CT, MRI, PET, PET/CT, and Ultrasound in the Evaluation of Obstetric and Gynecologic Patients

CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient

Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.

Successful Conservative Treatment of Maternal Spontaneous Unilateral Adrenal Hemorrhage Causing Severe Anemia in the Third Trimester of Pregnancy-A Case Report

We present the case of a 32-year-old pregnant woman in the 32 + 3 weeks of pregnancy who presented to the hospital with an exacerbation of pain in the right flank. The diagnostic evaluation revealed the presence of severe anemia and a spontaneous adrenal hemorrhage (SAH) in the right adrenal gland. The patient was transferred to the Perinatology, Obstetrics and Gynecology Clinic with the intention of undergoing preterm childbirth. However, the doctors made a risky decision to wait until week 37 and to terminate the pregnancy at that point. The decision was right, as a cesarean section was performed without complications, and the patient gave birth to a healthy child. Spontaneous adrenal hemorrhage (SAH) is a rare condition, defined as spontaneous hemorrhage without trauma or anticoagulant therapy. Due to bleeding and damage to the adrenal cortex, SAH can lead to adrenal insufficiency. Because of its non-specific symptoms and potentially fatal outcomes for the patient and fetus, it should be considered during diagnostics.

Contemporary Use of Computed Tomography (CT) Imaging in Suspected Urolithiasis in Pregnancy

PURPOSE OF REVIEW

We aimed to examine the role of low-dose CT (LDCT) in the diagnostic work-up for suspected urolithiasis in pregnancy. We reviewed contemporary urologic recommendations for CT in pregnancy, its utilization for suspected urolithiasis, and explored barriers to its use.

RECENT FINDINGS

National urologic guidelines and the American College of Obstetricians and Gynecologists recommend the judicious use of LDCT imaging in pregnancy when necessary. We noted inconsistencies in review article management pathways and recommendations for CT imaging for suspected urolithiasis in pregnancy. Overall CT utilization in pregnancy for suspected urolithiasis is low. Proposed barriers to LDCT use in pregnancy include fears of litigation and misperceptions of the harm of diagnostic radiation. Recent advancements in imaging technologies for urolithiasis in pregnancy are limited. More specific diagnostic pathway recommendations from national urologic guideline bodies for when to use LDCT to investigate renal colic in pregnancy may reduce diagnostic and intervention delays.

Unilateral Non-Hemorrhagic Adrenal Infarction in Pregnancy: Case Series and Literature Review

To summarize the evidence on non-hemorrhagic adrenal infarction (NHAI) and identify questions arising in diagnosis and management, cases in the PubMed database were merged with our case series. A total of 92 publications were retrieved, 15 of which reported on NHAI during pregnancy. Including the four in our case series, 24 cases have been described so far. Severe, unremitting pain requiring opioid analgesia was the leading symptom, often combined with nausea and vomiting. Laboratory results were non-contributory in most cases. Diagnosis was established via MRI in nine cases (37.5%) and via CT in six (25%); nine patients (37.5%) underwent both investigations. Location was predominantly on the right side (n = 16, 66.7%). In addition to analgesia, anticoagulation with heparin was commenced in 18 cases (75%). When thrombophilia screening was performed, major thrombogenic polymorphisms were detected in six cases (33.3%). One woman developed signs of adrenal insufficiency. The reported perinatal outcome was unremarkable. Unilateral NHAI has emerged as a rare but important cause of severe abdominal pain in pregnancy. The threshold to perform an MRI in pregnant women with characteristic clinical findings should be low. To prevent fetal radiation exposure, diagnostic imaging via CT should be avoided. In addition to symptomatic treatment with opioid analgesia, initiation of anticoagulant treatment should be strongly considered.

Intestinal obstruction in pregnancy-a rare presentation of uterine perforation

BACKGROUND

Intestinal obstruction is an uncommon non-obstetric condition during pregnancy which may cause maternal and fetal mortality. Clinicians are confronted with challenges in diagnosis and treatment of intestinal obstruction due to the overlapping symptoms, concerns over radiological evaluation, and surgical risks.

CASE PRESENTATION

We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired.

CONCLUSIONS

Although uncommon during pregnancy, clinical suspicion of bowel obstruction is necessary especially in women with a history of abdominal surgery. Surgical intervention is indicated when conservative therapy fails and when there are signs of abnormal fetal conditions and worsened symptoms.

