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Problem Statement

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  1. Effects of Radiation Exposure on the Developing FetusHannah Connolly, Janessa Gioia, Gillian Reid, Nadine Savoie, Suzanne TaylorUniversity of New Brunswick

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

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

  4. Harmful Retrieve from http://health-e-waste.blogspot.com/ Teratogenic- causing congenital malformations Carcinogenic- cancer causing Mutagenic- causing genetic changes (Whitt, 2010) Retrieve fromhttp://www.biomol.de/wiki/index.php/DNA_Damage_and_Repair_Antibodies Retrieve from feed://www.blogger.com/feeds/4105934082939383122/posts/default

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

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

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

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

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

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

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

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

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

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

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

  16. Cancer Diagnosis & Treatment when Pregnant Cancer: 1 per 1000 pregnancies (Kal & Struikmans, 2005; Pavlidis & Penteroudakis, 2005) Most common cancer types (Greskovich & Macklis, 2000; Pavlidis & Penteroudakis, 2005). Carcinoma of the cervix: is the most common Breast cancer pregnant patient 1 in 3000 (Berry et al. 1999; Greskovich & Macklis, 2000; Kal & Struikmans, 2005; Pandit-Taskar et al. 2006) Radiation therapy is not usually offered during pregnancy (Pavlidis & Penteroudakis, 2005; Kal & Struikmans, 2005) Retrieve from http://www.oregonlive.com/kiddo/index.ssf/2008/08/31-week/ Retrieved from http://www.fightpink.org/wp-content/uploads/2009/08/pregnantandcancer.jpg Retrieved from http://www.blogcdn.com/www.parentdish.com/media/2010/10/pregnant-breast-cancer-330-.jpg

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

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

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

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

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

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

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

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

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

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

  27. Perception of the Risks Ontario survey Misperceptions of physicians Could lead to anxiety, delay of care among pregnant woman (Ratnapalan et al., 2004) Misperception of patients may be caused by misinformation (Bentur et al. 1991) Retrieve from http://www.albertapci.ca/SiteCollectionImages/Subpages/doctorChildCheckup.jpg Retrieve from http://www.choa.org/images/photography/radiology/CTscan07.jpg Retrieve from http://www.babble.com/CS/blogs/strollerderby/2007/09/01-07/doctor-child.jpg

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

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

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

  31. References