1. Applications of IR in
Obstetrics and Gynecology
Grand Rounds
Obstetrics and Gynecology
1/29/2010
Justin McWilliams, MD
Assistant Professor
UCLA Interventional Radiology
2.
3. Stephen Kee, MD Christopher Loh, MD Cheryl Hoffman, MD
Section Chief Director, Santa Monica Director, Manhattan Beach
Justin McWilliams, MD
Michael Kuo, MD Antoinette Gomes, MD Susie Muir, MD
UCLA Interventional Radiology
6. Part I – Hemorrhage
Obstetric hemorrhage
Gynecologic hemorrhage
Part II – Thrombosis
Deep vein thrombosis
Pulmonary embolism
Part III – Elective procedures
Uterine fibroid embolization
Pelvic congestion syndrome
Fallopian tube recanalization
Part IV – Radiation and contrast
Outline of Discussion
8. Obstetric
hemorrhage
Obstetric hemorrhage is the single
most important cause of maternal Introduction
mortality worldwide
◦ 3rd leading cause of maternal
mortality in the USA
Complicates ~5% of deliveries
14. Obstetric
hemorrhage
Distal occlusion prevents
arterial reconstitution from
collaterals Post-partum
hemorrhage
Temporary occlusive effect
(usually 10-30 days)
Embolotherapy
Rapid (similar to trauma)
◦ Available at all times
◦ Procedure time usually less than one
hour
16. Obstetric
hemorrhage
Normal menstruation usually
resumes in 3-6 months
Post-partum
hemorrhage
Complications are uncommon
(3-7%) and much lower than
laparotomy
◦ Post-embolization syndrome Embolotherapy
◦ Access site hematoma
◦ Infection
◦ Rare ischemic complications
(bladder or uterine
necrosis, nerve paresis)
Vedantham 1997
17. Obstetric
hemorrhage
Fertility is usually preserved
◦ Picone 2003: Ultrasound showed normal Post-partum
fetal growth and Doppler findings in 8/8 hemorrhage
◦ Oman 2003: 28 patients post-
embolotherapy were followed for ~12
years
6/6 who desired pregnancy were successful
All pregnancies and deliveries were Embolotherapy
uncomplicated
◦ Delotte 2009: Review of all reported
cases of pregnancy following UAE for PPH
“Fertility appears greatly preserved”
18% miscarriage rate (similar to general
population)
Recurrent PPH can occur (19%)
18. Obstetric
hemorrhage
Advantages over surgical
ligation or hysterectomy
Post-partum
hemorrhage
◦ Less invasive/morbid
◦ Unanticipated (non-uterine)
bleeding sources can be
identified and treated Embolotherapy
◦ Immediate angiographic
confirmation of success
◦ No adverse impact on
subsequent arterial ligation if
necessary
19. Obstetric
hemorrhage
Embolization can be successful
even after all surgical options
have failed Post-partum
hemorrhage
◦ Arterial embolization successful
in 10/11 cases of failed surgical
ligation for PPH
Embolotherapy
◦ More technically difficult
Sentilhes 2009
20. Obstetric
hemorrhage
Conclusion
◦ Embolotherapy is a first-line Post-partum
hemorrhage
treatment for PPH refractory to local
measures
◦ Surgical options are always available
for embolization failures Embolotherapy
◦ Close collaboration between
obstetrics and IR should result in a
low rate of hysterectomy or
exsanguination in patients with PPH
22. Obstetric
hemorrhage
Defect in decidua basalis
resulting in abnormal
implantation of the placenta
Incidence has markedly
increased in recent years Invasive placenta
◦ 1930s: 1/30,000
◦ 1980s: 1/2,500 Background
◦ 2006: 1/540
May result in massive
hemorrhage at delivery
Historically high mortality rate
◦ 25% with conservative measures
◦ 6% with hysterectomy
◦ 90% will require blood transfusion
Fox 1972
23. Obstetric
hemorrhage
Cesarean delivery and
hysterectomy is the traditional
management
Invasive placenta
Estimated blood loss among 62
patients with placenta accreta Conventional therapy
undergoing Cesarean hysterectomy
◦ >2 L in 41 patients
◦ >5 L in 9 patients
◦ >10 L in 4 patients
◦ >20 L in 2 patients
Miller 1997
24. Obstetric
hemorrhage
How can we help?
