1. Effects of Radiation Exposure on the Developing Fetus Hannah Connolly, Janessa Gioia, Gillian Reid, Nadine Savoie, Suzanne Taylor University of New Brunswick

2. Problem Statement  Pregnant women may be denied diagnostic and therapeutic radiation procedures because physicians fear the radiation will cause harm to the developing fetus. Thus, fewer options are available for improving the health of pregnant women when they require medical attention. Understanding the effects of radiation on the developing fetus may help physicians better counsel their patients on the risks involved. This education would allow for an informed decision to be made on whether to proceed with radiation procedures. Retrieve from http://www.math.cmu.edu/~handron/problems/

3. Research Question  Are diagnostic and therapeutic radiation procedures harmful to the developing fetus? Retrieve from http://sites.mckesson.com/mprs/images/page/mprs_home.jpg

4. Harmful  Teratogenic- causing congenital malformations  Carcinogenic- cancer causing  Mutagenic- causing genetic changes (Whitt, 2010) Retrieve fromhttp://www.biomol.de/wiki/index.php/DNA_Damage_an d_Repair_Antibodies Retrieve from http://health-e-waste.blogspot.com/ Retrieve from feed://www.blogger.com/feeds/41059340829393831 22/posts/default

5. Related Diseases  Major Mutations  Other abnormalities  The major risk is of course, embryonic loss. (Brent 1999). Retrieve from http://www.sci-art.com/image.asp?id=2689&search=1&pagename=DNA_radiation_damage

6. Radiation: DNA Damage Retrieve from http://www.windows2universe.org/earth/Life/images/radiation_dna_damage_big_jpg_image.html

7. History of why these studies emerged  Hiroshima and Nagasaki, Chernobyl  In 1956: prenatal exposure to radiation from diagnostic X-ray (Naumburg et al. 2001; Doll & Wakeford, 1997) Retrieve fromhttp://awesometalks.files.wordpress.com/2008/08/ng30.jpgRetrieve from http://www.belarusguide.com/chernobyl1/chernobyl.htm

8. Fetal Stages and Radiation Sensitivity  (1) Preimplantation (days 0 to ~14)  (2) Organogenesis (week 2 to week 8)  (3) Fetal (week 9 to term) Retrieved from: http://www.scienceagogo.com/news/20080427022113data_trunc _sys.shtml Retrieve from http://microrespuestas.com/que-es-la- organogenesis Retrieve from http://www.webmd.com/baby/slideshow-fetal- development

9. Methods  Quantitative  Experimental  Non Experimental  Retrospective  Prospective  Surveys  Time frames  Longitudinal Retrieve from http://www.faqs.org/photo-dict/photofiles/list/664/1074test_tubes.jpg

10. Health Concerns  From our studies these are some health concerns that would bring pregnant woman to our departments  Pulmonary Embolism  Loss of bone density  Cancer  Abdominal/Pelvic issues Retrieve from http://rochesterchiro.files.wordpress.com/2008/06/chiropractor-patient.jpg

11. Pulmonary Embolism Retrieve from http://jenniferashe.com/thrombophilia/images/lungs-pulmonary-embolism-PU.jpg

12. Pulmonary Embolism  Chest X-ray + V-P Scan + Helical CT + Pulmonary Angiograpy with brachial approach = ~ 1000 uGy.  Ventilation perfusion scans:  The presence and absence of PE is inconclusive in up to 80% of these scans  Prior episodes of PE may cause a false-positive result (Winner-Muram et al., 2002)  Fetal dose > 10 cGy, the probability of congenital defects rises 10%. (Tutty, 2001) Retrieved from: http://www.pulmonaryreviews.com/nov00/images/CS-Fig%205.gif

13. Bone Density  There is evidence that some pre-existing disorders as well as heparin treatments may lead to significant diminution of bone mass during pregnancy.  Treatment would be administered to patients who demonstrate rapid bone lose during the first postconception months.  Emryo/fetus doses were found to be lower than the average daily natural background from a proximal femur scan.  Benefits Outweigh Risks! (Damilakis, 2002) Retrieve from http://www.tappmedical.com/page_images/dexa_femur.jpg

14. Abdominal and Pelvic Procedures  Medical imaging such as CT may be required of the abdominal/trunk/pelvic area due to trauma, acute abdominal pain, appendicitis, or renal issues in a pregnant patient.  Ultrasound  Survey respondents are more likely to choose CT for trauma in all three trimesters.  For acute abdominal indications they were more likely to choose CT in the second and third trimester, and MRI in the first trimester.  The trend found in radiology literature is that CT is fast, readily available and allows immediate surgical intervention if needed. (Jaffe, 2007) Retrieve from http://www.lakeridgehealth.on.ca/patient_care/interventional_radiol ogy/presentations/radiology/slide25.htm Retrieve from http://www.lakeridgehealth.on.ca/patient_care/inter.ventio nal_radiology/presentations/radiology/slide25htm

