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Today we are honored to welcome Dr. Douglas Katz,

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who is here to deliver a lecture entitled, imaging

0:28

of Acute Abdominal and Pelvic Conditions in Pregnancy.

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Dr. Katz is Vice Chair for research

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and Professor of Radiology at NYU Long

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Island's Radiology Department.

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Dr. Katz is authored award-winning exhibits,

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co-written multiple books

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and served on the editorial boards of major journals,

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including radiology, emergency Radiology,

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A JR, and radiographics.

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He's received numerous honors,

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including the RSNA Lifetime Honored Educator Award in 2023,

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and NYU, long Island's Dean's Award

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for Excellence in Clinical Research

1:00

and Scholarship, a leader in emergency

1:03

radiology RAD education.

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He's also dely committed to mentoring students, residents,

1:08

and faculty, and advancing radiology education globally.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may have

1:16

on today's topic.

1:18

Please remember to use the q

1:19

and a feature to submit your questions so we can get to

1:22

as many as we can before our time is up.

1:24

With that, we are ready to begin today's lecture. Dr.

1:27

Katz, please take it from here.

1:29

Good day everybody. Welcome to everyone watching this live

1:33

and also down the road.

1:34

It's always a pleasure to be involved in these,

1:36

uh, noon conferences.

1:39

So, um, today's lecture is a, I think, a discomfort point

1:43

for a lot of people, including, quite honestly myself,

1:47

even though I've been writing about this topic

1:49

and lecturing on it for over 20 years.

1:50

And I think that's the point.

1:52

You know, there are things that we, uh, do every day.

1:54

We're comfortable with things that are kind of esoteric

1:58

that we really don't really ever have to see or know,

2:00

and things that we see occasionally.

2:02

And that's the area of discomfort that I think we do have

2:05

to be familiar with because they come up every once in a

2:08

while and there are cases that are like reactions, like,

2:11

Ugh, I wish somebody else was the one interpreting this.

2:14

But unfortunately, we do have to occasionally be the ones

2:17

as the radiologists

2:18

who are head on taking these kinds of challenging cases.

2:22

So, let's dig in. So our purpose, uh, today is

2:25

to review the imaging

2:26

and briefly the clinical literature of selected conditions

2:30

of non appendiceal

2:32

and primarily non obstetric conditions in pregnancy,

2:36

variety of different systems.

2:37

We'll discuss, we'll go over current algorithms

2:40

and current recommendations for these conditions.

2:43

As you might imagine, the emphasis on initial sonography

2:48

and then heavy use of MRI

2:51

very occasionally radiography

2:53

and really es essentially only in the trauma setting.

2:57

Are we gonna more heavily use ct, very selectively CT

3:00

and other situations.

3:03

The sort of joke here is my disclosure is

3:05

that I've been challenged by imaging of the acute admin

3:08

for well over 35 years now, but I have no other disclosures.

3:12

I wanna thank some of my colleagues for contributing cases.

3:15

Their names are also listed for the individual cases.

3:18

And Dr. Deborah Reed, a mentor of mine

3:20

who got me involved some years ago initially in this topic.

3:24

And, you know, things become a bit more personal, um,

3:28

when you actually have children.

3:29

So I have an, an 8-year-old son

3:31

here is when he was, was young.

3:32

So when I first got involved in the topic,

3:34

it was a little more theoretical.

3:37

Now, not so much theoretical here is some years ago at the

3:40

Bronx Zoo visiting Thomas the tank engine.

3:44

So some background, um, very controversial,

3:49

not gonna get too much into this,

3:51

but there is, uh, controversial evidence regarding

3:56

is there an increased risk of development

3:59

of cancer in a fetus subsequently

4:03

after that fetus is born if irradiated

4:06

for medical proce imaging procedures.

4:09

Um, and I think the bottom line is whether you believe there

4:12

is or is not data to support that contention, is

4:15

that if we can completely eliminate ionizing radiation

4:19

to the mother when we're imaging acute abdominal

4:22

and pelvic conditions in pregnancy, then it,

4:25

it really becomes a moot point.

4:27

There have been a variety of papers over the years

4:30

that have looked at as estimated dose for a CT

4:33

of the abdo and pelvis.

4:34

Some of those numbers I present here,

4:36

and you can see they are in the range of from, say, 17

4:40

to about 30 milligram, uh, estimated dose to the fetus.

4:44

Presumably we can go lower,

4:47

but of course, as we reduce the dose

4:49

and the variety of ways to do that, image quality goes down.

4:53

And the worst case scenario is to have a non-diagnostic CT

4:57

and then still irradiate the mother and the fetus.

5:00

And of course, as you might imagine, as the, uh,

5:03

gestation progresses,

5:04

particularly later in the third gestation,

5:06

the anatomy becomes more complex, things become crowded,

5:09

and we're dealing with an overall larger, um,

5:12

cross-sectional diameter, um, was involved in a project,

5:17

um, a year ago where, um, I try to get a variety

5:21

of world-class medical physicists to write a review article,

5:25

not necessarily taking position one way or the other,

5:28

but just looking at the evidence

5:30

or the lack of evidence as

5:31

to whether there is an association with

5:34

CT and cancer in general.

5:36

And I could not get a single medical physicist on this

5:39

planet, and I tried multiple con countries

5:41

and multiple institutions to write this article.

5:45

So it shows you the level of controversy

5:47

and how people really are kind

5:48

of shying away from this topic.

5:50

However, a world famous medical physicist who I did not ask

5:53

to write that article, Cynthia McCullough at May

5:56

of Clinic some years ago is quoted as saying, quote,

5:58

the risk of, uh, to the conceptus from radiation doses

6:01

of less than 50 milligram is negligible Again,

6:04

presumably it can go lower than that.

6:06

Now here's some actual data.

6:08

This is from a group led

6:09

by Ray Atal in Ontario Province in Canada.

6:12

And they showed in a cohort group of a small number of women

6:16

who had ionizing radiation exposure during pregnancy

6:20

compared with a very large cohort of women

6:22

who did not have such radiation during pregnancy

6:24

for medical imaging that there was no statistically

6:27

increased risk of subsequent childhood malignancy

6:30

in the children born to them.

6:32

So that to my knowledge, is really one of the few papers

6:34

that actually shows that there really is no

6:37

definitive increased instance.

6:38

But again, very, very controversial topic.

6:40

There are a variety of ways

6:42

to reduce dose if we need to use ct.

6:44

We won't get into the details of that here.

6:47

Um, you may wanna get a medical physicist involved,

6:49

and again, we would get informed consent if we're gonna do

6:51

any kind of CT in a pregnant patient.

6:54

And that's our institutional policy.

6:56

And you may have similar policies as well in terms of MRI.

6:59

MRI's been used well over 20 years without any

7:02

known adverse effects.

7:03

If non-contrast imaging is used at, uh, sort of standard,

7:07

uh, field strengths.

7:09

Um, again, we get informed consent.

7:12

We typically don't go to three Tesla or greater,

7:15

but there is some debate about that now,

7:16

and there is some thought that three Tesla may be okay.

7:19

We wouldn't go greater than that.

7:21

Another paper from that group I mentioned,

7:23

Ontario province showed again in a cohort group of women

7:26

who had MR in pregnancy versus a larger group who didn't,

7:29

again, no definitive adverse effects

7:31

to the fetuses in a fairly long period

7:34

of subsequent observation.

7:36

But these are the kinds of exams

7:37

where I think ideally you want to be hands-on.

7:40

You don't want to just sort of have it done

7:42

and then you need to look at it.

7:43

You want to be monitoring things if at all possible.

7:45

You want to be giving input and again, getting consent.

7:48

What about gadolinium?

7:49

Well, there is animal, um, model data, rodent data

7:54

that there is, uh, a risk of teratogenicity

7:56

that's at much higher concentrations.

7:59

Um, to my knowledge, there is no conclusive adverse, uh,

8:02

effect evidence with IV gadolinium administration in human

8:05

fetuses either, um, purposefully given

8:08

or when a mother had gadolinium

8:10

and wasn't known that she was pregnant.

8:12

These are based on some fairly small series.

8:15

Again, that group in Ontario province, uh, eight years ago,

8:18

uh, presented some data that is really very controversial,

8:22

uh, showing supposedly increased incidents of rheumatologic

8:25

and can conditions and exposed fetuses.

8:27

But that data has not been reproduced

8:29

and again, remains controversial.

