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Wang Z, Yu X, Ding S, Zhang W, Liang C, Chen H. Management and outcomes of aortic dissection type B in late pregnancy: A retrospective case series. BJOG 2024. [PMID: 39075929 DOI: 10.1111/1471-0528.17923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Pregnancy complicated with type B aortic dissection is a rare but devastating condition. Guidelines for managing this condition are lacking. We present our observation and experiences in managing five pregnant women with complicated type B aortic dissection in the second or third trimesters, aiming to gain insights that can aid in proposing an appropriate management strategy. DESIGN A retrospective study. SETTING Zhongnan Hospital of Wuhan University. POPULATION Pregnant women with complicated type B aortic dissection. METHODS Clinical data of five pregnant women with complicated type B aortic dissection admitted to Zhongnan Hospital of Wuhan University from January 2022 to June 2023 were collected. The clinical characteristics, treatment strategies, and corresponding maternal and infant outcomes were retrospectively analysed. MAIN OUTCOME MEASURES Survival of mothers and foetuses. RESULTS All five study participants were diagnosed with complicated type B aortic dissection by computed tomography angiography (CTA). The range of gestational weeks at admission was 27 weeks + 3 days to 36 weeks + 6 days. The first patient, planning a caesarean section (C-section) followed by thoracic endovascular aortic repair (TEVAR), died of aortic dissection rupture during C-section. Her neonate was successfully rescued. In contrast, the remaining four patients who underwent TEVAR first survived. Among them, three patients underwent single-stage aortic repair and delivery, while one patient received C-section 31 days after TEVAR. Three preterm live births were recorded among these surviving mothers. Neonatal death occurred in one case with a gestational age of 29 weeks + 5 days, who had foetal distress before surgery. During the follow-up period of up to 3 months, no maternal or infant death occurred. No device-related or systemic complications were observed in the surviving mothers after discharge. Routine physical examinations of the four live births showed no abnormalities. CONCLUSIONS For pregnant women with thoracic back pain and high suspicion of aortic dissection, CTA should be conducted promptly to prevent missed or delayed diagnosis. Maternal survival should be prioritised over foetal outcome once diagnosed. TEVAR was demonstrated to be safe and feasible for such patients. For women with complicated type B aortic dissection in late pregnancy, TEVAR followed by C-section may be a promising treatment strategy.
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Affiliation(s)
- Zhen Wang
- Department of Obstetrics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, Hubei, China
| | - Xuechen Yu
- Department of Obstetrics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, Hubei, China
| | - Shuai Ding
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Zhang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Chuan Liang
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Huijun Chen
- Department of Obstetrics, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Clinical Medicine Research Centre of Prenatal Diagnosis and Birth Health in Hubei Province, Wuhan, Hubei, China
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Faj D, Bassinet C, Brkić H, De Monte F, Dreuil S, Dupont L, Ferrari P, Gallagher A, Gallo L, Huet C, Knežević Ž, Kralik I, Krstić D, Maccia C, Majer M, Malchair F, O'Connor U, Pankowski P, Sans Merce M, Sage J, Simantirakis G. Management of pregnant or potentially pregnant patients undergoing diagnostic and interventional radiology procedures: Investigation of clinical routine practice. Phys Med 2023; 115:103159. [PMID: 37852021 DOI: 10.1016/j.ejmp.2023.103159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/26/2023] [Accepted: 10/01/2023] [Indexed: 10/20/2023] Open
Abstract
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.
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Affiliation(s)
- Dario Faj
- Faculty of Medicine, J. J. Strossmayer University of Osijek, J. Huttlera 4, Osijek, Croatia; Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Crkvena 21, Osijek, Croatia
| | - Céline Bassinet
- Institute for Radiation Protection and Nuclear Safety, 31 avenue de la division Leclerc, Fontenay-aux-Roses, France
| | - Hrvoje Brkić
- Faculty of Medicine, J. J. Strossmayer University of Osijek, J. Huttlera 4, Osijek, Croatia; Faculty of Dental Medicine and Health, J. J. Strossmayer University of Osijek, Crkvena 21, Osijek, Croatia.
| | | | - Serge Dreuil
- Institute for Radiation Protection and Nuclear Safety, 31 avenue de la division Leclerc, Fontenay-aux-Roses, France
| | - Laura Dupont
- University Hospital of Geneva, Geneva, Switzerland
| | | | | | - Lara Gallo
- Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Christelle Huet
- Institute for Radiation Protection and Nuclear Safety, 31 avenue de la division Leclerc, Fontenay-aux-Roses, France
| | | | - Ivana Kralik
- Dubrava University Hospital, Avenija Gojka Suska 6, Zagreb, Croatia
| | - Dragana Krstić
- University of Kragujevac, Faculty of Science, R. Domanovica 12, 34000 Kragujevac, Serbia
| | | | - Marija Majer
- Ruđer Boškovć Institute, Bijenička 54, Zagreb, Croatia
| | | | - Una O'Connor
- Medical Physics & Bioengineering Dept, St. James's Hospital, Dublin, Ireland
| | - Piotr Pankowski
- Faculty of Physics and Applied Informatics, University of Lodz, Pomorska St. 149/153, 90-236 Lodz, Poland
| | | | - Julie Sage
- Institute for Radiation Protection and Nuclear Safety, 31 avenue de la division Leclerc, Fontenay-aux-Roses, France
| | - George Simantirakis
- Greek Atomic Energy Commission, P.O. Box 60092, 153 10, Agia Paraskevi, Athens, Greece
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Constantin A, Constantin R, Achim F, Socea B, Predescu D. Pregnancy and Gastric Cancer: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13111909. [PMID: 37296761 DOI: 10.3390/diagnostics13111909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Adrian Constantin
- Department of Esophageal and General Surgery, Sf. Maria Clinical Hospital Bucharest, 011192 Bucharest, Romania
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania
| | - Roxana Constantin
- Department of Obstetrics and Gynecology, Sanador Hospital, 010991 Bucharest, Romania
| | - Florin Achim
- Department of Esophageal and General Surgery, Sf. Maria Clinical Hospital Bucharest, 011192 Bucharest, Romania
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania
| | - Bogdan Socea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania
- Department of Surgery, Sf. Pantelimon Emergency Clinical Hospital, 021659 Bucharest, Romania
| | - Dragos Predescu
- Department of Esophageal and General Surgery, Sf. Maria Clinical Hospital Bucharest, 011192 Bucharest, Romania
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 050474 Bucharest, Romania
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The why, who, how, and what of communicating CT radiation risks to patients and healthcare providers. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:1514-1525. [PMID: 36799998 DOI: 10.1007/s00261-022-03778-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 02/18/2023]
Abstract
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.
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Burton CS, Frey K, Fahey F, Kaminski MS, Brown RKJ, Pohlen JM, Shulkin BL. Fetal Dose from PET and CT in Pregnant Patients. J Nucl Med 2023; 64:312-319. [PMID: 36215573 DOI: 10.2967/jnumed.122.263959] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 02/04/2023] Open
Abstract
When pregnancy is discovered during or after a diagnostic examination, the physician or the patient may request an estimate of the radiation dose received by the fetus as per guidelines and standard operating procedures. This study provided the imaging community with dose estimates to the fetus from PET/CT with protocols that are adapted to University of Michigan low-dose protocols for patients known to be pregnant. Methods: There were 9 patients analyzed with data for the first, second, and third trimesters, the availability of which is quite rare. These images were used to calculate the size-specific dose estimate (SSDE) from the CT scan portion and the SUV and 18F-FDG uptake dose from the PET scan portion using the MIRD formulation. The fetal dose estimates were tested for correlation with each of the following independent measures: gestational age, fetal volume, average water-equivalent diameter of the patient along the length of the fetus, SSDE, SUV, and percentage of dose from 18F-FDG. Stepwise multiple linear regression analysis was performed to assess the partial correlation of each variable. To our knowledge, this was the first study to determine fetal doses from CT and PET images. Results: Fetal self-doses from 18F for the first, second, and third trimesters were 2.18 mGy (single data point), 0.74-1.82 mGy, and 0.017-0.0017 mGy, respectively. The combined SSDE and fetal self-dose ranged from 1.2 to 8.2 mGy. These types of images from pregnant patients are rare. Conclusion: Our data indicate that the fetal radiation exposure from 18F-FDG PET and CT performed, when medically necessary, on pregnant women with cancer is low. All efforts should be made to minimize fetal radiation exposure by modifying the protocol.
