MRI safety considerations during pregnancy

CardSegNet: An adaptive hybrid CNN-vision transformer model for heart region segmentation in cardiac MRI

Cardiovascular MRI (CMRI) is a non-invasive imaging technique adopted for assessing the blood circulatory system's structure and function. Precise image segmentation is required to measure cardiac parameters and diagnose abnormalities through CMRI data. Because of anatomical heterogeneity and image variations, cardiac image segmentation is a challenging task. Quantification of cardiac parameters requires high-performance segmentation of the left ventricle (LV), right ventricle (RV), and left ventricle myocardium from the background. The first proposed solution here is to manually segment the regions, which is a time-consuming and error-prone procedure. In this context, many semi- or fully automatic solutions have been proposed recently, among which deep learning-based methods have revealed high performance in segmenting regions in CMRI data. In this study, a self-adaptive multi attention (SMA) module is introduced to adaptively leverage multiple attention mechanisms for better segmentation. The convolutional-based position and channel attention mechanisms with a patch tokenization-based vision transformer (ViT)-based attention mechanism in a hybrid and end-to-end manner are integrated into the SMA. The CNN- and ViT-based attentions mine the short- and long-range dependencies for more precise segmentation. The SMA module is applied in an encoder-decoder structure with a ResNet50 backbone named CardSegNet. Furthermore, a deep supervision method with multi-loss functions is introduced to the CardSegNet optimizer to reduce overfitting and enhance the model's performance. The proposed model is validated on the ACDC2017 (n=100), M&Ms (n=321), and a local dataset (n=22) using the 10-fold cross-validation method with promising segmentation results, demonstrating its outperformance versus its counterparts.

Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion

BACKGROUND

The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture.

CASE PRESENTATION

We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability.

CONCLUSION

Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.

Medical Imaging in Pregnancy: Safety, Appropriate Utilization, and Alternative Modalities for Imaging Pregnant Patients

This article reviews the existing literature on diagnostic and medical imaging of pregnant women, the risks and safety measures of different medical imaging modalities, and alternative modalities for imaging pregnant patients. Different medical imaging modalities such as MRI, CT scan, ultrasound, nuclear medicine, and X-ray imaging help to evaluate women with recognized or unrecognized pregnancies and identify any underlying complications among pregnant patients. Fetuses are more sensitive to radiation and the effects of medical imaging as compared to adults since they have a rapidly developing cell system. During cell proliferation, migration, and differentiation, fetuses suffer greatly from imaging radiation since they are developing under a dynamic system. To ensure safety, pregnant women should discuss the benefits and risks of medical imaging with their physicians. In addition, radiologists should not perform any medical imaging procedure without the patient's consent, unless the patient cannot make any sound decision. Fetal risks of medical imaging include slow growth and development of the fetus, abortion, malformations, impaired brain function, abnormal childhood growth, and neurological development. Diagnostic imaging procedures are necessary when a condition that needs medical evaluation arises during pregnancy such as appendicitis.

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Klippel-Trenaunay syndrome and pregnancy: A Case-Report

Klippel-Trenaunay Syndrome is a benign disease with a low incidence rate. Pregnant women with KTS may be at increased risk of thrombosis and coagulopathy due to normal hemodynamic changes during pregnancy. The choice of delivery route for KTS pregnant woman needs rigorous evaluation. This study reported a case of successful delivery by oxytocin combined with balloon catheter induction for the first time, providing more options for KTS pregnant woman. At the same time, this study reported a successful case of labor induced by oxytocin combined with balloon catheter for the first time, which further explored the obstetric management of pregnant women with KTS and provided them with more delivery options.

Agenesis of the corpus callosum: What to tell expecting parents?

Agenesis of the corpus callosum (ACC) is one of the most common brain malformations, with an incidence estimated to range from 0.5 to 70 in 10,000 among the general population. Prenatal diagnosis is made via ultrasound; however, fetal MRI is useful to confirm or exclude the presence of associated cerebral abnormalities-mostly cortical malformations-that may affect postnatal prognosis. When no additional central nervous system (CNS) or extra CNS anomalies are identified and no genetic cause is found, an isolated ACC is diagnosed. Overall, in cases of ACC, an underlying genetic cause can be identified in up to 12.5% with chromosomal microarray (CMA) and up to 47% with whole exome sequencing (WES). In cases where ACC is the only anomaly detected, the yield of WES is 30%. Postnatal outcomes are variable and depend on whether the condition is isolated or not. In truly isolated ACC, outcomes range from normal in 65% of cases through mild to severe neurodevelopmental impairments in 35% of cases. An interdisciplinary team of medical experts is key in guiding parents toward informed decision-making in pregnancies complicated by ACC. Considering current and expected advancements in genetic testing and imaging technologies in upcoming years, we herein summarize current recommendations for the management and prenatal counseling of expecting parents of fetuses with ACC. Our review pertains primarily to expecting parents of fetuses with complete ACC.

