DOI: 10.1111/tog.
12604 2019;21:255–62
The Obstetrician & Gynaecologist
http://onlinetog.org
Imaging in pregnancy
Kelly-Ann Eastwood MBBS PhD MRCOG PGDipClEd DFSRH,
a,
* Aarthi R Mohan
a
Sub-specialist Trainee in Maternal and Fetal medicine, St Michael’s Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8EG,
UK
b
Consultant in Obstetrics and Maternal Medicine, St Michael’s Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8EG, UK
*Correspondence: Kelly-Ann Eastwood. Email: keastwood01@qub.ac.uk
Accepted on 15 March 2019.
Key content
 The appropriate use of imaging in pregnancy is necessary for
prompt investigation and management of acute and chronic
medical symptoms.
 Healthcare professionals should consider carefully which imaging
modality and scanned area of interest will yield maximum
diagnostic information.
 The use of shielding techniques significantly reduces the dose of
ionising radiation to which the fetus is exposed.
 Theoretical concerns regarding magnetic resonance imaging use in
pregnancy have not been supported in human studies.
 Gadolinium contrast should be avoided in pregnancy unless the
maternal benefits outweigh fetal and neonatal risks.
Please cite this paper as: Eastwood KA, Mohan AR. Imaging in pregnancy. The Obstetrician & Gynaecologist 2019;21:255–62. https://doi.org/10.1111/tog.12604
Introduction
Imaging studies are important adjuncts for the diagnosis of
acute and chronic conditions. It is, however, important to
note that reliance on imaging is no substitute for thorough
history taking, clinical examination and selective use of
appropriate radiological investigations. Debate over the safety
of imaging modalities for pregnant women can result in
avoidance of useful diagnostic tests in pregnancy and the
potential for delayed diagnosis. This review will discuss the
benefits and risks of varied imaging techniques in pregnancy
and highlight appropriate techniques to image women
presenting with common medical symptoms to health-
care professionals.
Ionising radiation
Ionising radiation, including radiography and computed
tomography (CT), is commonly used in the evaluation of
medical conditions. Examinations that expose the fetus to
ionising radiation may be required during pregnancy to aid
clinical diagnosis and decision making. Alternatively, a fetus
may be unintentionally exposed to ionising radiation,
particularly in early pregnancy. It is estimated that the fetus
is exposed to background radiation in the order of 1 mGy
ª 2019 Royal College of Obstetricians and Gynaecologists
Review
BSc MBBS PhD MRCOG MRCP
b
Learning objectives
 To review the safety of different imaging modalities in pregnancy.
 To understand the risks and benefits of various imaging techniques
in pregnancy.
 To review the investigations required to image common medical
symptoms encountered by obstetricians.
Ethical issues
 Do obstetricians adequately counsel women regarding safety of
imaging in pregnancy to enable them to give informed consent for
the procedure?
Keywords: imaging / obstetric / pregnancy / radiation / safety
during pregnancy.1 Table 1 summarises the common units
used to measure ionising radiation.
Both X-rays and gamma rays are short wavelength
electromagnetic waves that can ionise tissues and alter
normal cellular structure in two ways: through stochastic
and deterministic effects.2 Stochastic effects – for example,
development of carcinogenesis – are theorised to occur at
any radiation dose as a result of cellular damage following a
germline mutation.3 There remains no known threshold
value at which these effects will not occur. Importantly,
stochastic effects are associated with an increased risk of
childhood malignancy including leukaemia and lymphoma.4
Deterministic effects involve the loss of tissue function
because of cell death and result from radiation doses above a
threshold value. These effects are predictable and involve
multicellular injury, including chromosomal anomalies.3 As a
result, major risks include fetal malformation (skeletal,
ophthalmic and genital tract anomalies), fetal growth
restriction and neurological effects (microcephaly,
intellectual or developmental disability).1 These outcomes
are dependent on gestational age and the dose used for the
diagnostic test (Table 2).
Our understanding of the effects of ionising radiation is
based on findings from animal studies, epidemiologic studies
of survivors of atomic bombs (Hiroshima and Nagasaki,
255
 Imaging in pregnancy