◦ Pre-operative occlusion balloon
placement in aorta or bilateral
internal iliac arteries
Invasive placenta
◦ Post-delivery uterine artery
embolization (with or without
pre-operative catheter
placement) IR assistance
◦ May also aid conservative
(uterine-sparing) treatment by
performing UAE to reduce
bleeding and shrink the
placental remnant
25. Obstetric
hemorrhage
Balloon occlusion technique:
◦ Bilateral femoral or axillary
artery access
Invasive placenta
◦ Bilateral occlusion balloons are
placed
IR assistance
◦ Balloons inflated in operating
room after delivery
Decreases uterine and pelvic
blood flow
Increases time for surgical control
of hemorrhage
Embolization can be performed if
necessary
26. Obstetric
hemorrhage
Invasive placenta
IR assistance
Salazar 2009
27. Obstetric
hemorrhage
Aortic occlusion balloon
◦ Paull 1995: 600 cc blood loss
(n=1)
◦ Masamoto 2009: 3200 cc blood
loss (n=1) Invasive placenta
Bilateral internal iliac occlusion
balloons IR assistance
◦ Dubois 1997: 1500-2000 cc
blood loss (n=2)
◦ Weeks : 1500 cc blood loss
(n=1)
◦ Kidney: 1100-4000 cc blood
loss (n=5)
28. Obstetric
hemorrhage
Comparative studies are
contradictory
◦ Levine 1999: No difference in
estimated blood loss (~5000 cc) Invasive placenta
◦ Tan 2007: Lower blood loss
(2000 cc) with balloon occlusion IR assistance
than control group (3300 cc)
◦ Shrivastava 2007: No difference
in estimated blood loss (~3000
cc)
Study bias?
29. Obstetric
hemorrhage
Uterine-sparing treatment may be
achievable with embolotherapy
◦ Bilateral uterine artery embolization
with gelfoam Invasive placenta
◦ Catheters can be placed prior to
delivery to facilitate rapid
embolization IR assistance
Currently there are 35 case
reports or case series of UAE for
placenta accreta (n=73)
◦ Success rate 77%
Alanis 2006
31. Obstetric
hemorrhage
Interventional radiology can
have several roles in managing
invasive placenta
Invasive placenta
◦ Balloon occlusion
◦ Pre-operative or intra-operative
embolization to limit blood loss
Conclusions
of caesarian hysterectomy or
other surgical procedures
◦ Uterine-sparing treatment with
uterine artery embolization
33. Obstetric
hemorrhage
Overall very limited role of IR
in ectopic pregnancy
◦ Prompt medical or operative
treatment is usually adequate
Embolization can be used to
limit blood loss in select cases Ectopic pregnancy
◦ Cervical ectopic pregnancies
Uterine cervix contains only 20%
smooth muscle tissue
Limited response to uterotonics
◦ Abdominal ectopic pregnancies
34. Obstetric
hemorrhage
11 reports of arterial
embolization for abdominal and
cervical pregnancies
◦ Total patients = 22
◦ 100% success rate in controlling Ectopic pregnancy
hemorrhage
Badawy 2001
35. Obstetric
hemorrhage
Post-partum hemorrhage can be
effectively and safely controlled by
UAE, with success rates of 90-95%
◦ Fertility maintained
◦ Low radiation dose
◦ Fast and readily available
Balloon occlusion or UAE can be Conclusions
considered for patients with
invasive placenta to reduce blood
loss
◦ Anecdotal effectiveness
◦ Data not yet mature
37. Gynecologic
hemorrhage
Gynecologic causes of pelvic
hemorrhage are much less Introduction
common than obstetric causes
◦ Pelvic malignancy
◦ Uterine AVMs