Clinical Issues - October 2023

Pregnant personnel in the magnetic resonance environment Key words: magnetic resonance (MR), pregnant personnel, zone IV, exposure, scanner. Patients with tattoos in the magnetic resonance environment Key words: tattoo ink, permanent cosmetic tattoo, magnetic resonance (MR), scanning, burns. Robotic procedure emergency preparedness Key words: emergency readiness, conversion to open, robotic surgery, checklists, undocking. Communication during robotic procedures Key words: communication, teamwork, robotic procedures, familiarity, perioperative team.

Management of transient bone osteoporosis: a systematic review

INTRODUCTION

Transient bone osteoporosis (TBO) is characterized by persistent pain, loss of function, no history of trauma and magnetic resonance image (MRI) findings of bone marrow edema.

SOURCE OF DATA

PubMed, Google scholar, EMABSE and Web of Science were accessed in February 2023. No time constrains were used for the search.

AREAS OF AGREEMENT

TBO is rare and misunderstood, typically affecting women during the third trimester of pregnancy or middle-aged men, leading to functional disability for 4-8 weeks followed by self-resolution of the symptoms.

AREAS OF CONTROVERSY

Given the limited evidence in the current literature, consensus on optimal management is lacking.

GROWING POINTS

This systematic review investigates current management of TBO.

AREAS TIMELY FOR DEVELOPING RESEARCH

A conservative approach leads to the resolution of symptoms and MRI findings at midterm follow-up. Administration of bisphosphonates might alleviate pain and accelerate both clinical and imaging recovery.

Developments in functional imaging of the placenta

The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of this enigmatic organ and serve to support obstetric decision making. Advanced imaging techniques are key to support these measurements. This review summarises emerging imaging technology being used to measure the function of the placenta and new developments in the computational analysis of these data. We address three important examples where functional imaging is supporting our understanding of these conditions: fetal growth restriction, placenta accreta, and twin-twin transfusion syndrome.

No Meta-analytic Evidence for Risks due to Prenatal Magnetic Resonance Imaging in Animal Models

BACKGROUND

Magnetic resonance imaging (MRI) is a powerful, noninvasive tool for both clinical practice and research. Though the safety of MRI has been endorsed by many professional societies and government bodies, some concerns have remained about potential risk from prenatal MRI. Case-control animal studies of MRI scanning during gestation and effects on offspring are the most direct test available for potential risks. We performed a meta-analysis of extant animal studies of prenatal MRI examining reproductive and offspring outcomes.

METHODS

Relevant articles were identified through PubMed search and citation searching of known articles and review papers. Eighteen relevant studies were identified with case-control designs of prenatal scanning conducted in vivo with mammalian species using MRI-relevant field strength. Standardized mean difference effect sizes were analyzed across k = 81 outcomes assessed across 649 unexposed dams, 622 exposed dams, 3024 unexposed offspring, and 3328 exposed offspring using a multilevel meta-analytic approach that clustered effect sizes within publications.

RESULTS

The meta-analysis indicated no significant evidence for a deleterious effects of prenatal MRI (standardized mean difference = 0.17, 95% CI [-0.19, 0.54], t80 = 0.94, p = .35) across outcomes. Similarly, no effects were observed when separately examining the 4 most commonly assessed outcomes: birth weight, litter size, fetal viability, and physical malformations (p > .05).

CONCLUSIONS

Case-control mammalian animal studies indicate no significant known risks of prenatal MRI to reproductive outcomes or offspring development. This finding is largely mirrored in human research, though the lack of randomized case-control designs limits direct comparison. The current findings provide additional support to the prevailing consensus that prenatal MRI poses no known risk to offspring.

