Medical Imaging in ObstetricsMedical Imaging in Obstetrics
Mohamed Kandeel, M.D.Mohamed Kandeel, M.D.
Professor of Obstetrics and GynecologyProfessor of Obstetrics and Gynecology
Menofyia University, EgyptMenofyia University, Egypt
At the end of this presentation, you should be:
1-Aware of the different imaging modalities which can be used safely during
2- Aware of the different uses and risks of the different imaging techniques.
I-I- X - RayX - Ray
X ray is a form of radiant energy, similar to light or radio waves, but they have the ability to
penetrate the body and produce pictures for different organs which can be interpreted on a TV
screen or a computer monitor. Unborn children are particularly sensitive to x-rays because
their cells are rapidly dividing and developing into different types of tissue and organs.
Ionizing radiation (x-ray) are capable of reducing cell division, and damaging genetic DNA
and it can be measured in different units, the gray (Gy) and the rem, or in the older and more
commonly recognized unit, the rad.
The maximal permissible limit of ionizing radiation to which the fetus should be exposed
during pregnancy is a cumulative dose of 5 rad (1). However, the March of Dimes has
reported that studies found no significant relationship between exposure of pregnant women to
5–10 rads of x–rays and malformations in their children (March of Dimes, September 1997).
The National Council on Radiation Protection (2) stated that the risk of malformations is
significantly increased only at doses above 15 rad.
I- X Ray –X Ray – (Cont.)(Cont.)
Exposure to as little as 1 or 2 rad has been associated with a slight increase in childhood
malignancies, especially leukemia. According to the Nuclear Regulatory Commission (NRC),
children exposed to 2–6 rads of x-rays in utero have an increased chance of developing cancer
(NRC, 1999, Biological Effects of Radiation).
Ionizing radiation is known to create bizarre new mutations. The dosage required to double the
baseline mutation rate, found in general population, is between 50 and 100 rad.
Federal laws have been established to protect the unborn children of women exposed to
radiation in the workplace. In the workplace, the dose of radiation to an unborn child
throughout the entire pregnancy should not exceed 0.5 rem. For x-rays, rem and rad are
equivalent and the limit of exposure for unborn children is therefore 0.5 rads.
I- X RayX Ray (Cont.)(Cont.)
A radiation physicist can calculate the estimated dose of radiation to the fetus to
assist in patient counseling. No single diagnostic procedure results in a radiation
dose that threatens the well-being of the developing embryo and fetus.
It is essential when you counsel your patient not to promise her a perfect baby to
avoid parenteral disappointments and lawsuits. As part of counseling, you should
inform mother that the actual risk depends on gestational age and that spontaneous
birth anomalies occur in 4 to 6 percent of all deliveries. It is also important to
clarify that x-rays affect only body tissues which come into direct contact with the
I-I- X RayX Ray (Cont.)(Cont.)
1-Diagnose Intrauterine fetal death, fetal presentation and position
2-Diagnose congenital malformations. e.g. hydrocephalus
5- Exclude vesicular mole: no boney skeleton at 15 weeks or more
I-I- X RayX Ray (Cont.)(Cont.)
1-Congenital fetal malformations. In early pregnancy, A single abdominal
exposure exposes the abdomen for 0.5 r while pelvimetry exposes the
abdomen for 1.1 r. Microcephaly and mental retardation occurs at a dose of
2-Abortion and Intrauterine fetal death
3-In late pregnancy, cleft palate and cataract
4-Fetal gene mutation and infertility
5-Fetal neoplasms especially leukaemia.
II-II-Iodinated Contrast MediaIodinated Contrast Media
The use of intravascular contrast media is better avoided in pregnancy.
Contrary to animal studies, in vitro studies have shown iodinated contrast
to be mutagenic to human cells. Also, the iodine content of contrast media
have the potential to produce neonatal hypothyroidism. The evidence for
this potential stems from the occurrence of neonatal hypothyroidism after
direct instillation of ionic contrast into the amniotic cavity. Therefore; it is
essential to screen all infants of mothers who received iodinated contrast
during pregnancy for hypothyroidism. On the other hand, the use of an
intravascular non-ionic contrast media was not found to have any
detrimental effect on neonatal thyroid function.
Management of Irradiated Pregnant womenManagement of Irradiated Pregnant women
1-According to Danish rule of 1959, termination was indicated for a fetal
dose > 10 rads.
2-Wagner et al suggested termination only be considered if a radiation
dose exceeds 5 rad between 2 and 15 weeks of gestation, and is indicated
only for doses over 15 rad.
3-Hall suggests termination for a radiation dose of over 10 rad received
between a gestational age of 10 days and 26 weeks.
III-III-Radionuclide ScansRadionuclide Scans
• Whenever a pregnant woman is scheduled for a Radionuclide exams
(nuclear medicine scan), she should inform her physician/technologist who
will consult with her caring physician for either possible postponement of
the procedure if not urgent, or taking extra precautions to minimize
• Another precaution is advised for women who are breast-feeding. Because
some of the pharmaceuticals that are used for the procedure can pass into
the mother's milk, the patient should discontinue breast-feeding for a short
while, pump her breasts in the interim and discard the milk. Breast-feeding
can often resume shortly afterwards.
This is a procedure which uses high-frequency sound waves to view internal
organs. Ultrasound imaging uses the principles of sonar developed for ships at sea,
or radar detection for speedy cars. As sound passes through the body it produces
echoes, which can be used to identify distance between body parts and their size
Ultrasound has no known detrimental effects on either mother or fetus.
Methods of UltrasoundMethods of Ultrasound
1-1-Vaginal UltrasoundVaginal Ultrasound
1-A specially designed transducer is covered with a condom, lubricated, and placed
inside the vagina.