8:31

So, uh, per, you know, a CR guidelines, we, uh,

8:34

use gadolinium very,

8:35

very selectively on a case by case basis.

8:38

For example, if the mother has a malignancy

8:40

and really, truly need to, to give it, uh,

8:42

but essentially almost never give it, um, in the scenarios

8:46

that we'll be discussing today.

8:47

So in general, allow a principle in this scenario is if we

8:52

can use any imaging that does not require izing radiation,

8:56

again, sonography typically first,

8:59

although we may not get an answer, MRI second,

9:01

that is the typical kind of algorithm that is used.

9:06

Um, we consider societal guidelines.

9:08

Of course, there are gonna be individual radiologists,

9:11

preferences, clinician preferences,

9:14

institutional preferences, et cetera.

9:16

Um, and you can imagine, um, very difficult to do any kind

9:20

of prospective research in this area.

9:22

Getting the IRB through, um, when you're dealing

9:25

with pregnant women is not an easy thing to do.

9:28

Um, eight years ago we published a,

9:30

a study looking at a survey of a relatively modest number

9:34

of, uh, academicians in, in the US looking at, uh, areas

9:39

where there was consensus

9:40

and also areas where there was emerging consensus

9:43

and no consensus when imaging was done in the acute ab

9:46

and pelvis in pregnant patients.

9:47

So again, not a big surprise

9:49

that there was consensus on doing flying things like getting

9:52

informed consent, having policies,

9:55

avoiding CT if at all possible,

9:56

or modifying CT if necessary, avoiding gadolinium

9:59

and using again ultrasound, um, if at all possible ct,

10:03

again, mostly in the trauma scenario,

10:05

there wasn't consensus at that point on using MR

10:08

after ultrasound for appendicitis.

10:10

Again, that's a whole big topic

10:12

we're not gonna get into today.

10:13

In the interest of time, it's just too big a topic.

10:15

I think now there's much more consensus.

10:17

It's a fairly standard thing to do.

10:19

So now let's go ahead

10:21

and dive into the different kinds of diagnoses.

10:23

Certainly in terms of alternative diagnosis,

10:25

if the concern is appendicitis, we know that, you know, any

10:28

of the cross central imaging, uh,

10:30

modalities can show us things other than

10:33

what we are specifically clinically suspecting.

10:35

So here's an example of a tors dermoid in pregnancy, and Mr.

10:40

A host of things can be seen, um, especially on ct,

10:43

which again, we are typically avoiding or MRI

10:45

because of it's more broad cross-sectional

10:48

ability to show us things.

10:49

Ultrasound may have substantial limitations,

10:51

especially later on in gestation.

10:53

But ultrasound can certainly show us a host of things both

10:56

related to, uh, ovarian pathology, gynecologic pathology,

11:00

GU pathology, et cetera.

11:01

And this has been known for many years,

11:03

and again, no surprise to any of us who do any sort

11:05

of cross-sectional imaging of the AB and pelvis.

11:08

So here are some earlier papers,

11:10

the first one from a colleague of mine in Rome,

11:12

Gabrielle Elli, small number of patients,

11:15

but again, no surprise

11:16

that MR had greater utility in the ultrasound

11:19

and pregnancy for patients with acute abdominal pelvic pain.

11:23

Broad spectrum of things we're seeing, as you can see here,

11:26

appendicitis in a small number

11:27

and then a host of different diagnoses, none

11:29

of which really could have been specifically suspected based

11:32

on clinical labs alone in, in most scenarios.

11:35

Um, Otto at the University of Texas, um, a little bit

11:38

of a bigger series again, showed a a host of other things,

11:42

uh, some able

11:43

to be managed conservatively appendicitis in a small number,

11:46

um, in a group of women undergoing MR of the AB

11:49

and pelvis with pain and pregnancy.

11:52

So briefly, ovarian torsion.

11:53

Again, we're mostly gonna talk about non gynecologic, non,

11:56

um, pregnancy specific things here.

11:59

But certainly there are a host of scenarios

12:01

where you can have, um, ovarian torsion in the setting

12:04

of being pregnant, having a, uh, cyst that is incited

12:08

by pregnancy or if you're trying to get pregnant,

12:11

having torsion in that scenario.

12:13

And, you know, in general, it, it's certainly well known

12:16

that there can be value in doing Mr

12:19

after an initially equivocal ultra center.

12:21

Vice versa, when it comes to, are we in fact dealing

12:23

with ovarian torsion

12:24

and are we gonna be sending a woman to, um,

12:28

to surgery whether she's pregnant or not?

12:30

And certainly in pregnancy in general,

12:32

if you're gonna doing any sort of operation,

12:34

the risks are obviously a lot higher

12:35

because you were dealing with two patients in this scenario,

12:37

both the mother and the fetus.

12:39

So I think this particular case has a bit challenging,

12:42

really not that impressive when you first look at it.

12:44

It is a fairly small cyst,

12:46

actually had been smaller compared with a prior ultrasound

12:49

that I haven't shown you here.

12:50

But notice the right image shows, uh, some small follicles,

12:53

peripheral, um, and this patient was in severe pain.

12:56

There's some adjacent fluid as we see on the left.

12:59

And in fact, this is proven, uh, right ovarian torsion, um,

13:03

in the setting of pregnancy.

13:05

This patient was 22 weeks pregnant.

13:06

You can see the fetus here clearly in the center

13:08

of the image, um, this patient.

13:11

And there are also other scenarios such as early gestation

13:14

that's not in the right place.

13:15

This is, uh, I think a fairly straightforward example

13:18

of ectopic pregnancy on ultrasound.

13:20

There's a, we don't like to use the term anymore,

13:22

but the sort of what used

13:23

to be called the pseudo gestational sac, um, on the left,

13:26

not, uh, evidence of a definitive int EU gestation.

13:30

And then we have a complex process in the

13:32

right ovary shown on the right.

13:33

And then we have complex free fluid.

13:35

So I think we would pretty be pretty comfortable in the

13:38

setting of a known pregnancy here

13:39

to call this an ectopic, but an MR was done.

13:41

So it gives an ex nice example of, of seeing this.

13:45

I was actually, um, called in to help consult on this.

13:48

This case was from some years ago.

13:50

And we see here a, uh,

13:52

abnormal process in the right eye necks,

13:53

almost like a swirl sign, if you will,

13:55

but it's, it's not torsion, it's actually an ectopic,

13:57

and there's extensive free fluid all over the place.

14:00

And this was an actively bleeding ly ectopic at surgery.

14:05

I said, you know, absolutely send this

14:06

patient immediately to surgery.

14:07

And that was what was done.

14:09

So let's dive in and talk about, uh,

14:11

some specific scenarios here.

14:12

The first is UIs.

14:14

And this goes hand in hand with urinary tract infection.

14:16

It's actually the most common non obstetric reason

14:19

for hospitalizing a pregnant patient, um, uh, in general.

14:24

And so no big surprise if we've ever seen, um,

14:28

third trimester women

14:29

and undone, uh, urinary tractography on them.

14:32

Very commonly, we're gonna have right side

14:34

or, uh, uh, relatively frequently bilateral quote,

14:38

hydronephrosis of pregnancy.

14:39

And the stasis leads to calculi and infection.

14:43

And there are a host of problems, as you can see on

14:45

that lower bolt in terms of risk to the fetus, um, if either

14:48

of those are occurring,

14:49

especially if there's concurrent infection

14:52

and ultrasound for years.

14:53

And the a CR certainly considers this, the initial exam,

14:56

it has major limitations.

14:58

It's what we do, but I think even more so than appendicitis,

15:01

and again, especially in later stages of gestation.

15:04

And, and the problem is really more complex than that

15:07

of the limitations of ultrasound for appendicitis.

15:10

We see this hydro pregnancy, uh,

15:13

typically starts somewhat in the second trimester.

15:15

It's very, very common

15:17

and very difficult to sort out, are we dealing with just

15:19

that or is there lysis?

15:22

Um, and MR has a role,

15:24

but it's, it's not used as much as it is an appendicitis

15:27

and it has more substantive limitations.

15:30

So here's a relatively recent study outta Kaiser Permanente.

15:33

I was a little bit surprised by the data in terms

15:35

of only a very small number of this large group of women

15:39

who had suspected neurolysis in pregnancy, who under NMR,

15:43

um, a bit surprised by the relatively high number

15:46

of radiography here, zero under one ct.

