Safety of Radiographic Imaging During Pregnancy - American Family Physician

Safety of Radiographic Imaging During Pregnancy - American Family P...
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Apr 1, 1999 Table of Contents ( /afp/1999/0401/ )
Safety of Radiographic Imaging During

Pregnancy
KEVIN S. TOPPENBERG, M.D., D. ASHLEY HILL, M.D., and DAVID P. MILLER, M.S., Florida
Hospital Medical Center, Orlando, Florida
Am Fam Physician. 1999 Apr 1;59(7):1813-1818.
See related patient information handout on radiographic imaging in pregnancy (http://www.aafp.org
written by the authors of this article.
/afp/1999/0401/p1820),
Maternal illness during pregnancy is not uncommon and sometimes requires radiographic
imaging for proper diagnosis and treatment. The patient and her physician may be
concerned about potential harm to the fetus from radiation exposure. In reality, however, the
risks to the developing fetus are quite small. The accepted cumulative dose of ionizing
radiation during pregnancy is 5 rad, and no single diagnostic study exceeds this maximum.
For example, the amount of exposure to the fetus from a two-view chest x-ray of the mother
is only 0.00007 rad. The most sensitive time period for central nervous system
teratogenesis is between 10 and 17 weeks of gestation. Nonurgent radiologic testing should
be avoided during this time. Rare consequences of prenatal radiation exposure include a
slight increase in the incidence of childhood leukemia and, possibly, a very small change in
the frequency of genetic mutations. Such exposure is not an indication for pregnancy
termination. Appropriate counseling of patients before radiologic studies are performed is
critical.
Many women become ill while pregnant and require acute medical care, including radiographic
imaging with ionizing radiation. Exposure of a fetus to radiation can be alarming to parents and is
dealt with by the general public with less objectivity than is evident with exposure to almost any
other agent.1 Even physicians are at times known to approach this topic in a biased and unscientific
manner, leading to poor patient care and inappropriate advice.2 With x-ray usage rates exceeding
an average of more than one study for every person in the United States each year,3 it is important
for primary care doctors to have a clear perception of the actual risks and benefits of radiographic
studies during pregnancy.
Because some studies will be performed before a pregnancy is recognized, even doctors not
routinely providing prenatal care should understand these issues. Family physicians must be ready
to counsel expectant mothers requiring radiographic imaging and women who have already been
exposed. They should also have a firm rationale for ordering such studies when interacting with
other clinicians.
Illustrative Case
A patient at 19 weeks of gestation presented with flank pain and microscopic hematuria. She was
diagnosed with pyelonephritis and treated with parenteral antibiotics. Her flank pain progressed
despite antibiotic treatment, necessitating a renal ultrasound examination, which was inconclusive.
An intravenous pyelogram (IVP) was ordered, but the radiologist refused to perform the study
because of concern about radiation exposure to the fetus. Despite further discussion, the study was
denied until a perinatologist verified the appropriateness and relative safety of the study.
The IVP revealed two stones, and the patient eventually required ureteral stent placement. Despite
treatment, she had progressive renal disease with obstruction, requiring induction of labor at 35
weeks of gestation. At birth, her infant was healthy and weighed an age-appropriate 2,500 g (5 lb, 8
oz).
Understanding the Nature of Radiation

Ionizing radiation (x-ray) is composed of high-energy photons that are capable of damaging DNA
and generating caustic free radicals.3 A patient's dose of photons is measured in the gray (Gy) and
the rem, or in the older and more commonly recognized unit, the rad. The range of doses provided
by common radiographs is outlined in Table 1.48
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TABLE 1
Estimated Fetal Exposure for Various Diagnostic Imaging Methods
ESTIMATED FETAL
DOSE PER
EXAMINATION (RAD)*
NUMBER OF EXAMINATIONS
REQUIRED FOR A
CUMULATIVE 5-RAD DOSE
Skull4
0.004
1,250
Dental5
0.0001
50,000
Cervical spine4
0.002
2,500
Upper or lower extremity 4
0.001
5,000
Chest (two views)6
0.00007
71,429
Mammogram6
0.020
250
Abdominal (multiple views)6
0.245
20
Thoracic spine4
0.009
555
Lumbosacral spine6
0.359
13
Intravenous pyelogram6
1.398
Pelvis 4
0.040
125
Hip (single view)6
0.213
23
EXAMINATION TYPE
Plain films
CT scans (slice thickness: 10 mm)

