Imaging of pregnant and lactating patients: part 1, evidence-based review and recommendations. AJR Am J Roentgenol. 2012;198:778-784. [PMID: 22451541 DOI: 10.2214/ajr.11.7405]

Breastfeeding and contrast agents-A critical review and presentation of new aspects

BACKGROUND

There are discrepancies between guidelines of scientific societies and information of the package inserts of contrast media concerning breastfeeding following the application of a contrast agent to the mother.

OBJECTIVES

The contents of different review articles reflect the opinion of scientific societies. Consequently, in clinical routine settings it is difficult to find the optimal advice for a breastfeeding woman and her baby.

METHODS

Therefore, the paper carefully summarized important information dealing with the topic 'breastfeeding and contrast media' from the literature. Among other things, the paper focuses on topics that are not yet taken into account in other reviews (e.g. approval for breastfeeding women, contrast agents that have been analysed in human breast milk).

RESULTS

In this way, the review shows new aspects. It has been revealed that data concerning the amount of contrast agents in human breast milk as well as contrast medium absorption by the infants' intestine are sparse. Instead of them, a lot of speculations and incorrect conclusions do exist in the literature. Because studies are rare or missing, contrast media are not approved for breastfeeding women (off-label-use).

CONCLUSION

Although breastfeeding women 100% prefers a break from breastfeeding, in current decision-making processes, their preference plays a minor role. However, this should change in the future. In addition, it would be very important to inform breastfeeding women in the future about the missing data concerning 'breastfeeding and contrast media'.

Emergency imaging protocols for pregnant patients: a multi-institutional and multi- specialty comparison of physician education

PURPOSE

Previous studies have demonstrated that radiologists and other providers perceive the teratogenic risks of radiologic imaging to be higher than they actually are. Thus, pregnant patients were less likely to receive ionizing radiation procedures. While it is imperative to minimize fetal radiation exposure, clinicians must remember that diagnostic studies should not be avoided due to fear of radiation, particularly if the imaging study can significantly impact patient care. Although guidelines do exist regarding how best to image pregnant patients, many providers are unaware of these guidelines and thus lack confidence when making imaging decisions for pregnant patients. This study aimed to gather information about current education, confidence in, and knowledge about emergency imaging of pregnant women among radiology, emergency medicine, and OB/GYN providers.

METHODS

We created and distributed an anonymous survey to radiology, emergency medicine, and OB/GYN providers to evaluate their knowledge and confidence in imaging pregnant patients in the emergent setting. This study included a questionnaire with the intent of knowing the correct answers among physicians primarily across the United States (along with some international participation). We conducted subgroup analyses, comparing variables by specialty, radiology subspecialty, and training levels. Based on the survey results, we subsequently developed educational training videos.

RESULTS

108 radiologists, of which 32 self-identified as emergency radiologists, ten emergency medicine providers and six OB/GYN clinicians completed the survey. The overall correct response rate was 68.5%, though performance across questions was highly variable. Within our 18-question survey, four questions had a correct response rate under 50%, while five questions had correct response rates over 90%. Most responding physicians identified themselves as either "fairly" (58/124, 47%) or "very" (51/124, 41%) confident. Amongst specialties, there were differences in performance concerning the knowledge assessment (p = 0.049), with the strongest performance from radiologists. There were no differences in knowledge by training level (p = 0.4), though confidence levels differed significantly between attending physicians and trainees (p < 0.001).

CONCLUSION

This study highlights deficiencies in knowledge to support appropriate decision-making surrounding the imaging of pregnant patients. Our results indicate the need for improved physician education and dissemination of standardized clinical guidelines.

Extracellular gadolinium-based contrast agents

Extracellular gadolinium-based contrast agents (GBCA) are commonly used in magnetic resonance imaging (MRI) because they increase the detection of alterations, improve tissue characterisation and enable a more precise differential diagnosis. GBCAs are considered to be safe but they are not risk-free. When using GBCAs, it is important to be aware of the risks and to know how to react in different situations (pregnancy, breastfeeding, kidney failure) including if complications occur (extravasations, adverse, allergic or anaphylactic reactions). The article describes the characteristics of the gadolinium molecule, the differences in the biochemical structure of these GBCA, their biodistribution and the effect on the MRI signal. It also reviews safety aspects and the most common clinical applications.