15:49

Again, I think it has a tertiary role if you use a low

15:52

radiation dose, and we'll talk about that.

15:54

And then, um, ultrasound three quarters under one ultrasound

15:57

and a small percentage under one interventions.

16:00

So the earlier literature talked about the vast majority

16:04

of these spontaneously passing in pregnancy,

16:07

be happy ureteral calculus,

16:08

but in fact, somewhat more recent data

16:10

showed that's not the case.

16:12

Uh, and again, this can be difficult to diagnose clinically,

16:15

and again, can occur in the setting of an

16:17

of infection as well.

16:19

And then we try to do maneuvers at sonography,

16:22

including looking for ureteral jets

16:24

and looking at resistive indices of the intrarenal vessels.

16:27

And they help a bit. But unfortunately,

16:30

the more recent literature compared

16:32

with these two older studies that I've shown here,

16:35

the data is just not as good.

16:37

It's just not as good. It helps,

16:38

but it's not, it's really not great.

16:40

So if you have hydron pregnancy in general,

16:44

you shouldn't have an elevated resistive index.

16:46

You shouldn't have a absence of a ureteral jet,

16:49

but it's really variable.

16:51

Ron Wabo years ago showed

16:53

that you can have false positives if you're not, um,

16:56

shifting the, the, the woman's position to try

16:58

to reduce false positives.

17:00

Again, the pressure of the uterus later on in gestation in

17:03

particular, can, can lead to false positives

17:04

and especially if you have a under hydrated patient.

17:07

Now, I don't think most people are are

17:09

specifically doing transvaginal sonography

17:12

to detect ureteral capital eye.

17:13

But data from years ago from the Brigham from Phang showed

17:16

that in fact does improve accuracy.

17:18

So something to think about if you're not seeing a ureteral

17:21

calculus and suspecting on percutaneous, um,

17:24

abdominal pelvic sonography.

17:26

So here's an example where if they all

17:28

look like this, it would be easy.

17:29

This is a 37-year-old right flank

17:32

pain, right lower quadrant pain.

17:33

She's in her third trimester.

17:34

We have hydro necrosis,

17:35

but we have a, a symmetry in the resistive index.

17:38

It's elevated in the right compared with the left boom,

17:42

there's our ureteral calculus

17:43

at the ureteral vesical junction.

17:45

That's easy. This is absolutely an outlier in my experience.

17:48

You know, I've done done, you know, many, many

17:50

of these exams over the years.

17:51

We have a busy obstetrical service at my institution,

17:54

ureteral jet on the left, absent on the right, boom,

17:56

this is a slam dunk.

17:58

Again, this is the exception, not the rule.

18:01

In contrast, here's sort of a more typical thing.

18:03

We have hydronephrosis, third trimester suspected calculus.

18:06

We just did not see it.

18:09

Few months later, after delivery notice the postpartum

18:12

changes in the left, uh, lower image there,

18:14

some residual blood in the endometrial cavity.

18:16

There's actually a calculate on the other side.

18:19

There's major hydro nephrosis and hydro ureter on the right.

18:21

And there is a fairly large distal left

18:24

ureteral calculus shown here.

18:27

So, um, yes, again, adding resistive indices, adding

18:32

the assessment of rural jets helps, but it, it isn't great.

18:36

And here's some additional, uh,

18:37

papers from the urology literature,

18:39

from the obstetrics literature showing, you know,

18:42

there is some utility, we'll do it, but it isn't great.

18:47

Here's a paper we never actually wrote up,

18:49

but we presented it at an emergency, um, medicine meeting,

18:53

actually the major emergency medicine meeting in the us.

18:56

But I think this data is still representative.

18:58

We would repeat this today,

18:59

we probably wouldn't do much better, quite honestly.

19:02

Um, as you can see here, you know, relatively small number

19:06

of women, 77 suspected neurosis, total

19:10

of 84 pregnancies over a five year period.

19:12

And we could only definitively find three ureteral calculi.

19:17

We could only find three alternative

19:19

diagnosis pylon nephrosis.

19:21

And so a very small percentage of these pregnant patients,

19:24

we could actually definitively show either u lysis

19:28

or an alternative diagnosis based on percutaneous ultrasound

19:32

limitations was a retrospective study.

19:35

We didn't have a great reference, uh, standard,

19:37

and we didn't have consistent use

19:38

of reive Ines in ureteral jets.

19:41

So what about MRI?

19:43

Well, again, earlier on MR is supposed to be really good,

19:47

but every time I look at the literature,

19:48

there isn't even a moderately sized series to show

19:52

how good or not good it is.

19:53

And it's inherently limited for a variety of reasons.

19:56

Now, one very helpful thing I think, is

19:58

that John Spencer in the UK years ago showed

20:01

that the hydro pregnancy really should

20:03

taper at the mid ureter.

20:04

So if it's, you know, spasm related to, um, infection,

20:08

or in particular if there's a ureteral calculus

20:11

or recently past calculus, um, they're typical dis distally.

20:14

Not always, but if you have, um,

20:16

hydroureter going all the way down, then

20:18

that is much more consistent with those processes opposed

20:22

to the hydro pregnancy.

20:23

Additionally, you shouldn't have perinephric edema,

20:25

you shouldn't have renal enlargement, you shouldn't have,

20:27

you know, peral edema, et cetera.

20:29

The things that we look for on CT all the time

20:32

and non-pregnant individuals.

20:34

So what do we do if we're gonna use MR or MRU?

20:38

Again, non-contrast.

20:39

The problem is, again, we're not using contrast.

20:41

Um, in contrast to appendicitis,

20:43

there are really substantial limitations.

20:45

Capital, even as big as a centimeter,

20:47

we're not necessarily gonna see.

20:49

And another pitfall is that there can be flow artifacts,

20:53

as I'll show in the proximal ureter

20:55

that are created on T two weighted fain echo sequences.

20:59

So we really wanna use, uh, balanced,

21:02

steady state free procession sequences in this situation

21:05

and look very carefully

21:06

and make sure that we're not being faked out.

21:09

So here is a woman

21:10

who we really thought was gonna have a ureteral calculus.

21:13

There was a history of her oph thigh, so she had pain,

21:17

and the images really seemed to show

21:21

that there was a ureteral calculus proximally,

21:23

but it was only on the single shot fast menal images,

21:26

which the arrows point to in the center.

21:28

Whereas the images, um, on the bottom

21:30

and the towards the right, those are the fiesta images,

21:35

and those do not show a filling defect.

21:37

So this is more consistent with a fake out flow artifact.

21:40

And in fact, the subsequent, um,

21:43

nephros gram did not show a ureteral calculus.

21:46

In contrast, this patient has a

21:49

apparent filling defect on both the single shot as echo

21:52

and the fiesta axial images.

21:54

So this is more consistent with a ureteral calculus.

21:58

Also, notice there is some right perinephric edema,

22:00

and there's some right renal swelling.

22:02

So this again, goes along with this being

22:04

a true proximal ureteral calculus.

22:06

But again, this can be challenging

22:08

and we don't do this that often, quite honestly.

22:11

Again, other limitations is we don't give gadolinium.

22:15

Um, the exact yield isn't really clear in terms of like,

22:19

are we missing pyelonephritis so that we can see it,

22:22

but again, we can potentially identify it

22:24

and we can also potentially suggest alternative diagnoses.

22:28

As with appendicitis,

22:29

this has become more available over the years.

22:31

We certainly can do at least my institution for years, any

22:34

of these imaging modalities anytime of the day

22:36

or night ultrasound, c tm RI, but it is not as convenient

22:40

and it is more, a bit more expensive.

22:42

Um, here's a case really beautifully, uh, demonstrating on

22:45

that bottom image, a small ureteral calculus distally.

22:49

Again, if they were all this sort

22:51

of beautifully laid out, it would be easy.

22:52

Again, it really didn't add much

22:54

because we already know there's a decent sized distal most

22:58

ral calculus based on the initial

23:00

ultrasound shown on the left.

23:03

Um, this is again, a more typical sort of scenario.

23:06

This is someone who has a little bit of hydro, um,

23:10

didn't see an appendix, we didn't see a calculus,

23:12

but we went on to MR.

23:13

And so this I think was helpful

23:15

because we have renal swelling, we have perinephric edema.

23:19

Notice the hydro ureter goes fairly distally.

23:23

So this goes along with either a calculus, we're not,

23:26

we were not able to see an actual calculus anywhere,

23:28

either a small calculus we can see

23:30

or a recently passed calculus, um, as opposed

23:33

to the hydro pregnancy.