Pregnancy and neuromyelitis optica spectrum disorders: 2022 recommendations from the French Multiple Sclerosis Society

BACKGROUND

In 2020, the French Multiple Sclerosis (MS) Society (SFSEP) decided to develop a national evidence-based consensus on pregnancy in MS. As neuromyelitis optica spectrum disorders (NMOSD) shares a series of commonalities with MS, but also some significant differences, specific recommendations had to be developed.

OBJECTIVES

To establish recommendations on pregnancy in women with NMOSD.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and universities databases (January 1975 through June 2021). The RAND/UCLA appropriateness method, which was developed to synthesise the scientific literature and expert opinions on health care topics, was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A sub-group of nine NMOSD experts was dedicated to analysing available data on NMOSD. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 66 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, loco-regional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses, and disease-modifying treatments.

CONCLUSION

Physicians and patients should be aware of the new and specific evidence-based recommendations of the French MS Society for pregnancy in women with NMOSD. They should help harmonise counselling and treatment practise, allowing for better individualised choices.

Pregnancy and multiple sclerosis: 2022 recommendations from the French multiple sclerosis society

OBJECTIVE

The objective of this study was to develop evidence-based recommendations on pregnancy management for persons with multiple sclerosis (MS).

BACKGROUND

MS typically affects young women in their childbearing years. Increasing evidence is available to inform questions raised by MS patients and health professionals about pregnancy issues.

METHODS

The French Group for Recommendations in Multiple Sclerosis (France4MS) reviewed PubMed and university databases (January 1975 through June 2021). The RAND/UCLA appropriateness method was developed to synthesise the scientific literature and expert opinions on healthcare topics; it was used to reach a formal agreement. Fifty-six MS experts worked on the full-text review and initial wording of recommendations. A group of 62 multidisciplinary healthcare specialists validated the final proposal of summarised evidence.

RESULTS

A strong agreement was reached for all 104 proposed recommendations. They cover diverse topics, such as pregnancy planning, follow-up during pregnancy and postpartum, delivery routes, locoregional analgesia or anaesthesia, prevention of postpartum relapses, breastfeeding, vaccinations, reproductive assistance, management of relapses and disease-modifying treatments.

CONCLUSION

The 2022 recommendations of the French MS society should be helpful to harmonise counselling and treatment practice for pregnancy in persons with MS, allowing for better and individualised choices.

A practical guide for radiographers focussing on safety during magnetic resonance imaging

Magnetic resonance imaging (MRI) poses some risk when adequate safety measures are not adhered to. Despite efforts on MRI safety, incidents still occur in MRI. Extensive training on MRI safety is essential to protect patients, staff and the public from the risks associated with magnetic fields. Safety issues in MRI include projectile and torque effects on ferromagnetic objects, thermal effects, claustrophobia and adverse reactions to contrast agents. Radiographers operating MRI scanners play a vital role in ensuring that all who enter the MRI environment adhere to the safety measures. However, radiographers are faced with challenges that impact how safety issues are monitored. This Continuing Professional Development article is aimed at highlighting these challenges and providing radiographers with some practical guidelines for these challenges.

Clinical Assessment of Fetal Well-Being and Fetal Safety Indicators

Delivering safe clinical trials of novel therapeutics is central to enable pregnant women and their babies to access medicines for better outcomes. This review describes clinical monitoring of fetal well‐being and safety. Current pregnancy surveillance includes regular antenatal checks of blood pressure and urine for signs of gestational hypertension. Fetal and placental development is assessed routinely using the first‐trimester “dating” and mid‐trimester “anomaly” ultrasound scans, but the detection of fetal anomalies can continue throughout pregnancy using targeted sonography or magnetic resonance imaging (MRI). Serial sonography can be used to assess fetal size, well‐being, and placental function. Carefully defined reproducible imaging parameters, such as the head circumference (HC), abdominal circumference (AC), and femur length (FL), are combined to calculate an estimate of the fetal weight. Doppler analysis of maternal uterine blood flow predicts placental insufficiency, which is associated with poor fetal growth. Fetal doppler analysis can indicate circulatory decompensation and fetal hypoxia, requiring delivery to be expedited. Novel ways to assess fetal well‐being and placental function using MRI, computerized cardiotocography (CTG), serum circulating fetoplacental proteins, and mRNA may improve the assessment of the safety and efficacy of maternal and fetal interventions. Progress has been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. A new system for improved safety monitoring for clinical trials in pregnancy, Maternal and Fetal Adverse Event Terminology (MFAET), describes 12 maternal and 18 fetal adverse event (AE) definitions and severity grading criteria developed through an international modified Delphi consensus process. This fills a vital gap in maternal and fetal translational medicine research.