Pregnancy and Gastric Cancer: A Narrative Review

Cases of digestive cancers diagnosed during pregnancy are rare. The increasing prevalence of pregnancy in women aged 30-39 years (and not exceptionally 40-49 years) could explain the frequent co-occurrence of cancers and pregnancy. The diagnosis of digestive cancers in pregnancy is difficult due to the overlap between neoplasm symptomatology and the clinical picture of pregnancy. A paraclinical evaluation may also be difficult depending on the trimester of the pregnancy. Diagnosis is also delayed by practitioners' hesitation to use invasive investigations (imaging, endoscopy, etc.) due to fetal safety concerns. Therefore, digestive cancers are often diagnosed during pregnancy in advanced stages, where complications such as occlusions, perforations, and cachexia have already arisen. In this review, we highlight the epidemiology, clinical aspects, paraclinical evaluation, and particularities of the diagnosis and treatment of gastric cancer during pregnancy.

Patient-Centered Care in the Management of Cancer During Pregnancy

The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.

Management of the Upper Airway Distress During Pregnancy

Pregnancy can induce significant upper airway distress in women by the induction of rhinitis of pregnancy (ROP). Pregnancy can also exacerbate underlying rhinopathies. Little is known regarding the pathophysiology of the ROP. Diagnosis of other coexistent rhinopathies is key. Treatment regimens closely mirror standard treatments for other rhinopathies that are independent of pregnancy and are generally accepted as safe. Early recognition of the progression of rhinitis in the pregnant patient into complications of rhinosinusitis is important to prevent harm to both mother and fetus.

Antenatal imaging: A pictorial review

Today, in parallel with the use of imaging modalities increases in all fields, the use of imaging methods in pregnant women is increasing. Imaging has become an integral component of routine pregnancy follow-up. Imaging provides parents with an early opportunity to learn about the current situation, including prenatal detection of anomalies or diseases, etiology, prognosis, and the availability of prenatal or postnatal treatments. Various imaging modalities, especially ultrasonography, are frequently used for imaging both maternal and fetal imaging. The goal of this review was to address imaging modalities in terms of usefulness and safety, as well as to provide demonstrative examples for disorders. And this review provides current information on selecting a safe imaging modality to evaluate the pregnant and the fetus, the safety of contrast medium use, and summarizes major pathological situations with demonstrative sonographic images to assist radiologists and obstetricians in everyday practice.

Pregnancy Considerations for Patients With Interstitial Lung Disease

Advances in our understanding of interstitial lung disease (ILD) pathophysiology and natural history have led to the development of guidelines for the diagnosis and management of several of these complex diseases. The demographics of patients with ILD indicate the disease is not restricted to older adults. Connective tissue disease-associated ILD, familial pulmonary fibrosis, and post-COVID-19 fibrosis may affect women of child-bearing age. Recent trials have excluded pregnant women, thereby limiting the applicability of contemporary therapeutic advances to these patients. This review synthesizes the current knowledge of pregnancy outcomes in those with ILD, with a focus on connective tissue disease-associated ILD, and potential treatment implications for patients with ILD who are pregnant or considering pregnancy. Pregnancy considerations for patients with ILD include the need for preconception counseling and planning to ensure disease stability, medication and vaccination optimization, and multidisciplinary involvement of a patient's pulmonologist, obstetrician, and, when indicated, rheumatologist and genetic counselor. Evidence to date suggests that women with ILD can have safe and healthy pregnancies but that complications may occur in those with severe ILD.

Imaging during pregnancy: What the radiologist needs to know

During the last decades, there has been a growing demand for medical imaging in gravid women. Imaging of the pregnant woman is challenging as it involves both the mother and the fetus and, consequently, several medical, ethical, or legal considerations are likely to be raised. Theoretically, all currently available imaging modalities may be used for the evaluation of the pregnant woman; however, in practice, confusion regarding the safety of the fetus often results in unnecessary avoidance of useful diagnostic tests, especially those involving ionizing radiation. This review article is focused on the current safety guidelines and considerations regarding the use of different imaging modalities in the pregnant population; also presented is an imaging work-up for the most common medical conditions of pregnant women, with emphasis on fetal and maternal safety.

Popliteal Artery Occlusion with Collateral Blood Flow in a Reducible Knee Dislocation During Pregnancy: A Case Report

CASE

A 29-year-old healthy woman, 19 weeks pregnant, sustained a right posterolateral knee dislocation with multiligamentous injury and a complete occlusive injury to the right popliteal artery yet had adequate distal perfusion. She declined operative management for both the knee dislocation and the arterial injury, and successful collaboration between obstetrical, vascular, and orthopaedic surgical services resulted in limb preservation and restoration of function.

