have been found to be teratogenic at high and repeated doses 1 , presumably because this allows for gadolinium to dissociate from the chelation agent.

In humans, the principal concern with gadolinium-based agents is that the duration of fetal exposure is not known because the contrast present in the amniotic fluid is swallowed by the fetus and reenters the fetal circulation. The longer gadolinium-based products remain in the amniotic fluid, the greater the potential for dissociation from the chelate and, thus, the risk of causing harm to the fetus 8. The only prospective study evaluating the effect of antepartum gadolinium administration reported no adverse perinatal or neonatal outcomes among 26 pregnant women who received gadolinium in the first trimester More recently, a large retrospective study evaluated the long-term safety after exposure to MRI in the first trimester of pregnancy or to gadolinium at any time during pregnancy This study interrogated a universal health care database in the province of Ontario, Canada to identify all births of more than 20 weeks of gestation, from to The risk also was not significantly higher for congenital anomalies, neoplasm, or vision or hearing loss.

Limitations of the study assessing the effect of gadolinium during pregnancy include using a control group who did not undergo MRI rather than patients who underwent MRI without gadolinium and the rarity of detecting rheumatologic, inflammatory, or infiltrative skin conditions Given these findings, as well as ongoing theoretical concerns and animal data, gadolinium use should be limited to situations in which the benefits clearly outweigh the possible risks 8, To date, there have been no animal or human fetal studies to evaluate the safety of superparamagnetic iron oxide contrast, and there is no information on its use during pregnancy or lactation.

Therefore, if contrast is to be used, gadolinium is recommended. The water solubility of gadolinium-based agents limits their excretion into breast milk. Less than 0. Although theoretically any unchelated gadolinium excreted into breast milk could reach the infant, there have been no reports of harm.

Therefore, breastfeeding should not be interrupted after gadolinium administration 13 , Commonly used for the evaluation of significant medical problems or trauma, X-ray procedures are indicated during pregnancy or may occur inadvertently before the diagnosis of pregnancy. In addition, it is estimated that a fetus will be exposed to 1 mGy of background radiation during pregnancy 2. Various units used to measure X-ray radiation are summarized in Table 1. Concerns about the use of X-ray procedures during pregnancy stem from the risks associated with fetal exposure to ionizing radiation.

The risk to a fetus from ionizing radiation is dependent on the gestational age at the time of exposure and the dose of radiation If extremely high-dose exposure in excess of 1 Gy occurs during early embryogenesis, it most likely will be lethal to the embryo Table 2 15, However, these dose levels are not used in diagnostic imaging. In humans, growth restriction, microcephaly, and intellectual disability are the most common adverse effects from high-dose radiation exposure Table 2 2, With regard to intellectual disability, based on data from atomic bomb survivors, it appears that the risk of central nervous system effects is greatest with exposure at 8—15 weeks of gestation.

It has been suggested that a minimal threshold for this adverse effect may be in the range of 60— mGy 2, 18 ; however, the lowest clinically documented dose to produce severe intellectual disability is mGy 14, Even multiple diagnostic X-ray procedures rarely result in ionizing radiation exposure to this degree. Fetal risk of anomalies, growth restriction, or abortion have not been reported with radiation exposure of less than 50 mGy, a level above the range of exposure for diagnostic procedures In rare cases in which there are exposures above this level, patients should be counseled about associated concerns and individualized prenatal diagnostic imaging for structural anomalies and fetal growth restriction Table 3 The risk of carcinogenesis as a result of in-utero exposure to ionizing radiation is unclear but is probably very small.

A 10—20 mGy fetal exposure may increase the risk of leukemia by a factor of 1. Thus, pregnancy termination should not be recommended solely on the basis of exposure to diagnostic radiation. Should a pregnant woman undergo multiple imaging studies using ionizing radiation, it is prudent to consult with a radiation physicist to calculate the total dose received by the fetus.

The Health Physics Society maintains a website with an ask-the-expert feature: www. There is no risk to lactation from external sources of ionizing radiation diagnostic X-rays Use of CT and associated contrast material should not be withheld if clinically indicated, but a thorough discussion of risks and benefits should take place 8.

In the evaluation for acute processes such as appendicitis or small-bowel obstruction, the maternal benefit from early and accurate diagnosis may outweigh the theoretical fetal risks. If accessible in a timely manner, MRI should be considered as a safer alternative to CT imaging during pregnancy in cases in which they are equivalent for the diagnosis in question. Radiation exposure from CT procedures varies depending on the number and spacing of adjacent image sections Table 2.

