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Ruptured ectopic pregnancy in a 10-week-pregnant patient who was involved in a motor vehicle collision. Although the patient initially was stable, her condition worsened, and she complained of severe abdominal pain. (a) Axial CT image shows large-volume hemoperitoneum. (b) Axial CT image shows high-attenuation material (arrow) near the right ovary, a finding consistent with active extravasation of contrast material. (c) Axial CT image shows fetal parts (arrow) outside the uterus ( * ). A fluid-filled structure near the right adnexa (arrowheads) is suggestive of a gestational sac. Although the finding of fetal parts outside the uterus suggests uterine rupture, the otherwise normal-appearing uterus and the suggestion of a gestational sac in the right adnexa raise the question of a ruptured ectopic pregnancy . A ruptured right tubal ectopic pregnancy was confirmed at surgery, and products of conception were found floating freely in the abdomen.
Source publication
The pregnant trauma patient presents an important and challenging encounter for the clinical team and radiologist. In this article, we present several key aspects of the imaging workup of pregnant trauma patients, beginning with a review of the modalities that are used in this setting. Ultrasonography plays an important role in initial evaluation o...
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Citations
... There is ample evidence to prove the safety of limited imagining and does not lead to delayed diagnosis 15 . Exposure of around 5 rad ionizing radiation is accepted for the foetus [16][17][18] . Any exposure above the accepted level leads to a high risk of congenital deformities or miscarriages 17 . ...
... Exposure of around 5 rad ionizing radiation is accepted for the foetus [16][17][18] . Any exposure above the accepted level leads to a high risk of congenital deformities or miscarriages 17 . Out of all the radiation doses absorbed by the mother, approximately 30% is received by the foetus 4 . ...
Managing an injured patient who is pregnant can be difficult in the management and investigation of the case especially when the patient presents atypically. We encountered a 25-year-old female patient who sustained a posterior dislocation of the right hip and was pregnant at 12 weeks gestation following a road traffic accident. The patient presented to OPD with an atypical attitude of limb i.e., both hip and knee in flexion without any internal rotation and adduction of the limb following which MRI was done which showed right hip posterior dislocation. Through an interdepartmental, skilful team approach the patient, after taking the obstetrician’s opinion and the patient under short GA, Closed reduction by Rochester method (longitudinal traction and rotation control) was done for the right hip joint without any complication. As pregnant females possess more risk and complication and more challenges are expected in management, Orthopaedic surgeons are well equipped to treat such patients to reduce patient morbidity and mortality resulting in better outcomes. Keywords Posterior dislocation of hip, Pregnant female, Atypical presentation, Closed reduction
... Radiation doses in IR procedures vary depending on the type of the procedure and the area exposed but can quickly exceed radiation levels historically thought to be associated with radiation-induced anomalies [32][33][34]. Adhering to basic principles of time, distance and shielding, aggressive collimation, and use of lowdose fluoroscopy (as opposed to formal angiographic exposures) can all be utilized in order to reduce the dose to both the mother and fetus [35]. These principles can also be more broadly applied when fluoroscopy is used in the operating room for procedures like pelvic or spinal fixation. ...
Trauma is the leading non-obstetric cause of maternal and fetal mortality and affects an estimated 5–7% of all pregnancies. Pregnant women, thankfully, are a small subset of patients presenting in the trauma bay, but they do have distinctive physiologic and anatomic changes. These increase the risk of certain traumatic injuries, and the gravid uterus can both be the primary site of injury and mask other injuries. The primary focus of the initial management of the pregnant trauma patient should be that of maternal stabilization and treatment since it directly affects the fetal outcome. Diagnostic imaging plays a pivotal role in initial traumatic injury assessment and should not deviate from normal routine in the pregnant patient. Radiographs and focused assessment with sonography in the trauma bay will direct the use of contrast-enhanced computed tomography (CT), which remains the cornerstone to evaluate the potential presence of further management-altering injuries. A thorough understanding of its risks and benefits is paramount, especially in the pregnant patient. However, like any other trauma patient, if evaluation for injury with CT is indicated, it should not be denied to a pregnant trauma patient due to fear of radiation exposure.