Whole-body MRI in oncology: A comprehensive review

Whole-Body Magnetic Resonance Imaging (WB-MRI) has cemented its position as a pivotal tool in oncological diagnostics. It offers unparalleled soft tissue contrast resolution and the advantage of sidestepping ionizing radiation. This review explores the diverse applications of WB-MRI in oncology. We discuss its transformative role in detecting and diagnosing a spectrum of cancers, emphasizing conditions like multiple myeloma and cancers with a proclivity for bone metastases. WB-MRI's capability to encompass the entire body in a singular scan has ushered in novel paradigms in cancer screening, especially for individuals harboring hereditary cancer syndromes or at heightened risk for metastatic disease. Additionally, its contribution to the clinical landscape, aiding in the holistic management of multifocal and systemic malignancies, is explored. The article accentuates the technical strides achieved in WB-MRI, its myriad clinical utilities, and the challenges in integration into standard oncological care. In essence, this review underscores the transformative potential of WB-MRI, emphasizing its promise as a cornerstone modality in shaping the future trajectory of cancer diagnostics and treatment.

Acute Pancreatitis during and after Pregnancy: A Review

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Use of gadolinium-based contrast agents in multiple sclerosis: a review by the ESMRMB-GREC and ESNR Multiple Sclerosis Working Group

Magnetic resonance imaging (MRI) is the most sensitive technique for detecting inflammatory demyelinating lesions in multiple sclerosis (MS) and plays a crucial role in diagnosis and monitoring treatment effectiveness, and for predicting the disease course. In clinical practice, detection of MS lesions is mainly based on T2-weighted and contrast-enhanced T1-weighted sequences. Contrast-enhancing lesions (CEL) on T1-weighted sequences are related to (sub)acute inflammation, while new or enlarging T2 lesions reflect the permanent footprint from a previous acute inflammatory demyelinating event. These two types of MRI features provide redundant information, at least in regular monitoring of the disease. Due to the concern of gadolinium deposition after repetitive injections of gadolinium-based contrast agents (GBCAs), scientific organizations and regulatory agencies in Europe and North America have proposed that these contrast agents should be administered only if clinically necessary. In this article, we provide data on the mode of action of GBCAs in MS, the indications of the use of these agents in clinical practice, their value in MS for diagnostic, prognostic, and monitoring purposes, and their use in specific populations (children, pregnant women, and breast-feeders). We discuss imaging strategies that achieve the highest sensitivity for detecting CELs in compliance with the safety regulations established by different regulatory agencies. Finally, we will briefly discuss some alternatives to the use of GBCA for detecting blood-brain barrier disruption in MS lesions. CLINICAL RELEVANCE STATEMENT: Although use of GBCA at diagnostic workup of suspected MS is highly valuable for diagnostic and prognostic purposes, their use in routine monitoring is not mandatory and must be reduced, as detection of disease activity can be based on the identification of new or enlarging lesions on T2-weighted images. KEY POINTS: • Both the EMA and the FDA state that the use of GBCA in medicine should be restricted to clinical scenarios in which the additional information offered by the contrast agent is required. • The use of GBCA is generally recommended in the diagnostic workup in subjects with suspected MS and is generally not necessary for routine monitoring in clinical practice. • Alternative MRI-based approaches for detecting acute focal inflammatory MS lesions are not yet ready to be used in clinical practice.

Ethical and societal aspects of radiological protection for offspring and next generations

PURPOSE

Over the last decade or so, ethical and societal aspects of radiological protection have received increasing attention. This is also reflected in the publications of the International Commission on Radiological Protection (ICRP). The current paper aims at identifying relevant ethical and societal topics which should receive attention in the context of radiological protection for offspring and next generations.

MATERIALS AND METHODS

We present a non-comprehensive review of the subject, based on presentation made at an ICRP workshop in Budapest in 2022. We first discuss the ethical values promoted by ICRP, and the application of these values in cases of (potential) pre-conceptual and prenatal radiation exposures. We then consider experience gained after the Fukushima accident indicating particular societal concerns about the health effects of such exposures.

RESULTS AND CONCLUSIONS

Beneficence/non-maleficence, prudence, justice and dignity, the "core values" of the system of radiological protection have special roles to play when heritable and/or in utero effects are to be considered. Prudence, in particular, must be taken account of in view of the fact that solid scientific data in humans are largely lacking in this area, and it is necessary to rely on insights from animal experiments as well as theoretical considerations. As regards societal considerations, the perception of risk among (potentially) affected populations needs to be taken seriously. Accountability, transparency, and inclusivity, the "procedural values" promoted by ICRP for the practical implementation of the system of radiological protection play a central role in overcoming skepticism and creating trust. Stakeholder involvement should emphasize cooperation and dialogue, which allows for the joint evaluation of an exposure situation by experts and affected people.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