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Affiliation(s)
| | - Kirk Frey
- Michigan Medicine, Ann Arbor, Michigan
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7
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Bagou G, Sentilhes L, Mercier FJ, Berveiller P, Blanc J, Cesareo E, Dewandre PY, Douai B, Gloaguen A, Gonzalez M, Le Conte P, Le Gouez A, Madar H, Maisonneuve E, Morau E, Rackelboom T, Rossignol M, Sibiude J, Vaux J, Vivanti A, Goddet S, Rozenberg P, Garnier M, Chauvin A. Guidelines for the management of urgent obstetric situations in emergency medicine, 2022. Anaesth Crit Care Pain Med 2022; 41:101127. [PMID: 35940033 DOI: 10.1016/j.accpm.2022.101127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward. DESIGN A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded. METHODS Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method. RESULTS Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made. CONCLUSIONS There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.
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Affiliation(s)
- Gilles Bagou
- SAMU-SMUR of Lyon, University Hospital Edouard Herriot, Lyon, France.
| | - Loïc Sentilhes
- Gynaecology and Obstetrics Department, University Hospital Pellegrin, Bordeaux, France
| | - Frédéric J Mercier
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Antoine Béclère, Clamart, France
| | - Paul Berveiller
- Gynaecology and Obstetrics Department, CHI Poissy Saint-Germain, Poissy, France
| | - Julie Blanc
- Gynaecology and Obstetrics Department, University Hospital Hôpital Nord, Marseille, France
| | - Eric Cesareo
- SAMU-SMUR 69, University Hospital Hospices Civils de Lyon, Lyon, France
| | - Pierre-Yves Dewandre
- Department of Anaesthesiology and Critical Care Medicine, University hospital of Liège, Liège, Belgium
| | | | - Aurélie Gloaguen
- Emergency Department, Hospital William Morey, Chalon-sur-Saone, France
| | - Max Gonzalez
- Department of Anaesthesiology and Critical Care Medicine in Gynaecology and Obstetrics, University Hospital Jeanne de Flandre, Lille, France
| | | | - Agnès Le Gouez
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Antoine Béclère, Clamart, France
| | - Hugo Madar
- Gynaecology and Obstetrics Department, University Hospital Pellegrin, Bordeaux, France
| | | | - Estelle Morau
- Department of Anaesthesiology, Critical Care, Pain and Emergency, University hospital Carémeau, Nîmes, France
| | - Thibaut Rackelboom
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Pellegrin, Bordeaux, France
| | - Mathias Rossignol
- University Paris Cité - APHP Nord, Department of Anaesthesiology and Critical Care Medicine, University Hospital Lariboisière, Paris, France
| | - Jeanne Sibiude
- Gynaecology and Obstetrics Department, University Hospital Louis Mourier, Colombes, France
| | - Julien Vaux
- SMUR 94, University Hospital Henri Mondor, Créteil, France
| | - Alexandre Vivanti
- Gynaecology and Obstetrics Department, Antoine Béclère University Hospital, Clamart, France
| | - Sybille Goddet
- SAMU-SMUR 21 and Emergency Department, University Hospital of Dijon, Dijon, France
| | - Patrick Rozenberg
- Gynaecology and Obstetrics Department, CHI Poissy Saint-Germain, Poissy, France
| | - Marc Garnier
- Sorbonne University, GRC29, DMU DREAM, Department of Anesthesiology and Critical Care Medicine, Tenon University Hospital, Paris, France
| | - Anthony Chauvin
- SAMU-SMUR 75 and Emergency Department, Lariboisière University Hospital, Paris, France; Université de Paris, INSERM U942 MASCOT, Paris, France
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8
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Bagou G, Sentilhes L, Mercier FJ, Berveiller P, Blanc J, Cesareo E, Dewandre PY, Douay B, Gloaguen A, Gonzalez M, Le Conte P, Le Gouez A, Madar H, Maissonneuve E, Morau E, Rackelboom T, Rossignol M, Sibiude J, Vaux J, Vivanti A, Goddet S, Rozenberg P, Garnier M, Chauvin A. Recommandations de pratiques professionnelles 2022 Prise en charge des urgences obstétricales en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kobayashi M, Nishihara Y, Haba T, Matsunaga Y, Minami K, Asada Y. SIZE-SPECIFIC DOSE ESTIMATES IN FETAL COMPUTED TOMOGRAPHY. RADIATION PROTECTION DOSIMETRY 2022; 198:339-348. [PMID: 35482288 DOI: 10.1093/rpd/ncac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 06/14/2023]
Abstract
During fetal computed tomography (CT) imaging, because of differences in the pregnancy period and scanning conditions, different doses of radiation are absorbed by the fetus. We propose a correction coefficient for determining the fetal size-specific dose estimate (SSDE) from the CT dose index (CTDI) displayed on the console at tube voltages of 80-135 kVp. The CTDIs corresponding to pregnant women and fetuses were evaluated using a Monte Carlo (MC) simulation, and the ratio of these CTDIs was defined as the Fetus-factor. When the effective diameter of a fetus was approximately 10 cm, the Fetus-factor was 1.0. The estimated pregnant SSDE was multiplied by the Fetus-factor to estimate the fetal SSDE, which was compared with the fetal dose obtained by the MC simulation of the image of the fetal CT examination. The fetal dose could be estimated with an error of 31.5% in fetal examinations conducted using helical CT.
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Affiliation(s)
- Masanao Kobayashi
- Graduate School of Health Sciences, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Yusei Nishihara
- Department of Radiology, Fujita Health University Hospital, Toyoake, Aichi 470-1192, Japan
| | - Tomonobu Haba
- Graduate School of Health Sciences, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Yuta Matsunaga
- Department of Imaging, Nagoya Kyoritsu Hospital, Nagoya 454-0933, Japan
| | - Kazuyuki Minami
- Graduate School of Health Sciences, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Yasuki Asada
- Graduate School of Health Sciences, Fujita Health University, Toyoake, Aichi 470-1192, Japan
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Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12030640. [PMID: 35328194 PMCID: PMC8947205 DOI: 10.3390/diagnostics12030640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023] Open
Abstract
Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.
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Gao LP, Kong GX, Wang X, Ma HM, Ding FF, Li TD. Pancreatic neuroendocrine carcinoma in a pregnant woman: A case report and review of the literature. World J Clin Cases 2021; 9:4327-4335. [PMID: 34141797 PMCID: PMC8173422 DOI: 10.12998/wjcc.v9.i17.4327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Portal venous thromboembolism caused by malignant pancreatic neuroendocrine tumor metastasis, as the initial presentation of portal hypertension and upper gastrointestinal bleeding, is a rare entity. To our knowledge, there are no reports of this entity in pregnant women. We describe a case of pancreatic neuroendocrine carcinoma during pregnancy with hematemesis and hematochezia as the initial presentation and review the literature to analyze the demographic, clinical, and pathological features to provide a reference for clinical diagnosis and treatment.
CASE SUMMARY A 40-year-old woman presented with hematemesis and hematochezia at 26-wk gestation; she had no other remarkable medical history. The physical examination revealed normal vital signs, an anemic appearance, and lower abdominal distension. Abdominal color Doppler ultrasonography showed portal vein thrombosis, splenomegaly, intrauterine pregnancy, and intrauterine fetal death. Esophagogastroduodenoscopy revealed esophageal and gastric varicose veins and portal hypertensive gastropathy. Contrast-enhanced computed tomography demonstrated multiple emboli formation in the portal and splenic veins, multiple round shadows in the liver with a slightly lower density, portal vein broadening, varicose veins in the lower esophagus and gastric fundus, splenomegaly, bilateral pleural effusion, ascites and pelvic effusion, broadening of the common bile duct, and increased uterine volume. According to the results of Positron emission tomography-computed tomography and immunohistochemical staining, the final diagnoses were that the primary lesion was a pancreatic neuroendocrine tumor and that there were secondary intrahepatic metastases and venous cancer thrombogenesis.
CONCLUSION Upper gastrointestinal bleeding in a pregnant woman may be caused by portal hypertension due to a malignant pancreatic neuroendocrine tumor.