23:35

So this was helpful in terms of, you know, going along

23:38

that diagnostic path.

23:39

Also, no evidence for appendicitis.

23:41

It is helpful information to the clinical team.

23:44

What about if we need to do ct?

23:46

Well, there've been a host of papers over the years,

23:48

including some work from our own.

23:49

We did, you know, paper that

23:51

for a citation years ago deal at all where we used, uh,

23:54

high pitch, uh, spiral CT in non-pregnant adults.

23:58

And then there have been a variety of actual and, and,

24:00

and more so stimulated load

24:04

of very low radiation dose, um, models of, of

24:08

lysis in pregnancy.

24:09

So you can go really quite low.

24:11

It's sort of like limbo, you know, how low can you go?

24:13

You can go really quite low.

24:14

And again, the, the issue isn't so much the, the ureteral

24:18

and renal calculates

24:19

or we potentially missing alternative diagnosis.

24:22

And that is the case when we use any kind of imaging

24:26

technique with CT to load that lower the dose, um, in

24:30

that scenario as well in non-pregnant patients.

24:31

So, uh, again, there's not a huge amount of data here.

24:34

There's some data from Vanderbilt white at all.

24:37

Um, was able to, uh, reduce the dose really quite low,

24:41

as you can see, well, well below that number

24:43

that Cynthia McCullough threw out a seven

24:46

milligram a fetal dose.

24:47

So it's really not used very much,

24:50

but I believe it is a potential third line test if you truly

24:54

have to do it.

24:55

And again, the mother has to come first.

24:57

And here's a more recent paper from

24:59

that group in Vanderbilt.

25:01

Again, fairly small number of patients, but no surprise.

25:04

And there were various combinations of ultrasound, CT

25:07

and non-constant contrast MR used here.

25:10

But no surprise, CT using a reference standard of Ute,

25:13

which is actually a pretty good reference standard.

25:15

Um, CT was the most accurate, followed by, um, MRI.

25:19

And then ultrasound last as an older case from Deborah Reed.

25:23

I'm not exactly sure why they gave oral contrast.

25:26

We wouldn't of course do that now,

25:27

but you can see the fetus on

25:28

the sagittal image to the right.

25:30

You can see the small right uretor vesicle, uh,

25:34

junction calculus and the small parametal calculus.

25:37

And you can see the hydro

25:38

and the swelling and that sort of thing.

25:39

So again, every once in a while, if you really have

25:41

to do it, you can use a quite low radiation dose ct.

25:45

Um, if the other modalities just simply don't give you the

25:47

information that you need.

25:50

I mentioned you can, um, make

25:52

or suggest a diagnosis of pyelonephritis on on non-contrast.

25:55

Mr Here's an example of that.

25:57

This was a, uh, four week pregnant patient, seven,

26:00

uh, 37 years old.

26:02

Um, left lower quadrant pain

26:03

and we see a, a swollen left kidney.

26:05

It's a bit heterogeneous, a little bit of perinephric edema,

26:08

and there was no hydro nephrosis hydroureter.

26:10

And the UI was positive for infection.

26:12

Further, uh, establishing the diagnosis.

26:16

So in terms of management, um, there are some, you know,

26:20

key points other than the clinical features.

26:22

One is that, um, absolutely lithotripsy is,

26:26

is, is contraindicated.

26:27

That's just not something that can be done.

26:29

The other general principle is that if direct visualization

26:33

with the scope can be used to extract calculi,

26:36

that's really the test of choice.

26:37

You're in that situation.

26:38

If there's a calculus that's not passing

26:40

with conservative management.

26:42

And, and then if ionizing radiation has to be used,

26:45

it should be used by operators who are very experienced

26:49

to minimize radiation dose exposure.

26:53

Let's talk about tract disease.

26:55

Our next major topic

26:56

and, um, what I learned when I first got involved in this

26:59

project some years ago is that if you have complicated

27:04

calculi, meaning poly dosis, um,

27:08

or especially if it's causing gallstone pancreatitis,

27:11

this is actually a major problem.

27:12

There are, there's good data showing that this is associated

27:15

with substantial morbidity, um,

27:18

and even potentially mortality

27:20

to the fetus and even the mother.

27:22

Um, so you may initially

27:25

manage gallstones conservatively,

27:27

but, um, if there's complications

27:30

that should be really be treated aggressively

27:33

and similar to, you know, non-pregnant adults, it's,

27:35

it's the same kind of algorithm.

27:37

Ultrasound first, MRI as a second line test

27:40

and for giving us additional information in terms of

27:43

procedures, again, if one can get away without ionizing

27:46

radiation, again,

27:48

an experienced operator using a choli doco scope,

27:51

in this case, removing calculi from the common duct.

27:54

Um, if one could also supplement that with endoscopic

27:58

or intraductal ultrasound.

27:59

But if you absolutely have to do ionizing radiation, IE

28:02

or CP, again, it should be someone who really is experienced

28:05

to minimize radiation dose

28:06

and minimize potential complications of the procedure.

28:10

Um, Otto again, uh, at Texas some years ago, um,

28:13

showed the utility in a small number of patients of the role

28:16

of MR compared with either negative

28:18

or equivocal ultrasound in pregnancy when there was an issue

28:22

of bi pen barely tract pathology.

28:24

You can see, um, that Mr.

28:26

MICP showed things like ductal calculi, acholic,

28:29

ductal cyst, and even Marzi syndrome.

28:31

Um, again, no surprise to any of us who deal

28:34

with these modalities and non-pregnant

28:35

individuals on a routine basis.

28:37

Um, ERCP is not a diagnostic test.

28:41

Of course, in this scenario it's purely for therapy.

28:44

Um, and Mr in this scenario, IE non-contrast,

28:48

MR really has a lot of utility.

28:50

There's some other things to be aware of.

28:52

You can have, um,

28:54

hyperlipidemia causing severe pancreatitis in pregnancy,

28:57

which is another potential scenario above,

28:59

beyond just gallstones.

29:01

So here is, you know, typical sort of gallstones, um, sort

29:04

of walk or shadow, sign an ultrasound,

29:06

and you can see early gestation, uh,

29:09

shown on the right in the same patient.

29:12

Patient will say history, history,

29:13

history of gastric bypass.

29:15

And here we have a different pregnant patient

29:17

where the gallbladder is completely filled with calculi.

29:20

No evidence for cholecystitis,

29:22

though no common duck calculus

29:24

and no evidence for associated pancreatitis.

29:31

In contrast, this patient's a lot more complicated.

29:34

We can see that there is on that lower left image, um,

29:38

a common duct that's about a centimeter in diameter.

29:41

We have a gallbladder that is, um, filled with calculi.

29:46

And in fact, if we look carefully, that lower right image on

29:50

with sonography shows the swollen pancreas.

29:53

So I've been a bit surprised.

29:54

You know, it's often very tough to see the pancreas

29:56

and non-pregnant patients,

29:57

but I've seen a few cases

29:59

where we can actually diagnose pancreatitis even in

30:02

pregnancy on the base of sonography alone.

30:04

And then the subsequent MR images

30:06

to the right axial coronal, um, show, uh,

30:10

very nicely the same findings

30:11

and also really quite swollen pancreas, which is why it was

30:14

so evident on, um, sonography, uh, this patient.

30:18

Again, the data points to, uh, being aggressive,

30:21

but this patient was successfully, uh,

30:23

managed conservatively.

30:26

Here's another patient with, um, in this case,

30:28

the gallbladder is fine, but the pancreas is, um, enlarged.

30:31

Patient is right upper quadrant pain.

30:34

And this subsequent MR shows, um, findings

30:37

of interstitial pancreatitis, the swollen pancreas, the,

30:40

um, adjacent edema.

30:42

And you can see the fetus on the bottom

30:45

coronal T two weighted image.

30:48

This is a really sad case, uh, from Deborah Reed, um,

30:53

when she was at long on college hospital some years ago.

30:55

This patient wasn't even initially aware she was pregnant.

30:58

She did have a known history of Hepatitis B, however,

31:02

and initially a sonogram was done, um,

31:06

for right upper quadrant pain.

31:07

And the liver is very heterogeneous with multiple masses.

31:11

The subsequent Mr Middle and right images shows the fetus

31:15

and shows the masses in the liver.

31:17

And these unfortunately ended up being multicentric,

31:19

hepatocellular carcinoma.