demonstrated an increase in haematological malignancies in

Table 1. Measurements of ionising radiation23
children whose mothers had been exposed to more than
Traditional Internationally 80 mGy ionising radiation while in utero (n = 58, excess
Measurement Definition units accepted units relative risk of 1.27, 95% confidence interval [CI]
0.02–2.56).7 Importantly, fetal exposure to ionising
Exposure Number of ions Roentgen (R) Coulomb/
produced by kilogram (C/kg)
radiation during diagnostic examinations is at a far lower
X-ray or 2.58 x 10–4 C/kg magnitude than fetal survivors who were exposed in
gamma Hiroshima and Nagasaki. Table 3 outlines fetal radiation
radiation per doses for common radiological investigations. Exact fetal
kilogram of air
exposure does, however, vary with gestational age, maternal
Dose Amount of Rad (rad)* Gray (Gy)* body mass index and image acquisition parameters.8
energy 1000 mGy = 1 Gy
deposited per 1 Gy = 100 rad
kilogram of
Radiography
tissue Radiographs are commonly used to investigate a wide range
of medical symptoms. The British Thoracic Society9
Relative Amount of Roentgen Sievert (Sv)
recommends chest radiography for all patients – including
effective dose energy equivalent 1000 mSv =1 Sv
deposited per man (rem) 1 Sv = 100 rem pregnant women – complaining of a chronic cough
kilogram of (>8 weeks) or who have atypical symptoms of haemoptysis,
tissue breathlessness, fever, chest pain or weight loss. Given the
normalised for
minimal risks to the fetus in pregnancy and potential for
biological
effectiveness delayed diagnosis, clinicians should proceed with chest
radiography for the same indications as in the non-
*For diagnostic X-rays: 1 rad = 1 rem; 1 Gy = 1 Sv.
pregnant patient.8

Japan)5,6 and studies of groups of people exposed to Computed tomography

radiation for medical reasons. The risk of carcinogenesis as
a result of in utero exposure to ionising radiation remains
uncertain.4 Legacy studies of the atomic bomb survivors in
Japan did not initially observe an association between in
utero exposure and excess cancer mortality or incidence.
However, longitudinal data collection has subsequently
identified significant associations between in utero exposure
and increased cancer risk.6 A study of 19 536 children born
to women either employed in a large nuclear facility in the
Southern Urals or living in areas near the Techa river, which
was contaminated by waste from the same nuclear facility,
The use of CT as a diagnostic imaging modality in pregnancy
has increased dramatically; in a review of 5270 examinations
in more than 3000 women in a 10-year period, Lazarus
et al.10 noted an annual increase of 25% in the use of CT in
the decade studied. CT is often essential for the diagnosis and
investigation of maternal conditions in pregnancy.
Indications for use of CT in pregnancy are wide ranging,
including assessing injuries following trauma,11 diagnosing
pulmonary embolism,12,13 investigating gastrointestinal
complications (appendicitis, small bowel obstruction)14,15
and malignancy.16,17 Although less common than fetal MRI,

Table 2. Summary of deterministic effects by gestational age19,23

Gestational Effect of Effect of 50–100 mGy

age (weeks) <50 mGy (<5 rad) (5–10 rad) Effect of >100 mGy (>10 rad) Estimated threshold dose*

0–2 None None None 50–100 mGy

3–4 None Probably none Possible spontaneous miscarriage
5–10 None Uncertain Possible congenital anomaly (skeletal, 200 mGy
May be clinically ophthalmic, genital tract)
undetectable Fetal growth restriction 200–250 mGy
11–17 None Uncertain Risk of diminished IQ or mental retardation 60–310 mGy
Microcephaly 200 mGy
Severity is dose dependent 25 IQ point loss per
1000 mGy
18–27 None None IQ deficits not detectable at diagnostic doses
>27 None None Not applicable to diagnostic medicine

*Data based on results of animal studies, epidemiological studies of survivors of atomic bombs and groups exposed to medical radiation. IQ =
intelligence quotient.