... Motor vehicle collisions (MVCs) account for half of all injuries in pregnant trauma patients [1,2]. In the general adult, nonpregnant population, MVCs are considered significant mechanisms of injury, and liberal computed tomography (CT) imaging is often recommended [2][3][4][5] to expeditiously identify and properly treat injuries. This is especially important with high-speed MVCs (≥25 miles per hour), which carry substantial risk for immediate life-threatening injuries [1,2,[4][5][6][7][8][9][10][11][12][13][14][15]. ...
... Historically, the principle of "benefits to the mother outweighs small risks to the fetus" has guided Extended author information available on the last page of the article trauma providers [1,2,4,5,12,17,18] and is professed in the Advanced Trauma Life Support (ATLS) textbook. Therefore, ATLS recommends that the principles of trauma assessment remain the same for the gravid and non-gravid trauma patient [3]. Despite this, some trauma centers have created their own guidelines for the imaging evaluation of pregnant trauma patients (PTPs). ...
... The amount of radiation exposure is dependent on the CT imaging protocol (e.g., the number of slices in a given area). However, location also matters, a CT scan with a thickness of 10 mm for the head would require >100 scans to equal a cumulative fetal toxic radiation dose, whereas a CT abdomen/pelvis with intravenous contrast followed by delayed imaging or a CT angiography scan followed by venous phase (e.g., multiphase imaging) would each have double the radiation exposure compared to a single phase scan and would surpass the toxic fetal dose of radiation (Table 7) [3,[22][23][24][25]. Due to the potential radiation risk to the fetus from CT imaging, PTPs in clinical practice may be evaluated differently than non-pregnant patients. ...
Following motor vehicle collisions (MVCs), patients often undergo extensive computed tomography (CT) imaging. However, pregnant trauma patients (PTPs) represent a unique population where the risk of fetal radiation may supersede the benefits of liberal CT imaging. This study sought to evaluate imaging practices for PTPs, hypothesizing variability in CT imaging among trauma centers. If demonstrated, this might suggest the need to develop specific guidelines to standardize practice.
A multicenter retrospective study (2016–2021) was performed at 12 Level-I/II trauma centers. Adult (≥18 years old) PTPs involved in MVCs were included, with no patients excluded. The primary outcome was the frequency of CT. Chi-square tests were used to compare categorical variables, and ANOVA was used to compare the means of normally distributed continuous variables.
A total of 729 PTPs sustained MVCs (73% at high speed of ≥ 25 miles per hour). Most patients were mildly injured but a small variation of injury severity score (range 1.1–4.6, p < 0.001) among centers was observed. There was a variation of imaging rates for CT head (range 11.8–62.5%, p < 0.001), cervical spine (11.8–75%, p < 0.001), chest (4.4–50.2%, p < 0.001), and abdomen/pelvis (0–57.3%, p < 0.001). In high-speed MVCs, there was variation for CT head (12.5–64.3%, p < 0.001), cervical spine (16.7–75%, p < 0.001), chest (5.9–83.3%, p < 0.001), and abdomen/pelvis (0–60%, p < 0.001). There was no difference in mortality (0–2.9%, p =0.19).
Significant variability of CT imaging in PTPs after MVCs was demonstrated across 12 trauma centers, supporting the need for standardization of CT imaging for PTPs to reduce unnecessary radiation exposure while ensuring optimal injury identification is achieved.
... In the second trimester, the placenta gradually becomes increasingly heterogeneous and increases in attenuation compared to the myometrium [24]. Placental cotyledons, appearing as foci of low attenuation, will also begin forming [25,27]. By the third trimester, the placenta continues to become increasingly heterogeneous with venous lakes appearing as hyperdense foci of patchy enhancement on contrast-enhanced CT on the maternal side of the placenta [27,28]. ...
... Placental cotyledons, appearing as foci of low attenuation, will also begin forming [25,27]. By the third trimester, the placenta continues to become increasingly heterogeneous with venous lakes appearing as hyperdense foci of patchy enhancement on contrast-enhanced CT on the maternal side of the placenta [27,28]. ...