15. Abdominal and Pelvic Procedures  Literature suggests that for most radiologic procedures, the risk of fetal demise in the first 2 weeks after conception is less than 1% (Jaffe, 2007).  Radiologists may also opt for a modified CT protocol to reduce the exposure by reducing the power of the x-rays (kVp or mAs) (Damilakis et al., 2000).  No direct radiation to the fetus. (Hurtwitz et al. 2006; Kal & Struikmans, 2005) Retrieved from http://findmeacure.com/wp- content/uploads/2010/10/CT- Scan.jpg

16. Cancer Diagnosis & Treatment when Pregnant  Cancer: 1 per 1000 pregnancies (Kal & Struikmans, 2005; Pavlidis & Penteroudakis, 2005)  Most common cancer types (Greskovich & Macklis, 2000; Pavlidis & Penteroudakis, 2005).  Carcinoma of the cervix: is the most common  Breast cancer pregnant patient 1 in 3000 (Berry et al. 1999; Greskovich & Macklis, 2000; Kal & Struikmans, 2005; Pandit-Taskar et al. 2006)  Radiation therapy is not usually offered during pregnancy (Pavlidis & Penteroudakis, 2005; Kal & Struikmans, 2005) Retrieve from http://www.oregonlive.com/kiddo/index.ssf/2008/08/31- week/ Retrieved from http://www.blogcdn.com/www.parentdish.com/media/201 0/10/pregnant-breast-cancer-330-.jpg Retrieved from http://www.fightpink.org/wp- content/uploads/2009/08/pregnantandcancer.jpg

17. Diagnosing Oncology Patients  To diagnose:  Fine-needle biopsy, ultrasound, mammography, MRI (Berry et al. 1999; Greskovich & Macklis, 2000; Pavlidis & Penteroudakis, 2005; Kal & Struikmans, 2005, Hurtwitz et al., 2006; Doll & Wakeford, 1997; Nicklas & Baker, 2000) Retrieve from http://drlindagalloway.wordpress.com/2009/12/14/why- pregnant-women-need-more-than-one-ultrasound/ Retrieve from http://medicineworld.org/news/news- archives/breast-cancer-blog/April-4-2006.html Retrieve from http://thetyee.ca/News/2009/09/29/HaltClinics/

18. Delaying Radiation  All chemotherapy drugs: crossing the placenta.  The first trimester: spontaneous abortion.  ethical balance must be achieved (Pavlidis & Penteroudakis, 2005; Kal & Struikmans, 2005).  Delaying treatment until the second and third trimester. (Greskovich & Macklis, 2000; Pavlidis & Penteroudakis, 2005, Doll & Wakeford, 1997; Departement of Health and Human Services, 2005). Retrieve from http://www.soc.ucsb.edu/sexinfo/article/effects- of-drugs-taken-during-pregnancy

19. Staging for Oncology Patients  The benefits vs. risks (Greskovich & Macklis, 2000; Osei & Faulkner, 2000).  Main concerns of doctors (Pavlidis & Penteroudakis, 2005).  The medical staff and patient need to decide as a team whether to begin treatment or to postpone it (Kal & Struikmans, 2005). Retrieve from http://www.4dbabyscan.com/3d-ultrasound-houston-tx.htm

20. How much radiation is to much?  It is concluded that radiation doses of the order of 10 mGy received by the fetus in utero produce a consequent increase in the risk of childhood cancer. (Doll & Wakeford, 1997)  Lymphoscintigraphy for sentinel lymph node mapping (SLN) led to a neglible dose to the fetus (0.014 mGy or less) (Pandit-Taskar, 2006). Retrieve from http://www.aboutcancer.com/sentinel.htm

21. Retrieve from http://www.elekta.com Retrieve from http://blog.elekta.com/tag/radiation-therapy/ Retrieve from http://wardray- premise.com/images/products/large/aprons/claire_h ugo.jpg Oncology Studies  Relative risk are higher: first (Greskovich & Macklis, 2000; Pavlidis & Penteroudakis, 2005; Doll, & Wakeford, 1997; Department of Health and Human Services, 2005).  Mastectomy with postpartum radiation (Berry et al. 1999)  Patients received a median of four cycles of chemotherapy (Berry et al. 1999; Doll, & Wakeford, 1997; Department of Health and Human Services, 2005).  Neonates: no unusual complications or malformations. (Berry et al. 1999)  Fetal dose was much less than the NCRP limit. Pandit-Taskar et al. (2006 )

