Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation

Unusual Presentation of Hip Pain in a Pregnant Woman Due to Bilateral Cervical Neck Stress Fractures: A Case Report

CASE

We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes.

CONCLUSION

Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

Investigating gastrointestinal disorders in pregnancy

This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.

Cerebral Venous Thrombosis in Pregnant and Postpartum Women Presenting to the Emergency Department with Headaches

Introduction

Cerebral venous thrombosis (CVT) is a thromboembolic disease of the intracranial venous systems. The disease can be difficult to diagnose as it often requires a high index of suspicion. Risk factors for the disease include pregnancy, oral contraceptive pills, congenital thrombophilia, infection, cancer, polycythemia, head trauma, and recent surgery. However, there have been no studies in the United States that have examined whether pregnancy and the postpartum stage are truly a risk factor for CVT. The aim of this study is to determine whether pregnant and postpartum women presenting to the emergency department with headaches have a higher incidence of CVT to better risk stratify which patients need to have advanced imaging pursued.

Methods

A retrospective, observational case-control study was performing by querying the electronic medical record at a large county hospital for patients presenting with a headache to the emergency department. Patients were stratified into groups based on whether they were diagnosed with CVT, pregnancy status, and comorbid conditions to determine the risk associated between pregnancy, the puerperium stage, and CVT.

Results

A total of 20,955 males and females presented to the emergency department between January 1, 2016 and April 13, 2023, with a chief complaint of headache. There were 19,474 female patients and 9581 male patients. In the case group, there were 793 pregnant women and 53 postpartum women. In the control group, there were 18,628 women who were not pregnant. Of the 22 patients diagnosed with CVT, 1 was in the puerperium stage and no patients were pregnant. Pregnant and postpartum patients were 1.05 (0.14-7.80) times more likely to develop CVT. Pregnant and postpartum patients were 1.73 (0.23-13.52) times more likely to develop CVT when controlled for comorbidities. Patients in the puerperium stage were 26.48 (3.33-210.87) times more likely to develop CVT when controlled for comorbidities.

Conclusion

Pregnant patients presenting to the emergency department with headaches do not have a significantly higher risk of CVT; however, puerperium patients have a significantly higher risk of CVT compared to the general population.

Chest CT scan predictors of intensive care unit admission in hospitalized pregnant women with COVID-19: a case-control study

PURPOSE

To investigate the role of chest computed tomography (CT) scan in the prediction of admission of pregnant women with COVID-19 into intensive care unit (ICU).

METHODS

This was a single-center retrospective case-control study. We included pregnant women diagnosed with COVID-19 by reverse transcriptase polymerase chain reaction between February 2020 and July 2021, requiring hospital admission due to symptoms, who also had a CT chest scan at presentation. Patients admitted to the ICU (case group) were compared with patients who did not require ICU admission (control group). The CT scans were reported by an experienced radiologist, blinded to the patient's course and outcome, aided by an artificial intelligence software. Total CT scan score, chest CT severity score (CT-SS), total lung volume (TLV), infected lung volume (ILV), and infected-to-total lung volume ratio (ILV/TLV) were calculated. Receiver operating characteristic curves were constructed to test the sensitivity and specificity of each parameter.

RESULTS

8/28 patients (28.6%) required ICU admission. These also had lower TLV, higher ILV, and ILV/TLV. The area under the curve (AUC) for these three parameters was 0.789, 0.775, and 0.763, respectively. TLV, ILV, and ILV/TLV had good sensitivity (62.5%, 87.5%, and 87.5%, respectively) and specificity (84.2%, 70%, and 73.7%, respectively) for predicting ICU admission at the following selected thresholds: 2255 mL, 319 mL, and 14%, respectively. The performance of CT-SS, CT scan score, and ILV/TLV in predicting ICU admission was comparable.

CONCLUSION

TLV, ILV, and ILV/TLV as measured by an artificial intelligence software on chest CT, may predict ICU admission in hospitalized pregnant women, symptomatic for COVID-19.

Safety of Magnetic Resonance Imaging in Pregnancy

Magnetic resonance imaging is being increasingly used to diagnose and follow up a variety of medical conditions in pregnancy, both for maternal and fetal indications. However, limited data regarding its safe use in pregnancy may be a source of anxiety and avoidance for both patients and their healthcare providers. In this review, we critically discuss the main safety concerns of Magnetic Resonance Imaging (MRI) in pregnancy including energy deposition, acoustic noise, and use of contrast agents, supported by data from animal and human studies. Use of maternal sedatives and concerns related to occupational exposure in pregnant personnel are also addressed. Exposure to gadolinium-based contrast agents and sedation for MRI during pregnancy should be avoided whenever feasible.

