1. RADIATION PROTECTION IN DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY
Part No...., Module No....Lesson No
Module title
IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology
Adapted for Regional Training Course on RP of Patients for Radiographers
Accra, Ghana, July 2011
RADIATION PROTECTION IN DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY
L14: Radiation exposure in pregnancy
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IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

2. Topics Introduction Effects and risks of in utero exposure
Typical doses
Practical implementation
14: Radiation exposure in pregnancy

3. Part 14: Radiation exposure in pregnancy
Part No...., Module No....Lesson No
Module title
IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology
Part 14: Radiation exposure in pregnancy
Topic 1: Introduction
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Learning objectives: Upon completion of this lesson, the students will be able to: …
. (Add a list of what the students are expected to learn or be able to do upon completion of the session)
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IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

4. Part No...., Module No....Lesson No
Module title
Introduction
Thousands of pregnant women are exposed to ionizing radiation each year
Lack of knowledge is responsible for much anxiety and possibly unnecessary termination of pregnancies
For most patients, the radiation exposure was medically appropriate and the radiation risk was minimal
Explanation or/and additional information
Instructions for the lecturer/trainer
14: Radiation exposure in pregnancy
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

5. Situation analysis Exposure of females of reproductive capacity:
Intended medical exposure:
Patients needing radiological procedures while pregnant
Unintended or accidental medical exposure:
Pregnancy not known or not declared
Occupational exposure
14: Radiation exposure in pregnancy

6. Example of justified use of CT on a pregnant female who was in a motor vehicle accident
Courtesy: Fred Mettler
14: Radiation exposure in pregnancy

7. A CT exam performed and then taken to the operating room
A CT exam performed and then taken to the operating room. The woman and the child survived
Free blood
Kidney ripped
off aorta (no contrast in it)
Splenic laceration
Courtesy: Fred Mettler
14: Radiation exposure in pregnancy

8. Part 14: Radiation exposure in pregnancy
Part No...., Module No....Lesson No
Module title
IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology
Part 14: Radiation exposure in pregnancy
Topic 2: Effects and risks of in utero exposure
Part …: (Add part number and title)
Module…: (Add module number and title)
Lesson …: (Add session number and title)
Learning objectives: Upon completion of this lesson, the students will be able to: …
. (Add a list of what the students are expected to learn or be able to do upon completion of the session)
Activity: (Add the method used for presenting or conducting the lesson – lecture, demonstration, exercise, laboratory exercise, case study, simulation, etc.)
Duration: (Add presentation time or duration of the session – hrs)
Materials and equipment needed: (List materials and equipment needed to conduct the session, if appropriate)
References: (List the references for the session)
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

9. Fetal Radiation Risk
There are radiation-related risks throughout pregnancy which are related to the stage of pregnancy and absorbed dose
Radiation risks are most significant during organogenesis and in the early fetal period somewhat less in the 2nd trimester and least in the third trimester
Most risk
Less
Least
14: Radiation exposure in pregnancy

10. In utero exposures 0 Conception Implantation 2 Organogenesis 8 13 1526
40 weeks
“All or nothing” - lethal effects
Threshold (0.1? – 1 Gy)
Malformations – gestation-age dependent
Threshold ~ 0.1 Gy
Severe mental retardation*#
40% risk at 1 Gy
Threshold ~ > 0.3 Gy
Severe mental retardation, but less risk
* Some data show a loss of 25 IQ points per Gy
# Spontaneous rate of SMR is about 3%
Fatal cancer risk: Childhood: ~ 6 % per Gy
Hereditary effects: assumed to be ~ 0.5% per Gy
Growth anomalies; e.g. head size
14: Radiation exposure in pregnancy

11. Spontaneous incidence Additional incidence after fetal dose of 25 mGy
In utero effects
Effect
Spontaneous incidence
Additional incidence after fetal dose of 25 mGy
Lethal effects, pre-implantation
> 15 %
~ 0
Malformations
~ %
Serious mental retardation
~ 3 %
Childhood cancer
~ 0.2 %
Lifetime cancer
~ 33 %
~ 0.1 %
Hereditary effects
~ %
14: Radiation exposure in pregnancy

12. Probability of bearing healthy children as a function of fetal dose
Fetal dose (mGy)
Probability of NO malformations %
Probability of NO childhood cancer 97
99.7 1 5 10
99.6 50
99.4
100
99.1
> 100
Possible malformations
Increased probability of childhood cancer
14: Radiation exposure in pregnancy

13. Part 14: Radiation exposure in pregnancy
Part No...., Module No....Lesson No
Module title
IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology
Part 14: Radiation exposure in pregnancy
Topic 3: Typical doses
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Module…: (Add module number and title)
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Learning objectives: Upon completion of this lesson, the students will be able to: …
. (Add a list of what the students are expected to learn or be able to do upon completion of the session)
Activity: (Add the method used for presenting or conducting the lesson – lecture, demonstration, exercise, laboratory exercise, case study, simulation, etc.)
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Materials and equipment needed: (List materials and equipment needed to conduct the session, if appropriate)
References: (List the references for the session)
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

14. In utero doses from diagnostic and interventional procedures
Magnitude of dose depends on whether fetus is:
Not in the beam and beam is distant from uterus
Fetal dose typically < 0.01 mGy
Not in the beam, but beam is close to the uterus
Fetal dose typically < 0.1 mGy
In the beam
Fetal dose typically in the range 0.1 to 50 mGy
Plain film ~ 1 mGy
Barium enema ~ 5 mGy
CT ~ 10 – 50 mGy
14: Radiation exposure in pregnancy