31:21

Really a sad case. What about other types

31:25

of bowel pathology?

31:26

Well, again, we're not gonna talk an appendix

31:28

'cause that's a 40, 45 minute lecture, uh,

31:31

a topic for another day.

31:33

Um, but in other kinds of scenarios such

31:36

as suspected bowel obstruction, um, known

31:39

or suspected inflammatory bowel disease, um,

31:42

here a non-contrast, MR protocol is the way to go.

31:46

Now, there's a bit of controversy, um, not exactly my area

31:50

of expertise here, but my take on the literature is that

31:55

the thought is that it's not so much

31:57

that there's an increased risk

31:58

of inflammatory bowel disease, um, exacerbations in terms

32:03

of the number and pregnancy compared

32:05

with the non-pregnant women,

32:06

but that if there is a flare up, the complications of them

32:10

or the severity of them may be greater.

32:12

That, that's sort of my take on the literature

32:13

that's a bit controversial.

32:16

And the, the protocol here is, is is similar to that

32:19

for appendicitis

32:20

and for UIs, it's these, you know, breath held

32:24

or if you can't do breath held, you know, individual, uh,

32:27

acquisitions, uh, images in multiple planes fast,

32:31

two weighted sequences, um, supplement by additional kinds

32:34

of sequences that I've mentioned.

32:36

Without contrast, we're gonna, if at all possible,

32:39

avoid radiography and avoid ct.

32:42

So here's an older case from one my former residents

32:45

who then went on to, uh, work at Cornell.

32:47

BA now is back at NYU.

32:49

And um, this, uh,

32:51

woman has a fairly high grade small valve obstruction.

32:55

You can notice there's a pretty good amount of ascites here.

32:59

And I always teach my my trainees that, um,

33:01

the more ascites you have in the setting

33:03

of a small bowel structure, the more concern I get, it,

33:06

it indicates a substantive peritonitis inflammatory process

33:10

and is, uh, more likely

33:11

to have me push the clinical team to operate.

33:14

Um, in this case, there's no clear etiology.

33:16

It's probably adhesions. It looks like a distal, um, uh,

33:20

obstruction, although there's no clear

33:22

transition zone on these images.

33:23

But you'll notice again, the, the,

33:25

the gestation in the, in the pelvis.

33:27

Here is a example of a woman with known Crohn's disease

33:31

and she had a flare up.

33:33

And again, in this scenario, it's, it's similar to

33:36

what we would do in the ER setting

33:37

for non-pregnant individuals.

33:39

We're not gonna be necessarily doing a

33:42

CT enterography or Mr.

33:43

Enterography program, you know, kind of, uh,

33:46

protocol in this, in this emergence situation,

33:48

we're typically gonna be doing, you know,

33:50

intravenous contrast only, um, CT

33:54

or sometimes MRI, you know,

33:56

we're not gonna have people drinking a thousand ccs

33:59

of neutral entire contrast and waiting around for two hours.

34:01

That's just not ideal. Uh,

34:03

but you can notice here the pretty thickened,

34:05

um, terminal ileum.

34:07

There's some tethering of bowel, um,

34:08

there's some stasis of bowel, et cetera.

34:11

We're just looking for major pathology,

34:13

major complications in this setting.

34:16

This was a really challenging patient.

34:18

This was a, um, 27 week pregnant, 34-year-old who

34:22

actually had a CT pulmonary angiogram.

34:25

First. Those are the images in the middle and left.

34:28

And what was found is this very dilated esophagus

34:31

and very dilated stomach for without,

34:33

without a clear etiology.

34:34

So then an MR was done.

34:37

And, um, this represented image shows substantially

34:40

distended small bowel.

34:41

There was also distension of the right and transverse colon.

34:44

And so she ended up going to the,

34:46

or she had peritoneal signs

34:48

and they found a perforated R colon, but no clear radiology.

34:51

So it's not clear what happened here,

34:53

but the sequence of events was interesting

34:56

and, um, the MR definitely helped, uh,

34:58

to manage the patient.

35:00

Um, the differential small bowel obstruction in pregnancy,

35:03

and it's, it's a bit more common than you might think.

35:05

It's upwards of one in 3000 gestations similar to

35:09

that in non-pregnant individuals, right?

35:10

It's adhesions, hernias, and then some unusual things.

35:14

And so here's a patient with an unusual thing.

35:16

We had an initial sonogram here, um, uh, showing a, a,

35:21

a mass like area,

35:22

and then, uh, an MR was done without contrast.

35:25

And there was an inception here.

35:27

And this small ception is not one

35:30

of those transient inceptions notice.

35:31

It's in the left, uh, mid to lower ab,

35:34

and it's a pretty long segment, uh, of bowels thicken.

35:38

There's edema there.

35:39

Ended up being an underlying stromal tumor associated

35:42

with this inception at surgery.

35:44

Patient did fine. So the latter part of the talk here,

35:48

we're gonna be finishing up talking about trauma

35:51

imaging and pregnancy.

35:53

And, uh, I'll tell you that, um, there've been a variety

35:56

of papers on this topic in the past.

35:58

And we have a, um,

36:00

manuscript in press in the journal radiographics.

36:03

It's gonna be in the October special monograph issue.

36:07

I happened to be one of the three co-editors of that,

36:10

but I did not choose that article to go in there.

36:12

That was cookie men, the editor's choice.

36:15

So just, um, keep an eye out for that if you're interested.

36:18

It's an update of this topic

36:20

and concludes includes all this information and more.

36:24

So, um, you know, this is a, a, a challenging topic

36:27

because, you know, many of you may have, uh,

36:30

busy obstetrical services like we do,

36:32

but thankfully we don't see that much of this.

36:35

But again, when it comes up,

36:37

there are some specific considerations, specific algorithms

36:40

and, and some challenges.

36:43

Um, and it turns out

36:44

that trauma is the leading non obstetric

36:46

cause of maternal death.

36:47

Um, trauma meaning anything from seemingly minor injury

36:52

to major injuries, either intentional

36:55

or sometimes unfortunately,

36:57

non-intentional in a big topic in the last few years has

37:00

been, um, intimate partner violence

37:02

and that includes against pregnant women, is upwards of six

37:06

to 7% during pregnancy.

37:08

So it's actually fairly common, unfortunately.

37:11

Um, and the physiologic changes that occur

37:14

during pregnancy can make it very difficult

37:16

to assess what's going on.

37:18

Things that may be seemingly minor,

37:20

in fact may pose significant risks

37:22

to both the mother and the fetus.

37:24

And so in that last bullet bullet, I've,

37:26

I've listed a whole host of things that can occur

37:29

from both major and minor trauma.

37:32

Um, the incidences in the literature is very variable.

37:34

The incidence of fetal demise is very variable and,

37:37

and a host of things can happen,

37:39

especially in the third trimester.

37:43

Um, and the data suggests that pregnant trauma patients tend

37:48

to be over admitted to the hospital, but surprisingly

37:51

and ironically, under evaluated,

37:53

and there's data showing that in age match controls, that,

37:58

um, the outcomes are, are worse in pregnant compared

38:01

with non-pregnant women with similar types

38:03

of severity of trauma.

38:06

And as I mentioned, there are a host

38:07

of things that can happen.

38:09

Um, there can be injury to the uterus, injury

38:11

to the fetus itself, injury to the placenta,

38:14

or some combination.

38:16

And again, this is most, um, significant,

38:19

particularly in the third trimester where there can be

38:22

spontaneous abortion, preterm labor, PROM, abruptions

38:27

lacerations, et cetera.

38:29

Um, and there is a bit of

38:33

increase in maternal organ protection.

38:34

But the injury rates in general, the data shows

38:37

that the injuries go up with penetrating trauma.

38:40

No surprise, I guess the bigger the fetus is

38:43

later on in gestation.

38:45

And so the group at, uh, Washington St.

38:48

Louis, Costa Aptis, who's, um,

38:50

this really wonderful article in Radiographics from 10 years

38:54

ago, uh, on imaging of, of trauma

38:56

and pregnancy, you know, pointed to the need

38:58

for accurate and rapid imaging.

39:00

And this is one scenario where we really are not

39:03

as concerned about the ion radiation.

39:05

We definitely much more liberal with going

39:08

to CT a varying various body parts as necessary.

39:12

And especially if the pregnant patient has a decreased, um,

39:16

you know, mental status, it makes life very difficult

39:18

to assess them clinically.