38. Gynecologic
hemorrhage
Causative tumors
◦ Cervical CA
◦ Endometrial CA
◦ Choriocarcinoma Pelvic malignancy
Bleeding is usually slow, but
persistent and poorly responsive to
surgical and radiation therapy
39. Gynecologic
hemorrhage
Subselective angiography and
embolization
Pelvic malignancy
◦ Permanent occlusion is desirable
Particles
Coils
◦ Gelfoam can be used if rapid
cessation of bleeding is
necessary
43. Gynecologic
hemorrhage
Uncommon vascular lesions with
direct communication between
arteries and veins
Uterine AVMs
Congenital AVM
Background
◦ Often extend beyond uterus
◦ Central nidus with multiple arterial
feeders and draining veins
Acquired AVM
◦ Confined to endometrium/myometrium
◦ No nidus
◦ Caused by endometrial
curettage, pelvic surgery, gestational
trophoblastic disease
Cura 2009
45. Gynecologic
hemorrhage
Congenital AVMs
◦ Difficult to treat
◦ Surgical ligation leads to rapid Uterine AVMs
recruitment of collateral vessels
◦ If AVM is limited to uterus, then pre-
operative embolization followed by
excision can be curative Treatment
◦ If AVM extends to pelvic organs, it is
usually unresectable
Repeated percutaneous embolization
Palliative rather than curative in most
instances
Calligaro 1992
46. Gynecologic
hemorrhage
Acquired AVMs
◦ Can usually be treated with embolotherapy
alone
◦ Subselective angiography is followed by Uterine AVMs
permanent embolization (particles or glue)
Treatment
Banovac 2007, Salazar 2009
47. Gynecologic
hemorrhage
More than 70 cases of acquired
uterine AVM embolization have
been reported
◦ Control of bleeding in 96% Uterine AVMs
◦ Complication rate of 4%
◦ Restoration of normal
menstruation and fertility have Treatment
been reported
Banovac 2007
48. Gynecologic
hemorrhage
Gynecologic hemorrhage (usually
from tumor bleeding) can be
effectively controlled with UAE
◦ Similar success rates to PPH
Most uterine AVMs can be
effectively treated with
Conclusions
embolization
Banovac 2007
50. Thrombosis
Pulmonary thromboembolism
(PE), arising from deep vein Introduction
thrombosis (DVT), is the #1 cause
of maternal mortality in the USA
Late pregnancy and puerperial
period are major risk factors
◦ 5-20x relative risk
Banovac 2007
51. Thrombosis
DVT in pregnancy
◦ 90% left-sided Deep venous
thrombosis
◦ 70% are iliofemoral (more likely to Background
embolize than femoropopliteal)
Banovac 2007
52. Thrombosis
Unilateral (usually left-sided)
leg pain and swelling
Deep venous
Ultrasound confirms diagnosis thrombosis
Diagnosis
53. Thrombosis
Medical therapy
◦ Warfarin is teratogenic and must be
avoided during pregnancy
Deep venous
thrombosis
◦ LMWH is the medical treatment of
choice, but is not a perfect solution
Some patients are not candidates for
anticoagulation
Increased bleeding risk
5% risk of breakthrough PE Treatment
Heparin-induced thrombocytopenia
Decousus 1998
54. Thrombosis
IVC filter
◦ Percutaneously placed device to
Deep venous
prevent venous thrombi from thrombosis
embolizing to the lungs
◦ Absolute indications are DVT or PE
with:
Treatment
Failure of anticoagulation
Contraindication to anticoagulation
Complication of anticoagulation
◦ May also be considered for:
Free-floating iliocaval thrombus
Iliofemoral DVT close to labor
