C a r d i o p u l m o n a r y I m a g i n g • R ev i ew

Colletti et al.
Cardiovascular Imaging of the Pregnant Patient

Cardiopulmonary Imaging
Review
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FOCUS ON:

Cardiovascular Imaging
of the Pregnant Patient
Patrick M. Colletti1 OBJECTIVE. The purpose of this review is to describe the selection and methods of im-
Kai H. Lee1 aging of pregnant women with cardiovascular conditions.
Uri Elkayam2 CONCLUSION. Common cardiovascular conditions may occur in 1% of all pregnant
women. The selection and methods of imaging studies require thoughtful planning. Use of
Colletti PM, Lee KH, Elkayam U radiation, radiopharmaceuticals, and contrast agents should be minimized. Pulmonary and
cardiac CT angiography deliver minimal fetal radiation, and ventilation-perfusion scintigra-
phy presents relatively low fetal irradiation. Cardiac catheterization, coronary angiography,
and electrophysiologic procedures, including complex interventions, also cause relatively low
fetal exposure. Even nuclear cardiology procedures are unlikely to exceed negligible-risk (50
mGy cutoff) fetal radiation doses.

Keywords: cardiovascular imaging, contrast agents, CT,
MRI, pregnancy, pulmonary embolism, radiation safety
DOI:10.2214/AJR.12.9864
Received September 2, 2012; accepted after revision
November 12, 2012.
1
Department of Radiology, University of Southern
California Keck School of Medicine, LAC+USC Medical
Center, 1200 N State St, Los Angeles, CA 90033. Address
correspondence to P. M. Colletti (Colletti@usc.edu).
2
Department of Medicine, University of Southern
California Keck School of Medicine, Los Angeles, CA.
AJR 2013; 200:515–521
0361–803X/13/2003–515
© American Roentgen Ray Society
I
n addition to preeclampsia [1], hy-
pertension of pregnancy [2, 3], and
peripartum cardiomyopathy [4–9],
the common cardiovascular condi-
tions that occur in adults of a similar age [10,
11] may affect nearly 1% of pregnant women
[4]. The most important conditions include
pulmonic, mitral, and aortic stenosis and re-
gurgitation, aortic coarctation and dissection,
congenital cyanotic disorders, pulmonary em-
bolism, and pulmonary hypertension [10–12].
During pregnancy, maternal blood volume
increases as much as 50%, heart rate increases
10–15 beats/min, and cardiac output increases
30–50% [11, 13, 14]. Hirata et al. [15] found
that 25 healthy patient volunteers followed with
sequential echocardiography through pregnan-
cy had increasing end-diastolic left ventricu-
lar and left atrial dimensions and increasing
mean velocity of circumferential fiber shorten-
ing throughout gestation with the peak at the
36th week. Left ventricular ejection fraction
remained stable, and cardiac dimensions and
function did not vary between the left lateral
and supine positions.
Gestation-related volume overload may be
expected to negatively affect preexisting car-
diovascular conditions, including valvular dis-
ease, cardiomyopathy, coronary artery disease,
and congenital heart disease [11, 12]. A preg-
nant patient may present with shortness of
breath, chest pain, or both. Occasionally, the
condition may be incidentally detected during
a physical examination. All of these cardio-
vascular conditions require imaging for quan-
titation and treatment planning [11].
The application of radiation and the ad-
ministration of radiopharmaceuticals and con-
trast agents should be minimized for pregnant
women. Most pregnant patients with cardi-
ac conditions undergo cardiac structural and
functional analysis by echocardiography, oc-
casionally including pharmacologic stress with
dobutamine [16], presumably with no signifi-
cant fetal risk [17]. The U.S. Food and Drug
Administration (FDA) criteria for pregnancy
categories of pharmaceuticals [18] are as fol-
lows: A, controlled clinical studies in humans
show safety; B, human data reassuring (ani-
mal positive), animal studies show no risk;
C, human data lacking, animal studies posi-
tive or not done (67%); D, human data show
risk, benefit may outweigh risk; and X, ani-
mal or human data positive for unacceptable
risk. Dobutamine (pregnancy category B) is fa-
vored over adenosine (pregnancy category C)
for echocardiographic stress testing. Although
agitated saline microbubble echographic con-
trast material may be used during pregnancy to
identify patent foramen ovale, pulmonary sys-
tem–traversing contrast agents such as perflu-
tren-containing human albumin microspheres
are pregnancy category C agents. If additional
imaging is required for management planning,
further imaging with radiography, fluorosco-
py, MRI, or scintigraphy may be indicated.