256 ª 2019 Royal College of Obstetricians and Gynaecologists

 Eastwood and Mohan

minimise scanning time.22 In general, increasing the voltage

Table 3. Fetal radiation dose for common radiological investigations8
Type of examination
Very low dose examinations (<0.1mGy)
Cervical spine X-ray (AP and lateral views)
Chest X-ray (two views)
Radiography of extremities
Mammography (two views)
Head and neck CT
Low to moderate dose examination
(0.1–10 mGy)
Abdominal X-ray
Lumbar spine X-ray
CT chest or pulmonary angiography
Limited CT pelvimetry
Low-dose perfusion scintigraphy
Technetium-99m bone scintigraphy
Pulmonary digital subtraction angiography
and decreasing the pitch will increase the radiation dose. In a
Fetal radiation dose single-slice CT, pitch is the ratio of table movement per
(mGy) gantry rotation (mm) to collimation (mm). Higher pitch
results in more scan artefact and lower-resolution images,
<0.001
but it may be required to image women with a higher
0.0005–0.01 body mass index and those with cardiovascular implanted
<0.001 electronic devices.21
0.001–0.01 The use of intravenous contrast agents may improve the
0.001–0.01
diagnostic accuracy of CT by enhancing soft tissue and
vascular structures.23 The most commonly used intravenous
contrast media contain iodine, which carries a small risk of
0.1–3.0
1.0–10
maternal adverse effects including nausea, vomiting, flushing
0.01–0.66 and anaphylactoid reactions.24 Iodinated contrast medium
<1 can cross the placenta and enter the fetal circulation or pass
0.1–0.5 directly into the amniotic fluid; however, animal studies have
4–5
0.5
not revealed any teratogenic effects from its use.25

Higher dose examinations (10–50 mGy)

Abdominal CT 1.3–35
Pelvic CT 10–50
18
F-FDG PET/CT whole-body scinitigraphy 10–50
18
F-FDG = 2-deoxy-2[fluorine-18]-fluoro-D-glucose; AP = anterior-
posterior; CT = computed tomography; PET = positron emission
tomography.
there has also been a move to use antenatal CT for the purposes
of better defining fetal anomalies before delivery – for example,
in cases of skeletal dysplasia.18
Minimising the effects of ionising radiation
The use of ionising radiation in pregnancy should follow the
ALARA (as low as reasonably achievable) principle.19 The
International Commission on Radiological Protection20
recommends that ‘imaging radiation must be applied at
levels as low as reasonably achievable, while the degree of
medical benefit must counterbalance the well-managed levels
of risk’. The use of modern shielding techniques has
significantly reduced the dose of ionising radiation
exposure to the fetus; for example, the fetal radiation dose
received during mammography is in the order of 0.001–
0.01 mGy.8 The use of lead shielding can further reduce this
risk by an additional 50%.17
The fetal radiation dose received as the result of CT is
dependent on a number of factors: the anatomical region of
interest, machine set-up, X-ray tube voltage, tube current and
number of image acquisitions.21 In general, the fetal radiation
dose is highest when the fetus is captured directly in the X-
ray beam – for example, when using abdominopelvic CT. For
head and chest CT, the fetus is exposed to scatter radiation,
which confers a low-dose radiation exposure.21 Radiologists
should aim to plan scans in advance, monitor the length of
scanning time and check the quality of images collected to
Other imaging modalities
Ultrasound
Following pioneering work on soft-tissue ultrasonography in
the USA in the late 1940s and early 1950s, ultrasound was
further applied to obstetrics by Professor Ian Donald in
Glasgow.26 Ultrasound quickly became a relied upon and
widely used imaging technique in pregnancy. Initially,
ultrasound imaging was assumed to be safe in pregnancy. It
is important to note, however, that early ultrasound
machines used relatively low output settings and did not
rely on colour flow, power Doppler or three-dimensional or
four-dimensional imaging of the fetus.27 Effects of potential
clinical significance have been demonstrated in laboratory
studies but not completely borne out in clinical practice.
These effects are as a result of thermal effects on tissue
temperature and mechanical effects resulting in tissue
cavitation. The fetal central nervous system is the most
susceptible tissue to thermal injury; animal studies have
demonstrated associations with neural tube defects,
arthrogryposis, disorders of muscle tone, miscarriage and
fetal growth restriction.28 The risk of temperature elevation is
lowest in B-mode imaging and is higher with colour Doppler
and spectral Doppler applications.23 Cavitation refers to the
development of gas bubbles in tissues exposed to ultrasonic
vibration.29 These bubbles can cause inertial (transient) or
non-inertial (stable) cavitation effects. Inertial cavitation
effects have been shown to cause genetic damage in vitro,29
while in vivo studies of non-inertial effects have remained
inconclusive.30 Overall, it is thought that there are no
significant effects of ultrasound unless fetal exposure is
prolonged (longer than 60 minutes).28
Concern over the biological effects of diagnostic
ultrasound has resulted in the development of safety
indices. The two most commonly used indices are the

