Intrauterine effects of ultrasound: animal studies

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Measurement of Thermal Effects of Doppler Ultrasound: An In Vitro Study

Objective

Ultrasound is considered a safe imaging modality and is routinely applied during early pregnancy. However, reservations are expressed concerning the application of Doppler ultrasound in early pregnancy due to energy emission of the ultrasound probe and its conversion to heat. The objective of this study was to evaluate the thermal effects of emitted Doppler ultrasound of different ultrasound machines and probes by means of temperature increase of in-vitro test-media.

Methods

We investigated the energy-output of 5 vaginal and abdominal probes of 3 ultrasound machines (GE Healthcare, Siemens, Aloka). Two in-vitro test objects were developed at the Center for Medical Physics and Biomedical Engineering, Medical University Vienna (water bath and hydrogel bath). Temperature increase during Doppler ultrasound emission was measured via thermal sensors, which were placed inside the test objects or on the probes’ surface. Each probe was emitting for 5 minutes into the absorbing test object with 3 different TI/MI settings in Spectral Doppler mode.

Results

During water bath test, temperature increase varied between 0.1 and 1.0°C, depending on probe, setting and focus, and was found highest for spectral Doppler mode alone. Maximum temperature increase was found during the surface heating test, where values up to 2.4°C could be measured within 5 minutes of emission.

Conclusions

Activation of Doppler ultrasound in the waterbath model causes a significant increase of temperature within one minute. Thermally induced effects on the embryo cannot be excluded when using Doppler ultrasound in early pregnancy.

Benefits and risks of ultrasound in pregnancy

Ultrasound is, arguably, the most commonly used diagnostic procedure in obstetrics. It is convenient, painless, yields immediate, extensive results, and is widely considered to be safe. Some (but not all) benefits described in the literature have been validated by evidence-based analysis, such as pregnancy dating. Others are considered clinically useful, although objective evidence may be less strong. As is the case with almost any medical procedure, however, its performance carries some risks: misdiagnosis on the one hand and possible undesired effects on the other. The general belief exists that diagnostic ultrasound (DUS) does not pose any risk to the pregnant patient nor to her fetus. Nonetheless, ultrasound is a form of energy and, as such, demonstrates effects in biological tissues it traverses (bioeffects). The physical mechanisms responsible for these effects are thermal or non-thermal (mechanical). It is the role of science to show whether any of these bioeffects may be harmful. A risk-benefit analysis may also be important, as well as education of the end users to assure patients' safety.

Ultrasound and autism: association, link, or coincidence?

Autism spectrum disorders (ASDs) affect an estimated 1% of children in the United States. The etiology is probably multifactorial, including genetic components and exposure to infections, toxins, and other environmental factors, particularly unfavorable perinatal and neonatal conditions. There has been an increase in the frequency of diagnosis of ASDs over the last 20 years with a parallel increase in the use of obstetric diagnostic ultrasound, with prenatal ultrasound exposure mentioned as the possible main etiology for autism "epidemics." Central nervous system alterations have been described in ASDs, and certain similar changes have been described in animals after exposure to ultrasound. However, analysis of in utero exposure in humans has failed to show harmful effects in neonates or children, particularly in school performance, attention disorders, and behavioral changes. There is no independently confirmed peer-reviewed published evidence that a cause-effect relationship exists between in utero exposure to clinical ultrasound and development of ASDs in childhood. Ultrasound is a form of energy with effects in the tissues it traverses, and its use should be restricted to medical indications, by trained professionals, for as short a period and as low an intensity as compatible with accurate diagnosis.

Knowledge of the bio-effects of ultrasound among physicians performing clinical ultrasonography: Results of a survey conducted by the Italian Society for Ultrasound in Medicine and Biology (SIUMB)

INTRODUCTION

Safety issues should always be kept in mind when using diagnostic ultrasound, which is associated with potentially hazardous bio-effects, especially with the introduction of new technologies.

AIM

To assess the level of awareness and knowledge of safety issues related to the clinical use of ultrasound among physician-members of the Italian National Society for Ultrasound.

MATERIALS AND METHODS

A questionnaire with 11 multiple-choice questions was sent to members of the Italian Society for Ultrasound in Medicine and Biology. The answers were forwarded from the Society's Secretariat to the investigators, who statistically analyzed the data.

RESULTS

The mean age of the 105 respondents was 44 years. The most frequent kind of ultrasound examinations (in addition to conventional B-mode) were: Doppler (74%), contrast-enhanced US (43%), and pediatric studies (43%). Only 50-60% of the responders knew the correct definitions of the terms thermal index and mechanical index. Almost all respondents understood the bio-effects reflected by the thermal index, but only a minority knew the most likely organ target of bio-effects related to the mechanical index and what do indicate the units in which the thermal index is expressed. The majority knew that fetuses are at higher risk of damage. Few respondents were able to identify the correct safety statements included in the recommendations of the International Ultrasound Societies.

CONCLUSION

In conclusion, the present findings indicate that greater efforts of National Ultrasound Societies are warranted in disseminating knowledge of the bio-effects of diagnostic ultrasound modalities among operators.