Management of pregnant or potentially pregnant patients undergoing diagnostic and interventional radiology procedures: Investigation of clinical routine practice

It is well known that foetuses are highly sensitive to ionising radiation and special attention to justification and optimisation of radiological procedures involving a pregnant patient is required. A task to review, validate and compare different approaches to managing the pregnant patient and to estimating the associated foetal doses arising from a diagnostic or interventional radiology (DIR) procedure was designed in the framework of EURADOS working group 12. As a first step, a survey of radiation protection practice including dosimetry considerations among EURADOS members was performed using online questionnaire. Then, to evaluate the possible differences in the estimated foetal doses, a comparison of assessed dose values was made for three cases of pregnant patients that underwent different CT procedures. More than 120 professionals from 108 institutions and 17 countries that are involved in managing pregnant patients undergoing DIR procedures answered the questionnaire. Most of the respondents use national or hospital guidelines on the management of pregnant patients undergoing DIR procedures. However, the guidelines differ considerably among respondents. Comparison of foetal dose assessments performed by dosimetry experts showed the variety of methods used as well as large variability of estimated foetal doses in all three cases. Although European and International commission on radiation protection guidelines already exist, they are more than 20 years old and, in some aspects, they are obsolete. This paper shows that there is a need to revise and update these guidelines.

Reconstruction and Validation of Arterial Geometries for Computational Fluid Dynamics Using Multiple Temporal Frames of 4D Flow-MRI Magnitude Images

PURPOSE

Segmentation and reconstruction of arterial blood vessels is a fundamental step in the translation of computational fluid dynamics (CFD) to the clinical practice. Four-dimensional flow magnetic resonance imaging (4D Flow-MRI) can provide detailed information of blood flow but processing this information to elucidate the underlying anatomical structures is challenging. In this study, we present a novel approach to create high-contrast anatomical images from retrospective 4D Flow-MRI data.

METHODS

For healthy and clinical cases, the 3D instantaneous velocities at multiple cardiac time steps were superimposed directly onto the 4D Flow-MRI magnitude images and combined into a single composite frame. This new Composite Phase-Contrast Magnetic Resonance Angiogram (CPC-MRA) resulted in enhanced and uniform contrast within the lumen. These images were subsequently segmented and reconstructed to generate 3D arterial models for CFD. Using the time-dependent, 3D incompressible Reynolds-averaged Navier-Stokes equations, the transient aortic haemodynamics was computed within a rigid wall model of patient geometries.

RESULTS

Validation of these models against the gold standard CT-based approach showed no statistically significant inter-modality difference regarding vessel radius or curvature (p > 0.05), and a similar Dice Similarity Coefficient and Hausdorff Distance. CFD-derived near-wall hemodynamics indicated a significant inter-modality difference (p > 0.05), though these absolute errors were small. When compared to the in vivo data, CFD-derived velocities were qualitatively similar.

CONCLUSION

This proof-of-concept study demonstrated that functional 4D Flow-MRI information can be utilized to retrospectively generate anatomical information for CFD models in the absence of standard imaging datasets and intravenous contrast.

Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond

Interventional radiology (IR) plays a unique and often invaluable role in the care of pregnant patients. Special considerations regarding radiation exposure and medication choice must be taken into account when evaluating a pregnant patient for an interventional procedure. In addition, the physiologic changes that occur during pregnancy can pose special challenges for an interventionalist when treating this patient population and should be appropriately recognized. Still, the majority of standard IR procedures can be safely performed in the pregnant population, often with additional precautions and proper patient education about the risks, benefits, and alternatives. In many cases, interventional radiologists can provide lifesaving and fertility-preserving alternatives to more invasive surgical intervention. The authors summarize radiation exposure effects and guidelines and medication choice during pregnancy. The physiologic changes that occur during pregnancy are discussed, with specific interest in the pathologic consequences that can be treated with IR. The authors also describe a wide variety of minimally invasive image-guided procedures offered by IR in pregnant, peripartum, or postpartum patients. The areas where IR can help in the treatment of pregnant patients include venous access, biopsies, genitourinary and biliary interventions, venous thromboembolism treatments, ectopic pregnancy management, aneurysm intervention, and management of trauma patients. IR is also involved in management during the peripartum or postpartum periods, with roles in treatment of invasive placenta spectrum, postpartum hemorrhage after vaginal delivery, and postcesarean delivery complications. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

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.

Management of the Pregnant Trauma Patient: A Systematic Literature Review

INTRODUCTION

Trauma during pregnancy is the leading cause of non-obstetric maternal death and complicates up to 5%-7% of pregnancies. This systematic review without meta-analysis explores the current literature regarding the assessment and management of pregnant trauma patients to provide evidence-based recommendations to guide the general surgeon regarding the prognostic value of laboratory testing including Kleihauer-Betke testing, duration of maternal and fetal monitoring, the use of tranexamic acid, the safety of radiographic studies, and the utility of perimortem cesarean section to improve maternal and fetal mortality.

