RADIOLOGICAL EXAMINATION

INTRODUCTION: -

Radiology is a branch of medicine that uses imaging technology of diagnostic

and treat disease. Radiologic examination in program women has increased by
107% in the last 10 years.

Imaging in obstetrics is indicated for the purpose of diagnosis and or

therapy to the fetus or the to the fetus or to the germ cells in the ovaries and the
appreciation of the use of radiography in obstetrics practice. It include X-ray,
MRI, ultrasonography. The realization that X-ray may be hazardous mother.
Most of the imagine studies are harmless or associated with minimal fetel risks
of these radiography is of most concern.
RADIATION EXPOSURE VALUES DOSIMETRY

 Amount of energy deposited per kilogram of tissue.

 Gray
 Rad
 1 red = 10 MG ray

Imaging in obstetrics is indicated for the purpose of diagnosis and or therapy to

the fetus or the to the fetus or to the germ cells in the ovaries and the
appreciation of the use of radiography in obstetrics practice. It includes X-ray,
MRI, ultrasonography.

INDICATIONS –

 Fetal
 Maternal
 Fetal – congenital malformation of the fetal and neonates, skeletal
malformations birth injuries like fracture or dislocations and secondary
abdominal pregnancy.
  Maternal – patient having cardio-pulmonary disease may require X-ray
chest during pregnancy and that should be done beyond 12 weeks.

Absorbed radiation by the fetus in different diagnostic

radiation procedure
Procedure Dose (rads)
Abdominal X-ray 0.2-63
Pelvic X-ray 0.5-1.1
Chest X-ray <0.001
Abdominal CT 0.50-1-10
Ventilation lung scan 0.004 – 0.019

MAGNETIC RESONANCE IMAGING (MRI) IN OBSTETRICS

MRI is useful to obtain high soft – tissue contrast and acquisition of images in
axial sagittal and coronal planes. Powerful magnets are used to alter temporarily
the state tissue proteins (mainly hydrogen protons) radio waves are used to
deflect the magnetic vector. The hydrogen protons return to their normal state
once the radio frequency source is turned off. During this phase they emit radio
waves of different frequencies which are received by radio coils wrapped
around the body part. An image is constructed from these pulse sequences using
their location and characteristics.

MRI is devoid of any ionising radiation and found to have no fetal harmful
effect at any gestational age with is tesla strength.

INDICATIONS: -

1. FETAL

Fetal anatomy survey (ii) fetal biometry (iii) fetal weight estimation
(superior to sonography) (iv) evolution of complex abnormalities (brain, chest,
genitourinary system) (v) as a complement to sonography.

2. MATERNAL –

Cerebral vascular flow study (eclampsia) and detection of thrombosis, (ii)

angiography (iii) evaluation of maternal tumours.

Contraindications:
Internal cardiac pacemaker implanted defibrillator, Implants or other metals in
the body contrast agents are not used.

USG (Ultrasonography) –

DEFINITION – ultrasonography (USG) is application of medical with

ultrasound based to visualize internal organs, their size, structure, and their
pathological lesions.

Obstetric ultrasound, also known as prenatal or pregnancy ultrasound, uses high

frequency sound waves to produce images up to developing embryo or fetus.

ULTRASOUND TECHNOLOGY –

 Principle of “SONAR” used by bats and ships.

 Generation of high – frequency sound waves through a transducer.
 Pulsed sound waves, penetrate till structure of different tissues densities
is reached reflected energy to the transducer is amplified and displayed
on a screen.
 Detection of breathing, cardiac action, and vessel pulsations through real
time ultrasonography.
 The commonly used frequency range in obstetrics is 3 to 5 MHz for
abdominal transducers and 5 to 7 MHz for vaginal transducers.
 In clinical practice standard ultrasound images are.
 B-mode (brightness mode display) – two dimensional (2-D) images
(width and brightness) are obtained.
 M-mode – it is used to study the moving organ e.g. fetal heart. This
results in a wavy pattern in the presence of motion.
 Doppler ultrasound (Christion J. Doppler 1942) is based on the principle
of Doppler frequency shift which means there is a change in frequency
and wavelength between the incident wave (from the transducer) and the
reflected wave (from the moving object) when the wave interacts with a
moving structure (red blood cells in the umbilical artery).