Banovac 2007
56. Thrombosis
Technique
◦ Right IJ access Deep venous
thrombosis
◦ Cavogram to locate renal veins
◦ Suprarenal IVC filter deployment
Treatment
Avoids contact with gravid uterus
Protects against emboli from
ovarian veins
Very safe (major complication
rate 0.3%)
Aburahma 2001
57. Thrombosis
IVC filters are safe and effective in
pregnancy
Deep venous
◦ IVC filter placed in 18 pregnant thrombosis
patients with DVT
◦ Mean fluoro time <2 minutes
Treatment
◦ No fetal or maternal morbidity or
mortality
◦ No PE or filter-related complications
with 6.5 year follow-up
Aburahma 2001
58. Thrombosis
Retrievable IVC filters
◦ Can be removed within 1-12
Deep venous
months after placement thrombosis
depending on design
◦ Prevents potential (though rare)
long-term complications of filters
Treatment
Caval occlusion
Delayed migration
Caval penetration
◦ Retrieval success rates are high
(>90%)
Athanasoulis 2000
59. Thrombosis
Retrievable IVC filters
Deep venous
thrombosis
Treatment
60. Thrombosis
Massive PE in pregnancy is rare
but life-threatening
Treatment options:
Pulmonary
embolism
◦ Surgical embolectomy
◦ Systemic (IV) thrombolysis
◦ Localized (catheter-directed)
thrombolysis
61. Thrombosis
Thrombolysis can be considered
when the patient has life-
threatening PE
Systemic lysis: 13 cases reported
◦ No maternal deaths
Pulmonary
◦ 4 major maternal bleeds embolism
◦ 2 fetal deaths
◦ 5 preterm deliveries
Catheter-directed lysis: 4 cases
reported
◦ No maternal deaths
◦ 1 fetal death
◦ 1 preterm delivery
te Raa 2009
62. Thrombosis
DVT is common in the
puerperial period
IVC filters are useful and safe in
select patients, and can be
retrieved after delivery
Conclusions
Though data is limited, lysis
should not be withheld from
pregnant women in cases of
life-threatening PE
66. Elective
procedures
20-40% of women over 35 have
symptomatic uterine fibroids
Uterine fibroid
200,000 of the 600,000 embolization
hysterectomies per year are for Background
fibroids
2002 FDA cleared particulate
embolic agents for use in treating
fibroids in women
Approximately 22,000 UFE
procedures are currently
performed yearly
courtesy of C. Hoffman, MD
68. Elective
procedures
Usual candidates for UFE
◦ Pre- and peri-menopausal women with
symptomatic fibroids (age 35-55) Uterine fibroid
embolization
◦ Women who have had their children or
do not want to have children Background
◦ Women who want to keep their uterus
◦ Women who do not want surgery
◦ Women who have failed myomectomy
◦ Women who want a short hospital stay
and as little time off work as possible.
courtesy of C. Hoffman, MD
69. Elective
procedures
Contraindications
◦ Pregnancy Uterine fibroid
◦ Suspicion of cancer - embolization
uterine, ovarian, cervical Background
◦ Infarcted fibroids
Relative contraindications
◦ Pedunculated fibroid
◦ Intracavitary fibroid (>4cm), due to
expulsion/infection risk
◦ Extremely large fibroids (bulk
symptoms may persist post UFE)
70. Elective
procedures
Technique:
Common femoral artery access Uterine fibroid
embolization
Select both uterine arteries using Background
coaxial (microcatheter) technique
Embolize using 500-700 micron
particles (PVA or tris-acryl
microspheres)
71.
72.
73.
74.
75.
76.
77.
78.