39:20

We're not gonna get into radiography.

39:22

It really doesn't have a major role at this point.

39:24

So ultrasound certainly has a role for rapid patient triage,

39:28

typically done at the bedside in the er, uh, done

39:32

by a variety of professionals, typically not radiologists,

39:35

but sometimes, and a variety of things can be done.

39:38

Obviously the fetus can be assessed directly.

39:40

Um, you can do a fast exam just like a non-pregnant

39:44

patients, um, et cetera.

39:46

And so the, the data on this mostly comes out

39:51

of uc, San Diego.

39:52

These two bullets in the third

39:54

and fourth slide are, are papers from, um, an older one,

39:58

a more recent one from uc, San Diego,

40:00

showing even though the yield is really not very high, um,

40:04

the data is reasonably good,

40:06

but again, you need to have a, a pretty good amount

40:08

of experience to do this.

40:10

So a couple of cases, uh, contributed

40:13

by my, my colleague, Dr.

40:14

Maria Scone from, um, Southern Italy.

40:17

Um, again, these cases, thankfully don't, in terms

40:20

of positivity imaging, they don't come up that often.

40:22

So this is a 20 year, year old.

40:24

Um, this was an unintentional fall downstairs,

40:27

she's 12 weeks pregnant.

40:28

And we see, um, a unilateral peri, uh,

40:31

renal hematoma was managed conservatively.

40:34

We see the fetus on the right.

40:37

Um, so certainly there is a role for initially looking

40:40

for injuries with sonography.

40:41

Now, in terms of the placea and abruption, um, whether early

40:46

or, uh, typically later on, this is

40:49

where ultrasound really has major limitations.

40:52

This had been known by obstetrical sonographers for years.

40:56

Um, it's really just not a great test.

40:59

So here's a paper for Priyanka Ja,

41:01

from a few years ago when she was at uc, um, Irvine,

41:06

and it's, you know, a small study, it's retrospective.

41:09

There were a lot of biases,

41:11

but I think it, it shows even then

41:14

how limited sonography was really just was a terrible test.

41:18

They looked at 27 patients.

41:20

Um, two radiologists retrospectively looked at these women

41:23

who had both CT and ultrasound.

41:25

There were three complete and, and a partial abruptions.

41:27

And CT was very sensitive.

41:29

But the reason it wasn't that specific is

41:32

because later in gestation, there are a, a host

41:34

of false positives

41:35

and everything from marginal sinus to co leadin

41:39

to age-related infarcts, which become greater

41:41

as the placenta ages become problematic.

41:45

Now, one important teaching point to keep in mind is that,

41:47

you know, you might think, well, female pelvis,

41:50

we often see a little bit of free fluid,

41:52

especially if someone's being, you know, fluid resuscitated

41:55

in the asymptomatic pregnant patient.

41:58

There really shouldn't be any free fluid.

41:59

So, um, it, it, it,

42:02

and especially if there's fluid elsewhere,

42:04

but even in the pelvis, it, it is a bit of a red flag.

42:07

So keep that in mind.

42:09

Um, and of course, like with all these modalities,

42:11

but especially sonography, um, as

42:14

with the other situations we've discussed, um,

42:17

in the third trimester, it just becomes more problematic.

42:19

So if the sonogram is negative

42:22

and there's clinical suspicion, the mechanism is there.

42:24

What do you do? Do you do an immediate ct?

42:26

Really is a clinical call. It's not our call.

42:29

Do, do MR, we'll talk about that.

42:30

If you do ct, how low do you reduce the dose

42:34

or you exclude the pelvis.

42:35

An interesting pap paper from uc, Davis, Mike Corwin at all,

42:39

where they did an exercise where they actually had done CT

42:43

of the FLAMIN pelvis, but they said,

42:45

what if we had excluded it

42:46

to not irradiate the fetus and trauma?

42:49

What would we have missed? And it was only a small

42:51

number of injuries, believe it or not.

42:52

But again, it's obviously gonna depend on mechanism

42:54

and clinical exam, et cetera.

42:56

So it's been known for, for years

42:58

that you can actually see not only placental uterine,

43:02

but even fetal injuries, um, on CT directly.

43:06

It's actually a pretty good test,

43:07

although you really, you know, these come up

43:09

so infrequently, you really need

43:11

to be comfortable looking at them,

43:12

especially for the placenta.

43:15

So, um, associations no surprise in the late throw trimester

43:20

of fetal skull fractures with maternal pelvic fractures.

43:24

Um, but similar to what we've already talked about with,

43:27

with the abruptions, it, it, it, if there is an abruption

43:31

and you're, you've just not seen many of these, it,

43:33

it really can be difficult to appreciate them.

43:37

Um, in terms of protocols, this is one situation where,

43:41

again, we're not gonna shy away from CT if appropriate,

43:43

but we're not gonna do multiple passes.

43:45

We're not gonna do multiple phases, um,

43:48

especially the fetuses in the field of view.

43:50

We're gonna want to be hands on if at all possible,

43:52

but we're not gonna want to use ultra low

43:54

radiation dose protocols.

43:55

We want to have diagnostic quality scans.

43:57

Now, going back to the issue of placental injury,

44:01

which is a key thing to recognize.

44:04

Again, no offense to the folks in Maricopa County in

44:07

Phoenix, but this is the largest series to date.

44:10

It's 10 years old, but the

44:13

largest series, there are two papers.

44:14

It's from the same group. Largest series of papers

44:17

to my knowledge, comes out of that, that in, you know,

44:19

in the Phoenix area.

44:21

And it was a very high yield.

44:23

It was, I mean, I'm laughing, but it's not funny,

44:25

but it, it's just, there,

44:27

there was 35% incidence of abruption.

44:30

That's a really high incidence.

44:32

And I, I, I don't know, uh,

44:34

hopefully it wasn't the women who were driving fast.

44:36

It was the, they were just unfortunate,

44:38

you know, victims of these.

44:39

But, um, uh, mostly motor vehicular collisions.

44:42

But no surprise if there was more than

44:45

50% placental abruption.

44:47

And I should say that the quantification

44:50

of the placental injury was not used

44:52

to prospectively manage the patient.

44:53

This was a retrospective analysis.

44:56

It correlated substantially, significantly

44:58

with the need for emergency delivery.

44:59

And then again, no surprises.

45:01

The, if the placenta was devascularized by more than 70%,

45:04

75% or more n CT retrospect,

45:06

that correlated most substantially

45:09

with the need for emergency delivery.

45:10

So that's the biggest series of my, uh,

45:13

of its kind, you know, to my nature.

45:14

But again, most folks are not seeing that level of,

45:17

you know, injuries on a routine basis.

45:19

Other considerations, the maternal bladder

45:21

and the, uh, enlarged kidneys

45:23

and pregnancy filtering more urine,

45:26

they get physiologically bigger, especially in,

45:28

in gestation, a more susceptible injury.

45:30

The enlarged uterus displaces liver

45:33

and spleen against ribs, making them

45:34

more susceptible to injury.

45:36

The vascular retroperitoneum is more susceptible to injury.

45:39

And then against, I mentioned,

45:40

the pelvic fracture associated with substantial, uh,

45:43

morbidity mortality to the fetus.

45:45

Here's an example from my institution a few years ago about

45:47

normal ultrasound of the fetus in the setting

45:50

of trauma, motor collision.

45:52

Everything looked fine. Here's an example of a normal,

45:57

um, third trimester, uh, placenta notice a bit, uh,

46:01

heterogeneous, but it, it is vascularized.

46:03

There's no abruption, there's no bleed,

46:05

there's no discontinuity.

46:07

Um, uh,

46:09

after motor vehicle collision, it's anteriorly located.

46:12

Um, two cases separate patients, uh, pregnant

46:15

after motor vehicle collision, able

46:16

to be managed conservatively with hep paddock on the left

46:19

and splenic on the right injuries.

46:23

This is a very sad case from my institution about 10 years

46:26

ago, um, the obstetricians knew that the

46:31

fetus, um, was not doing well.

46:32

There were no fetal doone.

46:34

Um, notice the substantial hepatic laceration centrally

46:39

on the right, in the right lobe.

46:41

There's peri hepatic hematoma there.

46:44

You can see the image to our right shows a, uh, jet

46:47

of active bleeding coming out of a, uh, placenta

46:51

that just looks like it was sheared in half.

46:54

It's abrupted. There's a large area

46:55

of hemorrhage coming out of it.