MATERIALS AND METHODS

A systematic search of MEDLINE (Ovid), the Cochrane Library (Wiley), and Embase (Elsevier) was performed. The reference lists of included studies were reviewed for relevant citations.

RESULTS

Of the 45 studies included in this review, there was reasonable evidence to suggest that the minimally injured pregnant trauma patient should be observed for a minimum of 4 h, CT scans to rule out traumatic injury are necessary and safe, perimortem cesarean sections should be performed as soon as maternal cardiac arrest occurs.

CONCLUSIONS

We recommend delivery by perimortem cesarean section as soon as possible after maternal cardiac arrest, to provide TXA to the hemorrhaging pregnant trauma patient, to obtain trauma CT scans as indicated, and to observe the injured pregnant patient for a minimum of at least 4 h. Additional high-quality studies focusing on the prognostic potential of KB tests and other laboratory studies are needed.

Brain cortical maturation assessed by magnetic resonance imaging in unaffected or mildly affected fetuses with cytomegalovirus infection

OBJECTIVES

To assess by magnetic resonance imaging (MRI) the cortical maturation pattern in fetuses with cytomegalovirus (CMV) infection with mild or no abnormalities on ultrasound (US) and MRI, and to establish possible differences compared with healthy controls.

METHODS

This was a retrospective case-control study of consecutive pregnancies with a CMV-infected fetus undergoing prenatal MRI as a complementary diagnostic tool in two centers, and a control group of singleton low-risk pregnancies without fetal structural abnormalities, with normal fetal growth and with healthy newborns. CMV infection was confirmed by extraction of CMV-DNA from fetal and neonatal samples. Only fetuses with mild (mildly affected) or no (unaffected) neuroimaging abnormalities on US and MRI were included. MRI measurements of fetal parieto-occipital sulcus, cingulate sulcus and calcarine sulcus depth, Sylvian fissure depth and Sylvian fissure angles were performed and cortical development grading of specific cortical areas and sulci were assessed by one operator who was blinded to CMV infection status. Data were compared between controls and fetuses with CMV infection, using linear regression and non-parametric trend analysis.

RESULTS

Twenty-four CMV-infected fetuses (seven unaffected and 17 mildly affected) and 24 healthy controls that underwent fetal MRI between 27 and 36 weeks' gestation were included. Compared with controls, CMV-infected fetuses showed significantly larger median lateral ventricular width (right side, 7.8 (interquartile range (IQR), 5.9-9.9) mm vs 3.9 (IQR, 2.6-5.3) mm; left side, 7.5 (IQR, 6.0-10.9) mm vs 4.2 (IQR, 3.2-5.3) mm), significantly decreased parieto-occipital sulcus depth (right side, 12.6 (IQR, 11.3-13.5) mm vs 15.9 (IQR, 13.5-17.3) mm; left side, 12.3 (IQR, 10.6-13.5) mm vs 16.0 (IQR, 13.3-17.5) mm) and calcarine sulcus depth (right side, 15.4 (IQR, 14.4-16.3) mm vs 17.5 (IQR, 16.1-18.7) mm; left side, 14.6 (IQR, 14.1-15.6) mm vs 16.7 (IQR, 15.6-18.9) mm) (P < 0.001 for all). Compared with controls, CMV-infected fetuses also had significantly smaller upper (right side, 42.8° (IQR, 35.8-45.8°) vs 48.9° (IQR, 38.4-64.7°); left side, 40.9° (IQR, 34.2-45.8°) vs 48.2° (IQR, 41.9-60.7°)) and lower (right side, 41.6° (IQR, 34.4-49.2°) vs 48.9° (IQR, 40.6-60.9°); left side, 42.2° (IQR, 38.8-46.9°) vs 48.9° (IQR, 39.5-57.5°)) Sylvian fissure angles (P < 0.05 for all). In addition, the mildly affected CMV-infected fetuses had a significantly lower cortical development grading in the temporal and parietal areas, and the parieto-occipital and calcarine sulci compared with healthy fetuses (P < 0.05). These differences persisted when adjusting for gestational age, ipsilateral atrium width, fetal gender and when considering small-for-gestational age as a confounding factor.

CONCLUSIONS

Unaffected and mildly affected CMV-infected fetuses showed delayed cortical maturation compared with healthy controls. These results suggest that congenital CMV infection, even in non-severely affected fetuses that are typically considered of good prognosis, could be associated with altered brain cortical structure. Further research is warranted to better elucidate the correlation of these findings with neurodevelopmental outcomes. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Medicolegal considerations associated with cancer during pregnancy

The management of pregnant patients with cancer is complex and requires a multidisciplinary team to effectively diagnose, stage, and manage the cancer while also being cognizant of the potential harm that diagnosis and treatment may have on the maternal and fetal well-being. Beyond the complex clinical management of these patients is additional medicolegal consideration. Radiologists play a crucial role in the management of these patients as their knowledge of diagnostic and interventional radiology techniques allows for appropriate and safe imaging for both the mother and fetus. In addition, radiologist are able to educate patient on the different imaging modalities and techniques, thus allowing patients to make informed decisions and maintain autonomy over there care. This article will review safety considerations associated with different imaging modalities, contrast agents, interventional radiology procedures and moderate sedation related to the imaging of pregnant patient with cancer with specific attention paid to the medicolegal aspects.

Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.

Management of pulmonary nodules in women with pregnant intention: A review with perspective

The process for the management of pulmonary nodules in women with pregnant intention remains a challenge. There was a certain proportion of targeted female patients with high-risk lung cancer, and anxiety for suspicious lung cancer in early stage also exists. A comprehensive review of hereditary of lung cancer, effects of sexual hormone on lung cancer, natural history of pulmonary nodules, and computed tomography imaging with radiation exposure based on PubMed search was completed. The heredity of lung cancer and effects of sexual hormone on lung cancer are not the decisive factors, and the natural history of pulmonary nodules and the radiation exposure of imaging should be the main concerns. The management of incidental pulmonary nodules in young women with pregnant intention is an intricate and indecisive problem we have to encounter. The balance between the natural history of pulmonary nodules and the radiation exposure of imaging should be weighed.

Australian inflammatory bowel disease consensus statements for preconception, pregnancy and breast feeding

OBJECTIVE

Because pregnancy outcomes tend to be worse in women with inflammatory bowel disease (IBD) than in those without, we aimed to update consensus statements that guide the clinical management of pregnancy in patients with IBD.

DESIGN

A multidisciplinary working group was established to formulate these consensus statements. A modified RAND/UCLA appropriateness method was used, consisting of a literature review, online voting, discussion meeting and a second round of voting. The overall agreement among the delegates and appropriateness of the statement are reported.

RESULTS

Agreement was reached for 38/39 statements which provide guidance on management of pregnancy in patients with IBD. Most medications can and should be continued throughout pregnancy, except for methotrexate, allopurinol and new small molecules, such as tofacitinib. Due to limited data, no conclusion was reached on the use of tioguanine during pregnancy. Achieving and maintaining IBD remission before conception and throughout pregnancy is crucial to optimise maternofetal outcomes. This requires a multidisciplinary approach to engage patients, allay anxieties and maximise adherence tomedication. Intestinal ultrasound can be used for disease monitoring during pregnancy, and flexible sigmoidoscopy or MRI where clinically necessary.

CONCLUSION

These consensus statements provide up-to-date, comprehensive recommendations for the management of pregnancy in patients with IBD. This will enable a high standard of care for patients with IBD across all clinical settings.

Chest Pain in Women: Considerations from the 2021 AHA/ACC Chest Pain Guideline

Chest pain is a common concern of women evaluated in both the inpatient and outpatient setting. There are significant differences in pathophysiology when comparing coronary artery disease (CAD) in women and men, including a higher prevalence of non-obstructive CAD. Furthermore, significant sex disparities exist in the care of women with acute coronary syndromes that stem from factors such as delays in diagnosis and inconsistencies in treatment. The 2021 AHA/ACC/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain is an important document comprised of recommendations for the assessment of acute and stable chest pain. In this review, we discuss key points from the guideline in the context of evaluating chest pain in women. We discuss the similarities and differences of chest pain presentation between the sexes, evaluation of chest pain in patients with known nonobstructive CAD and ischemia with no obstructive coronary arteries, and considerations for cardiac imaging during pregnancy.

Acute Ischemic Stroke in Pregnancy : A Practical Focus on Neuroimaging and Reperfusion Therapy

INTRODUCTION

Pregnancy increases the risk of acute ischemic stroke (AIS) among young women and is responsible for about 5% of maternal deaths and significant disability. Concerns of potential adverse events of imaging and reperfusion therapies in this group of patients can lead to a substantial delay or omission of treatment that can significantly worsen outcomes.

OBJECTIVE

The objective of this study is to discuss main concerns of diagnosis and therapy of pregnant patients with AIS regarding neuroimaging and reperfusion treatment.

RESULTS

The cumulative radiation dose of computed tomography (CT)-based entire diagnostic procedure (noncontrast CT, CT-angiography and CT-perfusion) is estimated to be below threshold for serious fetal radiation exposure adverse events. Similarly, magnetic resonance imaging(MRI)-based imaging is thought to be safe as long as gadolinium contrast media are avoided. The added risk of intravenous thrombolysis (IVT) and mechanical thrombectomy during pregnancy is thought to be very low. Nevertheless, some additional safety measures should be utilized to reduce the risk of radiation, contrast media and hypotension exposure during diagnostic procedures or reperfusion treatment.