ª 2019 Royal College of Obstetricians and Gynaecologists 257

 Imaging in pregnancy
thermal index and the mechanical index. Sonographers
should aim to follow the ALARA principle;20 in doing so,
the thermal index and mechanical index should be kept as
low as possible to obtain optimal images.
Magnetic resonance imaging
MRI enables the visualisation of deep soft tissue structures
and does not rely on the use of ionising radiation.23 MRI is
useful for assessing a variety of medical conditions – for
example, posterior reversible encephalopathy syndrome,
cerebral venous thrombosis,31 acute appendicitis,14 Crohn’s
disease32 and suspected morbidly adherent placenta.33
Antenatal MRI is increasingly used to further evaluate
structural fetal anomalies, including cranial lesions
(ventriculomegaly, agenesis of the corpus callosum, gyral or
sulcation pattern),34 neural tube defects, congenital
pulmonary airway malformations, congenital diaphragmatic
hernia and cardiovascular anomalies (teratoma,
rhabdomyoma or vascular abnormalities).33
Obstetric MRI can be technically challenging to perform
and interpret given the movement of the fetus and variable lie
and presentation. However, MRI has several advantages over
antenatal ultrasound. In comparison with ultrasound, MRI
has improved resolution, and cranial imaging allows direct
visualisation of both sides of the fetal brain. Additional
limitations of sonography, resulting from oligohydramnios,
fetal positioning and acoustic shadowing from the ossifying
calvaria, can be overcome using fetal MRI.35 Factors affecting
the quality of fetal MRI include fetal movement, and
therefore a need for repeated image acquisition, the small
size of the fetal anatomical structures under evaluation and
the increased distance between the fetus and the receiver
coil.36 Additional maternal complications include
claustrophobia and discomfort, particularly at advanced
gestations.35 Avoidance of prolonged supine positioning,
particularly in the third trimester, will reduce the occurrence
of significant maternal hypotension precipitated by
compression of the inferior vena cava by the gravid uterus.36
MRI is not associated with any radiation exposure but does
expose the fetus to a magnetic field more than 10 000 times
greater than that of Earth (50 lT).8 Theoretical concerns
include teratogenesis as a result of fetal exposure to the static
magnetic field and potential cell damage secondary to cell
migration, proliferation and differentiation; tissue heating
and possible disruption of organogenesis owing to exposure
to pulsed radiofrequency fields; and acoustic damage given
fetal exposure to high-gradient electromagnetic fields used
with the fast acquisition sequences required for fetal
imaging.37 The American College of Radiology38 stipulates
that MRI can be carried out at any time during pregnancy if
the maternal benefits outweigh fetal risks. Concerns
regarding the impact of first-trimester MRI on fetal growth,
the risk of miscarriage and ophthalmic anomalies have not