AJR:200, March 2013 515


Fetal Radiation Risks
Cardiac imaging with radiation may be per-
formed inadvertently on patients with unsus-
pected pregnancies. This would most often
occur early in pregnancy, perhaps after only a
few weeks of gestation, when results of rou-
tine urine pregnancy tests are less reliable.
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Occasionally, human error or miscommuni-
cation is responsible for such events. Medical
physicists and radiologists may be consulted
to evaluate such cases and consult with a preg-
nant patient before or after a planned or un-
planned examination with radiation [19–22].
Risk to the embryo or fetus depends on the
amount and type of radiation delivered and the
gestational age at irradiation. Spontaneous ad-
verse outcomes are common [23] (Table 1).
Although to our knowledge there are no fe-
tal case data directly linking diagnostic imag-
ing to fetal harm, Brent [24] projected a low
level of risk, citing an approximately 28.6%
risk of spontaneous abortion, major malfor-
mation, mental retardation, and childhood ma-
lignancy among the general population that a
dose of 50 mSv (50 mGy) increases approxi-
mately 0.17%. It is generally not possible to
convincingly differentiate radiation-induced
from spontaneous adverse fetal results. Table
2 shows recommendations for consulting with
and advising pregnant patients regarding fe-
tal risks associated with radiation exposure. In
general, termination of pregnancy is not rec-
ommended unless there is reasonable docu-
mentation that an estimated fetal dose is great-
er than 150 mGy [19, 25–27].
Cardiovascular Imaging With
Ionizing Radiation in the Pregnant
Patient
Most fetal radiation related to cardiovascu-
lar radiography, fluoroscopy, CT, and nuclear
methods is delivered by x-ray Compton scat-
ter, radiopharmaceutical maternal tissue irradi-
ation, and transplacental radiopharmaceutical
distribution [28, 29] (Fig. 1). Because the fetus
is only momentarily within the primary x-ray
beam during groin-to-heart catheter passes [30,
31] and abdominopelvic CT is only rarely per-
formed for conditions such as aortic dissection,
large fetal exposures are rare in the evalua-
tion and treatment of cardiovascular condi-
tions in pregnancy. Thus one would not expect
greater than minimal fetal risk associated with
cardiovascular radiography, fluoroscopy, or CT
[32–38]. Indicated cardiac catheterizations, in-
cluding interventional and electrophysiologic
procedures [30, 31], may be performed during
pregnancy with relatively low fetal radiation
516 AJR:200, March 2013
Colletti et al.
TABLE 1: Spontaneous Adverse Outcomes of Pregnancy
Gestational Age (d) Risk Spontaneous Occurrence Rate (%)
1–10 Reabsorption 30
10–50 Abnormal organogenesis 4–6 (0.6 severe)
> 50 Intrauterine growth retardation 4
TABLE 2: Recommendations Regarding Fetal Irradiation
Fetal Estimated Exposure (mGy) Recommendation
< 1 (total gestation) General public limit
< 5 (0.50/mo) Nuclear Regulatory Commission fetus exposure limit
Fetal dose < 50 Fetal risk negligible
Fetal dose < 100 Termination not justified
Fetal dose 100–150 Consider individual circumstances
Fetal dose > 150 Possible fetal damage; termination should be seriously considered
Fetal dose > 200 Termination generally recommended
exposure. Interventional cardiologists also may been associated with teratogenic effects and,
choose to perform vascular access via the up- to our knowledge, there have been no reports
per extremity in many cases, avoiding direct fe- of clinical sequelae induced by iodinated
tal irradiation during catheter passage. Typical contrast agents administered IV [27], iodin-
expected estimated fetal doses associated with ated contrast agents can cause neonatal hy-
maternal cardiovascular x-ray imaging are pre- pothyroidism if directly instilled into the am-
sented in Table 3 [32–37]. niotic fluid. A 2010 study of the effect of in
External shielding of the maternal pelvis utero exposure to a single high dose of io-
is of limited value. The radiation dose ab- dinated contrast material on neonatal thyroid
sorbed by the fetus without shielding was function identified no serious risks [40]. The
found to be only 3% higher than that with currently used low-osmolality iodinated con-
external shielding for all periods of gestation trast agents are in pregnancy category B [41].
[31]. It is an individual decision whether the The American College of Radiology manual
temporary fetal deformity and increased pa- on contrast media recommends that iodinated
tient discomfort associated with the weight contrast agents be used only as needed in the
of a lead apron are a reasonable tradeoff for imaging of pregnant patients [42].
the minimal potential reduction in fetal ra-
diation and the maternal psychologic advan- MRI and Gadolinium-Based Contrast
tages of such shielding. Agents During Pregnancy
Radiopharmaceutical imaging in pregnan- The Society for MRI Safety Committee
cy may yield higher estimated exposures to stated the following in 1991 “to date, there
the fetus via maternal bladder and placental lo- has been no indication that the use of clinical
calization, especially if transplacental distribu- MR imaging during pregnancy has produced
tion occurs. Radiopharmaceuticals excreted by deleterious effects” [43].
the fetus will enter the amniotic circulation, No new recommendations have evolved
prolonging exposure. Even so, typical diag- since that 1991 statement, despite the use of
nostic nuclear medicine and PET agents are 1.5- to 3-T MRI for imaging of numerous
not expected to approach radiation exposures pregnant patients [44–46]. Although the fe-
exceeding 50 mGy [28, 29] (Table 4). Radio- tus may be exposed to substantial acoustic
pharmaceutical doses should be minimized in noise during MRI, no cases of hearing dam-
pregnancy, and the patient should be well hy- age have been found, to our knowledge [47].
drated and encouraged to void frequently. Thus cardiac MRI is reasonable as a problem-
solving technique for selected pregnant pa-
Use of Iodinated Contrast Agents tients, including those with myocardial mal-
During Pregnancy function; maternal congenital cardiovascular
Iodinated contrast agents are known to cross abnormalities; and aortic aneurysms, aortitis,
the human placenta and enter the fetus [39]. coarctation, and dissection (Fig. 2). Myocar-
Although iodinated contrast agents have not dial perfusion and viability studies may also
 Cardiovascular Imaging of the Pregnant Patient