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Affiliation(s)
- Li-Ping Gao
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Gui-Xiang Kong
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xiang Wang
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui-Min Ma
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Fei-Fei Ding
- Department of Gastroenterology, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Ting-Dong Li
- Department of Musculoskeletal Tumor, Gansu Provincial Cancer Hospital, Lanzhou 730000, Gansu Province, China
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12
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Bourgioti C, Konidari M, Gourtsoyianni S, Moulopoulos LA. Imaging during pregnancy: What the radiologist needs to know. Diagn Interv Imaging 2021; 102:593-603. [PMID: 34059484 DOI: 10.1016/j.diii.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Charis Bourgioti
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece.
| | - Marianna Konidari
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
| | - Sofia Gourtsoyianni
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
| | - Lia Angela Moulopoulos
- Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Aretaieion Hospital, 76, Vassilisis Sofias Avenue, Athens 11528, Greece
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Radiation Dose to the Fetus From Computed Tomography of Pregnant Patients-Development and Validation of a Web-Based Tool. Invest Radiol 2021; 55:762-768. [PMID: 32604386 DOI: 10.1097/rli.0000000000000701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Estimations of radiation dose absorbed by the fetus from computed tomography (CT) in pregnant patients is mandatory, but currently available methods are not feasible in clinical routine. The aims of this study were to develop and validate a tool for assessment of fetal dose from CT of pregnant patients and to develop a user-friendly web interface for fast fetal dose calculations. METHODS In the first study part, 750 Monte Carlo (MC) simulations were performed on phantoms representing pregnant patients at various gestational stages. The MC code simulating vendor-independent dose distributions was validated against CT dose index (CTDI) measurements performed on CT scanners of 2 vendors. The volume CTDI-normalized fetal dose values from MC simulations were used for developing the computational algorithm enabling fetal dose assessments from CT of various body regions at different exposure settings. In the institutional review board-approved second part, the algorithm was validated against patient-specific MC simulations performed on CT data of 29 pregnant patients (gestational ages 8-35 weeks) who underwent CT. Furthermore, the tool was compared with a commercially available software. A user-friendly web-based interface for fetal dose calculations was created. RESULTS Weighted CTDI values obtained from MC simulations were in excellent agreement with measurements performed on the 2 CT systems (average error, 4%). The median fetal dose from abdominal CT in pregnant patients was 2.7 mGy, showing moderate correlation with maternal perimeter (r = 0.69). The algorithm provided accurate estimates of fetal doses (average error, 11%), being more accurate than the commercially available tool. The web-based interface (www.fetaldose.org) enabling vendor-independent calculations of fetal doses from CT requires the input of gestational age, volume CTDI, tube voltage, and scan region. CONCLUSIONS A tool for fetal dose assessments from CT of pregnant patients was developed and validated being freely available on a user-friendly web interface.
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14
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Karam M, Althuwaikh S, Alazemi M, Abul A, Hayre A, Alsaif A, Barlow G. Chest CT versus RT-PCR for the detection of COVID-19: systematic review and meta-analysis of comparative studies. JRSM Open 2021; 12:20542704211011837. [PMID: 34035931 PMCID: PMC8127597 DOI: 10.1177/20542704211011837] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To compare the performance of chest computed tomography (CT) scan versus reverse transcription polymerase chain reaction (RT-PCR) as the reference standard in the initial diagnostic assessment of coronavirus disease 2019 (COVID-19) patients. DESIGN A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A search of electronic information was conducted using the following databases: MEDLINE, EMBASE, EMCARE, CINAHL and the Cochrane Central Register of Controlled Trials. SETTING Studies that compared the diagnostic performance within the same patient cohort of chest CT scan versus RT-PCR in COVID-19 suspected patients. PARTICIPANTS Thirteen non-randomised studies enrolling 4092 patients were identified. MAIN OUTCOME MEASURES Sensitivity, specificity and accuracy were primary outcome measures. Secondary outcomes included other test performance characteristics and discrepant findings between both investigations. RESULTS Chest CT had a median sensitivity, specificity and accuracy of 0.91 (range 0.82-0.98), 0.775 (0.25-1.00) and 0.87 (0.68-0.99), respectively, with RT-PCR as the reference. Importantly, early small, China-based studies tended to favour chest CT versus later larger, non-China studies. CONCLUSIONS A relatively high false positive rate can be expected with chest CT. It is possible it may still be useful to provide circumstantial evidence, however, in some patients with a suspicious clinical presentation of COVID-19 and negative initial Severe Acute Respiratory Syndrome Coronavirus 2 RT-PCR tests, but more evidence is required in this context. In acute cardiorespiratory presentations, negative CT scan and RT-PCR tests is likely to be reassuring.
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Affiliation(s)
| | | | - Mohammad Alazemi
- School of Medical Sciences, University of Manchester, Manchester, UK
| | - Ahmad Abul
- School of Medicine, University of Leeds, Leeds, UK
| | - Amrit Hayre
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Gavin Barlow
- Experimental Medicine and Biomedicine, Hull York Medical School, University of York, York, UK
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15
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McEvoy-May JH, Bihari S, Hooker AM, Dixon DL. A retrospective audit of cumulative ionising radiation levels in hospitalised pregnant patients. Aust N Z J Obstet Gynaecol 2021; 61:700-707. [PMID: 33772762 DOI: 10.1111/ajo.13336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/05/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Among hospitalised patients, diagnostic radiation is possibly used least on pregnant patients due to the fear of ionising radiation on the fetus; however, what levels are currently being prescribed? AIMS To assess the cumulative levels of ionising radiation received by pregnant patients during a single admission to a tertiary hospital. MATERIALS AND METHODS A retrospective audit of pregnant patients admitted to Flinders Medical Centre, South Australia, Australia, between 2013 and 2017 inclusive was performed. All procedures utilising ionising radiation were collected including conventional radiology, computed tomography, fluoroscopy and nuclear medicine. Individual and cumulative effective doses for mother and fetus were calculated using patient dose reports and published conversion factors. RESULTS From 547 patients, the median cumulative effective dose was 0.02 mSv and only five patients received more than 10 mSv, with 19.07 mSv the highest dose received. The median fetal cumulative effective dose was 0.01 mSv but only three fetuses received more than 10 mSv, likely due to fetal exclusion in some procedural fields of view. Stays longer than ten days were associated with significantly higher cumulative effective dose, as did those with maternal cardiovascular related admission, for both maternal and fetal exposures. CONCLUSION These results suggest that pregnant patients are exposed to low doses of ionising radiation, in both individual procedures and cumulative doses. The detrimental risks associated with these levels of ionising radiation are not overt and so clinicians should question which risk is higher, the ionising radiation from the radiological procedures received or the lack of diagnostic information if avoided?
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Affiliation(s)
- James H McEvoy-May
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Biology, McMaster University, Hamilton, Ontario, Canada.,Centre for Radiation Research, Education and Innovation, University of Adelaide, Adelaide, South Australia, Australia
| | - Shailesh Bihari
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Antony M Hooker
- Centre for Radiation Research, Education and Innovation, University of Adelaide, Adelaide, South Australia, Australia
| | - Dani-Louise Dixon
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,Faculty of Medical Sciences, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
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16
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Abstract
Lymphomas afflict all age groups of people, with certain types demonstrating a female predilection in adolescents and young adults. A proportion of lymphomas that are diagnosed in this population demographic occur in the setting of pregnancy. Most of these behave aggressively at presentation and require immediate or urgent therapy. Treatment must consider both maternal and fetal health, and management approaches are therefore influenced by gestational age at diagnosis and treatment and timing of delivery. Although there is a paucity of literature on how to treat these patients, limited retrospective reports demonstrate generally good outcomes and highlight the necessity of an experienced multidisciplinary team approach to management.
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17
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The application of in utero magnetic resonance imaging in the study of the metabolic and cardiovascular consequences of the developmental origins of health and disease. J Dev Orig Health Dis 2020; 12:193-202. [PMID: 33308364 PMCID: PMC8162788 DOI: 10.1017/s2040174420001154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Observing fetal development in utero is vital to further the understanding of later-life diseases. Magnetic resonance imaging (MRI) offers a tool for obtaining a wealth of information about fetal growth, development, and programming not previously available using other methods. This review provides an overview of MRI techniques used to investigate the metabolic and cardiovascular consequences of the developmental origins of health and disease (DOHaD) hypothesis. These methods add to the understanding of the developing fetus by examining fetal growth and organ development, adipose tissue and body composition, fetal oximetry, placental microstructure, diffusion, perfusion, flow, and metabolism. MRI assessment of fetal growth, organ development, metabolism, and the amount of fetal adipose tissue could give early indicators of abnormal fetal development. Noninvasive fetal oximetry can accurately measure placental and fetal oxygenation, which improves current knowledge on placental function. Additionally, measuring deficiencies in the placenta’s transport of nutrients and oxygen is critical for optimizing treatment. Overall, the detailed structural and functional information provided by MRI is valuable in guiding future investigations of DOHaD.