CONCLUSION

Fetal safety concerns should not preclude routine diagnostic work-up (except for gadolinium contrast media administration) in childbearing AIS women, including procedures applied in unknown onset and late onset individuals. Due to rather low added risk of serious treatment complications, pregnancy should not be a sole contraindication for neither IVT, nor endovascular treatment.

Dose Reduction Strategies for Pregnant Women in Emergency Settings

In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman's pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.

The why, who, how, and what of communicating CT radiation risks to patients and healthcare providers

Computed tomography (CT) has witnessed tremendous growth in utilization. Despite its immense benefits, there is a growing concern from the general public and the medical community about the detrimental consequences of ionizing radiation from CT. Anxiety from the perceived risks associated with CT can deter referring physicians from ordering clinically indicated CT scans and patients from undergoing medically necessary exams. This article discusses various strategies for educating patients and healthcare providers on the benefits and risks of CT scanning and salient techniques for effective communication.

Medical microrobots in reproductive medicine from the bench to the clinic

Medical microrobotics is an emerging field that aims at non-invasive diagnosis and therapy inside the human body through miniaturized sensors and actuators. Such microrobots can be tethered (e.g., smart microcatheters, microendoscopes) or untethered (e.g., cell-based drug delivery systems). Active motion and multiple functionalities, distinguishing microrobots from mere passive carriers and conventional nanomedicines, can be achieved through external control with physical fields such as magnetism or ultrasound. Here we give an overview of the key challenges in the field of assisted reproduction and how these new technologies could, in the future, enable assisted fertilization in vivo and enhance embryo implantation. As a case study, we describe a potential intervention in the case of recurrent embryo implantation failure, which involves the non-invasive delivery of an early embryo back to the fertilization site using magnetically-controlled microrobots. As the embryo will be in contact with the secretory oviduct fluid, it can develop under natural conditions and in synchrony with the endometrium preparation. We discuss the potential microrobot designs, including a proper selection of materials and processes, envisioning their translation from bench to animal studies and human medicine. Finally, we highlight regulatory and ethical considerations for bringing this technology to the clinic.

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.

Management of COVID-19 Infection in Pregnancy

Although the majority of pregnant patients who contract severe acute respiratory syndrome coronavirus 2 will have a mild course of illness, pregnant patients with coronavirus disease-2019 are more likely than their nonpregnant counterparts to develop a severe illness with an increased risk of poor maternal and fetal outcomes. Although the extent of research in this specific patient population remains limited, there are tenets of care with which physicians and other providers must be familiar to increase the chances of better outcomes for the two patients in their care.

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.

Multimodality Imaging in the Detection of Ischemic Heart Disease in Women

Women with coronary artery disease tend to have a worse short and long-term prognosis relative to men and the incidence of atherosclerotic cardiovascular disease is increasing. Women are less likely to present with classic anginal symptoms when compared with men and more likely to be misdiagnosed. Several non-invasive imaging modalities are available for diagnosing ischemic heart disease in women and many of these modalities can also assist with prognostication and help to guide management. Selection of the optimal imaging modality to evaluate women with possible ischemic heart disease is a scenario which clinicians often encounter. Earlier modalities such as exercise treadmill testing demonstrate significant performance variation in men and women, while newer modalities such as coronary CT angiography, myocardial perfusion imaging and cardiac magnetic resonance imaging are highly specific and sensitive for the detection of ischemia and coronary artery disease with greater parity between sexes. Individual factors, availability, diagnostic performance, and female-specific considerations such as pregnancy status may influence the decision to select one modality over another. Emerging techniques such as strain rate imaging, CT-myocardial perfusion imaging and cardiac magnetic resonance imaging present additional options for diagnosing ischemia and coronary microvascular dysfunction.

Supporting Lactation in Otolaryngology Patients Through Medication Optimization, Radiology Considerations, and More: A Literature Review

Importance

The benefits of breastfeeding are well established, with the American Academy of Pediatrics and Canadian guidelines recommending exclusive breastfeeding for the first 6 months of life. However, maternal hospitalization, illness, medication use, and poor support can result in early termination of breastfeeding. Caring for breastfeeding patients in otolaryngology is a challenge because of the lack of literature regarding otolaryngology-specific medication safety, patient concerns, and inadequate education among otolaryngologists. This review highlights recent literature regarding lactation in otolaryngology patients, including medication, radiologic imaging, perioperative considerations, and subspecialty-specific considerations for lactating patients.

Observations

The majority of common medications used in general otolaryngology are safe for breastfeeding patients, including antihistamines, mucolytics, antitussives, antifungals, and decongestants. Certain analgesics and anti-inflammatories, such as tramadol, are not preferred in breastfeeding individuals. Some subspeciality-specific medications such as biologics (dupilumab) and methotrexate should be avoided. Lactating patients require special perioperative attention to ensure that optimal patient care is provided, such as managing supply, considering length of surgery, managing postoperative pain, and determining the safe amount of time until an infant can be fed.