79. Elective
procedures
Complications of UFE
◦ Data varies, 1-5%. Uterine fibroid
embolization
◦ Fibroid registry complication data
Treatment
1700 patients with 1-year follow-up
No deaths
4% major events (most common
readmission for pain)
1% readmission for D&C (fibroid being
expelled)
0.1% had hysterectomy within 30 days
courtesy of C. Hoffman, MD
80. UFE Symptom Improvement
Study # patients Mean F/U Menorrhagia Bulk sx Fibroid
sx improved improved volume
reduction
Hutchins 305 1 yr 92% 92% -
1999
Ravina 188 29 mo 90% - 87% @ 6 mo
1999
Mclucas 167 6 mo 82% 69% 49% 6 mo
2001 52% 1 yr
Spies 200 21 mo 90% 1 yr 91% 1yr 60% 1yr
2001
Walker 2002 400 16.7 mo 84% 79% 73% @ 9.7
mo
Pron 2003 550 8.9 mo 83% 77% 42%@3mo
(median)
Spies 2004 102 1 yr 83%@ 6mo 84% @1 yr 54%@6mo
Spies 2005 200 1yr 90% 91% 57%
5yr <------73% ---------
courtesy of C. Hoffman, MD
81. Elective
procedures
Summary of published results
◦ Improvement in menorrhagia in ~90% Uterine fibroid
Usually within 2 cycles embolization
◦ Improvement in bulk symptoms in ~80%
Takes at least 3 months
Results
◦ Uterine volume reduction is ~50% at 1 year
◦ Technical success of UFE procedure is 98%
◦ Clinical failure can occur due to collateral
supply from ovarian arteries (~10%)
82. Elective
procedures
EMMY Results-Randomized Clinical
EMbolization vs HysterectoMY
(n=177, 88 UFE & 89 Hysterectomy)
Uterine fibroid
◦ 6 weeks after treatment, UFE patients embolization
were more satisfied than the
hysterectomy pts.
◦ 2 years post UFE, 90% satisfied with their
procedure (same for hysterectomy) Results
“The 24 month cumulative cost of UAE
is lower than that of hysterectomy.
From a societal economic
perspective, UAE is the superior
treatment strategy in women with
symptomatic uterine fibroids.”
JVIR 2008
83. Elective
procedures
UFE and future pregnancy
◦ Only small studies on UFE and future
pregnancy are available. Uterine fibroid
embolization
◦ Myomectomy is preferred-there is less risk
of amenorrhea
◦ Consider UFE if the patient has failed Results
medical therapy and the only options are
extensive myomectomy or hysterectomy
◦ 2005 data…there is no increased risk with
pregnancy following UFE… Only an
increase in C-section rate.
courtesy of C. Hoffman, MD
84. Elective
procedures
With appropriate patient
selection, UFE is a proven effective
and safe minimally invasive
Uterine fibroid
therapy for the treatment of embolization
uterine fibroids
Further education of the public and
collaborative efforts between IR Results
and OB/Gyn are needed.
86. Elective
procedures
Chronic pelvic pain is a common and
distressing complaint among women of
childbearing age
◦ No diagnosis is made in more than half of
cases
◦ Historically, was often attributed to Pelvic congestion
syndrome
psychogenic causes
◦ Beard 1984: 91% of women with chronic Background
pelvic pain have pelvic varices
Pelvic congestion syndrome refers to the
presence of pelvic varices, which lead to
venous stasis and congestion of the pelvic
organs, and chronic pelvic pain
◦ Hormonal and anatomic factors
Liddle 2007
87. Elective
procedures
Clinical features
◦ Premenopausal woman
◦ Usually have had children Pelvic congestion
syndrome
◦ Dull ache similar to the pain of
varicose veins of the legs;
Diagnosis
predominantly unilateral
◦ Exacerbated by
standing, lifting, pregnancy, coitus
◦ Regresses completely after
menopause
88. Elective
procedures
Gynecologic exam is often normal
◦ Ovarian point tenderness may be present
Routine imaging and laparoscopy may
not detect ovarian varicosities
◦ Supine position collapses varices Pelvic congestion
◦ Dynamic MRI is gaining favor syndrome
Ovarian venography using a tilting table Diagnosis
is gold standard for diagnosis
◦ Abnormal dilation of ovarian veins >10 mm
◦ Ovarian vein reflux
◦ Uterine venous engorgement
◦ Filling of pelvic veins across the midline
90. Elective
Dynamic contrast-enhanced MRI procedures