Head (10 slices)6
< 0.050
> 100
Chest (10 slices)6
< 0.100
> 50
Abdomen (10 slices)6
2.600
Lumbar spine (5 slices)6
3.500
Pelvimetry (1 slice with scout

film)6
0.250
20
Upper GI series 6
0.056
89
Barium swallow6
0.006
833
Barium enema6
3.986
< 0.500
> 10
Fluoroscopic studies
Nuclear medicine studies

Most studies using
technetium (99mTc)7
15/11/2014 10:22
ESTIMATED FETAL
DOSE PER
EXAMINATION (RAD)*
NUMBER OF EXAMINATIONS
REQUIRED FOR A
CUMULATIVE 5-RAD DOSE
Hepatobiliary technetium
HIDA scan6
0.150
33
Ventilation-perfusion scan
(total)
0.215
23
Perfusion portion:
technetium6
0.175
28
Ventilation portion:
xenon (133Xe)6
0.040
125
590.000
EXAMINATION TYPE
Iodine (131I), at fetal thyroid

tissue 6
Environmental sources (for comparison)

Environmental background
radiation (cumulative dose
over nine months)8
0.100
N/A
CT = computed tomographic; GI = gastrointestinal; HIDA = hepatobiliary iminodiacetic acid; N/A

= not applicable.
*Where the reference provides a range of estimated doses, the highest value of the range is
listed here.
Authors' calculation from data provided in reference; values rounded to lowest whole
number.
Iodine (131I) is contraindicated during pregnancy.
Information from references 4 through 8.
Much of our information regarding the effects of radiation in humans has come from the study of
atomic bomb survivors who were irradiated with high doses while in utero in Nagasaki and
Hiroshima, Japan.2,9,10 Understanding outcomes after high-dose exposure can help physicians
understand potential effects from low-dose medical x-rays. These effects can be grouped into three
classic categories: teratogenesis (fetal malformation), carcinogenesis (induced malignancy) and
mutagenesis (alteration of germ-line genes).
RADIATION-INDUCED TERATOGENESIS
The fetal malformations most commonly caused by high-dose radiation are central nervous system
(CNS) changes, especially microcephaly and mental retardation.2 Many Japanese bomb victims
who were exposed in utero to doses greater than 10 to 150 rad developed microcephaly.9 A linear,
dose-related association between severe mental retardation and radiation was also found, with the
important caveat that most cases followed exposure during weeks 10 to 17 of gestation.3,10,11 This
trend reaches 40 percent at 100 rad, although it is not statistically significant at doses generated by
diagnostic radiographs.3 Nevertheless, until more data are available delineating potential fetal risk, it
is prudent to delay non-urgent radiographs during the sensitive period of 10 to 17 weeks of
gestation (eight to 15 weeks after conception).
RADIATION-INDUCED MALIGNANCY
Exposure to as little as 1 or 2 rad has also been associated with a slight increase in childhood
malignancies, especially leukemia.2,12 For example, the background rate of leukemia in children is
about 3.6 per 10,000.13 Exposure to one or two rad increases this rate to 5 per 10,000.2 While
these doses do fall within the range of that supplied by some radiographic studies, the absolute
increase of risk (about one in 10,000) is very small. Nevertheless, physicians should carefully weigh
the risks and benefits of any radiographic study and include the mother in the decision-making
process whenever possible.
15/11/2014 10:22
RADIATION-INDUCED GENE MUTATION