258
been borne out in human studies.36 From a practical
standpoint, MRI performed during the first trimester is
often for maternal indications and not to aid prenatal
diagnosis. Strizek et al.39 evaluated the effects of in utero
exposure to MRI (1.5 T) on fetal growth and neonatal
hearing function in a group of newborns at low risk for
congenital hearing impairment or congenital deafness
(n = 751). Median gestational age at first MRI exposure
was 37 weeks of gestation (range 16–41+6 weeks). There were
no neonates with hearing impairment in the exposure group.
No significant differences in birthweight percentiles were
apparent between cases (50.6%) and controls (48.4%,
P = 0.22).39 A further observational study of 72 healthy
pregnant women who had 1.5-T fetal MRI using single-shot
fast spin echo (SSFSE) sequences in the third trimester
reported child outcomes at a mean age of 24.5  6.7
months.40 These children demonstrated age-appropriate
scores in the communication, daily living, socialisation and
motor skills subdomains of the Vineland Adaptive Behaviour
Scale (P > 0.05). Furthermore, all exposed children passed
their newborn hearing tests and had normal hearing at
preschool age. MRI study duration and exposure time to
radio frequency waves and SSFSE sequences were not
associated with adverse functional outcomes or
hearing impairment.
Use of gadolinium contrast
Gadolinium-based contrast agents are useful in enhancing
MRI of the central nervous system as they cross the blood–
brain barrier. Lesions disrupting this barrier – such as
tumours, abscesses or demyelination – are therefore more
readily identifiable with the use of contrast.23 However, there
remains debate about using contrast-enhancing agents in
pregnancy because of the possible risk of teratogenicity in the
first trimester during organogenesis.41 It is also thought that
gadolinium may cross the placenta in the second and third
trimester, where it is then excreted by the fetal kidneys into
the amniotic fluid and recirculated. Theoretically, there are
concerns that persistent circulation of contrast agent may
cause nephrogenic systemic fibrosis in the child.42 In a large
retrospective cohort study conducted by Ray et al.,41 the
long-term safety of MRI was evaluated in 1 424 105 matched
maternal–child pairs. MRI was carried out either in the first
trimester of pregnancy or with gadolinium at any time
during pregnancy. The overall rate of MRI was 3.97 per 1000
pregnancies. Comparing first-trimester MRI (n = 1737) with
no MRI (n = 1 418 451), there was no significant difference
in stillbirth or neonatal death rate between the exposed and
unaffected groups (19 versus 9844, adjusted relative risk
[RR] 1.68, 95% CI 0.97–2.90). No additional risk of
congenital anomalies, neoplasm, visual loss or hearing loss
was seen in the first trimester MRI group. Comparing
gadolinium MRI (n = 397) with no MRI (n = 1 418 451),
ª 2019 Royal College of Obstetricians and Gynaecologists