46:57

Um, this is not a good situation.

46:59

So this, uh, woman was taken to the,

47:03

or unfortunately, the emergency c-section was notable

47:06

to save the fetus, but the mother did survive.

47:09

Here's a case from Washington St.

47:11

Louis Mallinckrodt, um,

47:12

from Cookie Mens when she was there in Vinnie Melnick.

47:14

And sometimes when things are so abnormal

47:18

that if you don't know what normal looks like, it's hard

47:20

to appreciate that the whole thing is abnormal.

47:22

And this is an example of that.

47:24

So this entire placenta is not enhancing,

47:28

it's completely revitalized.

47:29

It's, it devascularized.

47:30

There's no enhancement at all,

47:32

and there's blood extending into the vagina.

47:34

And lower amniotic cavity in this fetus did not make it.

47:37

As you might imagine. This was after major trauma.

47:39

Um, we did a paper a few years ago in abdominal radiology

47:43

on, um, uterine disruption in various scenarios.

47:47

This was someone with risk factors, history

47:49

of prior C-section and placenta accreta.

47:51

These are some, um, multiplanar reformats showing,

47:55

um, active bleeding.

47:57

This was follow blunt trauma, 36-year-old.

48:00

Um, and there's indistinct margins and, and,

48:04

and big areas of active hemorrhage as to show an example of,

48:07

um, the uterus that, uh, can be bleeding in this scenario

48:11

as well, uh, with, with blood all over the place.

48:16

Um, we mentioned intimate partner violence.

48:18

This is a case from my friend

48:19

and colleague Otto, who's chair at bu, uh,

48:22

from some years ago.

48:23

And this was an example where you might want

48:25

to consider using a double or triple contrast high protocol.

48:28

In this case it was double contrast protocol,

48:30

intravenous contrast and rectal contrast.

48:33

And there was no, um, colonic injury.

48:36

But you can see the flank injury here.

48:39

Um, this woman was stabbed by her partner,

48:42

and you can see the pregnancy here.

48:46

So there's no large scale study, to my knowledge,

48:48

supporting the use of ct.

48:50

Um, there's really no great data on this with

48:53

or without initial ultrasound.

48:54

And I keep looking every time I update this talk.

48:56

There's really no literature at all supporting the routine

48:59

use of abdominal pelvic mr, uh, in lieu of CT

49:02

or to supplement ct.

49:03

It's more kind of used very selectively on a, you know,

49:07

just sort of a logical basis without great data.

49:10

Um, in this scenario, in the trauma setting,

49:13

it's even more challenging to do r compared with say,

49:15

in suspected appendicitis or UIs or Billy tract disease.

49:19

But 10 years ago, and,

49:21

and again, we're gonna revisit this in

49:22

that paper coming out in a few months,

49:24

Raus proposed the following things based on the literature

49:27

and their experience at WashU St.

49:28

Louis Mallincrodt after initial ct,

49:31

if there's new clinical concerns or new signs

49:34

and symptoms to reduce further radiation exposure

49:36

to assess soft tissue injuries, known

49:38

or suspected to, of course,

49:40

this ima image any suspected spinal injuries

49:42

and also others have proposed to age BCE infarcts, um,

49:47

in the setting of, uh, you know,

49:49

other kinds of scenarios as well.

49:51

And again, we're using rapid non-contrast breath hold

49:54

sequences as our mainstay here.

49:55

So here's a patient from my institution a few years ago,

49:57

notice a little bit of a hydro pregnancy, her on the right,

50:00

um, that she was, uh, 24 weeks pregnant, 24 years of age.

50:05

She had, uh, some pain falling in her vehicle collision,

50:07

refused CT system.

50:08

I don't want a ct. She was stable.

50:10

We said, okay, we'll do a non mr.

50:13

And it was completely negative

50:14

and we were comfortable with calling that, you know,

50:16

negative and not doing anything else.

50:18

And here's a case from, uh, Mary SC Leon

50:20

and colleagues in Italy where, uh,

50:22

there was motor vehicle collision,

50:24

first trimester pregnancy.

50:25

And we can see there's everything from a right pleural

50:28

effusion to perio, uh, fluid to flank, uh, injury

50:34

when the mother is stabilized.

50:36

A, uh, we've already talked about sonography.

50:38

Um, uh, more formal ultrasound can be done to assess the,

50:41

you know, the fetus heart rate,

50:43

the placenta gestational age.

50:45

There should be continuous, uh, fetal electronic monitoring.

50:48

And mothers in the third trimester, if possible,

50:50

could be put in the left cubitus position.

50:52

Um, final couple of cases,

50:55

a case from Mario Scag Leone from Italy, a trauma patient.

50:58

And, um, there's saal injuries

51:01

and there's, uh, some fluid here and various compartments.

51:03

But notice you look really carefully here.

51:05

There's a roundish appearance to the endometrial cavity

51:09

because this patient is pregnant,

51:10

was not previously known to be pregnant.

51:12

And you can imagine we're not necessarily doing, uh,

51:15

pregnancy testing in the emergence setting

51:17

as someone who's in a, in a vehicle collision.

51:18

So, um, it, it occasionally comes up where,

51:22

and this was the situation here, that you may have someone

51:25

who you've radiated who didn't know she was pregnant.

51:28

Um, there's been some discussion in the obstetrical

51:32

literature about the need to collaborate

51:33

amongst various specialties

51:34

to integrate the fetal trauma survey

51:36

with the A TLS protocol.

51:38

So in conclusion,

51:40

and we have finished with a few minutes of questions,

51:42

which was left for questions, which was the goal.

51:45

Um, if we can obtain accurate imaging, get an answer, one

51:49

or the other without ionizing radiation, a pregnant one

51:52

with abdominal pelvic pain ultrasound

51:54

and the ni Mars typical protocol, that's great.

51:57

If we do need to go to ct,

51:59

we should use a low radiation dose,

52:01

but not so though that we don't get an answer.

52:04

And if we occasionally have a scenario like this,

52:06

another patient where if you look really carefully,

52:09

there is a bit of a roundish configuration

52:11

to the endometrial cavity here,

52:12

and there's a sort of a striped appearance of the uterus,

52:15

there's actually a fairly typical appearance

52:18

and we don't see it that often

52:19

'cause we don't wanna see it of a early uterus

52:22

and early intruding gestation on ct.

52:25

Then if we end up rating the woman

52:27

that we didn't know was pregnant,

52:28

then hopefully if we use the lateral principles,

52:30

then we have minimized the radiation exposure.

52:33

Um, there's risk of doing things

52:35

and risk of not doing things,

52:37

and there's still the need to educate

52:38

our clinical colleagues.

52:39

And I, I hate the word clinicians, I have it here,

52:41

but I mean, I consider myself a clinician.

52:45

Um, I work with our internal medicine colleagues

52:48

and our surgeons all the time,

52:49

and I, I'm embedded in the er, um, I, I'm kind

52:52

of their eyes and their ears.

52:54

So I, I think we are absolutely clinicians,

52:56

but we'll call it our, our other clinical colleagues still

52:58

need to be, uh, educated as to the role of these tests

53:02

and what they do and what they don't do.

53:03

And there are still a lot of misinformation

53:05

and misperceptions, and I really like this quote.

53:07

It's a, it's a bit old now from, um, the Journal

53:10

of Endourology, and I'll read it.

53:13

It says, inaccurate MR

53:14

or delayed diagnosis may represent a more significant risk

53:16

to the patient, IE the fetus

53:18

and the mother than the radiation risk.

53:19

And I think that absolutely is still the case.

53:22

Some more recent references, Abigail Stanley,

53:24

who was a medical student of ours,

53:26

actually went into emergency medicine, not radiology.

53:29

We did an Mr Clinics article two years ago on imaging the

53:32

acute ab and pelvis in pregnancy, uh, with MRI.

53:35

Um, that paper on imaging uterine, uh, rupture, uh, is there

53:39

and some additional papers that are in

53:41

the more recent literature.

53:42

And here's my little guy from a few years ago.

53:44

He is again, he is now eight.

53:46

And again, thank you for your attention.

53:48

Some additional images, some appendicitis

53:50

cases as well here.

53:52

Um, it's, it's an honor to be able

53:54

to present everybody at noon conference for those

53:56

who are here live and those

53:57

who are gonna be watching this, uh, down the road.

53:59

So at this point, I'm happy we have, um,

54:01

about six minutes for questions.