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18
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Sensakovic WF, Royall I, Hough M, Potrebko P, Grekoski V, Vicenti R. Fetal Dosimetry at CT: A Primer. Radiographics 2020; 40:1061-1070. [PMID: 32559149 DOI: 10.1148/rg.2020190166] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
CT scanning of a pregnant patient is often a source of distress for both patient and staff. Despite having expertise in image interpretation, a radiologist may not feel equipped to discuss the radiation-related safety issues during CT scanning of the fetus. In addition, patients are frequently concerned about the risk of adverse effects on the fetus from exposure to ionizing radiation. Recognizing the possibility of adverse effects from fetal exposure and the impossibility of direct in vivo measurement, medical physicists have developed several methods to estimate the amount of radiation reaching the fetus. A physician should know the potential biologic effects of fetal irradiation and at what radiation dose thresholds they occur. Physicians should also have an understanding of these methods and how the numbers they produce relate to potential fetal bioeffects. Furthermore, radiologists should have some understanding of how a qualified medical physicist calculates the fetal dose, how much they should trust those numbers, and the relevant variables that can affect the outcomes. Finally, the radiologist should know the magnitude of doses for CT scans commonly used in pregnant patients. Armed with this knowledge, a radiologist should be confident when discussing fetal dose and determining the best course of action for the pregnant patient. Online supplemental material is available for this article. ©RSNA, 2020.
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Affiliation(s)
- William F Sensakovic
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
| | - Ivey Royall
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
| | - Matthew Hough
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
| | - Peter Potrebko
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
| | - Vincent Grekoski
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
| | - Rebecca Vicenti
- From the Department of Radiology, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 (W.F.S.); Department of Radiology (I.R., V.G., R.V.) and Department of Diagnostic Medical Physics and Radiation Safety (M.H.), AdventHealth, Altamonte Springs, Fla; and Varian Medical Systems, Atlanta, Ga (P.P.)
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19
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Ciangura C, Coupaye M, Deruelle P, Gascoin G, Calabrese D, Cosson E, Ducarme G, Gaborit B, Lelièvre B, Mandelbrot L, Petrucciani N, Quilliot D, Ritz P, Robin G, Sallé A, Gugenheim J, Nizard J. Clinical Practice Guidelines for Childbearing Female Candidates for Bariatric Surgery, Pregnancy, and Post-partum Management After Bariatric Surgery. Obes Surg 2020; 29:3722-3734. [PMID: 31493139 DOI: 10.1007/s11695-019-04093-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.
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Affiliation(s)
- Cécile Ciangura
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Departments of Nutrition and Diabetology, Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne University, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.
| | - Muriel Coupaye
- Assistance Publique-Hôpitaux de Paris, Louis Mourier Hospital, Department of Explorations Fonctionnelles, Colombes, University Paris Diderot, Paris, France.,Association Française d'Etude et de Recherche sur l'Obésité (AFERO), Paris, France
| | - Philippe Deruelle
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France.,Collège National des Gynécologues et Obstétriciens Français (CNGOF), Paris, France
| | - Géraldine Gascoin
- Department of Neonatal Medicine, Angers University Hospital, Angers, France.,Société Française de Néonatologie et Société Française de Pédiatrie, Paris, France
| | - Daniela Calabrese
- Assistance Publique-Hôpitaux de Paris, Louis Mourier Hospital, Department of Digestive Surgery, Colombes, University Paris Diderot, Paris, France
| | - Emmanuel Cosson
- Assistance Publique-Hôpitaux de Paris, Jean Verdier Hospital, Department of Endocrinology-Diabetology-Nutrition, Bondy, 10 UMR U557 INSERM/U11125 INRA/CNAM, University Paris13, Bobigny, France.,Société Francophone du Diabète (SFD), Paris, France
| | - Guillaume Ducarme
- Department of Obstetrics and Gynecology, Departemental Hospital, La Roche-sur-Yon, France
| | - Bénédicte Gaborit
- Association Française d'Etude et de Recherche sur l'Obésité (AFERO), Paris, France.,Assistance Publique-Hôpitaux de Marseille, Department of Endocrinology, Metabolic Diseases and Nutrition, Marseille, INSERM, INRA, C2VN, Aix Marseille University, Marseille, France
| | - Bénédicte Lelièvre
- Laboratory of Pharmacology and Toxicology, Angers University Hospital, Angers, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Louis Mourier Hospital, Department of Gynecology and Obstetrics, Colombes, University Paris Diderot, Paris, France
| | - Niccolo Petrucciani
- Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, Division of Digestive Surgery and Liver Transplantation, UPEC University, Créteil, France
| | - Didier Quilliot
- Department of Diabetology-Endocrinology-Nutrition, CHRU Nancy, INSERM 954, University of Lorraine, Nancy, France.,Société Francophone Nutrition Clinique et Métabolisme (SFNCM), Paris, France
| | - Patrick Ritz
- Department of Endocrinology, Metabolic Diseases and Nutrition, Toulouse University Hospital, UMR1027, Paul Sabatier University, Toulouse, France
| | - Geoffroy Robin
- Collège National des Gynécologues et Obstétriciens Français (CNGOF), Paris, France.,Department of Medical Gynecology, and Sexology and Department of Assisted Reproductive Technologies and Fertility Preservation, Jeanne de Flandre Hospital, Lille, EA4308 "gametogenesis and gamete quality", Lille University, Lille, France
| | - Agnès Sallé
- Department of Diabetology-Endocrinology-Nutrition, Angers University Hospital, Angers, France
| | - Jean Gugenheim
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, University of Nice, Nice, France.,Société Française et Francophone de Chirurgie de l'Obésité et des Maladies Métaboliques (SOFFCOMM), Porte des Pierres Dorées, France
| | - Jacky Nizard
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Gynecology and Obstetrics, Sorbonne University, Paris, France
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20
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Ciangura C. Reply to the Letter to the Editor "Guidelines Regarding Management of a Surgical Emergency During Pregnancy After Bariatric Surgery". Obes Surg 2019; 30:1130-1131. [PMID: 31853862 DOI: 10.1007/s11695-019-04347-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Cécile Ciangura
- Departments of Nutrition and Diabetology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital (AP-HP), Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne University, 47-83 boulevard de l'hôpital, 75013, Paris, France.
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21
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Grossesses après chirurgie bariatrique: recommandations pour la pratique clinique (groupe BARIA-MAT). NUTR CLIN METAB 2019. [DOI: 10.1016/j.nupar.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Petrucciani N, Ciangura C, Debs T, Ducarme G, Calabrese D, Gugenheim J. Management of surgical complications of previous bariatric surgery in pregnant women. A systematic review from the BARIA-MAT Study Group. Surg Obes Relat Dis 2019; 16:312-331. [PMID: 31837948 DOI: 10.1016/j.soard.2019.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/14/2019] [Accepted: 10/22/2019] [Indexed: 12/29/2022]
Abstract
Considering the large and increasing population of women of childbearing age with history of bariatric surgery, surgical complications of bariatric surgery during pregnancy may become more frequent in the future. The aim of this study was to analyze the clinical presentation, diagnostic procedures, and treatment of surgical complications of bariatric surgery during pregnancies. A systematic literature search was performed in accordance with the PRISMA (preferred reporting items for systematic review and meta-analysis) guidelines to identify all studies published up to and including December 2018 that included women with previous bariatric surgery undergoing emergency surgery during pregnancy. Sixty-eight studies were selected, including 120 women with previous bariatric surgery undergoing emergency surgery during pregnancy. Fifty cases were reported as case reports and 70 in case series. Included patients had previous history of Roux-en-Y gastric bypass (n = 99), laparoscopic adjustable gastric banding (n = 17), Scopinaro procedure (n = 2), vertical banded gastroplasty (n = 1), or one-anastomosis gastric bypass (n = 1). Final diagnosis in 50 case reports was internal hernia in 26 cases, bowel intussusception in 10, intestinal obstruction in 2, laparoscopic adjustable gastric banding slippage in 3, bowel volvulus in 3, gastric or jejunal perforation in 2, and other complications in 4 cases. Maternal and fetal death occurred in 3 (2.5%) and 9 cases (7.5%), respectively. In the case series, the majority of women were operated for internal hernia and laparoscopic adjustable gastric banding slippage. Surgical complications of previous bariatric surgery during pregnancy have potentially severe outcomes. Availability of multidisciplinary expertise, including bariatric/digestive surgeons, and education of healthcare providers and women on clinical signs that require urgent surgical examination are recommended in this setting. Prompt diagnosis is fundamental and based on clinical and laboratory findings and on radiologic examinations if needed, including computed tomography scan or magnetic resonance if available. Rapid surgical exploration is mandatory in case of high clinical and/or radiologic suspicion.