The diagnosis and management of Cushing's syndrome in pregnancy

Endogenous Cushing's syndrome (CS) is rarely encountered during pregnancy. Clinical and biochemical changes in healthy pregnancy overlap with those seen in pregnancy complicated by CS; the diagnosis is therefore challenging and can be delayed. During normal gestation, adrenocorticotrophic hormone, corticotrophin-releasing hormone, cortisol, and urinary free cortisol levels rise. Dexamethasone administration fails to fully suppress cortisol in pregnant women without CS. Localisation may be hindered by non-suppressed adrenocorticotrophic hormone levels in a large proportion of those with adrenal CS; smaller corticotroph adenomas may go undetected as a result of a lack of contrast administration or the presence of pituitary hyperplasia; and inferior petrosal sinus sampling is not recommended given the risk of radiation and thrombosis. Yet, diagnosis is essential; active disease is associated with multiple insults to both maternal and foetal health, and those cured may normalise the risk of maternal-foetal complications. The published literature consists mostly of case reports or small case series affected by publication bias, heterogeneous definitions of maternal or foetal outcomes or lack of detail on severity of hypercortisolism. Consequently, conclusive recommendations, or a standardised management approach for all, cannot be made. Management is highly individualised: the decision for surgery, medical control of hypercortisolism or adoption of a conservative approach is dependent on the timing of diagnosis (respective to stage of gestation), the ability to localise the tumour, severity of CS, pre-existing maternal comorbidity, and, ultimately, patient choice. Close communication is a necessity with the patient placed at the centre of all decisions, with risks, benefits, and uncertainties around any investigation and management carefully discussed. Care should be delivered by an experienced, multidisciplinary team, with the resources and expertise available to manage such a rare and challenging condition during pregnancy.

A narrative review of current and emerging MRI safety issues: What every MRI technologist (radiographer) needs to know

Magnetic resonance imaging (MRI) has been traditionally regarded as a safe imaging modality due to the absence of ionising radiation. However, MRI is a source of potential hazards with a variety of risks including, but not limited to, those associated with the various electromagnetic fields used for imaging. All MRI technologists (radiographers) require sound knowledge of the physical principles of the MRI scanner and must understand the associated safety risks and how to avoid adverse events from occurring. MRI technologists now assume more responsibility in clinical decision-making, and their knowledge base has consequently had to expand significantly. In addition, rapid advancements in MRI technology and other correlated areas such as medical implant technology, and the associated increase in MRI safety issues, place increasing demands on the MRI technologist to constantly keep abreast of current and future developments. This article reviews current and emerging MRI safety issues relevant to the three MRI electromagnetic fields and highlights the key information that all MRI technologists should be fully cognisant of to ensure competent and safe practice within the MRI environment.

Fetal magnetic resonance imaging at 3 Tesla - the European experience

BACKGROUND

The Fetal Imaging Taskforce was established in 2018 by the European Society of Paediatric Radiology. The first survey on European practice of fetal imaging published in 2020 revealed that 30% of fetal magnetic resonance imaging (MRI) is performed at 3 tesla (T). The purpose of this second survey was to identify the impact of 3-T fetal MRI with an emphasis on image quality, diagnostic yield, and technical challenges and artifacts at higher field strengths.

OBJECTIVE

To describe the prenatal imaging practice at 3-T MRI units in various centres in Europe and to prepare recommendations on behalf of the Fetal Imaging Taskforce.

MATERIALS AND METHODS

A survey was sent to all members performing 3-T fetal MRI. Questions included practitioner experience, magnet brand, protocols, counselling, artifacts and benefits of imaging at higher field strengths.

RESULTS

Twenty-seven centres replied and reported improved spatial resolution and improved signal-to-noise ratio when performing fetal MRI at 3 T. Shading and banding artifacts and susceptibility to motion artifacts were common problems identified by practitioners at the higher field strength. For all neurological indications, practitioners reported a benefit of imaging at 3 T, most marked for posterior fossa evaluation and parenchymal lesions.