Placenta accreta spectrum disorder (PASD) encompasses various types of abnormal placentation in which chorionic villi directly adhere to or invade the myometrium. The incidence of PASD has dramatically risen in the US over the past 3 decades owing to the increased rates of patients undergoing cesarean sections. While PASD remains a significant cause of maternal morbidity and mortality, accurate prenatal identification and characterization of PASD is associated with improved outcomes. Although ultrasound is the first-line imaging modality in the evaluation of PASD, with MRI serving as an adjunct, computed tomography angiography (CTA) may also offer unique diagnostic advantages in cases of advanced PASD by providing superior visualization of placental and abdominopelvic vasculature and enabling the creation of comprehensive vascular maps to roadmap complex surgical interventions. This paper represents the first evaluation of CTA as a diagnostic tool and operative planning aid in this context. Appropriate indications and diagnostic advantages of CTA in this setting are reviewed, and key multimodal imaging features of normal and abnormal placentation are highlighted.
Graphical abstract
... Trauma is the most frequent reason for diagnostic imaging of a pregnant patient [1]. It occurs in up to 7% of pregnancies [1]. ...
... Trauma is the most frequent reason for diagnostic imaging of a pregnant patient [1]. It occurs in up to 7% of pregnancies [1]. Besides trauma, medical issues that occur more often during pregnancy are: pulmonary embolism, renal obstruction from stones, acute neurological conditions, appendicitis, venous thrombosis, tumour, and vascular malformation haemorrhage [2][3][4][5][6][7]. ...
It is well known that foetuses are highly sensitive to ionising radiation and special attention to justification and optimisation of radiological procedures involving a pregnant patient is required. A task to review, validate and compare different approaches to managing the pregnant patient and to estimating the associated foetal doses arising from a diagnostic or interventional radiology (DIR) procedure was designed in the framework of EURADOS working group 12. As a first step, a survey of radiation protection practice including dosimetry considerations among EURADOS members was performed using online questionnaire. Then, to evaluate the possible differences in the estimated foetal doses, a comparison of assessed dose values was made for three cases of pregnant patients that underwent different CT procedures. More than 120 professionals from 108 institutions and 17 countries that are involved in managing pregnant patients undergoing DIR procedures answered the questionnaire. Most of the respondents use national or hospital guidelines on the management of pregnant patients undergoing DIR procedures. However, the guidelines differ considerably among respondents. Comparison of foetal dose assessments performed by dosimetry experts showed the variety of methods used as well as large variability of estimated foetal doses in all three cases. Although European and International commission on radiation protection guidelines already exist, they are more than 20 years old and, in some aspects, they are obsolete. This paper shows that there is a need to revise and update these guidelines.
... This study explored the knowledge level regarding pregnancy and trauma, and assessed maternal and fetal radiation exposure [11]. First, there seems to be a considerable knowledge gap among providers treating these cases. ...
Background
Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed.
Methods
It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians’ imaging assessment with consideration of their medical specialty.
Results
Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12–30]. 78% of women (n = 42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23–63] and 0 mGy [0–1]. Maternal mortality (6%) was lower than fetal mortality (17%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 h following trauma.
Conclusions
Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe in experienced centres .
... Blunt abdominal trauma is the leading cause of traumatic injuries in pregnancy, with automobile accidents and falls being the most common etiologies. The evaluation of the polytraumatized pregnant patient is demanding, as the presence of the fetus implies the evaluation of two patients at risk [21,22], and therefore pregnant women should be managed in a medical center with the capacity to offer satisfactory care to both traumatized patients. Nonetheless, the mother's survival remains the priority, and all treatment should be centered on her hemodynamic stability. ...
... Although FAST may be less sensitive in pregnant patients for abdominal injury, it remains highly specific. Equivocal findings require alternative techniques to identify traumatic injuries and to allow proper management [14,21], since no one necessary diagnostic study should be omitted [14,21]. Additional diagnostic assessments include the head, thorax, abdomen, and pelvis CT and, if appropriate, MRI for neurological injuries [72,[109][110][111][112][113][114][115][116]. ...
... Although FAST may be less sensitive in pregnant patients for abdominal injury, it remains highly specific. Equivocal findings require alternative techniques to identify traumatic injuries and to allow proper management [14,21], since no one necessary diagnostic study should be omitted [14,21]. Additional diagnostic assessments include the head, thorax, abdomen, and pelvis CT and, if appropriate, MRI for neurological injuries [72,[109][110][111][112][113][114][115][116]. ...
In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman’s pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.