CONCLUSION

This is a unique case of traumatic complete popliteal artery occlusion with adequate collateral arterial perfusion after a reducible posterolateral knee dislocation in a pregnant patient that resulted in limb preservation with nonoperative management.

Managing Life-Threatening Malignant Superior Mediastinal Syndrome in Pregnancy: When Benefits of Radiation and Chemotherapy Outweigh the Risks—A Case Report and Review of Literature

There is scarce literature on managing superior mediastinal syndrome during pregnancy. We report a case of 26-year-old primigravida who presented with life-threatening superior mediastinal syndrome at 32 weeks of gestation. The diagnosis was significantly delayed and, as a result, she reached the emergency with stridor and impending respiratory failure. She was diagnosed with primary mediastinal B cell lymphoma Lugano Stage II with a bulky mediastinal mass. She was treated with chemoimmunotherapy and underwent a preterm vaginal delivery after a week. She delivered a 1.6 kg healthy child with no malformations. Later, she completed three cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisolone and five cycles of dose-adjusted etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin, rituximab, followed by radiotherapy. She continues to be in remission at 18 months of follow-up. Delaying diagnostic imaging that involves ionizing radiation exposure and chemotherapy to avoid teratogenic and obstetric complications during pregnancy can adversely affect the prognosis in certain patients with high-grade malignancies. On the contrary, prompt multidisciplinary management can lead to a gratifying outcome.

Imaging modalities in pregnant cancer patients

Cancer during pregnancy is increasingly diagnosed due to the trend of delaying pregnancy to a later age and probably also because of increased use of non-invasive prenatal testing for fetal aneuploidy screening with incidental finding of maternal cancer. Pregnant women pose higher challenges in imaging, diagnosis, and staging of cancer. Physiological tissue changes related to pregnancy makes image interpretation more difficult. Moreover, uncertainty about the safety of imaging modalities, fear of (unnecessary) fetal radiation, and lack of standardized imaging protocols may result in underutilization of the necessary imaging tests resulting in suboptimal staging. Due to the absence of radiation exposure, ultrasound and MRI are obvious first-line imaging modalities for detailed locoregional disease assessment. MRI has the added advantage of a more reproducible comprehensive organ or body region assessment, the ability of distant staging through whole-body evaluation, and the combination of anatomical and functional information by diffusion-weighted imaging which obviates the need for a gadolinium-based contrast-agent. Imaging modalities with inherent radiation exposure such as CT and nuclear imaging should only be performed when the maternal benefit outweighs fetal risk. The cumulative radiation exposure should not exceed the fetal radiation threshold of 100 mGy. Imaging should only be performed when necessary for diagnosis and likely to guide or change management. Radiologists play an important role in the multidisciplinary team in order to select the most optimal imaging strategies that balance maternal benefit with fetal risk and that are most likely to guide treatment decisions. Our aim is to provide an overview of possibilities and concerns in current clinical applications and developments in the imaging of patients with cancer during pregnancy.

Lymphoma Occurring During Pregnancy: Current Diagnostic and Therapeutic Approaches

PURPOSE OF REVIEW

Pregnancy-associated lymphoma (PAL) is an uncommon entity that lacks detailed prospective data. It poses significant management challenges that incorporate maternal and fetal risks associated with treatment or delayed intervention. Herein, we review the current literature for the diagnosis, management, and supportive care strategies for PAL.

RECENT FINDINGS

Establishment of a multidisciplinary team, including hematology-oncology, maternal-fetal medicine, and neonatology, is critical in the management of PAL. For staging, ultrasound and MRI are preferred modalities with use of computerized tomography in select situations. Data for the safety and effectiveness of therapy for PAL is largely based on retrospective studies. The timing of lymphoma-directed antenatal systemic therapy depends on the trimester, gestational age, lymphoma subtype and aggressiveness, and patient wishes. Therapy in the first trimester is usually not advocated, while treatment in the second and third trimesters appears to result in similar outcomes for PAL compared with non-pregnant patients with lymphoma. An overarching goal in most PAL cases should be to plan for delivery at term (i.e., gestational age > 37 weeks). For supportive care, most antiemetics, including agents such as neurokinin-1 receptor antagonists, have been used safely during pregnancy. For prevention or treatment of infections, particular antibiotics (i.e., macrolides, cephalosporins, penicillins, metronidazole), antivirals (i.e., acyclovir, valacyclovir, famciclovir), and antifungals (amphotericin B) have demonstrated safety and with use of growth factors reserved for treatment of neutropenia (vs. primary prophylaxis). Therapy for PAL should be individualized with goals of care that balance maternal and fetal well-being, which should include a multidisciplinary care team and overall intent for term delivery in most cases.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Expert consensus for managing pregnant women and neonates born to mothers with suspected or confirmed novel coronavirus (COVID-19) infection

Objective

To provide clinical management guidelines for novel coronavirus (COVID‐19) in pregnancy.