Effects of Prenatal Irradiation with an Accelerated Heavy-Ion Beam on Postnatal Development in Rats: I. Neurophysiological Alterations

Effects on postnatal neurophysiological development in offspring were studied after exposure of pregnant Wistar rats to accelerated carbon-ion beams with an LET of about 13 keV/ mum at doses ranging from 0.1 Gy to 2.5 Gy on the 15th day of gestation. The age at which four physiological markers appeared and five reflexes were acquired was examined prior to weaning. Gain in body weight was monitored until the offspring were 3 months old. Male offspring were evaluated as young adults using two behavioral tests. The effects of X rays estimated for the same biological end points were studied for comparison. For most of the end points at early age, no significant alterations were observed in offspring that received prenatal irradiation with 0.1 Gy of either accelerated carbon ions or X rays compared to the offspring of sham-irradiated dams. However, all offspring whose dams received 2.5 Gy died prior to weaning. Offspring from dams irradiated with accelerated carbon ions generally showed higher incidences of prenatal death and preweaning mortality, markedly delayed accomplishment in their physiological markers and reflexes, and gain in body weight compared to those exposed to X rays at doses of 0.5 to 2 Gy. Significantly reduced ratios of main organ weight to body weight at the postnatal ages of 30, 60 and 90 days were also observed within this dose range. The results indicate that irradiation with 0.5 to 2 Gy on day 15 of gestation caused permanent alterations in offspring that were dependent on dose. The alterations include permanent growth retardation, morphological malformations in main organs, including microcephaly, diminished reflex attainment, delayed appearance of physiological markers, and changes in adult behavior. Exposure to 1 to 2 Gy of radiation resulted in growth retardation and behavioral alterations that persisted throughout life. Accelerated carbon ions generally induced more detrimental effects than X rays.

Biological effects of high-frequency ultrasound exposure during mouse organogenesis

Little has been reported on bioeffects of high-frequency ultrasound (US) and guidelines for US use do not necessarily apply to high frequencies. Pregnant CD-1 mice were exposed to Doppler or B-mode US biomicroscopy (UBM) on embryonic day (E) 8.5 or E10.5, during organogenesis. Operating frequency was 40 MHz with a free field I(SPTA) of 11.9 W/cm(2) (Doppler) and 2.6 mW/cm(2) (B-mode), peak negative pressures of 6.61 MPa and MI of 1.05 (B-mode). Offspring were assessed weekly from 1 day postnatally to euthanasia at 6 weeks, with no significant difference in pup weight, body length or crown-rump length observed. E8.5 Doppler-exposed mice showed a small reduction in weight and length at 3 weeks and in weight at 6 weeks. E10.5 Doppler-exposed animals exhibited slight growth reduction in weeks 2 to 4, but were not significantly different at 6 weeks. Our results indicate similar exposures of mice should not cause significant adverse bioeffects.

Utilization of developmental basic science principles in the evaluation of reproductive risks from pre- and postconception environmental radiation exposures

The subject of the reproductive toxicity of various forms of radiation can be anxiety provoking to the public on two accounts, since reproductive failure engenders an unusual level of guilt and anger in the affected families, and radiation effects are misunderstood and feared by the public. Reproductive problems include an array of genetic and acquired diseases affecting parents and their offspring. Many of these problems are associated with the risk of being induced by preconception and/or postconception exposures to environmental agents. For the various forms of radiation, namely, ionizing radiation, ultrasound, low-frequency electromagnetic fields (EMF), and microwaves, the potential for producing reproductive effects varies considerably with the form of "radiation" and, of course, the dose. Whether the exposure occurs preconceptionally or postconceptionally is another major consideration. In evaluating the actual reproductive risks, we rely on accurate dosimetry and information obtained in epidemiological studies and animal studies. Epidemiological studies must demonstrate consistency of the reproductive finding, and animal studies should be designed to add to the findings of the epidemiological studies. Most importantly, the conclusions must not contradict the basic principles of teratology, genetics, and reproductive biology, and they should be biologically plausible. But frequently important basic science principles are ignored in the evaluation process. Yet developmental basic science principles can be instrumental in refuting or supporting the concern about possible risks. Although there is some overlap with regard to the preconception and intrauterine effects of ionizing radiation, there are significant differences. Preconception effects are mainly stochastic effects, while intrauterine effects are mainly deterministic effects. The stochastic genetic risks are lower than the deterministic risks at equivalent exposures. Thus, it is frequently difficult to demonstrate the occurrence of stochastic effects in populations that have received low preconception exposures to ionizing radiation. The reproductive effects from preconception and intrauterine exposures to electromagnetic fields (low-frequency EMF, video display terminals, microwaves) and ultrasound represent much different problems, since the main effects of microwaves and ultrasound occur because of their hyperthermic effects at high exposures. Low-frequency EMF does not have the capacity to produce hyperthermia, and none of these forms of nonionizing radiation has the specificity to damage the DNA comparable to the specificity of ionizing radiation. Not only do they not have targeted mutagenic effects at the usual exposures that populations receive, they are not cytotoxic at these exposure levels as well. From the viewpoint of biological plausibility, these other forms of radiation are much less likely to have the potential for producing reproductive toxicity at the usual population exposures.