CONCLUSION

The use of 3-T magnets in fetal MRI has improved the availability and quality of advanced imaging sequences and allowed for better anatomical evaluation. There remain significant challenges to minimize the impact of artifacts on image quality. This paper includes guidelines for clinical practice and imaging at 3 T.

Melanoma in pregnancy: Diagnosis and management in early-stage and advanced disease

Approximately one-third of women diagnosed with melanoma are of child-bearing age. The annual incidence of melanoma has risen steadily over the last 40 years, resulting in increasing numbers of women diagnosed with melanoma both during pregnancy, and post-partum. To date, there are no formal guidelines on the management of pregnancy associated melanoma (PAM), both early stage and metastatic. This article reviews the existing literature and provides a framework for the investigation and multidisciplinary management of PAM.

How Could Nanomedicine Improve the Safety of Contrast Agents for MRI during Pregnancy?

Pregnancy is a delicate state, during which timely investigation of possible physiological anomalies is essential to reduce the risk of maternal and fetal complications. Medical imaging encompasses different technologies to image the human body for the diagnosis, course of treatment management, and follow-up of diseases. Ultrasound (US) is currently the imaging system of choice for pregnant patients. However, sonographic evaluations can be non-effective or give ambiguous results. Therefore, magnetic resonance imaging (MRI), due to its excellent tissue penetration, the possibility of acquisition of three-dimensional anatomical information, and its high spatial resolution, is considered a valid diagnostical alternative. Nevertheless, currently employed contrast agents to improve the MRI image quality are harmful to the fetus. Because of their ability to cross the placenta, their use on pregnant patients is avoided. This review will firstly recapitulate the most common non-obstetrical, obstetrical, and fetal indications for magnetic resonance imaging on pregnant women. Fetal safety risks, due to the use of strong magnetic fields and exogenous contrast agents, will be presented. Then, possible advantages of nanostructured contrast agents compared to current molecular ones are explored. Nanosystems’ characteristics affecting contrast efficiency, and their potential for improving contrast-enhanced MRI’s safety in pregnant women, are discussed. Lastly, promising examples of nanoparticles as safer alternatives to current MRI contrast agents in pregnancy are discussed.

Cerebral venous sinus thrombosis after adenovirus-vectored COVID-19 vaccination: review of the neurological-neuroradiological procedure

Cerebral venous and sinus thrombosis (CVST) after adenovirus-vectored COVID-19 ChAdOx1 nCov-19 (Oxford–AstraZeneca) and Ad26.COV2.S (Janssen/Johnson & Johnson) is a rare complication, occurring mainly in individuals under 60 years of age and more frequently in women. It manifests 4–24 days after vaccination. In most cases, antibodies against platelet factor-4/polyanion complexes play a pathogenic role, leading to thrombosis with thrombocytopenia syndrome (TTS) and sometimes a severe clinical or even fatal course. The leading symptom is headache, which usually increases in intensity over a few days. Seizures, visual disturbances, focal neurological symptoms, and signs of increased intracranial pressure are also possible. These symptoms may be combined with clinical signs of disseminated intravascular coagulation such as petechiae or gastrointestinal bleeding. If TTS-CVST is suspected, checking d-dimers, platelet count, and screening for heparin-induced thrombocytopenia (HIT-2) are diagnostically and therapeutically guiding. The imaging method of choice for diagnosis or exclusion of CVST is magnetic resonance imaging (MRI) combined with contrast-enhanced venous MR angiography (MRA). On T2*-weighted or susceptibility weighted MR sequences, the thrombus causes susceptibility artefacts (blooming), that allow for the detection even of isolated cortical vein thromboses. The diagnosis of TTS-CVST can usually be made reliably in synopsis with the clinical and laboratory findings. A close collaboration between neurologists and neuroradiologists is mandatory. TTS-CVST requires specific regimens of anticoagulation and immunomodulation therapy if thrombocytopenia and/or pathogenic antibodies to PF4/polyanion complexes are present. In this review article, the diagnostic and therapeutic steps in cases of suspected TTS associated CSVT are presented.