Methods

On February 5, 2020, a multidisciplinary teleconference comprising Chinese physicians and researchers was held and medical management strategies of COVID‐19 infection in pregnancy were discussed.

Results

Ten key recommendations were provided for the management of COVID‐19 infections in pregnancy.

Conclusion

Currently, there is no clear evidence regarding optimal delivery timing, the safety of vaginal delivery, or whether cesarean delivery prevents vertical transmission at the time of delivery; therefore, route of delivery and delivery timing should be individualized based on obstetrical indications and maternal–fetal status.

Currently, there is no clear evidence regarding optimal delivery timing or route of delivery for pregnant women with COVID‐19 infection; these should be individualized based on obstetrical indications and maternal–fetal status.

Abdominal Imaging in pregnancy (maternal and foetal risks)

Imaging studies are useful in the diagnostic evaluation of inflammatory bowel diseases. However, concern often exists about the safety of imaging for pregnant and lactating women and their infants, leading to unwarranted avoidance of beneficial diagnostic tests or disruption of breastfeeding. Ultrasonography and magnetic resonance imaging (MRI) are not associated with ionizing radiation and are the imaging techniques of choice for pregnant patients. Safety of MRI contrast agent gadolinium in pregnancy is uncertain, therefore MRI without gadolinium should be performed. Intestinal ultrasound where available and MRI without gadolinium can be used to characterise disease complications such as bowel obstruction or intra-abdominal collections. Ionising radiation exposure through computed tomography (CT) is usually at much lower doses than those associated with foetal harm, however CT should be reserved for the rare clinical situations in which ultrasound and MRI are either unavailable or unable to provide the required diagnostic information.

Estimation of fetal radiation absorbed dose during the prophylactic use of aortic occlusion balloon for abnormally invasive placenta

PURPOSE

Abnormally invasive placenta is an important cause of maternal morbidity, and its primary complication is massive bleeding. Strategies for preventing bleeding include arterial endovascular occlusion. One concern with the use of intra-arterial occlusion balloons is radiation exposure to the fetus, which occurs while determining balloon position. In this study, we sought to determine the radiation absorbed dose by the fetus during intra-aortic occlusion balloon placement in patients with abnormally invasive placenta.

MATERIALS AND METHODS

We estimated the fetal absorbed dose and the entrance skin dose in the vaginal fundus and lumbar skin, respectively, using thermoluminescent dosimeter crystals, during intra-aortic balloon positioning using the mobile X-ray image intensifier system (C-arm) in digital radiography mode, directly in surgery room, without transfer to angiographic suite. We also performed a mannequin-based simulation to validate the entrance skin dose measurement technique.

RESULTS

Ten women undergoing surgical management of an abnormally invasive placenta, in whom the location of the intra-aortic occlusion balloon was verified using plain radiography with C-arm in the surgery room, were included in the study. Following maternal and fetal radiation exposure, the entrance skin dose and radiation absorbed dose by the fetus were 1.31 ± 0.96 mGy and 0.27 ± 0.28 mGy, respectively, with radiation exposure durations of <1 s.

CONCLUSIONS

There were no complications with the use of REBOA, the radiation absorbed dose by the fetus, entrance skin dose, and duration of radiation exposure during intra-aortic occlusion balloon placement were lower than those reported for other vascular occlusion techniques, being this a safe procedure.

Trauma in Pregnancy

Although trauma in pregnancy is rare, it is one of the most common causes of morbidity and mortality to pregnant women and fetus. Pathophysiology of trauma is generally time sensitive, and this is still true in pregnant patients, with the additional challenge of rare presentation and balancing the management of two patients concurrently. Successful resuscitation requires understanding the physiologic changes to the woman throughout the course of pregnancy. Ultimately, trauma management is best approached by prioritizing maternal resuscitation.

Cryptorchidism after the Fukushima Daiichi Nuclear Power Plant accident:causation or coincidence?