Radiation can cause germ-line mutations, potentially affecting future generations. Although radiation
is commonly believed to create bizarre new mutations, data show that usually it merely increases
the frequency of mutations occurring naturally in the general population.3 The dosage required to
double this baseline mutation rate is between 50 and 100 rad, far in excess of the radiation doses
occurring in common radiographic studies.3,14 Put another way, it is believed that if 10,000 persons
were exposed to 1 rad, 10 to 40 new genetic mutations would be induced.14
Table 2 presents various conclusions from key organizations that may help physicians better
understand the overall risks from x-rays and other diagnostic imaging methods. Perhaps the most
important fact for a physician to remember is that the currently accepted maximum limit of ionizing
radiation exposure to the fetus during pregnancy is a cumulative dose of 5 rad.2,5,6,7
TABLE 2
Key Statements on Diagnostic Imaging Modalities During Pregnancy
X-ray imaging
No single diagnostic procedure results in a radiation dose that threatens the well-being of the
developing embryo and fetus. American College of Radiology 3
[Fetal] risk is considered to be negligible at 5 rad or less when compared to the other risks of
pregnancy, and the risk of malformations is significantly increased above control levels only at
doses above 15 rad. National Council on Radiation Protection 5
Women should be counseled that x-ray exposure from a single diagnostic procedure does
not result in harmful fetal effects. Specifically, exposure to less than 5 rad has not been
associated with an increase in fetal anomalies or pregnancy loss. American College of
Obstetricians and Gynecologists 7
Magnetic resonance imaging
Although there have been no documented adverse fetal effects reported, the National
Radiological Protection Board arbitrarily advises against its use in the first trimester.
American College of Obstetricians and Gynecologists and National Radiological Protection
Board7
Ultrasound imaging
There have been no reports of documented adverse fetal effects for diagnostic ultrasound
procedures, including duplex Doppler imaging. There are no contraindications to ultrasound
procedures during pregnancy, and this modality has largely replaced x-ray as the primary
method of fetal imaging during pregnancy. American College of Obstetricians and
Gynecologists 7
Information from references 3, 5 and 7.
Safety Counseling
When an expectant mother considers any radiation exposure, the most prominent question in her
mind is likely to be, Is this safe for my baby? To answer this question, the clinician must carefully
choose words that will help a patient understand the real, although very small, risks of exposure.
Careful attention must also be given to the parents' potential emotional turmoil at the thought of
placing their infant at any increased risk, however small.
For example, the general population's total risk of spontaneous abortion, major malformations,
mental retardation and childhood malignancy is approximately 286 per 1,000 deliveries. Exposing a
fetus to 0.50 rad adds only about 0.17 cases per 1,000 deliveries to this baseline rate, or about one
additional case in 6,000.2,13 However, if numbers like these are quoted to patients, they are likely to
hear only the words risk, abortion, mental retardation and malignancy. This situation
emphasizes the challenge that doctors face in ensuring good communication during counseling.
Safe is a relative term, but one that physicians should not be afraid to use. When a radiographic
study is needed for appropriate management of a pregnant patient, the American College of
Radiology recommends that health care workers should tell patients that x-rays are safe and
15/11/2014 10:22
provide patients with a clear explanation of the benefits of x-ray examinations.8 One tool that
physicians may consider using to reassure patients is Figure 1, which graphically compares the
dosage of radiation provided by various common diagnostic studies or environmental sources with
the accepted limit of 5 rad. A patient's particular study could be also plotted on this graph, showing
the clear margin of safety that exists for all single diagnostic studies.
Common Radiographic Studies
FIGURE 1.
Graphic comparison of common radiographic studies with the accepted 5-rad cumulative fetal exposure limit. (CT
= computed tomographic; Gy = gray)
Understanding Baseline Risks

As part of counseling, physicians should help patients understand that birth anomalies frequently
occur spontaneously, with no identifiable cause. Statistics show that among the general population,
in 4 to 6 percent of all deliveries, some spontaneous malformation is present.2 For this reason, it is
important never to promise parents a perfect baby. Radiation from diagnostic x-rays is exceedingly
unlikely to cause harm to a fetus. Yet, if after any exposure an anomaly is found, a parent's natural
inclination may be to blame radiation, and it will then be difficult to help them understand baseline
malformation rates. For example, one author reported on a case of a woman who nearly instituted
legal action because of mild syndactyly of her infant's fourth and fifth fingers after third-trimester
dental radiographs (exposure 0.0001 rad or less).2 This case of syndactyly was almost certainly
coincidental, and yet it appeared that the mother had difficulty understanding or accepting this
explanation.
Using Reasonable Caution