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Affiliation(s)
- Niccolo Petrucciani
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France; Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University, Rome, Italy.
| | - Cecile Ciangura
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Nutrition, Sorbonne Université, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Tarek Debs
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Guillaume Ducarme
- Department of Obstetrics and Gynecology, Centre Hospitalier Departemental, La Roche-sur-Yon, France
| | - Daniela Calabrese
- Assistance Publique-Hôpitaux de Paris, Louis Mourier Hospital, Digestive Surgery Department, Sorbonne Paris Cité Diderot, Colombes, France
| | - Jean Gugenheim
- Division of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
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23
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Sazhin AV, Kirienko AI, Kurtser MA, Konoplyannikov AG, Panin AV, Son DA, Shulyak GD. [Acute appendicitis during pregnancy]. Khirurgiia (Mosk) 2019:70-77. [PMID: 30789612 DOI: 10.17116/hirurgia201901170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute appendicitis is the most frequent surgical disease complicating pregnancy. Accurate diagnosis is difficult due to atypical and misleading clinical manifestations. Surgeons frequently do not know about advantages and disadvantages of different diagnostic methods applied during pregnancy. Treatment of acute appendicitis in pregnant women remains the real challenge for surgeons. There are enough researches indicating on benefits and risks of both open and laparoscopic operations. The main risk is due to fetal loss after laparoscopic procedure. Safety of diagnostic techniques and laparoscopic procedures, surgical tactics and independent risk factors of pregnancy loss are touched in the article.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A I Kirienko
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - M A Kurtser
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia; Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - A G Konoplyannikov
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - A V Panin
- Clinical Hospital Lapino 'Mother and Child', Moscow region, Russia
| | - D A Son
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
| | - G D Shulyak
- Pirogov Russian National Research Medical University of Healthcare Ministry of Russia, Moscow, Russia
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24
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Iacopi S, Lombardo C, Menonna F, Mazzeo S, Caramella D, Amorese G, Vistoli F, Boggi U. Management of pregnancy-associated pancreatic cystic tumors: Review of the literature and results of a Pancreas Club Inc. Survey. Pancreatology 2018; 18:905-912. [PMID: 30274883 DOI: 10.1016/j.pan.2018.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/15/2018] [Accepted: 09/25/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Management of patients with pregnancy-associated cyst pancreatic cystic tumors (PA-PCT) is complicated by lack of large series. METHODS A systematic literature review was conducted to extrapolate data on management of PA-PCT, and make a questionnaire on pending issues to be administered to the members of the Pancreas Club Inc. RESULTS The literature review demonstrated a total of 35 PA-PCT in 34 women, described exclusively in the form of case reports, and permitted the identification of eleven key questions to be addressed in the survey. The combined analysis of literature review and survery responses provided several information. First, PA-PCT are predominantly located in the body-tail of the pancreas, cause non-specific symptoms, are of large size (mean size: 11.2 ± 4.5 cm), and are nearly always malignant or premalignant, making timing of surgery, and not indication for surgery, the main issue in the management of these tumors. Second, there is a risk of PA-PCT rupture during pregnancy. Ruptured PA-PCT had a mean size 13.5 ± 4.9 cm, but no prognostic factor could be identified. Survey opinions suggested that this occurrence is quite rare, even for large tumors. Third, most pregnancies were conducted to term (mean gestational age: 40.5 ± 0.7 weeks), with a vaginal delivery. Fourth, all procedures were carried out through an open approach and the spleen was rarely preserved. Survey indicated instead that laparoscopy could play a role, and that the spleen should be preserved when feasible. CONCLUSIONS PA-PCT require individualized treatment. The definition of a management algorithm requires the implementation of an International Registry.
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Affiliation(s)
- Sara Iacopi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Carlo Lombardo
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Francesca Menonna
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | | | | | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
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25
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Pierce T, Hovnanian M, Hedgire S, Ghoshhajra B. Imaging of Cardiovascular Disease in Pregnancy and the Peripartum Period. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:94. [PMID: 29134367 DOI: 10.1007/s11936-017-0593-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT Cardiovascular disease is an important cause of morbidity and mortality during pregnancy and the postpartum period. During pregnancy, the cardiovascular system undergoes extensive hemodynamic, hormonal, and microstructural changes which may exacerbate a preexisting underlying cardiovascular condition or predispose to cardiovascular complications not typically seen in young healthy women. Such conditions include spontaneous coronary artery dissection, atherosclerotic coronary artery disease, and peripartum cardiomyopathy. When evaluating this patient population, the diagnostic strategy should be tailored to specifically assess this distinct disease spectrum. The choice of imaging techniques must also consider potential risks to both the mother and child; a unique challenge of diagnostic imaging during pregnancy. The risk of radiation from radiography, computed tomography, and nuclear medicine imaging; iodinated and gadolinium-based contrast media for computed tomography and magnetic resonance imaging respectively; and heat deposition from sonography are of special importance during pregnancy. A thorough understanding of pregnancy-specific cardiovascular complications and the capabilities and risks of available diagnostic imaging modalities is crucial to appropriately manage the pregnant patient.
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Affiliation(s)
- Theodore Pierce
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Founders 216, Boston, MA, 02114, USA.
| | - Meline Hovnanian
- Department of Cardiothoracic Radiology, Mount Sinai School of Medicine - BISLR, 1000 Tenth Avenue, New York, NY, 10019, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Brian Ghoshhajra
- Division of Cardiovascular Imaging, Massachusetts General Hospital - Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Fetal radiation dose in three common CT examinations during pregnancy - Monte Carlo study. Phys Med 2017; 43:199-206. [PMID: 28941740 DOI: 10.1016/j.ejmp.2017.09.120] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 07/31/2017] [Accepted: 09/07/2017] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine fetal doses in different stages of pregnancy in three common computed tomography (CT) examinations: pulmonary CT angiography, abdomino-pelvic and trauma scan with Monte Carlo (MC) simulations. METHODS An adult female anthropomorphic phantom was scanned with a 64-slice CT using pulmonary angiography, abdomino-pelvic and trauma CT scan protocols. Three different sized gelatin boluses placed on the phantom's abdomen simulated different stages of pregnancy. Intrauterine dose was used as a surrogate to a dose absorbed to the fetus. MC simulations were performed to estimate uterine doses. The simulation dose levels were calibrated with volumetric CT dose index (CTDIvol) measurements and MC simulations in a cylindrical CTDI body phantom and compared with ten point doses measured with metal-oxide-semiconductor field-effect-transistor dosimeters. Intrauterine volumes and uterine walls were segmented and the respective dose volume histograms were calculated. RESULTS The mean intrauterine doses in different stages of pregnancy varied from 0.04 to 1.04mGy, from 4.8 to 5.8mGy, and from 9.8 to 12.6mGy in the CT scans for pulmonary angiography, abdomino-pelvic and trauma CT scans, respectively. MC simulations showed good correlation with the MOSFET measurement at the measured locations. CONCLUSIONS The three studied examinations provided highly varying fetal doses increasing from sub-mGy level in pulmonary CT angiography to notably higher levels in abdomino-pelvic and trauma scans where the fetus is in the primary exposure range. Volumetric dose distribution offered by MC simulations in an appropriate anthropomorphic phantom provides a comprehensive dose assessment when applied in adjunct to point-dose measurements.
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Pneumocystis Pneumonia in Non-HIV Pregnant Women Receiving Chemotherapy for Malignant Lymphoma: Two Case Reports. Case Rep Obstet Gynecol 2017; 2017:1073146. [PMID: 28932610 PMCID: PMC5592425 DOI: 10.1155/2017/1073146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 07/28/2017] [Accepted: 08/02/2017] [Indexed: 01/01/2023] Open
Abstract
Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection that sometimes occurs in immunocompromised patients with human immunodeficiency virus (HIV). Here, we report two extremely rare cases of PCP in non-HIV pregnant women who underwent chemotherapy for malignant lymphoma. Case 1 is a 34-year-old primigravida who was diagnosed with Hodgkin's lymphoma. She received ABVD chemotherapy and developed PCP at 37 weeks of gestation. After the onset of PCP, emergent cesarean section was performed due to a nonreassuring fetal status. Case 2 is a 31-year-old multigravida with diffuse large B-cell lymphoma who was administered R-CHOP chemotherapy. At 34 weeks of gestation, she complained of dyspnea and developed PCP. She delivered her baby vaginally immediately after the onset of symptoms. Both patients were treated with sulfamethoxazole-trimethoprim (ST) and recovered shortly thereafter. The babies' courses were also uneventful. PCP remains a serious cause of death, especially in non-HIV patients, and, therefore, appropriate prophylaxis and a prompt diagnosis are imperative.