What to Expect When Expecting in Lab: A Review of Unique Risks and Resources for Pregnant Researchers in the Chemical Laboratory

Pregnancy presents a unique risk to chemical researchers due to their occupational exposures to chemical, equipment, and physical hazards in chemical research laboratories across science, engineering, and technology disciplines. Understanding “risk” as a function of hazard, exposure, and vulnerability, this review aims to critically examine the state of the science for the risks and associated recommendations (or lack thereof) for pregnant researchers in chemical laboratories (labs). Commonly encountered hazards for pregnant lab workers include chemical hazards (organic solvents, heavy metals, engineered nanomaterials, and endocrine disruptors), radiation hazards (ionizing radiation producing equipment and materials and nonionizing radiation producing equipment), and other hazards related to the lab environment (excessive noise, excessive heat, psychosocial stress, strenuous physical work, and/or abnormal working hours). Lab relevant doses and routes of exposure in the chemical lab environment along with literature and governmental recommendations or resources for exposure mitigation are critically assessed. The specific windows of vulnerability based on stage of pregnancy are described for each hazard, if available. Finally, policy gaps for further scientific research are detailed to enhance future guidance to protect pregnant lab workers.

Early identification of uterine scar defect by preconception magnetic resonance imaging to achieve successful pregnancy outcome after laparoscopic-assisted myomectomy: Two case reports

Myomectomy improves the reproductive ability of women. However, the risk for uterine rupture and abnormal placentation remains a concern. In two cases with scar defects after laparoscopic-assisted myomectomy, one case developed amniocele, while other case showed abnormally invasive placenta. Obstetrical management measures with cesarean sections yielded uneventful postoperative courses.

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

Vulval cancer in pregnancy: Two case reports

Vulval cancer is rare in women of reproductive age. We report two cases of vulval squamous cell carcinoma (VSCC) in pregnancy. They presented with a solitary labial mass, at 20 and 21 weeks of gestation, diagnosed as stage 1B VSCC based on clinical examination and cross-sectional imaging. In the first case, the patient underwent close clinical surveillance whilst pregnant and had an elective caesarean section at 39 weeks of gestation. Two months post-partum she underwent a radical anterior vulvectomy and bilateral groin sentinel lymph node biopsy. In the second case, the patient underwent an anterior vulvectomy at 33 weeks of gestation followed by a vaginal delivery at 37 weeks of gestation. Six weeks post-natally she had bilateral groin sentinel lymph node biopsies. We conclude that surgical resection is safe during pregnancy under spinal anaesthesia but it can be deferred until the post-partum period if the cancer presents at early stage.

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Vulval cancer is rare in pregnancy and management is tailored according to gestation age.

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Surgical resection of a local tumour for symptom control is feasible antenatally and the decision should be made on a case-by-case basis with antenatal surveillance of the tumour.

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Staging surgery for inguinal lymphatics should be deferred until the post-natal period if there is no suspicion of clinical or radiology metastasis.

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Sentinel inguinal lymph node biopsy is absolutely contraindicated during the antenatal period due to risks of radiation exposure of the foetus.

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Vaginal birth is possible after vulvectomy and reconstructive surgery may be considered in the future.

MRI in Pregnancy and Precision Medicine: A Review from Literature

Magnetic resonance imaging (MRI) offers excellent spatial and contrast resolution for evaluating a wide variety of pathologies, without exposing patients to ionizing radiations. Additionally, MRI offers reproducible diagnostic imaging results that are not operator-dependent, a major advantage over ultrasound. MRI is commonly used in pregnant women to evaluate, most frequently, acute abdominal and pelvic pain or placental abnormalities, as well as neurological or fetal abnormalities, infections, or neoplasms. However, to date, our knowledge about MRI safety during pregnancy, especially about the administration of gadolinium-based contrast agents, which are able to cross the placental barrier, is still limited, raising concerns about possible negative effects on both the mother and the health of the fetus. Contrast agents that are unable to cross the placenta in a way that is safe for the fetus are desirable. In recent years, some preclinical studies, carried out in rodent models, have evaluated the role of long circulating liposomal nanoparticle-based blood-pool gadolinium contrast agents that do not penetrate the placental barrier due to their size and therefore do not expose the fetus to the contrast agent during pregnancy, preserving it from any hypothetical risks. Hence, we performed a literature review focusing on contrast and non-contrast MRI use during pregnancy.

A National Survey on Safety Management at MR Imaging Facilities in Japan

PURPOSE

To investigate safety management at Japanese facilities performing human MRI studies.