Cryptorchidism (undescended testes) is among the most common congenital diseases in male children. Although many factors have been linked to the incidence of cryptorchidism, and testicular androgen plays a key role in its pathogenesis, the cause remains unknown in most cases. Recently, a Japanese group published a speculative paper entitled, "Nationwide increase in cryptorchidism after the Fukushima nuclear accident." Although the authors implicated radionuclides emitted from the Fukushima accident as contributing to an increased incidence of cryptorchidism, they failed to establish biological plausibility for their hypothesis, and glossed over an abundance of evidence and expert opinion to the contrary. We assessed the adequacy of their study in terms of design setting, data analysis, and its conclusion from various perspectives. Numerous factors must be considered, including genetic, environmental, maternal/fetal, and social factors associated with the reporting of cryptorchidism. Other investigators have established that the doses of external and internal radiation exposure in both Fukushima prefecture and the whole of Japan after the accident are too low to affect testicular descent during fetal periods;thus, a putative association can be theoretically and empirically rejected. Alternative explanations exist for the reported estimates of increased cryptorchidism surgeries in the years following Japan's 2011 earthquake, tsunami, and nuclear crisis. Data from independent sources cast doubt on the extent to which cryptorchidism increased, if at all. In any case, evidence that radionuclides from the Fukushima Daiichi Nuclear Power Plant could cause cryptorchidism is lacking.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound

OBJECTIVE

Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty.

METHODS

This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups.

RESULTS

A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist.

CONCLUSION

There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

Committee Opinion No. 656: Guidelines for Diagnostic Imaging During Pregnancy and Lactation

Imaging studies are important adjuncts in the diagnostic evaluation of acute and chronic conditions. However, confusion about the safety of these modalities for pregnant and lactating women and their infants often results in unnecessary avoidance of useful diagnostic tests or the unnecessary interruption of breastfeeding. Ultrasonography and magnetic resonance imaging are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently and only when use is expected to answer a relevant clinical question or otherwise provide medical benefit to the patient. With few exceptions, radiation exposure through radiography, computed tomography 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 magnetic resonance imaging or are more readily available for the diagnosis in question, they should not be withheld from a pregnant patient. Breastfeeding should not be interrupted after gadolinium administration.

Clinical scoring for diagnosis of acute lower abdominal pain in female of reproductive age

Background. Obstetrics and gynecological conditions (OB-GYNc) are difficult to be differentiated from appendicitis in young adult females presenting with acute lower abdominal pain. Timely and correct diagnosis is clinically challenging. Method. A retrospective data analysis was performed on 542 female patients who were admitted to a tertiary care hospital with a chief complaint of acute lower abdominal pain. Diagnostic indicators of appendicitis and OB-GYNc were identified by stepwise multivariable polytomous logistic regression. Diagnostic performances of the scores were tested. Result. The developed clinical score is comprised of (1) guarding or rebound tenderness, (2) pregnancy, (3) sites of abdominal tenderness, (4) leukocytosis, (5) peripheral neutrophils ≥75%, and (6) presence of diarrhea. For diagnosis of appendicitis, the area under the ROC curve was 0.8696, and the sensitivity and specificity were 89.25% and 70.00%. For OB-GYNc, the corresponding values were 0.8450, 66.67%, and 94.85%, respectively. Conclusion. The clinical scoring system can differentiate the diagnosis of acute lower abdominal pain in young adult females. Time spent for diagnosis at the emergency room may be shortened, and the patients would be admitted to the appropriate departments in less time.

Maternal and preterm fetal sheep responses to dexmedetomidine

BACKGROUND

The α(2) adrenergic receptor agonist dexmedetomidine has some unique pharmacologic properties that could benefit pregnant patients (and their fetuses) when they require sedation, analgesia, and/or anesthesia during pregnancy. The purpose of the present study was to delineate maternal and fetal responses to an intravenous infusion of dexmedetomidine.

METHODS

This study was conducted on surgically-recovered preterm sheep instrumented for physiologic recording and blood sampling. Maternal and fetal cardiovascular and blood gas parameters and fetal cerebral oxygenation levels were recorded before, during, and after 3h of dexmedetomidine infusion to the ewe at a rate of 1 μg/kg/h.