Pelvic congestion
syndrome
Diagnosis
Early arterial Late arterial Early venous
91. Elective
procedures
Medical therapy (chemical
menopause) is effective but often
unacceptable to patients
Surgery (hysterectomy +/- Pelvic congestion
oophorectomy) was traditionally syndrome
considered for medical failures
Treatment
Chung 2003, Cordts 1998
92. Elective
procedures
Ovarian vein embolization is a
minimally invasive alternative
◦ Outpatient procedure
Pelvic congestion
◦ Coils or sclerosing agent syndrome
administered to ovarian veins
◦ Technical success 89-97%
Treatment
◦ Clinical success rates are 74-89%
over follow-up to 15 months
Chung 2003, Cordts 1998
95. Elective
procedures
Prospective study compared ovarian
vein embolization to hysterectomy (with
unilateral or bilateral oophorectomy) for
chronic pelvic pain
Pelvic congestion
◦ 106 patients syndrome
◦ All had failed medical treatment
◦ After follow-up out to 32 months, ovarian Treatment
vein embolization was significantly more
effective at reducing pelvic pain
◦ Treatment was safe and well-tolerated
Chung 2003
97. Elective
procedures
Tubal abnormalities account for a
significant proportion of female
infertility
◦ Often due to plugs of amorphous
material in an otherwise normal tube
Selective salpingography can Fallopian tube
diagnose true obstruction, and recanalization
subsequent recanalization may aid Background
fertility
Chung 2003
98. Elective
procedures
Catheter placed transcervically into
tubal ostium
Contrast media injected directly into
fallopian tube
◦ Evaluate tube patency and peritoneal spillage
◦ Differentiate spasm from true obstruction Fallopian tube
recanalization
If proximal tubal occlusion is
seen, recanalization can be attempted
Technique
using a microcatheter and guidewire
Ovarian radiation exposure is low (1
rad)
Chung 2003
100. Elective
procedures
RCT showed diagnostic accuracy was
comparable to laparoscopy and dye
test (and less invasive)
Pregnancy rates after the procedure
are difficult to compare due to
multifactorial causes of infertility Fallopian tube
◦ Range 9-56% recanalization
◦ Average 30%
Complications are rare
◦ Tubal perforation (2%) Results
◦ Pelvic infection (1%)
Chung 2003
101. Elective
procedures
Can (should?) be used as initial tubal
assessment test
◦ Largest series (n=110) published in 2003
◦ Selective salpingography possible in 92%
◦ Proximal tubal blockage (unilateral or
bilateral) detected in about 1/3 of patients
◦ Spontaneous conception at least once in Fallopian tube
22% of women (no other interventions) recanalization
Recanalization and flushing of the tubes
may maximize unassisted fertility
Results
Papaioannou 2003
102. Elective
procedures
Endorsed by American Fertility Society
and Royal College of Obstetricians and
Gynaecologists for at least the last 10
years, but rarely used
Comparable fertility results to more
expensive and invasive treatments
Fallopian tube
◦ In vitro fertilization / embryo transfer recanalization
◦ Microsurgical proximal tube repair
Wider role has been advocated recently
◦ Simple Results
◦ Inexpensive
◦ Appears effective
Chung 2003
103. Elective
procedures
UFE is an effective and minimally
invasive alternative to surgical fibroid
treatments
◦ Patient awareness is important
Pelvic congestion syndrome should be
considered in patients with chronic
pelvic pain without discernible cause
◦ MRI or venography to diagnose
Conclusions
◦ Ovarian vein embolization is safe and
effective
Fallopian tube recanalization can aid
fertility in patients with proximal tubal
obstruction
105. Radiation
and contrast
Radiographic examinations in
obstetric patients cause significant Introduction
anxiety
◦ To the mother
◦ To the referring physician
Potentially harmful effects to the
fetus are often misunderstood
106. Radiation
and contrast
Potential effects of in utero
radiation exposure
◦ Prenatal death
Radiation
◦ IUGR
◦ Mental retardation
◦ Organ malformation