Conclusions and Relevance

Most medications can be safely used with lactating patients. If physicians are unsure about a medication's safety, they should consult appropriate resources prior to recommending breastfeeding cessation or to discard pumped milk.

Role of MRI and CT in the Evaluation of Headache in Pregnancy and the Postpartum Period

Approximately 35% of acute headaches in pregnant women are secondary to an underlying condition. Headaches are also common in the postpartum period where they occur in 30% to 40% of patients. The majority of secondary headaches are due to hypertensive disorders: preeclampsia-eclampsia, posterior reversible encephalopathy syndrome, and acute arterial hypertension. Other causes include reversible cerebral vasoconstriction syndrome and pituitary apoplexy, as well as life-threatening conditions such as cerebral venous thrombosis. In this article, we review general recommendations for imaging the pregnant patients and discuss the imaging findings of common causes of headaches in pregnancy and the postpartum period.

Neuroimaging of Headache: Indications and Controversies

Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.

Imaging Cancer in Pregnancy

Pregnancy-associated cancer (PAC) is defined as cancer that is detected during pregnancy and up to 1 year postpartum. Although rare (~1:1000 pregnancies), PAC is increasing owing to postponed childbearing and advanced maternal age at conception. Cancer-related symptoms masked by physiologic gestational changes may delay diagnosis. Imaging, clinical management, and treatment require a carefully choreographed multidisciplinary team approach. The risk-benefit of every imaging modality, the strategies to balance the safety of mother and fetus, and the support of the patient and family at every step are crucial. US and MRI are preferred imaging modalities that lack ionizing radiation. Radiation dose concerns should be addressed, noting that most imaging examinations (including mammography, radiography, CT, and technetium 99m-labeled sulfur colloid sentinel lymph node staging) are performed at radiation levels below thresholds at which deterministic side effects are seen. Dose estimates should be provided after each examination. The use of iodinated intravenous contrast material is safe during pregnancy, but gadolinium-based contrast material should be avoided. Accurate diagnosis and staging combined with gestational age affect decisions about surgery and chemotherapy. Whole-body MRI with diffusion-weighted sequences is ideal to screen for primary and metastatic sites, determine disease stage, identify biopsy targets, and guide further cancer site-specific imaging. The authors provide an update of the imaging triage, safety considerations, cancer-specific imaging, and treatment options for cancer in pregnancy. An invited commentary by Silverstein and Van Loon is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

Challenges in management of gastrointestinal cancers in pregnancies: A report of three cases

Gastrointestinal cancer occurs in approximately 1 in 13,000 pregnancies, making up 4% of malignancies detected in pregnancy. It is a complex and challenging condition to diagnose and manage and is often only detected in its more advanced stages. This is partly due to symptoms of gastrointestinal cancer being incorrectly attributed to physiological symptoms of pregnancy, as well as concerns about the safety of diagnostic investigations in pregnancy, both of which may delay diagnosis and lead to disease progression. Challenges in management also arise from under-treatment in pregnancy due to concerns about the impact of surgery or chemotherapy on the pregnancy. We present here three cases of gastrointestinal cancer diagnosed in pregnancy in our centre and discuss the challenges and pitfalls one may encounter in the diagnosis and management of gastrointestinal malignancies in pregnancy.

Prevalence of supratentorial anomalies assessed by magnetic resonance imaging in fetuses with open spina bifida

OBJECTIVES

To determine the prevalence of brain anomalies at the time of preoperative magnetic resonance imaging (MRI) assessment in fetuses eligible for prenatal open spina bifida (OSB) repair, and to explore the relationship between brain abnormalities and features of the spinal defect.

METHODS

This was a retrospective cross-sectional study, conducted in three fetal medicine centers, of fetuses eligible for OSB fetal surgery repair between January 2009 and December 2019. MRI images obtained as part of the presurgical assessment were re-evaluated by two independent observers, blinded to perinatal results, to assess: (1) the type and area of the defect and its anatomical level; (2) the presence of any structural central nervous system (CNS) anomaly and abnormal ventricular wall; and (3) fetal head and brain biometry. Binary regression analyses were performed and data were adjusted for type of defect, upper level of the lesion (ULL), gestational age (GA) at MRI and fetal medicine center. Multiple logistic regression analysis was performed in order to identify lesion characteristics and brain anomalies associated with a higher risk of presence of abnormal corpus callosum (CC) and/or heterotopia.

RESULTS

Of 115 fetuses included, 91 had myelomeningocele and 24 had myeloschisis. Anatomical level of the lesion was thoracic in seven fetuses, L1-L2 in 13, L3-L5 in 68 and sacral in 27. Median GA at MRI was 24.7 (interquartile range, 23.0-25.7) weeks. Overall, 52.7% of cases had at least one additional brain anomaly. Specifically, abnormal CC was observed in 50.4% of cases and abnormality of the ventricular wall in 19.1%, of which 4.3% had nodular heterotopia. Factors associated independently with higher risk of abnormal CC and/or heterotopia were non-sacral ULL (odds ratio (OR), 0.51 (95% CI, 0.26-0.97); P = 0.043), larger ventricular width (per mm) (OR, 1.23 (95% CI, 1.07-1.43); P = 0.005) and presence of abnormal cavum septi pellucidi (OR, 3.76 (95% CI, 1.13-12.48); P = 0.031).