the hazard ratio (HR) for nephrogenic systemic fibrosis-like
outcomes was not statistically significant. However,
rheumatological, inflammatory and infiltrative skin
conditions were more likely in the group exposed to MRI
with gadolinium contrast (123 versus 384 180 births,
adjusted HR 1.36, 95% CI 1.09–1.69). In addition, the
stillbirth and neonatal death rate was higher in the
gadolinium-exposed group (adjusted RR 3.70, 95% CI
1.55–8.85). Given the available evidence, it is therefore
recommended that gadolinium contrast be avoided in
pregnancy unless the benefits clearly outweigh the possible
risks to the fetus.23 If gadolinium is used, the American
College of Radiology43 recommends that clinicians seek
informed consent from the patient and document that
information requested from the MRI cannot be acquired
without the use of IV contrast or by using other imaging
modalities, that the information needed affects the care of the
patient and/or fetus during the pregnancy, and that it is the
opinion of the referring physician that it is not prudent to
wait to obtain this information until after the delivery.
Nuclear medicine imaging
Nuclear studies are useful to determine organ function by
tagging a chemical agent with a radioisotope (radiotracer).
Investigations include pulmonary ventilation/perfusion
(V/Q), thyroid, bone and renal scans.23 In pregnancy, fetal
exposure during nuclear medicine studies depends on both
the physical and biochemical properties of the radioisotope.
Technetium-99m is a commonly used isotope in V/Q
scanning to diagnose pulmonary embolism in pregnancy. It
is a gamma ray emitter and has a half-life of approximately
6 hours. In general, V/Q scans result in a fetal radiation
exposure of <5 mGy.24 To reduce fetal radiation exposure, a
normal chest radiograph can be used as a surrogate marker of
ventilation and half-dose perfusion scans could be
considered. In contrast, radioactive iodine (iodine-131), for
assessment of thyroid pathology, readily crosses the placenta,
has a half-life of 8 days and may cause fetal hypothyroidism,
especially if used after 10–12 weeks of gestation. It is therefore
not routinely recommended for use in pregnancy. If a
diagnostic scan of the thyroid is essential, technetium-99m is
the isotope of choice.23,24
Imaging of malignancy during pregnancy may warrant
investigation with a positron emission tomography (PET)
scan.44 In pregnant women with cancer, the use of PET
imaging has been debated because it uses radioactive-labelled
tracers, therefore increasing the risk of exposing the fetus to
radiation. The most commonly used radiotracer is 2-deoxy-2
[fluorine-18]-fluoro-D-glucose (18F-FDG). The amount of
fetal radiation exposure depends on the weight of the fetus,
the type of radiotracer, the administered dose and
physiological changes during pregnancy.45 Data indicate
that the fetus is at highest radiation exposure risk in the
ª 2019 Royal College of Obstetricians and Gynaecologists
Eastwood and Mohan
first trimester but that the total absorbed dose of radiation is
well below the threshold for non-cancer health effects
throughout pregnancy.46 Studies in the second and third
trimester of pregnancy also indicate that the fetal radiation
dose from 18F-FDG administration is low. When medically
indicated in pregnant women, 18F-FDG PET scanning should
therefore not be withheld for fear of excessive radiation
exposure to the fetus.47
Radiological investigation of common
medical symptoms in pregnancy
Venous thromboembolism (VTE) remains one of the leading
direct causes of maternal death during pregnancy and in the
immediate postpartum period.12 In the UK and Ireland
between 2014 and 2016, 39 women died as a direct result of
VTE.48 Subjective clinical assessment of deep venous
thrombosis (DVT) and pulmonary embolism is particularly
unreliable in pregnancy, and only a minority of women with
clinically suspected VTE have the diagnosis confirmed when
objective testing is used (2–6%).12
Calf pain/swelling
First-line imaging for suspected DVT is with compression
duplex ultrasound, and women should remain on therapeutic
anticoagulation until imaging is completed. If the ultrasound
is negative and a high level of clinical suspicion remains,
anticoagulant treatment should be discontinued but the
ultrasound repeated on days 3 and 7.12
Shortness of breath
Shortness of breath is a common presenting complaint in
pregnancy with a wide range of differential diagnoses.
Women presenting with signs or symptoms of an acute
pulmonary embolism should be investigated as a matter of
urgency. Initial investigations should include an
electrocardiogram and a chest radiograph. In those
presenting with a suspected pulmonary embolism but
without symptoms and signs of DVT, a V/Q scan or a CT
pulmonary angiogram (CTPA) should be performed. A
Cochrane review to determine the diagnostic accuracy of
CTPA and V/Q scanning for diagnosis of pulmonary
embolism demonstrated no significant difference between
the imaging techniques. The median frequency of
inconclusive results was 5.9% for CTPA and 4.0% for
V/Q scanning.13
It is important that clinicians and patients are aware of the
benefits and limitations of these diagnostic tests. CTPA has
potential advantages over V/Q imaging, including
availability, relatively low fetal radiation exposure and
superior identification of other pathology including
pneumonia (5–7%) and pulmonary oedema (2–6%). A
significant drawback to the use of CTPA in pregnancy,
259
 Imaging in pregnancy