... [88] According to the 2008 American College of Radiology guidelines, a fetal radiation dose of <50 mGy does not increase the risk of fetal anomalies or loss. [89] Exposure to >50 mGy leads to an increased risk of fatal childhood cancer from 1 in 500 to 1 in 200 and lifetime cancer by 2%. [88,89] Exposure to >100 mGy radiation is associated with central nervous system defects, growth retardation, and intellectual impairment. ...
... [89] Exposure to >50 mGy leads to an increased risk of fatal childhood cancer from 1 in 500 to 1 in 200 and lifetime cancer by 2%. [88,89] Exposure to >100 mGy radiation is associated with central nervous system defects, growth retardation, and intellectual impairment. [88] US Food and Drug Administration states that the iodinated contrast for vascular opacification is considered a category B drug. ...
In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.
... At any point during the pregnancy, there is a risk of fetal carcinogenesis, approximated as an increased lifetime risk of cancer by 2% with a fetal dose exposure of 50 mGy. 16,17 Adverse effects of radiation on the fetus were a bigger concern in the past when the doses from earlier generations of CT scanners were generally higher. With the newer generation technology, the radiation dose exposure to the fetus for any single study is considerably less than 50 mGy (Table 1). ...
... With the newer generation technology, the radiation dose exposure to the fetus for any single study is considerably less than 50 mGy (Table 1). 16,18 Hence, when it is clinically indicated, the risk of adverse events from radiation exposure to the fetus is generally outweighed by the benefits of detecting life-threatening injuries, and a thorough radiological workup of the patient should not be avoided. ...
... 3 It is more common after 16 weeks of gestation, and affects 1% to 5% of minor trauma patients and 30% to 50% of major trauma patients during pregnancy. 16,38 Fetal mortality in cases of traumatic placental abruption is up to 67% to 75%. 14 The term placental abruption refers to complete or partial detachment of the placenta from the underlying myometrium before the expected delivery time. 39 It results from the shear forces between relatively inelastic placental tissue and the elastic myometrium, with a rapidly accumulating intervening hemorrhage. ...
A pregnant patient with acute trauma is not commonly encountered by clinicians and radiologists. A multidisciplinary approach is key. Although radiography and ultrasound examination are frequently used modalities in the setting of maternal-fetal trauma, the fear of radiation should not preclude from carrying out a thorough diagnostic workup of the patient with a computed tomography scan. MRI mainly serves as a problem solving and follow-up modality. After stabilizing the mother, fetal well-being should be assessed with external fetal monitoring and a dedicated obstetric ultrasound examination. Radiologists should be familiar with the sonographic and computed tomography findings of catastrophic entities.
... [8] To minimize these risks, MRI with a field strength of 1.5T or less is used in pregnant patients. [9] As per FDA, gadolinium is considered a category C drug in pregnancy, meaning that it should be used only when it is crucial to perform contrast imaging for evaluation. [9] e anatomical artifact during female pelvic imaging concedes the diagnostic features. ...
... [9] As per FDA, gadolinium is considered a category C drug in pregnancy, meaning that it should be used only when it is crucial to perform contrast imaging for evaluation. [9] e anatomical artifact during female pelvic imaging concedes the diagnostic features. An antispasmodic agent's intake of glucagon reduces the bowel movement artifacts and improves imaging quality. ...
Acute uterine emergencies constitute both obstetric and gynecologic conditions. The superior image resolution, superior soft-tissue characterization, and lack of ionizing radiation make magnetic resonance imaging (MRI) preferable over ultrasonography (USG) and computed tomography (CT) in investigating uterine emergencies. Although USG is the first-line imaging modality and is easily accessible, it has limitations. USG is an operator dependent and limited by patient factors such as obesity and muscle atrophy. CT is limited by its risk of teratogenicity in pregnant females, poor tissue differentiation, and radiation effect. The non-specific findings on CT may lead to misinterpretation of the pathology. MRI overcomes all these limitations and is emerging as the most crucial imaging modality in the emergency room (ER). The evolving 3D MR sequences further reduce the acquisition times, expanding its ER role. Although MRI is not the first-line imaging modality, it is a problem-solving tool when the ultrasound and CT are inconclusive. This pictorial review discusses the various MRI techniques used in uterine imaging and the appearances of distinct etiologies of uterine emergencies across different MRI sequences.