Heart Heart Heart

Lung Lung Lung Lung Lung Lung
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M
M

at

at
at

er

er
er

nta
nta

nta

na

na
na

ce
lT

lT
lT
ce

ce

is

is
is

Pla
Pla

Pla

su

su
su
Fetus Fetus Fetus

es

es
es

Maternal Bladder Maternal Bladder Maternal Bladder

Scatter Radiation Maternal Tissue Radiation Transplacental Radiation

Fig. 1—Schematic shows mechanisms of radiation to fetus during cardiovascular imaging. Left, fetal radiation from chest radiography, fluoroscopy, or CT is primarily caused
by Compton scatter from thoracic tissues. Center, fetal radiation from radiopharmaceuticals localized to tissues outside of fetus depends on biodistribution and distance from
fetus and attenuation by intervening tissues. Right, internal fetal radiation occurs when low-molecular-weight (< 500–1000 Da) radiopharmaceuticals traverse placental barrier.
Radiopharmaceuticals that are excreted through fetal urinary or intestinal tract may enter amniotic circulation with associated prolonged fetal exposure.

TABLE 3: Cardiac Imaging with Radiography, Fluoroscopy, and CT be considered but with the additional risks
Examination Estimated Fetal Dose (mGy) associated with the use of gadolinium-based
contrast agents in pregnancy.
Chest radiography < 0.0001
The placenta is highly vascular and has a
Pulmonary CTA 0.01–0.66 large blood pool, and MRI contrast agents ex-
Coronary CTA (prospective gating) ≈1 hibit prominent placental localization. Most
Coronary CTA (retrospective gating) ≈3 currently approved MRI contrast agents are of
low molecular weight (500–700 Da) and read-
Abdominopelvic CTA 6.7–56
ily cross the placental barrier. Massive doses
Direct fluoroscopy for groin-to-heart catheter passagea 0.094–0.244/min of these agents have been found to cause post-
Coronary angiography 0.074 implantation fetal loss, delayed development,
Complex electrophysiologic intervention 0.0023–0.012/min increased locomotive activity, and skeletal
and visceral abnormalities in experimental an-
Note—Reasonable estimates are presented. Fetal exposure increases as the fetus grows and ascends
toward the maternal thorax. Larger patients requiring greater peak kilovoltage and tube current will have imals [41]. The FDA lists MRI contrast agents
greater secondary fetal exposure. CTA = CT angiography. as pregnancy category C. Statements such as
a Avoidable with upper-extremity vascular access.
“adequate and controlled studies in pregnant