MAS-UNet: a U-shaped network for prostate segmentation

Prostate cancer is a common disease that seriously endangers the health of middle-aged and elderly men. MRI images are the gold standard for assessing the health status of the prostate region. Segmentation of the prostate region is of great significance for the diagnosis of prostate cancer. In the past, some methods have been used to segment the prostate region, but segmentation accuracy still has room for improvement. This study has proposed a new image segmentation model based on Attention UNet. The model improves Attention UNet by using GN instead of BN, adding dropout to prevent overfitting, introducing the ASPP module, adding channel attention to the attention gate module, and using different channels to output segmentation results of different prostate regions. Finally, we conducted comparative experiments using five existing UNet-based models, and used the dice coefficient as the metric to evaluate the segmentation result. The proposed model achieves dice scores of 0.807 and 0.907 in the transition region and the peripheral region, respectively. The experimental results show that the proposed model is better than other UNet-based models.

Patient-Centered Care in the Management of Cancer During Pregnancy

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

Multisystem Imaging Recommendations/Guidelines: In the Pursuit of Precision Oncology

With an increasing rate of cancers in almost all age groups and advanced screening techniques leading to an early diagnosis and longer longevity of patients with cancers, it is of utmost importance that radiologists assigned with cancer imaging should be prepared to deal with specific expected and unexpected circumstances that may arise during the lifetime of these patients. Tailored integration of preventive and curative interventions with current health plans and global escalation of efforts for timely diagnosis of cancers will pave the path for a cancer-free world. The commonly encountered circumstances in the current era, complicating cancer imaging, include coronavirus disease 2019 infection, pregnancy and lactation, immunocompromised states, bone marrow transplant, and screening of cancers in the relevant population. In this article, we discuss the imaging recommendations pertaining to cancer screening and diagnosis in the aforementioned clinical circumstances.

Prognosis, counseling, and indications for termination of pregnancy

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

Pancreatitis in Pregnancy-Comprehensive Review

Acute and chronic pancreatitis, until recently observed incidentally in pregnancy, has occurred much more frequently in the last 2-3 decades. Particularly severe complications for the mother and fetus may be a consequence of acute pancreatitis. Therefore, it is important to know more about the diagnostic and therapeutic possibilities of pancreatic diseases in the course of pregnancy. Epidemiology, causes, clinical characteristics, differential diagnosis, and complex management are presented in this review. Particular emphasis is on the prevention of acute pancreatitis (AP) through the proper diagnosis and treatment of cholelithiasis and hypertriglyceridemia, both before and during pregnancy. The most up-to-date reports and management strategies are presented. This publication contributes to a wide group of scientists and practitioners better understanding the discussed issues, and indicates the directions of research for the future.

Systematic review of postpartum and pregnancy-related cervical artery dissection

BACKGROUND

Cervical artery dissection (CeAD) is responsible of one fifth of cases of ischemic stroke, but is uncommon during pregnancy or the early postpartum period and evidence is derived from published case reports and case series.

OBJECTIVES

This systematic review with a prospectively registered protocol was conducted to study the clinical presentation, management and prognosis of this condition.

METHODS

Ovid-Medline, PubMed Central, and CINAHL were searched without language restriction.

RESULTS

Fifty-seven articles (50 case reports and seven case series) reporting on 77 patients were included. The mean age was 33.7 years. The main possible risk factors identified were migraine, hyperlipidemia, connective tissue disorders, preeclampsia and eclampsia, HELLP syndrome and prolonged second stage of labor. Headache was the most frequent symptom, followed by neck pain. Acute medical treatments included anticoagulation, antiplatelets, and endovascular therapy. No patients received thrombolysis. The overall prognosis was good with 77.8% of patients making full clinical recovery.

CONCLUSIONS

Cervical artery dissection is a rare, but an important complication of pregnancy and puerperium. Diagnosis requires a high index of suspicion. The strong association with hypertensive and connective tissue disorders requires further research.

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

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

Magnetic Resonance Imaging-Based Nomogram to Antenatal Predict Cesarean Delivery for Cephalopelvic Disproportion in Primiparous Women

BACKGROUND

Cephalopelvic disproportion (CPD)-related obstructed labor is associated with maternal and neonatal morbidity and mortality. Accurate prediction of whether a primiparous woman is at high risk of an unplanned cesarean delivery would be a major advance in obstetrics.

PURPOSE

To develop and validate a predictive model assessing the risk of cesarean delivery in primiparous women based on MRI findings.

STUDY TYPE

Prospective.

POPULATION

A total of 150 primiparous women with clinical findings suggestive of CPD.

FIELD STRENGTH/SEQUENCE

T1-weighted fast spin-echo sequences, single-shot fast spin-echo (SSFSE) T2-weighted sequences at 1.5 T.