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Contemporary Modalities to Image the Fetal Brain. Clin Obstet Gynecol 2017; 60:656-667. [PMID: 28742597 DOI: 10.1097/grf.0000000000000307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fetal brain ultrasound remains as the mainstay for screening fetal intracranial anatomy. One of its main advantages is the availability of 3 dimensional and other ultrasound modalities for a better understanding of fetal neurodevelopment. Neurosonography is performed when findings, suggestive of an abnormality, are present on a screening ultrasound or if a high-risk situation of brain injury is present. This technique offers the use of complementary imaging planes, axial, coronal and sagittal, and the ability to image intracranial anatomy from the transabdominal and transvaginal approaches. Fetal brain magnetic resonance imaging is more sensitive than ultrasound. As an adjunctive imaging modality, magnetic resonance imaging offers additional sequences to complete the information on neurodevelopment from different perspectives, such as brain metabolism, microstructure, and connectivity.
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Tirada N, Dreizin D, Khati NJ, Akin EA, Zeman RK. Imaging Pregnant and Lactating Patients. Radiographics 2016; 35:1751-65. [PMID: 26466183 DOI: 10.1148/rg.2015150031] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As use of imaging in the evaluation of pregnant and lactating patients continues to increase, misperceptions of radiation and safety risks have proliferated, which has led to often unwarranted concerns among patients and clinicians. When radiologic examinations are appropriately used, the benefits derived from the information gained usually outweigh the risks. This review describes appropriateness and safety issues, estimated doses for imaging examinations that use iodizing radiation (ie, radiography, computed tomography, nuclear scintigraphy, and fluoroscopically guided interventional radiology), radiation risks to the mother and conceptus during various stages of pregnancy, and use of iodinated or gadolinium-based contrast agents and radiotracers in pregnant and lactating women. Maternal radiation risk must be weighed with the potential consequences of missing a life-threatening diagnosis such as pulmonary embolus. Fetal risks (ie, spontaneous abortion, teratogenesis, or carcinogenesis) vary with gestational age and imaging modality and should be considered in the context of the potential benefit of medically necessary diagnostic imaging. When feasible and medically indicated, modalities that do not use ionizing radiation (eg, magnetic resonance imaging) are preferred in pregnant and lactating patients. Radiologists should strive to minimize risks of radiation to the mother and fetus, counsel patients effectively, and promote a realistic understanding of risks related to imaging during pregnancy and lactation.
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Affiliation(s)
- Nikki Tirada
- From the Department of Radiology, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037 (N.T., N.J.K., E.A.A., R.K.Z.); and Department of Diagnostic Radiology, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, Md (D.D)
| | - David Dreizin
- From the Department of Radiology, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037 (N.T., N.J.K., E.A.A., R.K.Z.); and Department of Diagnostic Radiology, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, Md (D.D)
| | - Nadia J Khati
- From the Department of Radiology, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037 (N.T., N.J.K., E.A.A., R.K.Z.); and Department of Diagnostic Radiology, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, Md (D.D)
| | - Esma A Akin
- From the Department of Radiology, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037 (N.T., N.J.K., E.A.A., R.K.Z.); and Department of Diagnostic Radiology, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, Md (D.D)
| | - Robert K Zeman
- From the Department of Radiology, George Washington University Hospital, 900 23rd St NW, Washington, DC 20037 (N.T., N.J.K., E.A.A., R.K.Z.); and Department of Diagnostic Radiology, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, Baltimore, Md (D.D)
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How to Manage Allergic Reactions to Contrast Agent in Pregnant Patients. AJR Am J Roentgenol 2016; 206:247-52. [DOI: 10.2214/ajr.15.14976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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JOURNAL CLUB: Quantification of Fetal Dose Reduction if Abdominal CT Is Limited to the Top of the Iliac Crests in Pregnant Patients With Trauma. AJR Am J Roentgenol 2016; 206:705-12. [PMID: 26796990 DOI: 10.2214/ajr.15.14770] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purposes of this study were to correlate fetal z-axis location within the maternal abdomen on CT with gestational age and estimate fetal dose reduction of a study limited to the abdomen only, with its lower aspect at the top of the iliac crests, compared with full abdominopelvic CT in pregnant trauma patients. MATERIALS AND METHODS We performed a study of pregnant patients who underwent CT of the abdomen and pelvis for trauma at a single institution over a 10-year period. The inferior aspect of maternal liver, spleen, gallbladder, pancreas, adrenals, and kidneys was recorded as above or below the iliac crests. The distance from the iliac crest to the top of the fetus or gestational sac was determined. The CT images of the limited and full scanning studies were independently reviewed by two blinded radiologists to identify traumatic injuries. Fetal dose profiles, including both scatter and primary radiation, were computed analytically along the central axis of the patient to estimate fetal dose reduction. Linear regression analysis was performed between gestational age and distance of the fetus to the iliac crests. RESULTS Thirty-five patients were included (mean age, 26.2 years). Gestational age ranged from 5 to 38 weeks, with 5, 19, and 11 gestations in the first, second, and third trimesters, respectively. All solid organs were above the iliac crests in all patients. In three of six patients, traumatic findings in the pelvis would have been missed with the limited study. There was high correlation between gestational age and distance of the fetus to the iliac crests (R(2) = 0.84). The mean gestational age at which the top of the fetus was at the iliac crest was 17.3 weeks. Using the limited scanning study, fetuses at 5, 20, and 40 weeks of gestation would receive an estimated 4.3%, 26.2%, and 59.9% of the dose, respectively, compared with the dose for the full scanning study. CONCLUSION In pregnant patients in our series with a history of trauma, CT of the abdomen only was an effective technique to reduce fetal radiation exposure compared with full abdomen and pelvis CT.
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Helm A, Arrizabalaga O, Pignalosa D, Schroeder IS, Durante M, Ritter S. Ionizing Radiation Impacts on Cardiac Differentiation of Mouse Embryonic Stem Cells. Stem Cells Dev 2016; 25:178-88. [PMID: 26506910 PMCID: PMC4733326 DOI: 10.1089/scd.2015.0260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022] Open
Abstract
Little is known about the effects of ionizing radiation on the earliest stages of embryonic development although it is well recognized that ionizing radiation is a natural part of our environment and further exposure may occur due to medical applications. The current study addresses this issue using D3 mouse embryonic stem cells as a model system. Cells were irradiated with either X-rays or carbon ions representing sparsely and densely ionizing radiation and their effect on the differentiation of D3 cells into spontaneously contracting cardiomyocytes through embryoid body (EB) formation was measured. This study is the first to demonstrate that ionizing radiation impairs the formation of beating cardiomyocytes with carbon ions being more detrimental than X-rays. However, after prolonged culture time, the number of beating EBs derived from carbon ion irradiated cells almost reached control levels indicating that the surviving cells are still capable of developing along the cardiac lineage although with considerable delay. Reduced EB size, failure to downregulate pluripotency markers, and impaired expression of cardiac markers were identified as the cause of compromised cardiomyocyte formation. Dysregulation of cardiac differentiation was accompanied by alterations in the expression of endodermal and ectodermal markers that were more severe after carbon ion irradiation than after exposure to X-rays. In conclusion, our data show that carbon ion irradiation profoundly affects differentiation and thus may pose a higher risk to the early embryo than X-rays.
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Affiliation(s)
- Alexander Helm
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Onetsine Arrizabalaga
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
- IKERBASQUE, Basque Foundation for Science, Bilbao, Spain
| | - Diana Pignalosa
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Insa S. Schroeder
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Marco Durante
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
- Physics Department, Institute for Condensed Matter Physics, Technical University Darmstadt, Darmstadt, Germany
| | - Sylvia Ritter
- Biophysics Department, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
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Gomes M, Matias A, Macedo F. Risks to the fetus from diagnostic imaging during pregnancy: review and proposal of a clinical protocol. Pediatr Radiol 2015; 45:1916-29. [PMID: 26271622 DOI: 10.1007/s00247-015-3403-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/25/2015] [Accepted: 06/01/2015] [Indexed: 11/25/2022]
Abstract
Every day, medical practitioners face the dilemma of exposing pregnant or possibly pregnant patients to radiation from diagnostic examinations. Both doctors and patients often have questions about the risks of radiation. The most vulnerable period is between the 8th and 15th weeks of gestation. Deterministic effects like pregnancy loss, congenital malformations, growth retardation and neurobehavioral abnormalities have threshold doses above 100-200 mGy. The risk is considered negligible at 50 mGy and in reality no diagnostic examination exceeds this limit. The risk of carcinogenesis is slightly higher than in the general population. Intravenous iodinated contrast is discouraged, except in highly selected patients. Considering all the possible noxious effects of radiation exposure, measures to diminish radiation are essential and affect the fetal outcome. Nonionizing procedures should be considered whenever possible and every radiology center should have its own data analysis on fetal radiation exposure. In this review, we analyze existing literature on fetal risks due to radiation exposure, producing a clinical protocol to guide safe radiation use in a clinical setting.