however, is delivery of up to 20 mGy radiation to maternal

breast tissue, which is associated with an increased risk of Box 1. Red flag symptoms associated with headache in pregnancy50
breast cancer. Delivery of 10 mGy radiation to a woman’s
Red flag symptoms
breast before the age of 35 years is expected to increase her Sudden-onset headache reaching maximal intensity in <1 minute
lifetime risk of developing breast cancer by 13.6% above that New onset of severe headache
of the general population.49 In contrast, V/Q scanning has a Significant change in chronic headaches
Headache  fever, meningism
high negative predictive value for pulmonary embolism and
Headaches triggered by cough, valsalva, sneezing or exercise
delivers a lower radiation dose to the breast tissue of a Orthostatic headache
pregnant woman. In women with a personal or significant New-onset focal neurological deficit, cognitive dysfunction or seizure
family history of breast cancer, many centres advocate a V/Q Head or neck trauma (within last 3 months)
Headache with aura including motor weakness (lasting >1 hour)
scan as the first-line investigation.12 V/Q scanning may carry
Worsening headache (weeks or months)
an increased childhood malignancy risk when compared with Visual disturbances/visual field defects
CT owing to a slightly higher fetal radiation dose. The
International Commission on Radiological Protection20 Other considerations
Patient blood pressure
estimates an increased risk of fatal childhood cancer up to Past history of neurological conditions
the age of 15 years following in utero radiation exposure of Pituitary disease
0.006% per mGy, which equates to a risk of one in 17 000 Immunocompromise (HIV infection, immunosuppression)
Malignancy
per mGy.
Conditions associated with procoaguable state (thrombophilia,
antiphospholipid syndrome, etc.)
Abdominal pain Current medication (medication overuse/abuse)
Abdominal pain in pregnancy can be attributed to a wide Family history
range of underlying conditions, including hepatobiliary,
gastrointestinal, genitourinary, infectious, inflammatory,
vascular and malignant aetiologies. Perhaps the most
common causes of non-obstetric pain in pregnancy are
appendicitis and cholecystitis.14 Ultrasound and MRI Table 4. Recommended neurological imaging for suspected
(without contrast) are the primary imaging modalities intracranial lesions31
recommended for evaluation of abdominal pain in
Suspected intracranial lesion Recommended imaging
pregnancy; however, abdominal radiography may also be
indicated.14 Ultrasound is a useful first-line investigation to Acute cerebrovascular accident CT/MRI and angiography*
image the appendix, bowel, hepatobiliary tree, renal tract and (stroke)
adnexae. In the setting of active infection or inflammation, Subarachnoid haemorrhage Non-contrast enhanced CT
particularly inflammatory bowel disease, MRI can also help Central venous thrombosis MRI and MRV or CT and CTV
Arterial dissection Cervical MRI, duplex scanning,
identify bowel obstruction, fistulas or abscess formation.14 MRA  CTA
Pituitary tumour MRI
Headache Choriocarcinoma MRI or CT
Posterior reversible MRI
Headaches remain the most frequent reason for referral to an
encephalopathy syndrome
outpatient neurology clinic.31 Most headaches are benign but Idiopathic intracranial MRI and MRA
warrant prompt investigation because they can herald hypertension
intracranial catastrophe. In many cases, headaches are a *May require multiple imaging modalities. CT = computed
primary disorder: migraine, tension-type headache and tomography; CTA = computed tomography angiogram; CTV =
cluster headache. However, clinicians must be alert to computed tomography venogram; MRA = magnetic resonance
causes of secondary headache in pregnancy, including pre- angiogram; MRI = magnetic resonance imaging; MRV = magnetic
resonance venogram.
eclampsia, posterior reversible encephalopathy syndrome,
reversible cerebral vasoconstriction syndrome and acute
arterial hypertension. Other causes of secondary headache
in pregnancy include cerebral venous thrombosis, intracranial pressure (papilloedema, ocular palsy,
intracranial haemorrhage, subarachnoid haemorrhage, hypertension) should be referred for urgent intracranial
ischaemic stroke, pituitary adenoma and malignancy.31 imaging.50 Table 4 summarises the intracranial imaging
Box 1 summarises red flag symptoms associated with techniques that can be employed to investigate underlying
headache that require further investigation in pregnancy.50 causes of headache in pregnancy.31 Fetal exposure following
Following detailed history taking and clinical assessment, CT of the maternal head is estimated at 0.001–
women with focal neurological deficits or signs of raised 0.01 mGy (Table 3).