ASSESSMENT

Pelvimetry and fetal biometry were assessed independently by two radiologists. A nomogram model combined that the clinical and MRI characteristics was constructed.

STATISTICAL TESTS

Univariable and multivariable logistic regression analyses were applied to select independent variables. Receiver operating characteristic (ROC) analysis was performed, and the discrimination of the model was assessed by the area under the curve (AUC). Calibration was assessed by calibration plots. Decision curve analysis was applied to evaluate the net clinical benefit. A P value below 0.05 was considered to be statistically significant.

RESULTS

In multivariable modeling, the maternal body mass index (BMI) before delivery, bilateral femoral head distance, obstetric conjugate, fetal head circumference, and fetal abdominal circumference was significantly associated with the likelihood of cesarean delivery. The discrimination calculated as the AUC was 0.838 (95% confidence interval [CI]: 0.774-0.902). The sensitivity and specificity of the nomogram model were 0.787 and 0.764, and the positive predictive and negative predictive values were 0.696 and 0.840, respectively. The model demonstrated satisfactory calibration (calibration slope = 0.945). Moreover, the decision curve analysis proved the superior net benefit of the model compared with each factor included.

DATA CONCLUSION

Our study might provide a nomogram model that could identify primiparous women at risk of cesarean delivery caused by CPD based on MRI measurements.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center

Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.

Microdiscectomy Under Local Anesthesia and Spinal Block in a Pregnant Female

The surgical plan and the anesthetic approach are vital in determining the proper treatment of lumbar disc herniation in pregnancy. The diagnostic tools available, as well as the anesthetic agents and methods of delivery, vary in pregnant patients due to factors such as radiation exposure and hemodynamics in the patient and fetus. The gestational age also plays an important role in determining treatment options. When possible, surgery should be avoided during the first trimester, especially during the period of organogenesis, as general anesthesia can interfere with this process. However, when focal neurological deficits are present, urgent surgical decompression may be necessary. In such cases, the selection of anesthesia must be guided by maternal indications and the nature of the surgery. Maternal safety and avoidance of fetal hypoxia and subsequent preterm labor are crucial when pregnant patients receive anesthesia. As a result, local anesthesia is often preferred when possible due to the decreased risk of systemic toxicity. Decompression surgery in pregnant females with lumbar disc herniation, using a multidisciplinary approach among the surgeon, obstetrician, and anesthesiologist, is an effective and safe procedure for both the mother and the fetus. We present the case of a pregnant female at four weeks of gestation who presented with lower back pain radiating down her right leg. MRI of the lumbar spine showed large L4-5 disc herniation. She underwent a successful right L4-5 microdiscectomy under local anesthesia and spinal block using bupivacaine and was completely awake throughout the procedure. Postoperatively, she experienced immediate improvement of symptoms.

Breast cancer and pregnancy: Why special considerations prior to treatment are needed in multidisciplinary care

Breast cancer diagnosed during pregnancy poses ethical and professional challenges. Clinical management of that condition should ensure the safety of both the mother and fetus. Clinical trials on breast cancer exclude pregnant women, so sufficient evidence with which to formulate guidelines for the management of these patients is lacking. Failing to undergo a breast examination during pregnancy, breast symptoms explained by physiological changes such as pregnancy, and unnecessary abortions after the diagnosis of breast cancer lead to worse outcomes for these patients. Multidisciplinary teams including breast surgeons, obstetricians, radiologists, pathologists, and anesthesiologists need to make an early diagnosis and comprehensively evaluate patients in different gestational weeks and with different stages of breast cancer in order to optimize outcomes.

X-RAY AND MOLECULAR IMAGING DURING PREGNANCY AND BREASTFEEDING-WHEN SHOULD WE BE WORRIED?

Some of the ethically most sensitive issues in radiation protection arise at imaging of pregnant-and potentially pregnant-patients and of newborn. This article reviews the current literature and recommendations on imaging during pregnancy and breastfeeding. Risks related to alternative non-ionizing radiation methods are also considered. With few exceptions, exposure of the fetus through radiography, computed tomography (CT) and nuclear medicine imaging can be limited to safe levels, although studies such as abdominal-pelvic CT cannot avoid significant exposure to fetuses. Eight to 10 weeks post-conception, the fetus has a thyroid which starts to concentrate iodide having crossed the placenta barrier resulting in unacceptably high doses to the fetal thyroid after administration of 131I- and even 123I-iodide and other radiopharmaceuticals with a high content of free radioiodine. Many radiopharmaceuticals are excreted through breast milk. Breastfeeding interruption recommendations should be followed to keep the effective dose to the infant below 1 mSv.