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Affiliation(s)
- Mafalda Gomes
- Faculty of Medicine, University of Porto, Praça de Gomes Teixeira, 4099-002, Porto, Portugal.
| | - Alexandra Matias
- Faculty of Medicine, University of Porto, Praça de Gomes Teixeira, 4099-002, Porto, Portugal
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Kelaranta A, Kaasalainen T, Seuri R, Toroi P, Kortesniemi M. Fetal radiation dose in computed tomography. RADIATION PROTECTION DOSIMETRY 2015; 165:226-230. [PMID: 25836690 DOI: 10.1093/rpd/ncv097] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The connection between recorded volumetric CT dose index (CTDI vol) and determined mean fetal dose (Df) was examined from metal-oxide-semiconductor field-effect transistor dose measurements on an anthropomorphic female phantom in four stages of pregnancy in a 64-slice CT scanner. Automated tube current modulation kept the mean Df fairly constant through all pregnancy stages in trauma (4.4-4.9 mGy) and abdomino-pelvic (2.1-2.4 mGy) protocols. In pulmonary angiography protocol, the mean Df increased exponentially as the distance from the end of the scan range decreased (0.01-0.09 mGy). For trauma protocol, the relative mean Df as a function of gestational age were in the range 0.80-0.97 compared with the mean CTDI vol. For abdomino-pelvic protocol, the relative mean Df was 0.57-0.79 and for pulmonary angiography protocol, 0.01-0.05 compared with the mean CTDI vol, respectively. In conclusion, if the fetus is in the primary beam, the CTDI vol can be used as an upper estimate of the fetal dose. If the fetus is not in the primary beam, the fetal dose can be estimated by considering also the distance of the fetus from the scan range.
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Affiliation(s)
- Anna Kelaranta
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00290 Helsinki, Finland Department of Physics, University of Helsinki, PO Box 64, FI-00014 Helsinki, Finland
| | - Touko Kaasalainen
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00290 Helsinki, Finland Department of Physics, University of Helsinki, PO Box 64, FI-00014 Helsinki, Finland
| | - Raija Seuri
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00290 Helsinki, Finland
| | - Paula Toroi
- STUK - Radiation and Nuclear Safety Authority, Laippatie 4, PO Box 14, FI-00881 Helsinki, Finland
| | - Mika Kortesniemi
- HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, PO Box 340, FI-00290 Helsinki, Finland Department of Physics, University of Helsinki, PO Box 64, FI-00014 Helsinki, Finland
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Abstract
OBJECTIVE The objective of this study was to assess the potential of anterior in beam bismuth shields placed on the abdomen and the pelvis of a RANDO phantom to decrease radiation dose to a simulated fetus. METHODS Thermal luminescent dosimeters irradiated in a RANDO phantom were used to measure radiation dose at 0 weeks and 18 weeks after conception. An 18-week gestation was simulated by adding the corresponding equivalent of super-stuff to account for additional subcutaneous tissue. To assess image quality, a 461A body phantom with low contrast resolution phantom insert was used. The minimum size of low contrast resolution target visualize was recorded with no shielding and 25-cm-wide shielding. RESULTS With shields, there was a radiation dose reduction of 19% to 23% at 0-week gestation and 16% to 24% at 18-week gestation. No qualitative difference was found in low contrast detectability with the shields. CONCLUSIONS These shields reduce fetal radiation exposure early in pregnancy with acceptable image quality.
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Aggenbach L, Zeeman GG, Cantineau AEP, Gordijn SJ, Hofker HS. Impact of appendicitis during pregnancy: no delay in accurate diagnosis and treatment. Int J Surg 2015; 15:84-9. [PMID: 25638737 DOI: 10.1016/j.ijsu.2015.01.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 01/10/2015] [Accepted: 01/26/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute appendicitis during pregnancy may be associated with serious maternal and/or fetal complications. To date, the optimal clinical approach to the management of pregnant women suspected of having acute appendicitis is subject to debate. The purpose of this retrospective study was to provide recommendations for prospective clinical management of pregnant patients with suspected appendicitis. METHOD Case records of all pregnant patients suspected of having appendicitis whom underwent appendectomy at our hospital between 1990 and 2010 were reviewed. RESULTS Appendicitis was histologically verified in fifteen of twenty-one pregnant women, of whom six were diagnosed with perforated appendicitis. Maternal morbidity was seen in two cases. Premature delivery occurred in two out of six cases with perforated appendicitis cases and two out of six cases following a negative appendectomy. Perinatal mortality did not occur. CONCLUSION Both (perforated) appendicitis and negative appendectomy during pregnancy are associated with a high risk of premature delivery. Clinical presentation and imaging remains vital in deciding whether surgical intervention is indicated. We recommend to cautiously weigh the risks of delay until correct diagnosis with associated increased risk of appendiceal perforation and the risk of unnecessary surgical intervention. Based upon current literature, we recommend clinicians to consider an MRI following an inconclusive or negative abdominal ultrasound aiming to improve diagnostic accuracy to reduce the rate of negative appendectomies. Accurate and prompt diagnosis of acute appendicitis should be strived for to avoid unnecessary exploration and to aim for timely surgical intervention in pregnant women suspected of having appendicitis.
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Affiliation(s)
- L Aggenbach
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - G G Zeeman
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - A E P Cantineau
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - S J Gordijn
- Department of Gynaecology and Obstetrics, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - H S Hofker
- Department of Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB Groningen, The Netherlands
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Masselli G, Derme M, Bernieri MG, Polettini E, Casciani E, Monti R, Laghi F, Framarino-Dei-Malatesta M, Guida M, Brunelli R, Gualdi G. Stone disease in pregnancy: imaging-guided therapy. Insights Imaging 2014; 5:691-6. [PMID: 25249333 PMCID: PMC4263802 DOI: 10.1007/s13244-014-0352-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/06/2014] [Accepted: 08/20/2014] [Indexed: 12/02/2022] Open
Abstract
Renal colic is the most frequent nonobstetric cause for abdominal pain and subsequent hospitalization during pregnancy. The physio-anatomical changes in the urinary tract and the presence of the fetus may complicate the clinical presentation and management of nephrolithiasis. Ultrasound (US) is the primary radiological investigation of choice. Magnetic resonance urography (MRU) and low-dose computed tomography (CT) have to be considered as a second- and third-line test, respectively. If a study that uses ionizing radiation has to be performed, the radiation dose to the fetus should be as low as possible. The initial management of symptomatic ureteric stones is conservative during pregnancy. Intervention will be necessary in patients who do not respond to conservative measures. Therefore, it is crucial to obtain a prompt and accurate diagnosis to optimize the management of these patients. Teaching Points • In pregnancy, renal colic is the most frequent nonobstetric cause for abdominal pain and hospitalization. • Magnetic resonance urography should be considered when ultrasound is nondiagnostic. • Low-dose CT should be considered as a last-line test during pregnancy.
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Affiliation(s)
- Gabriele Masselli
- Department Radiology, Università di Roma Sapienza, Viale del Policlinico 155, Rome, 00161, Italy,
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Trattner S, Pearson GDN, Chin C, Cody DD, Gupta R, Hess CP, Kalra MK, Kofler JM, Krishnam MS, Einstein AJ. Standardization and optimization of CT protocols to achieve low dose. J Am Coll Radiol 2014; 11:271-278. [PMID: 24589403 DOI: 10.1016/j.jacr.2013.10.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 10/15/2013] [Indexed: 02/03/2023]
Abstract
The increase in radiation exposure due to CT scans has been of growing concern in recent years. CT scanners differ in their capabilities, and various indications require unique protocols, but there remains room for standardization and optimization. In this paper, the authors summarize approaches to reduce dose, as discussed in lectures constituting the first session of the 2013 UCSF Virtual Symposium on Radiation Safety and Computed Tomography. The experience of scanning at low dose in different body regions, for both diagnostic and interventional CT procedures, is addressed. An essential primary step is justifying the medical need for each scan. General guiding principles for reducing dose include tailoring a scan to a patient, minimizing scan length, use of tube current modulation and minimizing tube current, minimizing tube potential, iterative reconstruction, and periodic review of CT studies. Organized efforts for standardization have been spearheaded by professional societies such as the American Association of Physicists in Medicine. Finally, all team members should demonstrate an awareness of the importance of minimizing dose.