260 ª 2019 Royal College of Obstetricians and Gynaecologists


Breast mass
Breast cancer remains the leading cause of death in women
aged 35–54 years (lifetime risk of one in nine).16 Women
presenting with a breast mass in pregnancy persisting for
more than 2 weeks should be referred to a
multidisciplinary team. Ultrasound of the affected breast
is recommended in addition to tissue biopsy. Samples
should be sent for histological examination,16and if
malignancy is identified, mammography is advised to
assess the extent of disease, visualise microcalcifications
and assess the contralateral breast. Because of physiological
hyper-vascularisation and the increased density of breast
tissue in pregnancy, mammography is often challenging to
interpret.44 Sensitivity of mammography during pregnancy
is thought to be between 78% and 90% in women with
clinical abnormalities, and both breasts should be
evaluated.44 To reduce exposure of the fetus to ionising
radiation, fetal shielding is recommended. The overall dose
of radiation exposure from mammography is thought to be
in the order of 0.001–0.01 mGy (Table 3).8 Additional
imaging may be required to stage the malignancy. When
there is a high index of clinical suspicion of metastases in
pregnancy, women should have a chest radiograph and
liver ultrasound. Conventionally, MRI with gadolinium
contrast is recommended for additional staging of
malignancy.41 Women should be counselled regarding the
real risk of maternal morbidity, and therefore fetal
morbidity and mortality, if malignancy in pregnancy is
not assessed and treated appropriately, in addition to the
potential risks to the neonate with use of gadolinium
contrast in pregnancy.41 Ultimately, the importance of
prompt optimal treatment of breast cancer is the most
crucial factor in determining the further management of
the woman and her pregnancy.
Conclusion
Timely investigation and management of complex medical
symptoms in pregnancy is essential to reduce maternal
morbidity and mortality. The available literature
demonstrates that effects of diagnostic imaging studies on
the fetus involving <50 mGy radiation at any gestation are
likely to be negligible. MRI remains preferable to studies
using ionising radiation, and for MRI examinations requiring
contrast, gadolinium can be used if the maternal benefits
outweigh fetal risks. Safety of imaging in pregnancy is
improved by careful history taking and examination, clear
identification of the clinical question to be answered and the
timeframe in which it should be investigated, advice from a
senior radiologist regarding the most suitable imaging
modality and appropriate counselling of the woman by a
competent clinician.
ª 2019 Royal College of Obstetricians and Gynaecologists
Eastwood and Mohan
Disclosure of interests
ARM is an Associate Editor on the Editorial Board of The
Obstetrician & Gynaecologist. She was excluded from editorial
discussions regarding the paper and had no involvement in
the decision to publish. KAE has no conflicts of interest.
Contribution to authorship
KAE researched and wrote the article. ARM instigated and
edited the article. Both authors approved the final version
for publication.
Supporting Information
Additional supporting information may be found in the online
version of this article at http://wileyonlinelibrary.com/journal/tog
Infographic S1. Imaging in pregnancy
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ª 2019 Royal College of Obstetricians and Gynaecologists