Deep Attention and Graphical Neural Network for Multiple Sclerosis Lesion Segmentation from MR Imaging Sequences

The segmentation of multiple sclerosis (MS) lesions from MR imaging sequences remains a challenging task, due to the characteristics of variant shapes, scattered distributions and unknown numbers of lesions. However, the current automated MS segmentation methods with deep learning models face the challenges of (1) capturing the multiple scattered lesions in multiple regions and (2) delineating the global contour of variant lesions. To address these challenges, in this paper, we propose a novel attention and graph-driven network (DAG-Net), which incorporates (1) the spatial correlations for embracing the lesions in distant regions and (2) the global context for better representing lesions of variant features in a unified architecture. Firstly, the novel local attention coherence mechanism is designed to construct dynamic and expansible graphs for the spatial correlations between pixels and their proximities. Secondly, the proposed spatial-channel attention module enhances features to optimize the global contour delineation, by aggregating relevant features. Moreover, with the dynamic graphs, the learning process of the DAG-Net is interpretable, which in turns support the reliability of segmentation results. Extensive experiments were conducted on a public ISBI2015 dataset and an in-house dataset in comparison to state-of-the-art methods, based on the geometrical and clinical metrics. The experimental results validate the effectiveness of the proposed DAG-Net on segmenting variant and scatted lesions in multiple regions.

Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies

Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies.

Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.

Deuterium Magnetic Resonance Imaging and the Discrimination of Fetoplacental Metabolism in Normal and L-NAME-Induced Preeclamptic Mice

Recent magnetic resonance studies in healthy and cancerous organs have concluded that deuterated metabolites possess highly desirable properties for mapping non-invasively and, as they happen, characterizing glycolysis and other biochemical processes in animals and humans. A promising avenue of this deuterium metabolic imaging (DMI) approach involves looking at the fate of externally administered ²H_6,6′-glucose, as it is taken up and metabolized into different products as a function of time. This study employs deuterium magnetic resonance to follow the metabolism of wildtype and preeclamptic pregnant mice models, focusing on maternal and fetoplacental organs over ≈2 h post-injection. ²H_6,6′-glucose uptake was observed in the placenta and in specific downstream organs such as the fetal heart and liver. Main metabolic products included ²H_3,3′-lactate and ²H-water, which were produced in individual fetoplacental organs with distinct time traces. Glucose uptake in the organs of most preeclamptic animals appeared more elevated than in the control mice (p = 0.02); also higher was the production of ²H-water arising from this glucose. However, the most notable differences arose in the ²H_3,3′-lactate concentration, which was ca. two-fold more abundant in the placenta (p = 0.005) and in the fetal (p = 0.01) organs of preeclamptic-like animals, than in control mice. This is consistent with literature reports about hypoxic conditions arising in preeclamptic and growth-restricted pregnancies, which could lead to an enhancement in anaerobic glycolysis. Overall, the present measurements suggest that DMI, a minimally invasive approach, may offer new ways of studying and characterizing health and disease in mammalian pregnancies, including humans.

Imaging during pregnancy: What the radiologist needs to know

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

MRI in pregnant patients with suspected abdominal and pelvic cancer: a practical guide for radiologists

The incidence of abdominal and pelvic cancer in pregnancy is low, but it is rising as the population of pregnant women gets older. Depending on disease stage, gestational age and patient's preference, active surveillance as well as surgery and chemotherapy are feasible options during pregnancy. Correct diagnosis and staging of the tumor is crucial for choosing the best therapeutic approach. Moreover, a reproducible modality to assess the treatment response is requested. Magnetic resonance imaging (MRI) is commonly used with good results for the local staging and treatment response evaluation of most abdominal and pelvic cancers in nonpregnant patients, and it is considered relatively safe during pregnancy. The purpose of this article is to analyze the most relevant topics regarding the use of MRI in pregnant women with abdominal and pelvic cancer. We discuss MRI safety during pregnancy, including the use of gadolinium-based contrast agents (GBCAs), how to prepare the patient for the exam and MRI technique. This will be followed by a brief review on the most common malignancies diagnosed during pregnancy and their MRI appearance.

Imaging modalities in pregnant cancer patients

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

Conservative Management of a Splenic Artery Aneurysm in Pregnancy: A Case Report

Splenic artery aneurysms (SAA) are a rare and life-threatening pathology. Ruptured SAA has a mortality rate of up to 25%, with increased rates of rupture in pregnancy, pseudoaneurysm, liver transplantation, portal hypertension, symptomatic SAA and diameter >2 cm. Management of SAA in pregnant women is poorly described in the literature, making treatment of these patients difficult. Furthermore, careful consideration of complications for both the mother and the foetus need to be taken into account. This case report demonstrates that conservative management with monthly surveillance MRI can be used as viable treatment option of an asymptomatic 17 mm splenic artery aneurysm in a pregnant woman.