22. Oncology- Thyroid Cancer  Radioiodine ( 131 I) Therapy  Abnormalities  Indirect exposure to: the uterus, 131 I uptake in the blood, bladder, gut, kidneys  Within a year after the therapy: miscarriages and induced abortions.  A number of stillbirths after radioiodine therapy: high.  Thyroid hormone  DO NOT: conceive one month prior the therapy and postponing conception until the thyroid hormone status has been verified. (Garsi, J-P., et al. 2008, Bohuslavizki, 1999) Retrieve from http://www.qatarpark.com/park/2010/01/d r-abdul-azim-hussain/ Retrieve from http://ahmadnour.maktoobblog.com/ category/thyroid-cancer/

23. Childhood Development  Preschool aged children  No damaging effects of diagnostic imaging, low dose x- radiation. (Ornoy et al., 1996)  Large radiation doses (Department of Health and Human Services, 2005) Retrieve from http://photos.ibibo.com/photo/5598752/cute- child Retrieve from http://www.topnews.in/files/baby-girls.jpg

24. Childhood Cancer  The USNCRP: doses of 50 mGy or less is negligible  Baseline risks  However…  increases in use of of CT and nuclear medicine radiodiagnostic procedures  Inadvertent exposure in early pregnancy may occur (Ratnapalan et al., 2003; Ray et al. 2010) Reftrieve from http://www.istockphoto.com/stock-photo- 3348400-cancer-kids-baby-with-daffodils.php Retrieve from http://www.dienviro.com/index1.aspx?BD=17957

25. Childhood Cancer Leukemia  Leukemia is the most common malignancy among children.  Study: children born in Sweden between 1973- 1989.  Association between leukemia and diagnostic x-rays is likely to be small. (Naumburg et al., 2001) Retrieve from http://www.casperwyoming.info/dining.php?sort=Family

26. Childhood Cancer Malignancy  Ontario study: Between April 1, 1992 and March 31, 2008.  Researchers looked at the incidence of malignancy in those children  Exposed mothers vs. unexposed mothers  They concluded: no difference noted (Ray et al., 2010) Retrieve from http://www.retros.org/sargent_04.html

27. Perception of the Risks  Ontario survey  Misperceptions of physicians  Could lead to anxiety, delay of care among pregnant woman (Ratnapalan et al., 2004)  Misperception of patients may be caused by misinformation (Bentur et al. 1991) Retrieve from http://www.babble.com/CS/blogs/strollerderby/2 007/09/01-07/doctor-child.jpg Retrieve from http://www.albertapci.ca/SiteCollectionImages/Subpages/do ctorChildCheckup.jpg Retrieve from http://www.choa.org/images/photography/radiology/CTsca n07.jpg

28. Recommendations & Precautions  Menstrual Cycle (Vollman, 1977; Zanotti-Fregonara et al. 2009)  Modify daily procedures  ALARA- as low as reasonably achievable  Radiation Therapy  Do treatment planning and risk management. (Bednarz & Xu, 2008).  Lead shielding (Sechopoulos et al. 2008)  http://www.youtube.com/watch?v=eziUXYwl_Cs  Serum testing (Ray et. al, 2010)  MRI and Ultrasonography  Bone densitometry on a pregnant patient  Physician education (Ratnapalan et al., 2004)  Brief counseling  Pregnant nuclear workers (Damilakis et al. 2005) Retrieve from http://www.life123.com/career-money/small- business/small-business-insurance/health-insurance-options-for- the-self-employed.shtml

29. Retrieve from http://www.babble.com/CS/blogs/strollerderby/pregnant-doctor.jpg Limitations  Randomization  Small sample size  The use of phantoms instead of real-life subjects.  Phantom does not take into account all different body variation  Retrospective designs  Results are only approximations. Retrieve from http://fotosa.ru/ru/stock/search.asp?ID=2874611&anchor=18

30. Conclusion  The amount of radiation absorbed by the fetus varies  Misperceptions exist  2 most important determining factors : dose & stage of gestation  The effects of radiation may be harmful: threshold value of 50 mGy  ALARA  Benefits outweigh risks Retrieve from http://media.photobucket.com/image/baby%20flower/TheseAreThingsILike/Album%203/BabyFlower.jpg

31. References