54:03

Happy to, to answer any questions regarding this topic,

54:05

which I think is still a, a challenging case.

54:08

Again, often when, uh, these cases come up, there's, uh,

54:12

the tendency, even as an experienced radiologist say, God,

54:14

I hope someone else will take it.

54:16

You know, now at, at my institution,

54:17

we have a distributor system.

54:19

So now you have to sort of beg, plea, and plead

54:21

and borrow to get someone else to take a case

54:23

that is assigned to you if it's something that really is

54:26

outside of your area of, of comfort.

54:31

Dr. Katz, thank you so much for that awesome lecture.

54:33

Really appreciate it.

54:34

And yes, we will open the floor to questions.

54:38

Got a couple in the q and a box already.

54:40

So we will start with is free procession,

54:45

steady state contraindicated for pregnancy? In pregnancy?

54:49

Excuse me. No, no, no, it's not, it's not.

54:51

Again, I'm not an, you know, I, the joke is I'm not an Mr.

54:54

Physicist, but I play one on tv, so no,

54:56

I, I, I've dabbled in it.

54:57

I like doing things that are outta my comfort zone.

55:00

So we, we've written a variety.

55:01

I've co-written a variety of medical physics papers over the

55:04

years, and, but I'm absolutely not a medical physicist.

55:07

So to my knowledge, it's not, um, contraindicated.

55:09

We do, again, wanna minimize the number of sequences.

55:13

We wanna minimize the sar, right? Um, but it's safe.

55:18

We do it routinely.

55:19

I don't believe there's a problem with that.

55:21

I think the broader issues are the overall time

55:24

that the patient's in the magnet and the field strength

55:26

and in a particular kind of sequence.

55:28

But again, I'm, the caveat is I'm not an phys,

55:31

but I think it's, I think it's okay

55:32

to do those sequences. How

55:35

Do you differentiate between real hydrosis

55:38

and dilation related to uterine pressure?

55:41

Yeah, so again, this is,

55:43

and unfortunately he's no longer alive, unfortunately,

55:45

John Spencer, he, he died in an early age,

55:47

but he wrote that paper some, you know,

55:49

20 something years ago.

55:51

Um, showing in a small number of women based on Mr.

55:54

And Urography, that the hydro quote unquote, a pregnancy

55:58

that we sort of see all the time.

56:00

It, it typically tapers at the level of the mid ureter,

56:03

meaning that in the later second, uh, trimester in,

56:08

into the third trimester, one side

56:10

or both sides, we see hydro nephrosis.

56:11

We see hydro ureter approximately,

56:14

but the distal most ureter, if it's just due

56:16

to pressure on the uterus, should not be distended.

56:19

Whereas if there's a ureteral calculus

56:21

or a recently passed calculus, the entire ureter and,

56:25

and typically calculator, not always,

56:26

but often are distal, right?

56:27

This is a non-pregnant patients, um, the,

56:30

the entire ureter is gonna be distended.

56:32

The caveat of course, if, if, if the

56:35

uterus pressing on the ureter is causing stasis at the mid

56:39

ureter and there's where the calculus is, then

56:40

that's not gonna work.

56:42

But we're looking for those other findings that I've shown.

56:44

So in hydro pregnancy, there shouldn't be swelling,

56:47

there shouldn't be an emini appearing kidney on R,

56:51

there shouldn't be perinephric and peric edema.

56:53

There shouldn't be other asymmetries.

56:54

It should just be the collecting system

56:56

that's distended and nothing else.

56:58

Those other ancillary findings that we see all the time,

57:02

every day on non-contrast CT for suspected neurosis

57:06

and non-pregnant adults, those are the things we're looking

57:09

for to help tell us that there is an

57:11

obstructing calculus in the ureter.

57:12

It recently passed calculus or possibly infection

57:15

or some combination of those.

57:18

And I think that, that, that holds up.

57:20

Again, we don't see these things that often

57:22

and there's not a huge amount of doubt on this,

57:24

but I think that's a very helpful thing.

57:30

Alright. Um, let's say you're doing a CT brain

57:33

or a lung x-ray.

57:34

Do you recommend abdomen shielding in pregnancy?

57:38

Oh boy. So, uh, a bit of an off topic.

57:42

Um, my under, we used to shield, um,

57:45

my understanding is the, the A A PM, uh,

57:48

some years ago got rid of shielding

57:51

because in fact the scatter paradoxically in,

57:54

like if you're doing a, uh, CT pulmonary angiogram,

57:57

for example, do you shield the AB and and pelvis?

58:00

And the answer is no,

58:02

because my understanding is

58:03

that the lead shield could actually increase the scatter

58:06

and increase the dose of the fetus.

58:08

So, you know, similar to like breast shielding,

58:10

we don't breast shield anymore with, with CHAS ct.

58:13

Um, so, uh, again, not a medical physicist,

58:16

but the answer is we don't,

58:18

and I believe the A PM doesn't support that anymore.

58:22

Gotcha. Okay. And these,

58:23

and these CT scanners are, they're, they're

58:25

so closely coated, um, the scatter should be fairly minimal.

58:29

So I mean, the real, the issue is, is,

58:30

is only if the fetus is directly in the beam, that

58:33

that's really the only major issue in terms

58:35

of any substantive dose.

58:37

And then there's a whole other issue with, you know,

58:39

once the, the earlier in the third trimester,

58:42

if you're doing CT pulmonary angiography, for example,

58:45

the breasts are maybe more radio sensitive, uh,

58:48

since they're preparing to to produce milk.

58:50

And then later on postpartum there's a whole other.

58:52

So I have a whole lecture on imaging of, uh,

58:55

cardiovascular conditions,

58:57

what's called the fourth trimester, um,

58:59

which is basically postpartum peripartum.

59:01

We get into P and that kinda stuff

59:02

and get into those considerations.

59:04

But, um, bottom line is no, no shielding.

59:07

Gotcha. All right.

59:08

One more question and we'll end with this one.

59:10

How can we distinguish between placental abruption

59:13

and ovarian torsion in pregnant woman,

59:15

in a pregnant woman presenting with acute abdominal pain?

59:19

So initially it's gonna be sonography typically.

59:23

Um, and again, abruption is typically more

59:26

of a third trimester condition associated

59:29

with things like hypertension and that sort of thing.

59:31

And then trauma, um, torsion can be variable in terms of

59:35

how it presents, you know, it's sometimes it's classic.

59:38

Um, the typical torsion is you have a woman who's in severe

59:41

pain, but it, again, it can come and go.

59:43

So the initial testing for those sort of sorting out GYN,

59:47

you know, slash obstetrical conditions

59:50

is gonna be ultrasound.

59:51

That's how the initial things are gonna be,

59:54

you know, sorted out.

59:55

Um, it's not gonna be MRI.

59:58

So, um, and again, it's, it,

60:00

it's somewhat different considerations at different stages

60:02

of gestation and it's, you know, different parts

60:04

of the reproductive track are affected there.

60:06

So it's different sort of scenarios, different conditions.

60:10

Um, if there's an underlying cyst, that's certainly a risk,

60:13

but just the act of being pregnant can increase the,

60:16

the incidence of torsion.

60:18

Um, and you're looking for, you know, direct, um,

60:22

demonstration, the point of maximal tendus

60:24

corresponding to an ovary.

60:26

But again, MRI definitely has a role in both

60:28

of those scenarios in terms

60:29

of if the ultrasound is equivocal,

60:31

if the body habitus is limited,

60:33

if you're not getting a clear answer one way

60:35

or the other, particularly for torsion ultra, you know,

60:38

MRI has a role, non-contrast.

60:40

And then for sorting out placental pathology, you

60:42

of various types in the emergent and less emergent setting.

60:45

Certainly MRI has a role

60:47

and then CT in the trauma more in the trauma setting

60:49

that not so much, we're not really doing cts for abruptions

60:52

that are not, you know, like if you have someone who's

60:55

hypertensive or preeclamptic

60:56

or something like that, you're not really gonna do ct.

60:58

It's more of the trauma setting, if that makes sense.

61:01

Gotcha. Well, Dr.

61:03

Katz, thank you so much for that great lecture

61:06

and for sticking around to answer some questions with us.

61:10

Thank you always an honor. Appreciate

61:11

You being here and for everyone else, thank you so much

61:14

for your participation in this noon conference

61:16

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61:18

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61:20

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61:23

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61:27

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61:28

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61:32

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61:35

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