How to read a fetal magnetic resonance image 101

Accurate antenatal diagnosis is essential for planning appropriate pregnancy management and improving perinatal outcomes. The provision of information vital for prognostication is a crucial component of prenatal imaging, and this can be enhanced by the use of fetal MRI. Image acquisition, interpretation and reporting of a fetal MR study can be daunting to the individual who has encountered few or none of these examinations. This article provides the radiology trainee with a general approach to interpreting a fetal MRI. The authors review the added value of prenatal MRI in the overall assessment of fetal wellbeing, discuss MRI protocols and techniques, and review the normal appearance of maternal and fetal anatomy. The paper concludes with a sample template for structured reporting, to serve as a checklist and guideline for reporting radiologists.

[The (severely) injured pregnant patient from the perspective of radiology]

Trauma is one of the leading causes of mortality in pregnant women and significantly increases the likelihood of an unwanted termination of pregnancy. Particularly in severe trauma with an increased risk of significant maternal injuries, computed tomography (CT) remains the imaging modality of choice as it is comprehensively available, quick to carry out and has a high diagnostic accuracy in the detection and classification of life-threatening trauma-associated pathologies compared to other imaging techniques. Considering the radiation-associated risks, it is unlikely that a single, monophasic CT in the emergency trauma room will exceed the threshold of deterministic radiation damage; therefore, fetal malformations or fetal loss are not to be expected; however, there is a low stochastic risk for the delayed occurrence of radiation-induced cancer both for the child and the mother that can be considered small in comparison to missed or delayed diagnoses after severe trauma. Intravenous, nonionic iodinated contrast agents are not contraindicated during pregnancy and should be administered whenever their use would also be considered appropriate in a nonpregnant patient; however, unnecessary scans and, if possible, multiple contrast agent phases should be avoided in order to reduce radiation. Magnetic resonance imaging (MRI) has a major role in the subacute setting and constitutes an excellent problem solver for specific questions, such as the evaluation of discoligamentous injuries of the spine. Its use is deemed acceptable at any stage of pregnancy when the required information is considered important for the management of further treatment. Due to potential teratogenic effects of MRI contrast media containing gadolinium on the fetus, including an increased likelihood of fetal loss, they should only be administered with great caution and under strictly defined indications.

Breast Imaging in Pregnancy and Lactation

All breast disorders found during pregnancy and lactation should be carefully evaluated. Most of them are benign, but it is essential to exclude pregnancy-associated breast cancer (PABC), which is too often diagnosed late. The first-line imaging technique is ultrasound (US), which must be completed by mammography if there is any clinical or US suspicious sign . In lactating patients with PABC , breast magnetic resonance imaging (MRI) can be useful for local assessment.Management depends on the precise analysis and BI-RADS classification of the lesion. During pregnancy and lactation, there is an overlap in imaging: many benign lesions can grow, infarct, become heterogeneous and thus suspicious, and on the other hand, PABC does not always present with typical malignant features. That is why biopsy must be performed if after the clinical and radiological evaluation the doubt persists, i.e. for all BI-RADS 4 and 5 lesions, and for some BI-RADS 3 lesions.

Current Recommendations for Breast Imaging of the Pregnant and Lactating Patient

During pregnancy and lactation, the breast undergoes unique changes that manifest as varied clinical and imaging findings. Understanding the expected physiologic changes of the breast as well as recognizing the best imaging modalities for a given clinical scenario can help the radiologist identify the abnormalities arising during this time. Discussion with the patient about the safety of breast imaging can reassure patients and improve management. This article reviews the physiologic changes of the breast during pregnancy and lactation; the safety and utility of various imaging modalities; upto-date consensus on screening guidelines; recommendations for diagnostic evaluation of breast pain, palpable abnormalities, and nipple discharge; and recommendations regarding advanced modalities such as breast MRI. In addition, the commonly encountered benign and malignant entities affecting these patients are discussed.