METHODS

All Japanese facilities performing human MRI studies were invited to participate in a comprehensive survey that evaluated their MRI safety management. The survey used a questionnaire prepared with the cooperation of the Safety Committee of the Japanese Society for Magnetic Resonance in Medicine. The survey addressed items pertaining to the overall MRI safety management, questions on the occurrence of incidents, and questions specific to facility and MRI scanner or examination. The survey covered the period from October 2017 to September 2018. Automated machine learning was used to identify factors associated with major incidents.

RESULTS

Of 5914 facilities, 2015 (34%) responded to the questionnaire. There was a wide variation in the rate of compliance with MRI safety management items among the participating facilities. Among the facilities responding to this questionnaire, 5% reported major incidents and 27% reported minor incidents related to MRI studies. Most major incidents involved the administration of contrast agents. The most influential factor in major incidents was the total number of MRI studies performed at the facility; this number was significantly correlated with the risk of major incidents (P < 0.0001).

CONCLUSION

There were large variations in the safety standards applied at Japanese facilities performing clinical MRI studies. The total number of MRI studies performed at a facility affected the number of major incidents.

Neuroimaging safety during pregnancy and lactation: a review

PURPOSE

Imaging studies are crucial adjuncts when studying acute and chronic diseases, so pregnant and lactating women are as likely to be evaluated with one of the available imaging modalities. Due to the specific condition of the mother and child in this time period it is crucial to make an appropriate selection of imaging studies.

METHODS

We review the existing literature and analyse the latest evidence and guidelines regarding neuroimaging safety during pregnancy and lactation, proposing an algorithm of action based on risk/benefits assessment.

RESULTS

Choosing the most appropriate neuroimaging modality implicates assessing the pretest pertinence of the study-the possibility of a serious treatable neurologic disease, pondering what is the most useful imaging modality for the diagnosis and evaluating the associated risks. Among physicians (and patients), however, the risk component is perhaps the least well understood, with misperceptions regarding safety and potential hazards. Computed tomography (CT) risks are principally related to ionizing radiation and intravenous (IV) administration of iodinated contrast. However, as very low risks for the mother and foetus have been reported and CT remains the most available tool for initial rapid diagnosis of acute neurological conditions, it should not be withheld in urgent situations. Magnetic resonance imaging (MRI), unlike CT, does not use ionizing radiation or iodinated contrast mediums, having the best anatomical detail possible. However, there are some usage safety concerns regarding the magnetic field strength and gadolinium-based contrast use.

CONCLUSION

There are lacking longitudinal and prospective studies to sustain evidence based choices of imaging studies during pregnancy and lactation. Ultimately the decision should be based on the risk/benefit, taking into account the patient's safety, care and outcomes. However, using a specific algorithm can guide decisions in daily clinical practice.

Susac syndrome and pregnancy: a review of published cases and considerations for patient management

Susac syndrome (SuS) is a rare autoimmune endotheliopathy leading to hearing loss, branch retinal artery occlusions and encephalopathy. Young females are more frequently affected than males, making counselling for family planning an important issue. We reviewed published cases on SuS during pregnancy or in the postpartum period, and selected 27 reports describing the details of 33 patients with SuS. Treatment options and implications for pregnancy and breastfeeding are discussed. We propose new areas for research and suggest a management strategy.

The effects of maternal position, in late gestation pregnancy, on placental blood flow and oxygenation: an MRI study

KEY POINTS

Maternal supine sleep position in late pregnancy is associated with an increased risk of stillbirth. Maternal supine position in late pregnancy reduces maternal cardiac output and uterine blood flow. Using MRI, this study shows that compared to the left lateral position, maternal supine position in late pregnancy is associated with reduced utero-placental blood flow and oxygen transfer across the placenta with an average 6.2% reduction in oxygen delivery to the fetus and an average 11% reduction in fetal umbilical venous blood flow.