RESULTS

Drug infusion produced overt sedation but no apparent respiratory depression as evidenced by stable maternal arterial blood gases; fetal blood gases were also stable. The one blood parameter to change was serum glucose, By the end of the 3-h infusion, glucose increased from 49±10 to 104±33mg/dL in the ewe and from 22±3 to 48±16mg/dL in the fetus; it declined post-drug exposure but remained elevated compared to the starting levels (maternal, 63±12mg/dL, P=0.0497; and fetal, 24±4mg/dL, P=0.012). With respect to cardiovascular status, dexmedetomidine produced a decrease in maternal blood pressure and heart rate with fluctuations in uterine blood flow but had no discernable effect on fetal heart rate or mean arterial pressure. Likewise, maternal drug infusion had no effect on fetal cerebral oxygenation, as measured by in utero near-infrared spectroscopy.

CONCLUSIONS

Using a clinically-relevant dosing regimen, intravenous infusion of dexmedetomidine produced significant maternal sedation without altering fetal physiologic status. Results from this initial acute assessment support the conduct of further studies to determine if dexmedetomidine has clinical utility for sedation and pain control during pregnancy.

Misdiagnosed uterine rupture of an advanced cornual pregnancy

Cornual pregnancy is a diagnostic and therapeutic challenge with potential severe consequences if uterine rupture occurs with following massive intraabdominal bleeding. We report a case of a misdiagnosed ruptured cornual pregnancy occurring at 21 weeks of gestation. Ultrasound examination and computer tomography revealed no sign of abnormal pregnancy. The correct diagnosis was first made at emergency laparotomy. Uterine rupture should be considered in pregnant women presenting with abdominal pain and haemodynamic instability.

Transvaginal ultrasound in fertile patients with suspected appendicitis: an experience report of current practice

Background. Transvaginal ultrasound (TVU) in female patients with acute right lower quadrant (RLQ) abdominal pain is time and infrastructure intensive and not always available. This study aims to evaluate the role of TVU in these patients. Methods. Retrospective analysis identified 224 female patients with RLQ pain and TVU. Results. TVU revealed an underlying pathology in 34 (15%) patients, necessitating a diagnostic laparoscopy in 12 patients. Six patients (2%) had a true gynaecological emergency. The remaining 23 patients did not require surgery. The other 190 patients with RLQ pain had a bland TVU; 127 (67%) were discharged, while 63 patients (33%) received a diagnostic laparoscopy. Conclusion. The incidence of true gynaecological emergencies requiring urgent surgical intervention is very low in our patient cohort. TVU is a helpful tool if performed by a physician who is well trained in TVU.

Update on imaging for acute appendicitis

Acute appendicitis is a common surgical emergency and the diagnosis can often be made clinically; however, many patients present with atypical findings. For these patients, there are multiple imaging modalities available to aid in the diagnosis of suspected appendicitis in an effort to avoid a negative appendectomy. Computed tomography is the test of choice in most patients in whom the diagnosis is not certain. Ultrasonography is particularly useful in children and pregnant women. Magnetic resonance imaging is recommended when ultrasonography is inconclusive. Appropriate use of these imaging studies avoids delays in treatment, prolonged hospitalization, and unnecessary surgery.

The Roles of Fluorodeoxyglucose-PET/Computed Tomography in Ovarian Cancer: Diagnosis, Assessing Response, and Detecting Recurrence

The potential roles of fluorodeoxyglucose positron emission tomography/computed tomography imaging in ovarian cancer include noninvasive characterization of an ovarian mass, staging, and treatment planning. This article assesses these roles for predicting and monitoring response to treatment, restaging, and early diagnosis of recurrence.

Appendicitis and cholecystitis in pregnancy

Acute abdominal pain in pregnancy may be attributable to a broad range of nonobstetrical causes. The evaluation of an acute abdomen during pregnancy must include in the differential diagnosis appendicitis and cholecystitis, which are 2 of the most common reasons for nonobstetric surgical intervention in pregnancy. Both conditions may be associated with significant maternal and fetal morbidity and/or mortality. This study will provide a contemporary synopsis regarding the diagnosis and management of appendicitis and cholecystitis during pregnancy.

Imaging during pregnancy

The use of imaging techniques in women who are pregnant has increased greatly over the past decade. This focused review discusses the risks and indications of ultrasonography, magnetic resonance imaging, computed tomographic scanning, and fluoroscopy for the evaluation of the parturient with non-obstetric disorders. Diagnostic imaging of the pregnant woman for the evaluation of disorders not related to pregnancy is evolving, and protocols will vary from institution to institution. The potential benefit from indicated diagnostic radiological procedures in the parturient nearly always outweighs risk to the fetus because radiation exposure from a single procedure conveys little fetal risk.