Management of breast cancer risk in BRCA1/2 mutation carriers who are unaffected with cancer

Pathogenic mutations in BRCA1 and BRCA2 genes markedly increase the risk of breast cancer and other cancers such as ovarian/fallopian tube, pancreatic, prostate, and melanoma. Patients with BRCA1 mutations have a slightly higher lifetime risk of breast cancer than BRCA2 mutation carriers, and both BRCA1 and BRCA2 carriers tend to develop breast cancer at an earlier age than the general population. In this review, we will discuss management recommendations to reduce breast cancer risk for BRCA1/2 mutation carriers including special populations of carriers such as pregnant or lactating patients and men. Breast cancer screening, including clinical breast examination, mammogram, and breast MRI, is important for detecting breast cancer at an early and likely curable stage. In addition to screening, counseling on risk-reducing surgeries is strongly recommended for BRCA1/2 carriers. Risk-reducing mastectomy decreases the risk of breast cancer development, and risk-reducing salpingo-oophorectomy decreases ovarian cancer-specific as well as overall mortality, but controversy exists regarding its impact on breast cancer-specific mortality. Given the effectiveness of screening for breast cancer, further management should be carried out on an individual basis taking into account quality of life and psychosocial factors, and recommendations should be readdressed periodically as science progresses and patients' goals may change.

3D APA-Net: 3D Adversarial Pyramid Anisotropic Convolutional Network for Prostate Segmentation in MR Images

Accurate and reliable segmentation of the prostate gland using magnetic resonance (MR) imaging has critical importance for the diagnosis and treatment of prostate diseases, especially prostate cancer. Although many automated segmentation approaches, including those based on deep learning have been proposed, the segmentation performance still has room for improvement due to the large variability in image appearance, imaging interference, and anisotropic spatial resolution. In this paper, we propose the 3D adversarial pyramid anisotropic convolutional deep neural network (3D APA-Net) for prostate segmentation in MR images. This model is composed of a generator (i.e., 3D PA-Net) that performs image segmentation and a discriminator (i.e., a six-layer convolutional neural network) that differentiates between a segmentation result and its corresponding ground truth. The 3D PA-Net has an encoder-decoder architecture, which consists of a 3D ResNet encoder, an anisotropic convolutional decoder, and multi-level pyramid convolutional skip connections. The anisotropic convolutional blocks can exploit the 3D context information of the MR images with anisotropic resolution, the pyramid convolutional blocks address both voxel classification and gland localization issues, and the adversarial training regularizes 3D PA-Net and thus enables it to generate spatially consistent and continuous segmentation results. We evaluated the proposed 3D APA-Net against several state-of-the-art deep learning-based segmentation approaches on two public databases and the hybrid of the two. Our results suggest that the proposed model outperforms the compared approaches on three databases and could be used in a routine clinical workflow.

The Radiology Resident as Teaching Consultant: An Innovative Peer-to-Peer Teaching Consultation Service to Strengthen Relationships With Referring Colleagues in the Era of Imaging 3.0

BACKGROUND

The American College of Radiology Imaging 3.0 paradigm emphasizes the need for radiologists to serve as imaging consultants to their referring colleagues. However, outside the reading room, teaching interactions between radiology and nonradiology residents are limited. Internal Medicine Morning Report (IMMR) is a resident-run educational program widely employed by internal medicine (IM) residencies. Although medical imaging is regularly discussed in IMMR, radiology residents are not typically involved in case preparation. We aimed to develop a peer-to-peer imaging teaching consultation service (TCS) incorporated into the well-established structure of IMMR. By creating illustrative, "dynamic" teaching slides for use at these conferences, we sought to provide salient radiology teaching material, demystify jargon, discuss appropriate imaging use, and review relevant anatomy. We hypothesized that TCS could improve the quality of IMMR as perceived by the IM presenter.

METHODS

TCS was piloted over a 7-month period. Each referred case was reviewed by a senior radiology resident who produced a set of "dynamic" teaching slides for each case. These included patient imaging overlayed with extensive annotations and animations highlighting teaching points, with particular attention to radiologic terminology. Slides were shared with the IM presenter, who could use them for preparation and include the animations in the talk if desired. TCS effectiveness was evaluated with a survey distributed to participating IM residents.

RESULTS

In the pilot period, 12 TCS requests were received and 10 were performed in collaboration with 6 IM residents. Survey results indicated that most IM residents did not consult radiologists prior to TCS (5/6, 83%). IM residents used the "dynamic" teaching slides to both prepare for and present at IMMR (5/6, 83%). TCS improved IM residents' perceived ability to engage their audience (6/6, 100%), confidence in teaching radiology material (4/6, 67%), ability to understand radiology reports (4/6, 67%) and appreciation for what radiologists do (6/6, 100%).

CONCLUSIONS

The TCS pilot resulted in successful radiology-IM collaboration and improved knowledge and confidence in teaching imaging concepts. Continuous program evaluation will be performed and future work will assess the effect of TCS on radiologist confidence in real-world clinical consultations.