2-The transducer is then moved around the vagina, pressed up on either sides of the
cervix, to allow visualization inside the uterus and pelvis. The procedure might
cause some tolerable pain, which usually does not prevent the examination.
Trans-vaginal ultrasound is most useful in the first trimester and is of great help in
fat women and in those with an RVF uterus.
2-2-Abdominal UltrasoundAbdominal Ultrasound
1-The patient should be advised to drink plenty of fluids before examination so that to have a full
bladder. This allows the uterus to be lifted out of the pelvis during examination for better
image. This advise is valid till 28 weeks gestation.
2-Warmed lubricant is applied over the patient’s abdomen.
3-The transducer is then palced in contact with the patient’s abdomen and moved around over the
patient’s abdomen as needed to visualize the fetus and determine its viability, its organs, the
placenta, and the cervix for length and comptence. Gestational age is determined using a set
of parameters including crown-rump Length, abdominal circumference, biparietal diameter,
head circumference or femur length.
3-3-3-4 D Ultrasound3-4 D Ultrasound
• Using a specially designed probe for 3 D image, the transducer takes a series of
imagesof the subject and the computer, using special software, processes these
images and presents them as a 3 dimensional image.
• Having a good quality image depends on many factors:
1-The operator skill
2-The amount of amniotic fluid
3- Fetal position
4-Abdominal maternal obesity
• 4-D scanners allows parents to see the details of their baby before birth helping the
establishment of strong psychological and emotional bonds.
Uses in pregnancy:
1-Determine gestational age, growth, viability & presentation of the fetus
2-Identify multiple gestations and zygosity
3-Measurements of the amniotic fluid volume and diagnosis of oligo/polyhydramnios
4-Diagnosis of placenta previa and placental abruption
5-Diagnosis of congenital fetal malformations, IUGR and IUFD
6-As a guide for amniocentesis, cordocentesis and chorionic villus sampling and during
intrauterine blood transfusion in treating RH isoimmunization
7- 3-D ultrasound improves the diagnosis of congenital anomalies such as spina
bifida,cardiac malformations, cleft lips/palate, polydactyly, facial dysmorphism or
clubbing of feet.
V-V-Computed TomographyComputed Tomography
Computed tomography (CT) scans allow for cross-sectional views of
body organs and tissues. The procedure utilizes ionizing radiation and
therefore; pregnant women or those intending to become pregnant
should have a CT scan only if the diagnostic benefits outweigh the risks.
They should avoid full body or abdominal scans. It is important not to
repeat the film should any error occur during scanning.
The amount of exposure depends on maternal and fetal sizes, fetal
position and distance from the radiation. Pregnant patients receiving CT
or any x-ray exam away from the abdominal area should be protected by
a lead apron.
V-V-Computed TomographyComputed Tomography (Cont.)(Cont.)
1-Cranial CT: detect acute hemorrhage in eclamptic women
3-Abdominal CT: done only if the fetus is dead
4-Evaluate brain, lung, liver & pelvic metastases in GTD
5-Diagnoses of DVT
6-Diagnosis of acute neurological catastrophy during pregnancy
VI-VI-Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)
MRI is a form of low-energy non-ionizing radio waves and it gives different and more detailed
information compared with X-ray, ultrasound, or computed tomography scan. During
examination, the part of the body being scanned is placed inside a special machine that
contains a strong magnet. Digital pictures from an MRI scan are then taken and stored on a
computer for more study either on the spot or remote as in a clinic or an operating room.
An informed consent must be signed by the patient. Before the procedure.
VI-VI-MRI-Safety during pregnancyMRI-Safety during pregnancy
MRI avoids the use of ionizing radiation and therefore, is considered safe. During
pregnancy, it should only be performed for maternal rather than fetal reasons. It
should be reserved for pregnant patients with suspected serious problems.
MRI is better avoided during the first trimester and more specifically during the
period of organogenesis. Hazards that may affect the fetus include heating, noise
(which theoretically may cause acoustic damage) and the use of the contrast agents;
gadolinium compounds, which cross the placenta and enter the fetal bloodstream,
and their use during pregnancy should be avoided. Evidence for teratogenic effects
was shown in animal studies.
VIVIMRI-Safety during pregnancyMRI-Safety during pregnancy (Cont.)(Cont.)
A reduction in crown-rump length was seen in mice exposed to MRI in
mid-gestation. Exposure to the electromagnetic fields caused eye
malformations in a mouse strain and several hours of exposure of chick
embryos in the first 48 hours of life to a strong static magnetic field
resulted in an excess number of dead or abnormal chick embryos when
examined at day 5.
If you are going to scan a breast feeding mother receiving a contrast agent,
advise patient to pump breast milk before the study, to be used until
injected contrast material has cleared from the body, which typically takes
about 24 hours.
VIVIMagnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI) (Cont.)(Cont.)
Uses of MRI:
1-Role out associated medical emergencies during pregnancy. e.g. appendicitis
during pregnancy: Typically, ultrasound is the preferred method for imaging the
appendix in pregnant women, but the enlarged uterus and other physiologic
changes--particularly during the third trimester--may prevent proper visualization
of the appendix, rendering the exam inconclusive.
2-Diagnoses of congenital fetal malformations and fetal tumors
3-Facilitating open fetal surgery and other fetal interventions
4-Planning for procedures (such as the EXIT procedure = ex utero intrapartum
treatment procedure) to safely deliver and treat babies whose defects would
otherwise be fatal.
1-American College of Obstetricians and Gynecologists, Committee on
Obstetric Practice. Guidelines for diagnostic imaging during pregnancy.
ACOG Committee opinion no. 158. Washington, D.C.: ACOG, 1995.
2-Hall EJ. Scientific view of low-level radiation risks. Radiographics