Diagnostic x-rays during pregnancy are considered safe, yet physicians should use reasonable
caution while remaining sensitive to patients' fears and concerns. As with all patient care, good
communication promotes a trusting relationship. Unexpected outcomes often lead to anger and legal
action. Thus, a factual discussion of the nature of the planned examination and its potential
outcomes, and documenting consent are appropriate steps before ordering a study. Asking
nonpregnant women with child-bearing potential about the possibility of pregnancy is also an
important way to avoid unpleasant surprises.
Women exposed to radiation exceeding a cumulative dose of 5 rad and those with particular
concerns about their infant's health may require further evaluation or referral. A radiation physicist
can calculate the estimated dose of radiation to the fetus to assist in patient counseling.
A physician's caution should not become unreasonable. Concerns of medicolegal liability may lead
some caregivers to inappropriately withhold needed x-rays, thus jeopardizing the health of both
mother and fetus. Yet legal liability with exposures less than 5 rad should be minimal and, in fact,
many key organizations have declared such exposures to be safe (Table 2). Furthermore, it would
be difficult to prove that a given radiograph caused harm in light of the high baseline rate of
malformations. Ensuring that radiographs are truly indicated and are ordered in accordance with
applicable published guidelines will give further support to a physician's course of action at any
review.
If a mother's illness necessitates x-rays, there should usually be no hesitation in ordering the
needed study.15 A reasonable guideline has been proposed by the American Academy of Pediatrics
and the American College of Obstetricians and Gynecologists (ACOG) that balances these issues.
15/11/2014 10:22
The two groups state that Diagnostic radiologic procedures should not be performed during
pregnancy unless the information to be obtained from them is necessary for the care of the patient
and cannot be obtained by other means (especially ultrasound).16
Abortion Counseling
A woman may fear radiation so much that she believes she should abort a fetus after exposure. Up
to 25 percent of exposed women believe their infants are at risk for major malformation.17 After the
nuclear reactor accident in Chernobyl, Russia, 23 percent of pregnancies in Greece were
terminated because of unfounded concerns about fetal teratogenicity.18 Timely counseling can often
correct such a misunderstanding.17 While electively terminating an early pregnancy is legal in the
United States, it is important that patients and physicians not confuse social issues with medical
ones. Medically, the additional risk imposed by diagnostic radiation is simply too small to justify
terminating a pregnancy. For example, one risk associated with lower-dose radiation is childhood
leukemia. Yet it would be necessary to abort 1,999 exposed fetuses to prevent one case of
leukemia.2 Guidelines from ACOG clearly support this understanding: Exposure to x-ray during
pregnancy is not an indication for therapeutic abortion.7
Final Comment
A pregnant woman who is ill and requires radiographic imaging faces potential risks from her
disease to her own health as well as that of her developing infant's. These risks almost always
outweigh the minor hazards posed by low-dose radiation exposure. Physicians should not hesitate
to order a study if an appropriate work-up of the mother requires a specific test to guide diagnosis
and treatment. However, nonurgent x-rays should be avoided in weeks 10 to 17, the period of
greatest CNS sensitivity. When diagnostic imaging is acutely needed, ultrasonography may
represent an alternative to ionizing radiation and is considered safe throughout pregnancy. Patient
counseling before radiation exposure will help alleviate anxiety and misunderstandings. Proper
communication may also reduce unnecessary litigation in the event of an unexpected outcome.
The Authors
KEVIN S. TOPPENBERG, M.D., is a fellow in family practice obstetrics at Florida Hospital, Orlando.
Dr. Toppenberg graduated from Loma Linda (Calif.) University School of Medicine and recently
completed postgraduate training in family medicine at Florida Hospital's Family Practice Residency
Program.
D. ASHLEY HILL, M.D., is associate director of the Department of Obstetrics and Gynecology at
the Florida Hospital Family Practice Residency Program. A graduate of the University of South
Florida College of Medicine, Tampa, Dr. Hill served an internship at Charity Hospital in New Orleans
and a residency in obstetrics and gynecology at the University of South Florida College of Medicine.
DAVID P. MILLER, M.S., is director of the Department of Medical Physics and radiation safety
officer for Florida Hospital. He is also director of Florida Hospital's Medical Physics Residency
Program in therapeutic oncology. He received a master's degree in medical physics from Emory
University, Atlanta, and is certified by the American Board of Radiology and the American Board of
Medical Physics for each of the disciplines of medical physics: therapeutic oncology, diagnostic
radiology and nuclear medicine.
Address correspondence to D. Ashley Hill, M.D., 500 E. Rollins Ave., Suite 201, Orlando, FL
32803.
Figure 1 is based on data derived from references 4 through 8.
REFERENCES
1. Jones KL. Effects of therapeutic, diagnostic, and environmental agents. In: Creasy RK, Resnik R,
eds. Maternal-fetal medicine. 3d ed. Philadelphia: Saunders, 1994:17181.

2. Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound:
counseling the pregnant and nonpregnant patient about these risks. Semin Oncol. 1989;16:34768.
3. Hall EJ. Scientific view of low-level radiation risks. Radiographics. 1991;11:50918.
4. Brent RL, Gorson RO. Radiation exposure in pregnancy. In: Current Problems in Radiology.
Technic of pneumoencephalography. Chicago: Year Book Medical, 1972:147.

5. National Council on Radiation Protection and Measurements. Medical radiation exposure of
pregnant and potentially pregnant women. NCRP Report no. 54. Bethesda, Md.: The Council, 1977.
6. Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC, eds. Williams Obstetrics.
20th ed. Stamford, Conn.: Appleton & Lange, 1997:104557.

7. American College of Obstetricians and Gynecologists, Committee on Obstetric Practice.
Guidelines for diagnostic imaging during pregnancy. ACOG Committee opinion no. 158. Washington,
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D.C.: ACOG, 1995.

8. Gray JE. Safety (risk) of diagnostic radiology exposures. In: American College of Radiology.
Radiation risk: a primer. Reston, Va.: American College of Radiology, 1996.

9. Blot WJ, Miller RW. Mental retardation following in utero exposure to the atomic bombs of
Hiroshima and Nagasaki. Radiology. 1973;106:6179.

10. Yamazaki JN, Schull WJ. Perinatal loss and neurological abnormalities among children of the
atomic bomb: Nagasaki and Hiroshima revisited, 1949 to 1989. JAMA. 1990;264:6059.
11. Otake M, Schull WJ. In utero exposure to A-bomb radiation and mental retardation: a
reassessment. Br J Radiol. 1984;57:40914.

12. Brent R, Meistrich M, Paul M. Ionizing and nonionizing radiations. In: Paul M, ed. Occupational
and environmental reproductive hazards: a guide for clinicians. Baltimore: Williams & Wilkins,
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13. Miller RW. Epidemiological conclusions from radiation toxicity studies. In: Fry RJ, Grahn D,
Griem ML, Rust JH, eds. Late effects of radiation. London: Taylor & Francis, 1970.
14. Committee on Biological Effects of Ionizing Radiation, Board on Radiation Effects Research,
Commission on Life Sciences, National Research Council. Health effects of exposure to low levels
of ionizing radiation: BEIR V. Washington, D.C.: National Academy Press, 1990.
15. Niebyl JR. Teratology and drug use during pregnancy and lactation. In: Scott JR, DiSaia PJ,
Hammond CB, Spellacy WN, eds. Danforth's Obstetrics and gynecology. 7th ed. Philadelphia:
Lippincott, 1994:22544.
16. Guidelines for perinatal care. 3d ed. Elk Grove Village, Ill.: American Academy of Pediatrics and
American College of Obstetricians and Gynecologists, 1992:2103.

17. Bentur Y, Horlatsch N, Koren G. Exposure to ionizing radiation during pregnancy: perception of
teratogenic risk and outcome. Teratology. 1991;43:10912.

18. Trichopoulos D, Zavitsanos X, Koutis C, Drogari P, Proukakis C, Petridou E. The victims of
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