The Hepatobiliary System: An Overview of Normal Function and Diagnostic Testing in Pregnancy

Pregnancy is associated with physiological adaptions that affect every organ system. Changes in liver function in pregnancy have important effects on nutrient metabolism, protein synthesis, and the biotransformation of substances in preparation for excretion. A clear understanding of the anatomic and functional changes of the hepatobiliary system is necessary for the diagnosis and evaluation of disease, as well as understanding how these changes predispose women to pregnancy-specific hepatic conditions. In this review, the effect of gestational changes in hepatobiliary function on laboratory tests and the role of diagnostic imaging of the liver and gallbladder in pregnancy will be discussed.

Medical doctors' awareness of radiation exposure in diagnostic radiology investigations in a South African academic institution

Background

Diagnostic investigations using radiation have become a critical feature of medical practice in recent times. However, the possibility of doctors’ underestimation of risks of over-exposure of patients to diagnostic radiation still warrants further evaluation.

Objectives

To investigate doctors’ awareness of diagnostic radiation exposure at Dr George Mukhari Academic Hospital, South Africa.

Methods

This was a cross-sectional, analytical investigation of the awareness of doctors about radiation exposure in diagnostic radiology investigations. A cluster sampling technique was employed to recruit 217 participants. Consent and approval of the participants were sought and obtained before questionnaire administration during departmental meetings between October 2017 and March 2018.

Results

Of the participants, 80% had no formal training on radiation exposure and 33.8% of them correctly estimated natural background radiation. Correct estimates of the effective dose from a single-view abdominal X-ray (AXR) were expressed by 7.5%, quantity of radiation of a single-phase computed tomography (CT) abdomen by 30.3% and dosage from a two-view unilateral mammogram by 29.1% of the participants. More than 75% of participants agreed that children are more sensitive to radiation, but only 10.5% suggested medical termination of pregnancy for a woman who had CT abdomen and pelvis with contrast. Dosage and risk of inducing fatal cancer from common but more complex imaging procedures were poorly understood. Only the doctors of the radiology department showed a statistically significant (p < 0.0001) association with regards to their radiation awareness.

Conclusion

Because of the high rate of poor awareness of radiation risks observed in this study, it is important to initiate, early in the medical curriculum for medical students, the need for a rotation in the Department of Radiology, similar to such rotations in other medical specialties.

Evaluation of fetal exposure to external loud noise using a sheep model: quantification of in utero acoustic transmission across the human audio range

BACKGROUND

There is mounting evidence that neural memory traces are formed by auditory learning in utero and that premature newborns are particularly sensitive to the intense, sustained noises or impulses sounds associated with the use of intensive care equipment. One area of critical importance is the determination of sound level exposure in utero associated with maternal occupation. The attenuation factors provided by the abdomen and tissue as well as the routes by which the inner ear receives stimulation need careful consideration and investigation to provide prenatal protection from external sound levels and frequencies that may cause harm.

OBJECTIVE

To measure how sound from external sound sources is transmitted to the fetus inside the uterus of a pregnant sheep in 6 Hz frequency steps between 100 Hz and 20 kHz (ie, across most of the human audio range).

STUDY DESIGN

We measured acoustic transfer characteristics in vivo in 6 time-mated singleton pregnant Romney ewes (gestational age, 103-130 days, weight, 54-74 kg). Under general anesthesia and at hysterotomy, a calibrated hydrophone was attached to the occiput of the fetal head within the amniotic sac. Two calibrated microphones were positioned in the operating theater, close to the head and to the body of each ewe. Initial experiments were carried out on 3 pregnant ewes 3 days after transport recovery to inform the data acquisition protocol. This was followed by detailed data acquisition of 3 pregnant ewes under general anesthesia, using external white noise signals. Voltage signals were acquired with 2 calibrated microphones, located near the head and the body of each ewe and with a calibrated hydrophone located in the amniotic fluid.

RESULTS

Measurement of acoustic transmission through the maternal abdominal and uterine walls indicates that frequency contents above 10 kHz are transmitted into the amniotic sac and that some frequencies are attenuated by as little as 3 dB.

CONCLUSION

This study provides new data about in utero sound transmission of external noise sources beyond physiological noise (cardiovascular, respiratory, and intestinal sounds), which help quantity the potential for fetal physiological damage resulting from exposure to high levels of noise during pregnancy. Fine-frequency acoustic attenuation characteristics are essential to inform standards and clinical recommendations on exposure of pregnant women to noise. Such transfer functions may also inform the design of filters to produce an optimal acoustic setting for maternal occupational noise exposure, use of magnetic resonance imaging during pregnancy, and for neonatal incubators.