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Affiliation(s)
- Sigal Trattner
- Department of Medicine, Division of Cardiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY
| | - Gregory D N Pearson
- Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY
| | - Cynthia Chin
- Departments of Radiology and Biomedical Engineering, University of California, San Francisco
| | - Dianna D Cody
- Department of Imaging Physics, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rajiv Gupta
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Christopher P Hess
- Departments of Radiology and Biomedical Engineering, University of California, San Francisco
| | | | | | | | - Andrew J Einstein
- Department of Medicine, Division of Cardiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY.,Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY
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Hoshiko S, Smith D, Fan C, Jones CR, McNeel SV, Cohen RA. Trends in CT scan rates in children and pregnant women: teaching, private, public and nonprofit facilities. Pediatr Radiol 2014; 44:522-8. [PMID: 24526278 DOI: 10.1007/s00247-014-2881-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/20/2013] [Accepted: 01/16/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radiation exposure from medical sources now equals or exceeds that from natural background sources, largely attributable to a 20-fold increase in CT use since 1980. Increasing exposure to children and fetuses is of most concern due to their heightened susceptibility. More recently, CT use may be leveling or decreasing, but it is unclear whether this change is widespread or varies by type of institution. OBJECTIVE We sought to characterize trends in CT utilization in California hospitals and emergency departments among children and pregnant women, looking at different types of facilities, such as teaching, private, public and nonprofit institutions. MATERIALS AND METHODS We examined frequency of CT examinations by year from 229 facilities reporting CT usage in routinely collected California statewide data for 2005-2012. We modeled trends overall and by facility type. RESULTS CT scans for pediatric and pregnant patient visits in the emergency department increased initially, then started to decline after 2008. Among hospital admissions, rates declined or leveled after 2005. In the emergency department, CT rates varied between types of facilities, with teaching hospitals reducing use sooner and more sharply than other types of facilities. CONCLUSION CT utilization in California among children and pregnant women has begun to level or decline. Still, population exposure remains at historically high levels, warranting consideration of potential public health implications. Further examination of reasons for trends among hospital types, particularly how teaching hospitals have reduced rates of CT utilization, may help identify strategies for CT reduction without compromising patient care.
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Affiliation(s)
- Sumi Hoshiko
- Environmental Health Investigations Branch, California Department of Public Health, 850 Marina Bay Parkway, Building P, 3rd Floor, Richmond, CA, 94804, USA,
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Gu J, Xu XG, Caracappa PF, Liu B. Fetal doses to pregnant patients from CT with tube current modulation calculated using Monte Carlo simulations and realistic phantoms. RADIATION PROTECTION DOSIMETRY 2013; 155:64-72. [PMID: 23222824 PMCID: PMC3670590 DOI: 10.1093/rpd/ncs312] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Revised: 10/11/2012] [Accepted: 11/01/2012] [Indexed: 06/01/2023]
Abstract
To investigate the radiation dose to the fetus using retrospective tube current modulation (TCM) data selected from archived clinical records. This paper describes the calculation of fetal doses using retrospective TCM data and Monte Carlo (MC) simulations. Three TCM schemes were adopted for use with three pregnant patient phantoms. MC simulations were used to model CT scanners, TCM schemes and pregnant patients. Comparisons between organ doses from TCM schemes and those from non-TCM schemes show that these three TCM schemes reduced fetal doses by 14, 18 and 25 %, respectively. These organ doses were also compared with those from ImPACT calculation. It is found that the difference between the calculated fetal dose and the ImPACT reported dose is as high as 46 %. This work demonstrates methods to study organ doses from various TCM protocols and potential ways to improve the accuracy of CT dose calculation for pregnant patients.
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Affiliation(s)
- Jianwei Gu
- Program of Nuclear Engineering and Engineering Physics, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - X. George Xu
- Program of Nuclear Engineering and Engineering Physics, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Peter F. Caracappa
- Program of Nuclear Engineering and Engineering Physics, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Bob Liu
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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Imaging of pregnant and lactating patients: part 1, evidence-based review and recommendations. AJR Am J Roentgenol 2012; 198:778-84. [PMID: 22451541 DOI: 10.2214/ajr.11.7405] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The objectives of this article are to discuss the current evidence-based recommendations regarding radiation dose concerns, the use of iodinated and gadolinium-based contrast agents, and the comparative advantages of multimodality imaging (ultrasound, CT, and MRI) during pregnancy and lactation. We also discuss the use of imaging to evaluate pregnant trauma patients. CONCLUSION Maternal and fetal radiation exposure and dose are affected by gestational age, anatomic site, modality, and technique. The use of iodinated and gadolinium-based contrast agents during pregnancy and lactation has not been well studied in human subjects. Imaging should be used to evaluate pregnant trauma patients only when the benefits outweigh the risks.
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Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy. AJR Am J Roentgenol 2012; 198:W352-6. [PMID: 22451572 DOI: 10.2214/ajr.11.7458] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to review fetal radiation doses and associated risks resulting from CT performed during pregnancy. The scanning parameters that influence dose and the techniques for estimating and reducing dose are explained. CONCLUSION Fetal radiation doses for CT examinations in which the fetus is not directly imaged-for example, head or chest CT-are minimal and need not figure in the risk-benefit analysis to perform the examination. In contrast, radiation dose should be considered with abdominopelvic CT because the fetus is likely to be exposed directly to the scanning beam. Safe implementation of CT in this setting requires an understanding of the factors influencing radiation dose. With this knowledge, when a risk-benefit analysis in a given clinical situation favors imaging using CT, the radiologist need not withhold or delay the examination and can achieve diagnostic-quality images while reducing radiation exposure.
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Misdiagnosed uterine rupture of an advanced cornual pregnancy. Case Rep Radiol 2012; 2012:289103. [PMID: 22606565 PMCID: PMC3350117 DOI: 10.1155/2012/289103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 02/01/2012] [Indexed: 12/26/2022] Open
Abstract
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.
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Pulmonary CT angiography protocol adapted to the hemodynamic effects of pregnancy. AJR Am J Roentgenol 2011; 197:1058-63. [PMID: 22021496 DOI: 10.2214/ajr.10.5385] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the image quality of a standard pulmonary CT angiography (CTA) protocol with a pulmonary CTA protocol optimized for use in pregnant patients with suspected pulmonary embolism (PE). MATERIALS AND METHODS Forty-five consecutive pregnant patients with suspected PE were retrospectively included in the study: 25 patients (group A) underwent standard-protocol pulmonary CTA and 20 patients (group B) were imaged using a protocol modified for pregnancy. The modified protocol used a shallow inspiration breath-hold and a high concentration, high rate of injection, and high volume of contrast material. Objective image quality and subjective image quality were evaluated by measuring pulmonary arterial enhancement, determining whether there was transient interruption of the contrast bolus by unopacified blood from the inferior vena cava (IVC), and assessing diagnostic adequacy. RESULTS Objective and subjective image quality were significantly better for group B-that is, for the group who underwent the CTA protocol optimized for pregnancy. Mean pulmonary arterial enhancement and the percentage of studies characterized as adequate for diagnosis were higher in group B than in group A: 321 ± 148 HU (SD) versus 178 ± 67 HU (p = 0.0001) and 90% versus 64% (p = 0.05), respectively. Transient interruption of contrast material by unopacified blood from the IVC was observed more frequently in group A (39%) than in group B (10%) (p = 0.05). CONCLUSION A pulmonary CTA protocol optimized for pregnancy significantly improved image quality by increasing pulmonary arterial opacification, improving diagnostic adequacy, and decreasing transient interruption of the contrast bolus by unopacified blood from the IVC.
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Dauer LT, Thornton RH, Miller DL, Damilakis J, Dixon RG, Marx MV, Schueler BA, Vañó E, Venkatesan A, Bartal G, Tsetis D, Cardella JF. Radiation management for interventions using fluoroscopic or computed tomographic guidance during pregnancy: a joint guideline of the Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe with Endorsement by the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2011; 23:19-32. [PMID: 22112899 DOI: 10.1016/j.jvir.2011.09.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 09/08/2011] [Accepted: 09/08/2011] [Indexed: 12/16/2022] Open
Affiliation(s)
- Lawrence T Dauer
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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