CONCLUSIONS

Half of the fetuses assessed for OSB repair had an abnormal CC and/or an abnormal ventricular wall prior to prenatal repair. The likelihood of brain abnormalities was increased in cases with a non-sacral lesion and wider lateral ventricles. These findings highlight the importance of a detailed preoperative CNS evaluation of fetuses with OSB. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Beyond the BMI: Validity and Practicality of Postpartum Body Composition Assessment Methods during Lactation: A Scoping Review

The assessment of body composition during lactation is an important indicator of maternal nutritional status, which is central to the overall health of the mother and child. The lactating woman’s nutritional status potentially impacts on breastmilk composition and the process of lactation itself. The purpose of this scoping review was to synthesize comparative studies that sought to validate various body composition assessment techniques for use in lactating women in the postpartum period. Using the PRISMA-ScR guidelines, a comprehensive, systematic literature search was conducted using Scopus, Web of Science, and PubMed. Eight comparative studies were included in the review, with data from 320 postpartum women. The design methodologies varied substantially across studies, and included a range of simple techniques to advanced multi-compartment models for assessing body composition. The validity and reliability of measurement tools must be considered alongside issues of safety, practicality, and appropriateness to guide the research design when applied to lactating women.

Factors affecting spine–femur discordance in the percentage of young adult mean on dual-energy X-ray absorptiometry in the elderly population: a retrospective study

Background

Several retrospective studies have reported spine–femur discordance in bone mineral density (BMD) values. However, the average age of individuals in these studies was the mid-50s, which is younger than the typical age of individuals requiring treatment for primary osteoporosis. Therefore, we aimed to investigate factors associated with discordance in the percentage of young adult mean (YAM) between the lumbar spine and femoral neck in the elderly population.

Methods

We evaluated 4549 dual-energy X-ray absorptiometry (DXA) measurements obtained from 2161 patients (269 men and 1892 women) between January 2014 and December 2017 at our hospital. For individuals with more than one eligible set of measurements, the first record was used. We investigated each patient’s age, sex, body mass index, current smoking status, alcohol consumption, use of steroids, presence of diabetes mellitus, and presence of rheumatoid arthritis.

Results

The mean age of the patients was 76.4 ± 8.9 years. Older age (p <  0.001), male sex (p <  0.001), and diabetes mellitus (p = 0.007) were significantly associated with spine–femur discordance in the percentage of YAM.

Conclusion

The frequency and magnitude of spine–femur discordance in the percentage of YAM from DXA scans increased with age. Notably, more than 77.4% of patients in their 90s had spine–femur discordance > 10% of YAM. Furthermore, the frequency of spine–femur discordance was higher in men and in patients with diabetes mellitus, suggesting that the percentage of YAM at the lumbar spine may not be reliable for diagnosis of osteoporosis in patients with these factors.

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.

Clinical Decision Making in the Management of Breast Cancer Diagnosed During Pregnancy: A Review and Case Series Analysis

Purpose: To highlight the various options available for the management of breast cancer diagnosed during pregnancy by describing the investigations, treatment, and outcomes in relation to these women. Methods: This is a narrative review of the literature to describe the issues related to pregnancy and obstetric management in patients with breast cancer. It incorporates a description of six cases of women (aged 29-39 years) with a first-time diagnosis of breast cancer during pregnancy to illustrate a number of issues that need to be considered during different trimesters. Results: Of the six cases, two were diagnosed in each pregnancy trimester. A painless breast mass was the presenting symptom in five cases (83%). In all cases, breast ultrasound was the primary diagnostic imaging procedure. Chest X-ray was performed in 3 (50%) and computed tomography in 2 (33%). A core needle biopsy was performed in all cases, and sentinel lymph node biopsy in 3 (50%) cases. Four women had grade 3 tumor; five had estrogen receptor-positive tumors. Four women had breast surgery during pregnancy. Five women gave birth after the induction of labor and/or cesarean section. In all six cases, a multidisciplinary team was involved in the delivery of health care. Conclusion: Regular breast examinations are needed for all pregnant woman during prenatal visits. Breast ultrasonography should be offered if a breast lump or other symptoms are detected. Breast surgery can be safely performed during all pregnancy trimesters, and some systemic therapeutic agents can be administered safely in the second and third trimesters.

Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management

Rectal bleeding is a common symptom experienced by pregnant women. Although the majority of cases are attributable to benign conditions such as haemorrhoids and anal fissures, other more serious diagnoses such as inflammatory bowel disease and malignancy should not be overlooked. Most investigations are safe during pregnancy and these should not be withheld as significant implications on both fetal and maternal morbidity may result. In these cases, a multidisciplinary team approach is essential. This review explores the differential diagnosis, investigation and management of rectal bleeding during pregnancy.

The Value of Targeted Ultrasound for the Primary Evaluation of Breast Symptoms in Pregnant Women of All Ages

OBJECTIVE

Data on breast imaging in symptomatic pregnant women are limited. Our aim was to assess the value of targeted breast US for the primary evaluation of breast symptoms in pregnant women of all ages.

METHODS

This IRB-approved retrospective study included all pregnant patients who underwent targeted US for focal breast symptoms at an academic imaging facility over an 18-year period (2000-2018). Clinical, imaging, and pathology results were reviewed. Malignant outcomes were determined by histology. Benign outcomes were confirmed by pathology or ≥2 years of follow-up. Descriptive statistics and 2 × 2 contingency table analyses were performed at the presentation level.

RESULTS

The study cohort comprised 178 presentations in 175 pregnant women. Mean age was 34.7 years (standard deviation, 5.2). The majority (153/178, 86.0%) were more than 30 years old. At presentation, 42.1% (75/178) were in the first trimester of pregnancy, 27.0% (48/178) in the second, and 29.8% (53/178) in the third. The most common presenting symptom was a palpable lump (162/178, 91.0%), followed by focal pain (7/178, 3.9%). The vast majority (174/178, 97.8%) of cases were non-malignant. However, targeted US detected all 4 malignancies (cancer detection rate, 22/1000; negative predictive value 136/136, 100%). Sensitivity and specificity were 100% (4/4) and 78.2% (136/174), respectively.

CONCLUSION

Benign causes of symptoms in pregnant women were far more common; malignancy was rare, accounting for only 2.2% (4/178) of cases. Targeted breast US detected all malignancies, supporting US as the primary imaging modality for evaluating symptomatic pregnant women, regardless of age.

Controversies in Hereditary Cancer Management

Personalized management of patients at risk ideally should involve a multidisciplinary team of not only genetic counselors and surgeons, but also women's health or menopause specialists, knowledgeable psychologists, and primary care providers or obstetrician-gynecologists aware of the risks and fears "previvors" (survivors of a predisposition to cancer who have not had the disease) face as well as the issues that are common postoperatively. Identification of patients at risk for hereditary cancer, understanding of current genetic testing modalities and potential results, knowledge about screening and prevention including timing of surveillance, preventive medication and risk-reducing surgeries, understanding limitations and comorbidities associated with these risk management strategies and long-term psychological support are all important in hereditary cancer management. We describe issues surrounding the identification of the high-risk patient, universal testing in breast and ovarian cancer, and testing in special populations. We describe a simplified approach to understanding and communicating genetic testing results and nuances of testing including direct-to-consumer testing. We highlight concerns surrounding breast cancer screening during pregnancy and lactation. A framework for practical management and counseling of women who opt for risk-reducing salpingo-oophorectomy or risk-reducing mastectomy or both is provided. We provide an in-depth discussion of questions that arise in relation to timing of surgery, fertility preservation, management of menopausal symptoms, and surgical technique. Alternative choices in women who choose to delay bilateral salpingo-oophorectomy are reviewed. Finally, the psychosocial effects of carrying a genetic mutation and the issues that women face when undergoing to risk-reducing surgery including adjustment, sexuality issues, and cosmesis are addressed.

Diagnostic Imaging and Outcomes for Nonobstetric Surgery During Pregnancy

A surgical disease occurring during pregnancy can present a diagnostic dilemma due to the desire to make a timely and accurate diagnosis within the constraints of limiting radiation exposure to the fetus. However, required diagnostic imaging should be pursued when indicated and attempts made to minimize the radiation dose by utilizing abdominal shielding and low-dose protocols when feasible. When surgery is indicated due to disease processes, treatment should not be altered or delayed due to pregnancy as the evidence for adverse pregnancy outcomes including early pregnancy loss and preterm delivery are overall of low quality due to substantial confounding by the disease process itself.

Neuroimaging During Pregnancy and the Postpartum Period

New onset or exacerbation of preexisting neurologic symptoms during pregnancy often necessitates brain or spinal cord imaging. Magnetic resonance techniques are preferred imaging modalities during pregnancy and the postpartum period. Ionizing radiation with computed tomography and intravenous contrast material with magnetic resonance or computed tomography should be avoided during pregnancy. New onset of headaches in the last trimester or in the postpartum period may indicate cerebrovascular disease or a mass lesion, for which brain imaging is necessary. The continuum of cerebrovascular complications of pregnancy and enlarging lesions may produce neurologic symptoms later in pregnancy and after delivery, necessitating imaging.