TABLE 4: Doses to the Fetus From Nuclear Medicine Examinations

Examination Activity (mCi) Radiopharmaceutical and Exposure Early Pregnancya Fetal Dose (mGy)
Lung perfusion 5.5 (200) 99mTc–macroaggregated albumin (P) 0.56
Lung ventilation 30 (1100) 133 Xe gas 0.0054
Lung ventilation 30 (1100) 99mTc aerosol 0.1–0.9
Myocardial perfusion 1.5 (55) 201TlCl (P, F, A) 5.3
Myocardial perfusion 30 (1100) 99mTc-sestamibi (P) 17
Myocardial perfusion 30 (1100) 99mTc-tetrofosmin (P) 8.45
Gated blood pool 25 (930) 99mTc-tagged RBCs (P) 6.0
PET viability 10 (367) 18 F-FDG (P, F, A) 6.3–8.1
PET perfusion 80 (2960) 82 RbCl (P, F, A) ≈2
Note—Data from [28, 29]. Values in parentheses are megabecquerels. Maternal hydration and frequent voiding can reduce the fetal dose after administration of a
number of radiopharmaceuticals, especially 99mTc–macroaggregated albumin, 99mTc aerosol, 201TlCl, 18F-FDG, and 82RbCl. P = likely to enter placenta, F = likely to cross
placental barrier, A = likely to enter amniotic circulation.
aRadiopharmaceutical is assumed to be administered at 12 weeks’ gestational age; administrations before or after 12 weeks postconception would likely deliver a lower

fetal dose.

AJR:200, March 2013 517

 Colletti et al.

Fig. 2—27-year-old woman with Marfan syndrome with back pain and decreased
right femoral pulse at 27 weeks’ gestation and history of mechanical aortic valve
replacement.
A and B, Sagittal (A) and axial (B) gated steady-state free precession breath-hold
MR images show sternal surgical artifact and mechanical aortic valve (oval, A),
descending aortic dissection (asterisks indicate true lumen), fetus with placenta
(p), and right iliac dissection extension (circle, B).
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A B

Fig. 3—36-year-old woman with shortness of breath in week 12 of pregnancy.

A and B, Coronal (A) and axial (B) steady-state free precession breath-hold
localizer images show left main pulmonary artery filling defects (oval, A; circle, B)
interpreted as acute pulmonary embolism. No further examination was required.

A B

woman have not been conducted” and “[this
agent] should only be used during pregnancy if
the potential benefit justifies the potential risk
to the fetus” are typically noted in package in-
serts [48]. Because gadolinium-based contrast
agents traverse the placental barrier, they are
excreted by the fetus in a manner similar to ex-
cretion of iodinated contrast agents and small-
molecule radiopharmaceuticals and enter the
amniotic circulation. Because of the possibili-
ty of gadolinium accumulation, for imaging of
pregnant patients, it is reasonable to avoid the
three least thermodynamically stable gadolini-
um-based contrast agents: gadodiamide, gado-
versetamide, and gadopentetate.
Suspected Pulmonary Embolism
in Pregnant Patients
Compared with age-matched nonpregnant
women, pregnant women are at two to four
times the risk of pulmonary embolism (PE).
One in 1000 pregnancies [21, 49–50] may be
complicated by PE, and PE is the cause of 20%
of all maternal deaths [51]. The clinical diag-
nosis of PE in a pregnant patient is particular-
ly difficult because mild shortness of breath,
elevated heart rate, and swollen legs are ex-
pected in late pregnancy, and Wells criteria
and d-dimer levels may be unreliable in preg-
nancy [51]. In view of the clinical problem of

518 AJR:200, March 2013

 Cardiovascular Imaging of the Pregnant Patient

TABLE 5: Comparison of Imaging Strategies for Pulmonary Embolism in a fetal radiation. The maternal breast may be
Pregnant Patient relatively more radiosensitive than the breasts
Ventilation-Perfusion of nonpregnant women. Ventilation-perfusion
Characteristic Pulmonary CT Angiography Scintigraphya scintigraphy presents relatively low fetal irra-
Accuracy High High (with pulmonary CT diation, although the radiation is somewhat
angiography backup) greater than that of pulmonary CTA. Myocar-
dial perfusion, viability, and blood pool studies
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Availability High Low