For example, CT pelvimetry exposure can be as high as 50 mGy but can be reduced to approximately 2. In the case of suspected pulmonary embolism, CT evaluation of the chest results in a lower dose of fetal exposure to radiation compared with ventilation-perfusion scanning 2. With typical use, the radiation exposure to the fetus from spiral CT is comparable with conventional CT.

Oral contrast agents are not absorbed by the patient and do not cause real or theoretical harm.

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The use of intravenous contrast media aids in CT diagnosis by providing for enhancement of soft tissues and vascular structures. The contrast most commonly used for CT is iodinated media, which carries a low risk of adverse effects eg, nausea, vomiting, flushing, pain at injection site and anaphylactoid reactions 9. Although iodinated contrast media can cross the placenta and either enter the fetal circulation or pass directly into the amniotic fluid 22 , animal studies have reported no teratogenic or mutagenic effects from its use 8, Additionally, theoretical concerns about the potential adverse effects of free iodide on the fetal thyroid gland have not been borne out in human studies Despite this lack of known harm, it generally is recommended that contrast only be used if absolutely required to obtain additional diagnostic information that will affect the care of the fetus or woman during the pregnancy.

Traditionally, lactating women who receive intravascular iodinated contrast have been advised to discontinue breastfeeding for 24 hours. Therefore, breastfeeding can be continued without interruption after the use of iodinated contrast 1, 9, 13, 16, This type of imaging is used to determine physiologic organ function or dysfunction rather than to delineate anatomy.

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Hybrid systems, which combine the function of nuclear imaging devices with computed tomography, improve the quality of information acquired and can help to correct artifacts produced by nuclear medicine imaging alone 9. In pregnancy, fetal exposure during nuclear medicine studies depends on the physical and biochemical properties of the radioisotope. Technetium 99m is one of the most commonly used isotopes and is used for brain, bone, renal, and cardiovascular scans.

Its most common use in pregnancy is in ventilation-perfusion lung scanning for detection of pulmonary embolism. In general, these procedures result in an embryonic or fetal exposure of less than 5 mGy, which is considered a safe dose in pregnancy. Not all radioisotopes can be used safely during pregnancy. Radioactive iodine iodine readily crosses the placenta, has a half-life of 8 days, and can adversely affect the fetal thyroid, especially if used after 10—12 weeks of gestation 9. Whether for diagnostic or therapeutic treatment purposes, iodine should not be used during pregnancy.

If a diagnostic scan of the thyroid is essential, technetium 99m is the isotope of choice. Radionuclide compounds are excreted into breast milk in varying concentrations and for varying periods of time. In addition, rates of excretion of the same compound can vary between patients.

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  • Because some specific nuclear materials excreted into breast milk can have deleterious effects, consultation with experts on breastfeeding and nuclear medicine are recommended when these compounds are used in lactating women. All rights reserved.

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    No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Guidelines for diagnostic imaging during pregnancy and lactation. Committee Opinion No. American College of Obstetricians and Gynecologists.

    Obstet Gynecol ;e—6. Women's Health Care Physicians.

    Diagnostic imaging

    With few exceptions, radiation exposure through radiography, computed tomography CT scan, or nuclear medicine imaging techniques is at a dose much lower than the exposure associated with fetal harm. If these techniques are necessary in addition to ultrasonography or MRI or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. The use of gadolinium contrast with MRI should be limited; it may be used as a contrast agent in a pregnant woman only if it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome.

    Introduction Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic conditions. Ultrasonography Ultrasound imaging should be performed efficiently and only when clinically indicated to minimize fetal exposure risk using the keeping acoustic output levels As Low As Reasonably Achievable commonly known as ALARA principle. Magnetic Resonance Imaging The principal advantage of MRI over ultrasonography and computed tomography is the ability to image deep soft tissue structures in a manner that is not operator dependent and does not use ionizing radiation.

    Ionizing Radiation Including X-rays Commonly used for the evaluation of significant medical problems or trauma, X-ray procedures are indicated during pregnancy or may occur inadvertently before the diagnosis of pregnancy. Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation.

    Obstet Gynecol ;— Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics ;— Statement on mammalian biological effects of heat. Retrieved October 5, Statement on the safe use of Doppler ultrasound during week scans or earlier in pregnancy.