THREE – DIMENSIONAL (3D) IMAGES

Common uses of obstetric USG

 Obstetrical ultrasound is a useful clinical test to:
 Establish the presence of a living embryo / fetus.
 Estimate the age of the pregnancy.
  Diagnose congenital abnormalities of the fetus.
 Evaluate the position of the fetus.
 Evaluate the position of the placenta.
 Suspected fetus death.
 Suspected uterine abnormality.
 Ovarian follicle development surveillance.
 Biophysical profile after 28 wk of gestation.
 Observation of intra-partum events
 Suspected poly or oligohydramnios.
 Suspected abruption placenta.
 Adjunct to external version from breech to vertex presentation.

ULTRASOUND IN FIRST TRIMESTER

Intra decidual gestational sac (GS) is identified as early as 29 to 35 days of

gestation.

Fetal viability and gestational age is determined by detecting the following

structures by trans vaginal ultra sonography gestational sae and yolk sae by 5
menstrual weeks, fetal pole and cardiac activity – 6 week

Embryonic movements by 7 weeks. Fetal gestation age is best determined by

measuring the CRL between 7 and 12 weeks (variation 5 days)

Doppler effect of ultrasound can pick up the fetal heart rate reliably by 10 th
week.

Ultrasound markers for fetal anomalies nuchal

translucency – increased fetal nuchal skin thickness (in the first trimester) >
3mm by TVS a strong marker for chromosomal anomalies (triploids 21,18,13
triploids and turner’s syndrome)

MULTIPLE PREGNANCY – Identification of two gestational sacs indicates

twin birth in 52 to 63% of cases. Anembryonic pregnancy.

ECTOPIC PREGNANCY – TVS cum detect 90% of tubal ectopic pregnancy.

The double decadal sac sigh differentiates normal pregnancy from pseudo
gestational sac of an ectopic pregnancy.
MID TRIMESTER ULTRASONOGRAPHY

Benefits of mid trimester ultrasonography –

 Viability of the fetus

 Pregnancy dating
 Detection of multiple pregnancy.
 Detection of congenital anomalies
 Placental localisation
 Monitoring of high risk pregnancy (biophysical scoring)
 Baseline record of fetul biometry.
 Adjunct to any producer e.g. amniocentesis, cordocentesis, cervical
cerclage, external cephalic version.
GESTATIONAL AGE ASSESSMENT

 Bi – parietal diameter measurement – around 09 weeks until and of

pregnancy
 Head circumference measurement – head circum, gestational age
prediction when abnormal skull shape., measured on some plane as bi-
parietal diameter.
 Abdominal circumference measurement – measurement similar to
head circumference, less accurate for establishing gestational age.,
perpendicular plane to the long axis of fetus.
 Femur measurement – only long bone measured routinely, fetal age
assessment when head cannot be utilized for
bi- parietal diameter., multiple fetal growth parameters.
 Single parameter increases variability in predicting fetal age in 3 rd
trimester.
 Variability reduction through parameter combination.

FETAL ANOTOMIC SURUEY –

Majority of major fetal anomalies can be identified in the second trimester.

Neural tube defect (NTDs) – spinal bifida anencephaly fetal face – for cleft
lip or palate
PLACENTA AND UMBICAL CORD – Placenta thickness
more than 45 mm at any period of gestation is considered abnormal.

FETAL WEIGHT – Hadlock formula. Commonly uses four variables: BPD, HC, AC. FL,
ultrasound, and clinical examination have similar accuracy for prediction birth weight.