◦ Childhood cancer
Risk of each effect depends on
gestational age and magnitude of
dose
McCollough 2007
107. Radiation
and contrast
Prenatal death
◦ Most sensitive time: 0-8 days Radiation
◦ Threshold dose: 10-25 rads (animal
studies)
◦ If embryo survives, no radiation
effects are likely
McCollough 2007
108. Radiation
and contrast
Growth retardation
◦ Most sensitive time: 1 week-2 Radiation
months
◦ Threshold dose: 20 rads
◦ Atomic bomb survivors receiving
>20 rads were ~1 inch shorter than
controls
McCollough 2007
109. Radiation
and contrast
Organ malformation
◦ Most sensitive time: 2 weeks – 2 Radiation
months
◦ Threshold dose: 25 rads
McCollough 2007
110. Radiation
and contrast
Mental retardation/reduced IQ
◦ Most sensitive time: 2-4 months Radiation
◦ Threshold dose: 10 rads
◦ IQ reduction is about 0.25 points per
rad
McCollough 2007
111. Radiation
and contrast
Childhood cancer
◦ Most sensitive time: 0-3 months Radiation
◦ Threshold dose: None
◦ Leukemia is most common
McCollough 2007
112. Radiation
and contrast
Dose to fetus No No childhood No
malformation cancer malformation
and no Radiation
childhood
cancer
0 96% 99.93% 95.93%
1 rad 95.98% 99.84% 95.83%
10 rads 95.8% 99.07% 94.91%
McCollough 2007
113. Radiation
and contrast
ACOG policy statement
◦ “Women should be counseled that x-ray
exposure from a single diagnostic
procedure does not result in harmful fetal Radiation
effects. Specifically, exposure to less than 5
rad [50 mGy] has not been associated with
an increase in fetal anomalies or pregnancy
loss.”
Even with 10 rad dose, increase over
background incidence for organ
malformation and childhood cancer
combined is only ~1%
McCollough 2007
114. Radiation
and contrast
Iodinated contrast media is
required in many radiologic
studies
Contrast
Anxiety occurs regarding safety
for the fetus and with breast-
feeding
115. Radiation
and contrast
There is no evidence of mutagenic
or teratogenic effects of iodinated
contrast
Contrast
◦ In vitro testing
◦ In vivo animal testing
Some IV contrast does traverse the
placenta into the fetus
Webb 2005
116. Radiation
and contrast
Depression of thyroid function is the main
concern
◦ Fetal thyroid function is important for CNS
development
Contrast
◦ Excessive iodide uptake by the fetal thyroid can
cause fetal hypothyroidism
◦ Only the free iodide portion is potentially harmful;
99.9% of iodine in contrast media is bound
◦ Likely that the free iodide diffuses out of the
placenta rapidly and fetus is only exposed for a
short time, but there are no experimental data
◦ Hypothyroid screening should be performed during
the 1st week of life
Webb 2005
117. Radiation
and contrast
Contrast media in lactating mothers
◦ Very low levels of IV contrast agent are excreted
into the milk (about 0.4% of the dose)
Contrast
◦ Very small amounts of the contrast agent that is
ingested by the baby will be absorbed (about
0.8%)
◦ These amounts are orders of magnitude less
than what would be used for typical radiographic
exams in infants (pediatric urography, etc)
Likelihood of direct toxicity or allergic
reaction are extremely low
Webb 2005
118. Radiation
and contrast
The increased risk of fetal abnormalities
or childhood cancer from radiation is
quite small
◦ Negligible for fetal exposure <5 rads
◦ ~1% increased incidence (from 4% to 5%)
for 10 rads
Radiographic procedures should be
performed when essential Conclusions
The use of IV contrast should be
minimized in pregnancy due to lack of
experimental data
◦ Potential thyroid effects (likely minimal)
Breast-feeding can continue normally
after IV contrast administration
Webb 2005
119. Final
thoughts
Interventional radiology can offer
several minimally invasive procedures
to save or improve the lives of women
◦ Excessive bleeding
◦ DVT/PE
◦ Fibroids
◦ Pelvic pain
◦ Infertility
Awareness is crucial!
A close relationship between our
departments can benefit your patients