ABSTRACT

Maternal sleep position in late gestation is associated with an increased risk of stillbirth, though the pathophysiological reasons for this are unclear. Studies using magnetic resonance imaging (MRI) have shown that compared with lateral positions, lying supine causes a reduction in cardiac output, reduced abdominal aortic blood flow and reduced vena caval flow which is only partially compensated for by increased flow in the azygos venous system. Using functional MRI techniques, including an acquisition termed diffusion-relaxation combined imaging of the placenta (DECIDE), which combines diffusion weighted imaging and T2 relaxometry, blood flow and oxygen transfer were estimated in the maternal, fetal and placental compartments when subjects were scanned both supine and in left lateral positions. In late gestation pregnancy, lying supine caused a 23.7% (P < 0.0001) reduction in total internal iliac arterial blood flow to the uterus. In addition, lying in the supine position caused a 6.2% (P = 0.038) reduction in oxygen movement across the placenta. The reductions in oxygen transfer to the fetus, termed delivery flux, of 11.2% (P = 0.0597) and in fetal oxygen saturation of 4.4% (P = 0.0793) did not reach statistical significance. It is concluded that even in healthy late gestation pregnancy, maternal position significantly affects oxygen transfer across the placenta and may in part provide an explanation for late stillbirth in vulnerable fetuses.

The application of in utero magnetic resonance imaging in the study of the metabolic and cardiovascular consequences of the developmental origins of health and disease

Observing fetal development in utero is vital to further the understanding of later-life diseases. Magnetic resonance imaging (MRI) offers a tool for obtaining a wealth of information about fetal growth, development, and programming not previously available using other methods. This review provides an overview of MRI techniques used to investigate the metabolic and cardiovascular consequences of the developmental origins of health and disease (DOHaD) hypothesis. These methods add to the understanding of the developing fetus by examining fetal growth and organ development, adipose tissue and body composition, fetal oximetry, placental microstructure, diffusion, perfusion, flow, and metabolism. MRI assessment of fetal growth, organ development, metabolism, and the amount of fetal adipose tissue could give early indicators of abnormal fetal development. Noninvasive fetal oximetry can accurately measure placental and fetal oxygenation, which improves current knowledge on placental function. Additionally, measuring deficiencies in the placenta’s transport of nutrients and oxygen is critical for optimizing treatment. Overall, the detailed structural and functional information provided by MRI is valuable in guiding future investigations of DOHaD.

Real-time Assessment of the Development and Function of the Placenta Across Gestation to Support Therapeutics in Pregnancy

The placenta is vital to the health and development of the fetus, serving to deliver oxygen and nutrients, facilitate the removal of waste products, and provide a barrier to pathogens and other harmful substances present in the maternal circulation. When these processes fail to operate normally, they can lead to complications of pregnancy such as preeclampsia or fetal growth restriction. The development of novel therapeutics for the mother, fetus, or placenta requires a mechanistic understanding of the development and functions of the placenta. For the obstetric clinician, being able to monitor the placenta throughout the pregnancy and to measure the impact of any treatment modality on the mother and the developing fetus are essential for providing the best possible care. The Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health has been a longtime supporter of research on the placenta. In 2014, the Human Placenta Project was initiated to help to drive an understanding of the biology of the human placenta and to facilitate the development of novel tools and approaches to allow for safe, noninvasive, real-time assessment of the placenta across pregnancy. Those efforts, along with others from around the globe, are showing promise. Although not yet ready for clinical application, these advances are moving the field forward and are certain to have a tremendous impact on the development and assessment of therapeutics designed for treating conditions of pregnancy.

Quantitative systematic review: Methods used for the in vivo measurement of body composition in pregnancy

AIMS

Because of the increased overall prevalence of pre-pregnancy obesity among racial-ethnic groups, we conducted a review of published methods for body composition measurement during pregnancy considering at present there is no consensus on the best practices and type of study design that researchers should use for this purpose.

DESIGN

Quantitative systematic review.

DATA SOURCES

PubMed, EMBASE, Scopus, Web of Science, and Virtual Library of Health. Search dates from 1997-2016.

REVIEW METHODS

Search of articles indexed in selected databases from 1997-2016. Studies were published in English, Spanish, and Portuguese. Graphs were carried out using data visualization software.

RESULTS

From the 112 included studies, 70 were prospective cohorts, 30 cross-sectional studies, 10 randomized controlled trial, and two retrospective studies. Cross-sectional studies and randomized controlled trial depicted a positive correlation with significant trend.

CONCLUSIONS

Although several methods for body composition measurement exist, only bioelectrical impedance analysis, displacement plethysmography, and displacement plethysmography show a significant growing trend. Use of data visualization allows understanding various associations among categorical variables, with a graphical display of their multidimensional behaviour.

IMPACT

Public and private health-care institution evaluating pregnancy women. Health-care personnel, including nursing professional, dealing with measurements of body composition during pregnancy will find reading this manuscript beneficial.