Efficiency <1h
Expense High
Reliability High (may be reduced in pregnancy)
Risks Iodinated contrast agent
Fetal dose (mGy) 0.01–0.66
Maternal breast dose (mGy) 20–70
aPulmonary CT angiography may be required if ventilation-perfusion scanning is nondiagnostic.
suspected PE in a pregnant patient, 2011 con-
sensus guidelines from the American Tho-
racic Society and the Society of Thoracic
Radiology along with the Society of Nucle-
ar Medicine and Molecular Imaging and the
American College of Obstetricians and Gyne-
cologists recommend initial lower-extremity
Doppler imaging and chest radiography fol-
lowed by pulmonary CT angiography (CTA)
if the chest radiographic findings are abnor-
mal and ventilation-perfusion scintigraphy if
the radiographic findings are normal (and in
the absence of asthma). Follow-up is conduct-
ed with pulmonary CTA if the ventilation-per-
fusion findings are neither clearly positive nor
clearly negative [52, 53]. Proceeding direct-
ly to pulmonary CTA is a credible alternative
strategy [54–58].
Physiologic increased breast glandular tis-
sue of pregnancy can cause increased breast
radiosensitivity [58]. CT strategies to reduce
breast exposure should be considered [59].
Table 5 compares the advantages and disad-
vantages of pulmonary CTA and ventilation-
perfusion scanning for pregnant patients [21,
49–51, 57].
MRI and MR angiography (MRA) are al-
ternatives for imaging of pregnant patients
with suspected PE. Unenhanced and enhanced
MRA have satisfactory sensitivity (89–100%)
and specificity (93–98%) for the detection of
PE [60, 61]. Use of newer unenhanced 3D high-
resolution respiratory-triggered cardiac-gated
MRA sequences will likely improve depiction
of more peripheral pulmonary vessels, further
reducing the use of gadolinium-based contrast
agents in pregnant patients. Figure 3 shows a
PE identified on breath-hold steady-state free
precession localizer images of a 36-year-old
woman with a 12-week pregnancy.
Several hours
High
Moderate (3–25% nondiagnostic)
0.1–0.8
0.22–0.28
Summary
Nine sequential questions to consider re-
garding cardiovascular imaging of a preg-
nant patient are as follows: 1, Is the patient
pregnant, and if so, what is the gestational
age? 2, Is echocardiography satisfactory for
diagnosis? 3, Is additional imaging appropri-
ate to address the clinical question? 4, Can
imaging be delayed until later in pregnancy
(second or third trimester) or until after de-
livery? 5, Is obstetric intervention before im-
aging a possibility, termination of pregnancy
a consideration, or early delivery a consider-
ation? 6, Can MRI address the clinical situ-
ation? 7, Is imaging with radiography, fluo-
roscopy, CT, or radiopharmaceutical agents
required? 8, Is imaging with a contrast agent
essential for diagnosis and treatment? 9, Are
interventions (reduced tube current, reduced
voltage, reduced radiopharmaceutical dose;
increased hydration and voiding) appropriate
to reduce fetal radiation exposure?
Relative risk considerations for cardiovas-
cular imaging of a pregnant patient may be
summarized as follows: Echocardiography can
be performed at any time. Cardiac MRI, MRA,
echocardiography with agitated saline micro-
bubble contrast or dobutamine (pregnancy cat-
egory B) stress studies, and chest radiography
may be performed as indicated. Gadolinium-
based cardiac MRI contrast agents, including
the more stable agents gadoteridol and gado-
benate dimeglumine; echocardiographic hyper-
emic challenge agents such as adenosine and
regadenoson; and radiopharmaceuticals are
pregnancy category C. Although iodinated
contrast agents typically traverse the placenta,
the use of contrast agents in pregnancy is con-
sidered relatively safe (pregnancy category B).
Pulmonary and cardiac CTA deliver minimal
can expose the fetus to radiation doses. Even so,
nuclear cardiology procedures are unlikely to
exceed fetal radiation doses of 50 mGy. Cardiac
catheterization, coronary angiography, and
electrophysiologic studies, even with complex
interventions, may be performed during preg-
nancy with relatively low fetal exposure. Fetal
shielding with a lead apron is minimally helpful
at best during chest CT and fluoroscopy. The
use of fluoroscopy and CT must be minimized
when the fetus is in the primary x-ray beam.
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