15. Part 14: Radiation exposure in pregnancy
Part No...., Module No....Lesson No
Module title
IAEA Training Material on Radiation Protection in Diagnostic and Interventional Radiology
Part 14: Radiation exposure in pregnancy
Topic 4: Practical implementation
Part …: (Add part number and title)
Module…: (Add module number and title)
Lesson …: (Add session number and title)
Learning objectives: Upon completion of this lesson, the students will be able to: …
. (Add a list of what the students are expected to learn or be able to do upon completion of the session)
Activity: (Add the method used for presenting or conducting the lesson – lecture, demonstration, exercise, laboratory exercise, case study, simulation, etc.)
Duration: (Add presentation time or duration of the session – hrs)
Materials and equipment needed: (List materials and equipment needed to conduct the session, if appropriate)
References: (List the references for the session)
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

16. Diagnostic and Interventional procedures for females of reproductive potential
For all procedures:
Signs asking female patients to notify staff if they are or might be pregnant
Appropriate languages
Appropriate placement
For procedures that could lead to significant embryo or fetal dose:
Radiological medical practitioner
Procedures in place to ascertain pregnancy status
14: Radiation exposure in pregnancy

17. 4 outcomes to the pregnancy question
Diagnostic and Interventional procedures for females of reproductive potential
4 outcomes to the pregnancy question
No possibility of pregnancy
Proceed as normally
Patient definitely or probably pregnant
Pregnancy cannot be excluded
low dose procedure
high dose procedure
14: Radiation exposure in pregnancy

18. Patient definitely or probably pregnant
Review the justification
Radiological medical practitioner
Referring medical practitioner
Decide whether to defer the procedure until after the delivery (or pregnancy is ruled out)
Does delaying procedure involve greater risk?
Patient needs to be informed of benefits and risks
If still justified, then the procedure should be optimized
So that the fetal dose is the minimum consistent with the clinical purpose
14: Radiation exposure in pregnancy

19. Pregnancy cannot be excluded: low dose
Low dose means fetal dose < ~10 mGy
If pregnancy cannot be excluded but menstrual period not overdue
Proceed as normal
If pregnancy cannot be excluded and menstrual period is overdue
Treat patient as probably pregnant
Follow advice as in previous slide
14: Radiation exposure in pregnancy

20. Pregnancy cannot be excluded: high dose
High dose means fetal dose > ~ 10 mGy
For these high dose procedures
Either: Apply a “ten day” rule
I.e. females of childbearing potential are always booked for these procedures during the first ten days of their menstrual cycle, when conception is unlikely to have occurred
Or: Book as any patient, but the procedure is not performed and is re-booked if the attending patient is:
In 2nd-half of their menstrual cycle, and
Is of childbearing potential, and
Pregnancy cannot be excluded
14: Radiation exposure in pregnancy

21. Inadvertent exposure in pregnancy
Can occur in two ways:
A pregnant patient is asked whether she is or might be pregnant and denies it
Either deliberately or in ignorance of her condition; and
Procedure takes place
A pregnant patient is NOT asked and the procedure takes place regardless
Revised BSS requires the licensee to investigate any inadvertent exposure of the embryo or fetus
Dose and risk estimation
Patient and referring doctor informed
14: Radiation exposure in pregnancy

22. Termination of pregnancy
Termination of pregnancy for fetal doses of less than 100 mGy is NOT justified based solely upon radiation risk
For fetal doses in excess of 100 mGy, there can be fetal damage, the magnitude and type of which is a function of dose and stage of pregnancy
In these cases decisions on termination should be based upon individual circumstances
14: Radiation exposure in pregnancy

23. Occupational Exposure of Pregnant Workers
Pregnant medical radiation workers may work in a radiation environment as long as there is reasonable assurance that the fetal dose can be kept below 1 mGy during the pregnancy
Typically 3 options for pregnant workers
No change in assigned work duties
Change to an area where the radiation exposure may be lower
Change to a role that has no radiation exposure
Discussions are needed
Pregnant worker must be informed of potential risks, local policies and the dose limits
14: Radiation exposure in pregnancy

24. Occupational Exposure of Pregnant Workers
From an occupational dose perspective there are few situations in diagnostic and interventional radiology where a pregnant worker would actually need to change their duties
“Front line” operators in image guided interventional procedures are a possible exception
Need to use previous monitoring history to establish likely levels of exposure
Need to be confident that accidents with the potential for occupational exposure are unlikely
There will be other concerns of the pregnant worker that will need to be taken into account
14: Radiation exposure in pregnancy

25. Part No...., Module No....Lesson No
Module title
Summary
The radiation dose to the embryo or fetus from any diagnostic or interventional procedure in current use should present no risk of causing fetal death, malformation, growth retardation or impairment of mental development
For the majority of diagnostic procedures, giving fetal doses up to about a milligray, the associated risks of childhood cancer are very low
For high fetal dose procedures, systems must be in place to ascertain pregnancy status, with ensuing review of the justification for each patient, and appropriate optimization if the procedure is performed
Let’s summarize the main subjects we did cover in this session. (List the main subjects covered and stress again the important features of the session)
14: Radiation exposure in pregnancy
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources

26. Where to Get More Information
Part No...., Module No....Lesson No
Module title
Where to Get More Information
ICRP Publication 84. Pregnancy and Medical Radiation (1999).
ICRP Publication 90. Biological Effects after Prenatal Irradiation (Embryo and Fetus)(2003)
ICRP Publication 103. The 2007 Recommendations of the International Commission on Radiological Protection (2007)
Protection of Pregnant Patients during Diagnostic Medical Exposures to Ionizing Radiation. Advice from the HPA, RCR and CoR (2009)
14: Radiation exposure in pregnancy
IAEA Post Graduate Educational Course in Radiation Protection and Safe Use of Radiation Sources