Determining and reporting fetal radiation exposure from diagnostic radiation

Choledocholithiasis in Pregnancy: A Case Report

Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus.

A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP).

In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.

Laparoscopic surgery for non-obstetric acute abdomen in pregnancy: A retrospective case series review

BACKGROUND

Laparoscopic techniques have been used during pregnancy by obstetricians since the 1970's, primarily to diagnose and treat ectopic and heterotopic pregnancies. Pregnancy was considered as an absolute contraindication to laparoscopy by surgeons as recently as 1991, and a few still doubt the safety of minimal access in gravid patients. When an emergent operation is indicated, the surgery should not be withheld on the sole basis of patient's gravid state. On the contrary, the alleviation of maternal disease is thought to take priority because the health of the foetus is dependant on the mother.

MATERIALS AND METHODS

This is a retrospective study of a case series of 18 obstetric patients who presented with non-obstetric causes of acute abdomen requiring surgical intervention. Ultrasonography and magnetic resonance imaging (MRI) along with other laboratory investigations were carried out to reach the diagnosis. Laparoscopic surgery was considered as the modality of treatment. All the patients were given the necessary care post-surgery and were followed up till parturition to look for any complications.

RESULTS

The data were analysed considering the presentation, diagnostic variations and the surgical modifications statistically.

CONCLUSION

The decision of surgery should be prompt and should be weighed against complications of conserving the patient. Due to the diagnostic limitations of ultrasonography, MRI should be coupled to confirm the diagnosis. Laparoscopy offers less analgesic requirements and shorter hospital stay. The operative time is highly subjective to the experience and training of the surgeon and the laparoscopic set-up itself.

Management of pregnant patients undergoing general surgical procedures

Pregnant patients have a 0.2% to 0.75% chance of developing a medical condition that requires a general surgical intervention during pregnancy. To safely and appropriately care for patients, surgeons must be cognizant of the maternal physiologic changes in pregnancy as well as of the unique risk to both mothers and fetuses of diagnostic modalities, anesthetic care, operative intervention, and postoperative management. Surgeons can be assured that, if these risks are understood and considered, operating during pregnancy, even in the abdomen, can be safely undertaken.

Endoscopic reduction of a volvulus of the sigmoid colon in pregnancy: case report and a comprehensive review of the literature

Sigmoid volvulus is a rare, but serious, complication that can occur during pregnancy. We present a case of a 33-year-old pregnant female in the third trimester with a sigmoid volvulus. Detorsion of the volvulus was performed during colonoscopy. The patient underwent an elective sigmoidectomy at a later date. Prompt diagnosis of the volvulus sigmoid is critical to minimize fetal and maternal morbidity and mortality. Sigmoidoscopic detorsion or surgical resection are the treatment options, depending on bowel viability. A review of the literature was done.

Sigmoid volvulus in pregnancy and puerperium: a surgical and obstetric catastrophe. Report of a case and review of the world literature

Sigmoid volvulus is a rare surgical complication occurring in pregnancy and puerperium. Only 84 cases of sigmoid volvulus in pregnancy have been reported in the English literature so far. We have reviewed the available literature on this subject and present another case recently managed at our institution. The available literature suggests that over the years, there has been an improvement in the maternal and fetal outcome for this critical condition, but delay in presentation and a further delay in diagnosis remain a challenge for the treating physicians. Our patient was a 30-week pregnant lady, who presented late with 6 days history of abdominal pain, distension and absolute constipation. She had evidence of multi-organ dysfunction at presentation due to complicated sigmoid volvulus. She was resuscitated and surgical exploration revealed gangrenous large bowel. Bowel resection with diverting ileostomy was performed, but she succumbed to the septic shock due to late presentation. Acute surgical pathology may be overlooked in pregnant patients due to reluctance in radiological workup and a high index of suspicion is essential for enhanced outcome. There is a need to increase the awareness amongst the obstetricians and general practitioners. Early diagnosis and referral and timely surgical intervention could significantly improve the outcome of this surgical and obstetric catastrophe.

Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy

Over the past 50 years, our laboratory has provided consultations dealing with the risks of various environmental toxicant exposures during pregnancy. These contacts were primarily by telephone or written communications. Since the year 2000, the primary source of consultations has been via the internet. In 2007, the pregnancy website of the Health Physics Society received 1,299,672 visits. The contacts who downloaded information totaled 620,035. After reading the website information, 1442 individuals who were still concerned contacted me directly. Unfortunately, we have learned that many physicians and other counselors are not prepared to counsel patients concerning radiation risks. Approximately, 8% of the website contacts, who had consulted a professional, were provided inaccurate information that could have resulted in an unnecessary interruption of a wanted pregnancy. Research from our and other investigators' laboratories has provided radiation risk data that are the basis for properly counseling contacts with radiation exposures. Mammalian animal research has been an important source of information that improves the quality and accuracy of estimating the reproductive and developmental risks of ionizing radiation in humans. What are the reproductive and developmental risks of in utero ionizing radiation exposure? 1. Birth defects, mental retardation, and other neurobehavioral effects, growth retardation, and embryonic death are deterministic effects (threshold effects). This indicates that these effects have a no adverse effect level (NOAEL). Almost all diagnostic radiological procedures provide exposures that are below the NOAEL for these developmental effects. 2. For the embryo to be deleteriously affected by ionizing radiation when the mother is exposed to a diagnostic study, the embryo has to be exposed above the NOAEL to increase the risk of deterministic effects. This rarely happens when the pregnant women have x-ray studies of the head, neck, chest or extremities. 3. During the preimplantation and preorganogenesis stages of embryonic development, the embryo is least likely to be malformed by the effects of ionizing radiation because the cells of the very young embryo are omnipotential and can replace adjacent cells that have been deleteriously affected. This early period of development has been designated as "the all-or-none period." 4. Protraction and fractionation of exposures of ionizing radiation to the embryo decrease the magnitude of the deleterious effects of deterministic effects. 5. The increased risk of cancer following high exposures to ionizing radiation exposure to adult populations has been demonstrated in the atomic bomb survivor population. Radiation-induced carcinogenesis is assumed to be a stochastic effect (nonthreshold effect) so that there is theoretically a risk at low exposures. Whereas there is no question that high exposures of ionizing radiation can increase the risk of cancer, the magnitude of the risk of cancer from embryonic exposures following diagnostic radiological procedures is very controversial. Recent publications and analyses indicate that the risk is lower for the irradiated embryo than the irradiated child, which surprised many scientists interested in this subject, and that there may be no increased carcinogenic risk from diagnostic radiological studies. Examples of appropriate and inappropriate counseling will be presented to demonstrate how counseling can save lives and change family histories. The reader is referred to the Health Physics Society website to obtain many examples of the answers to questions posed by women and men who have been exposed to radiation (www.hps.org). Then click on ATE (ask the expert).

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

Lauriston S. Taylor lecture: fifty years of scientific research: the importance of scholarship and the influence of politics and controversy

Over the past 50 years our laboratory has performed and published many studies in the fields of teratology, radiation biology and radiation embryology. The early work took place when I was a research employee at the University of Rochester Manhattan Project in 1944 and where I had my introduction to embryology and genetics. Over the years our lab has provided consultations dealing with the risks of various environmental toxicant exposures during pregnancy. With the advent of the Internet, consulting has become more rapid and efficient. In the past year our pregnancy Web site of the Health Physics Society received approximately 154,000 hits, of which over a thousand contacts were still quite anxious after reading the Web site answers and requested a personal consultation. From this extensive experience we have learned that many physicians and other counselors are not prepared to counsel patients concerning radiation risks. Approximately 8% of the patient contacts who have consulted a professional have been provided with inaccurate information that would have resulted in an unnecessary interruption of a wanted pregnancy. There are five areas of radiation embryology that are considered to be controversial. 1) Can the fetus be harmed by ionizing radiation if the fetus is not directly exposed? 2) Is the production of mental retardation from radiation during pregnancy a threshold phenomenon? 3) Does fractionation and protraction of radiation decrease the magnitude of the reproductive and developmental risks? 4) Is there a period during pregnancy when radiation will result in an increased mortality but not an increase in malformations? 5) How sensitive is the fetus to the oncogenic effects of radiation? We utilize the scientific information obtained from studies in these five areas to counsel patients concerning pregnancy radiation risks. The willingness and persistence of scientists to debate the controversial aspects of this research and apply the best available scientific information to assist patients in turmoil about the risks of radiation to themselves and their offspring has saved thousand of lives and changed family histories.

Estimation of dose to the unborn child at diagnostic X-ray examinations based on data registered in RIS/PACS

The aim of this work was to determine mean absorbed doses to the unborn child in common conventional X-ray and computed tomography (CT) examinations and to find an approach for estimating foetal dose based on data registered in the Radiological Information System/Picture Archive and Communication System (RIS/PACS). The kerma-area product (KAP) and CT dose index (CTDI(vol)) in common examinations were registered using a human-shaped female dosimetry phantom. Foetal doses, D(f), were measured using thermoluminescent dosimeters placed inside the phantom and compared with calculated values. Measured foetal doses were given in relation to the KAP and the CTDI(vol) values, respectively. Conversion factor D(f)/KAP varies between 0.01 and 3.8 mGy/Gycm(2), depending on primary beam position, foetus age and beam quality (tube voltage and filtration). Conversion factors D(f)/CTDI(vol) are in the range 0.02 - 1.2 mGy/mGy, in which the foetus is outside or within the primary beam. We conclude that dose conversion factors based on KAP or CTDI(vol) values automatically generated by the RIS/PACS system can be used for rapid estimations of foetal dose for common examination techniques.

Determination of potential uterine (conceptus) doses from axial and helical CT scans

A tissue equivalent Rando Phantom and thermoluminescent dosimeters (TLDs) (LiF) were used to determine potential doses to the uterus at approximately the position of a conceptus from axial and helical CT scans of that region of the body. Doses were measured at the surface of the phantom and at various locations throughout the phantom. The results indicate that measurements taken on the surface of a patient or phantom are generally higher than the level at the location of the uterus within the patient. The results also indicate that the dose to tissue that is 12.7 cm (5 in) out of the direct beam is less than 10% of the dose within the beam. For tissues that are 20 cm (8 in) out of the beam, the dose is approximately 1% of the dose in the beam.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.