TAIRD TRIMESTER ULTRASONOGRAPHY

All the information of second trimester sonography can be obtained in third

trimester.

 A detailed anatomical survey – should be done now even if the previous

survey was normal. Achondroplasty dwarfism is diagnosed in this
trimester.
 Estimated fetal weight (EFW)- is determined from the average of three
readings for each of the following FL, AC and BPD. AC is most
important. Sonographic ESW has an error risk of 15-20%
 Growth profile – (i) asymmetric IUGR – the HC is maintained but the
AC falls off around 30 wks. The HC: AC ratio is therefore elevated. (ii) in
symmetric IUGR both the HC and AC are affected early: therefore, HC:AC
ratio remains normal.
 Computed tomography (CT) – A form of tomography in which a
computer controls the motion of the X-ray source and detectors,
processers the data and produces the image. CT imaging is done by
obtaining a spiral 360-degree images that are processed in multiple
planes. Multidetector CT (MDCT) are. Now used. MDCT has got
increased dosimeter compared to traditional CT. Due to its radiation risks
use of CT is restricted in pregnancy as with plain radiology. fetal during
CT pelvimetry varies b/w 0.25 – 1.5 rad. CT pelvimetry may be obtained
with little or no exposure to the fetus. Chest CT scan is done in cases with
suspected pulmonary embolism and cranial CT scan is done in cases with
eclampsia with neurological features.

X-RAY IN PREGNANCY –
X- ray are electromagnetic waves with wavelengths falling between
ultraviolet light and gamma rays. They are classified as ionizing radiation.

Most x-ray exams – including those the legs, head, teeth or chest won’t
expose reproductive organ to direct x-ray beam, and a lead apron cum be
won’t to provide protection from radiation scatter.
The exception is abdominal x-rays, which expose abdomen and baby to the
direct x-ray beam. The risk of harm to fetus depends on gestational age and
amount of radiation exposure. Exposure to extremely high dose radiation in
the first two weeks after conception might result in a abortion exposure to
high dose radiation two to eight wk after conception might increase the risk of fetal
growth restriction or birth defects.

Exposure b/w 8 wk to 16 wk increase the risk of a learning or intellectual

disability.

RADIATION HAZARD –

Risk is primarily based on the estimated dose and the period of gestation.

 Teratogenicity – Diagnostic range of radiation exposure (less than 5

rads) is not associated with any significant congenital malformation either
in human or in animal.
 Oncogenicity – Dividing cell particularly in the first trimester are more
sensitive to injury from radiation. Diagnostic radiation with fetal
exposure is associated with an increased risk of malignancy.
 Genetic damage – No radiation induced transmissible gene mutations
have been scan in human.
 Intra uterine death – low close radiation (1-5 rads) is not associated with
any fetal death.
 Caution – radiation during pregnancy can damage the early phase of
embryo but the risk can be minimised by using the “10-day rule”. This
rule states that no woman should be exposed to x-ray for a non-urgent
indication outside 10 days from her last period during reproductive
period.
 Conclusion –
fetal age estimation is fundamental to obstetric care.
 Ultrasound is a reliable method for establishing the length of pregnancy
and in this way con improve obstetric care. The use of MRI in obstetrics
has been limited, until recently with fast MRI sequences it is not
necessary so sedate the fetus.
BIBILOGRAPHY –
Daffary Shirish N. Chakravarti Sudip “MANUAL OF OBSTETRICS “3 rd
edition ELESEVIER A division of reed Elsevier Indian private limited
publisher page no 437 to 447

Rao Kamini “Textbook of midwifery and obstetrics for nurses Elsevier a

division of reed Elsevier Indian private limited.

Dutta’s D.C. Konar Hiralal “text book of obstetric” 7 th edition new central
book agency (P)ltd. Page No. 640 t o 647

Net reference:

Bhasker Nima “midwifery & obstetrical nursing” 3rd edition publisher

Manjunath S. Hedge EMMESS MEDICAL Publisher.