Resources on Subject
Radiation Management of Pregnant
Patients and Pregnant Staff
Louis K. Wagner, Ph.D.
Department of Radiology
http://www.uth.tmc.edu/radiology/web_pub.html
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Educational objectives of this course
Assessing risks to a conceptus at < 0.25 Gy
•
• Depends on gestation age
• Depends on dose
• Requires attention to communication for
proper assessment
• Requires attention to records for proper
assessment
• Perspective is always a matter of science,
opinion, and presentation
•
•
To develop a working perspective on the
risks involved with radiation exposure to
the pregnant individual.
To itemize procedural tasks necessary to
properly manage and monitor radiation
delivery.
To review professional counseling and
the role of the medical physicist in the
management of patients and personnel.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Risks and gestation age
Risks and gestation age
• In obstetrics, gestation age is usually
dated on menstruation, not conception.
• Menstrual age may be based on tests or
on menstrual history, and conception age
may differ depending on patient’s
menstrual patterns and health.
• Roughly speaking menstrual age and
gestation age are the same thing and both
= conception age + 2 weeks.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Lesson:
Before discussing risks, be sure to
determine the age of a conceptus
according to a common reference –
menstruation or conception. Two weeks
can make an enormous difference in risk
assessment.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Potential Risks at Doses under 200 mGy
Risks and gestation age
Risk
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
Mechanisms for effects:
Misrepaired sub-cellular changes – stochastic
in nature, include cancer and heritable
genetic effects.
Cell death – detectable effects due to cell death
have a practical threshold below which the
effect is not observed, include all forms of
malformation.
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Potential Risks at Doses under 200 mGy
Potential Risks at Doses under 200 mGy
Risk
Risk
Cancer
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
~0
All stages??
Cancer
Early Termination
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
~0
All stages??
~100
<2wks (postconception)
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Potential Risks at Doses under 200 mGy
Potential Risks at Doses under 200 mGy
Risk
Risk
Cancer
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
~0
All stages??
Early Termination
~100
<2wks (postconception)
Malformation
~100
>2, <9 wk
Cancer
Early Termination
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Probable single-dose
threshold (mGy)
10
Vulnerable
Postconception age
~0
All stages??
~100
<2wks (postconception)
Malformation
~100
>2, <9 wk
Cretinism
I-131
After thyroid function
commences ~ 8 wk
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Potential Risks at Doses under 200 mGy
Potential Risks at Doses under 200 mGy
Risk
Risk
Cancer
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
~0
All stages??
Early Termination
~100
<2wks (postconception)
Malformation
~100
>2, <9 wk
Cretinism
I-131
Small head size
> 50
After thyroid function
commences ~ 8 wk
>2, <16 wk
Vulnerable
Postconception age
~0
All stages??
Early Termination
~100
<2wks (postconception)
Malformation
~100
>2, <9 wk
Cretinism
I-131
Cancer
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Probable single-dose
threshold (mGy)
13
Small head size
> 50
After thyroid function
commences ~ 8 wk
>2, <16 wk
IQ deficit
~100
>7, <16 wk
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Potential Risks at Doses under 200 mGy
Risk
Cancer
Probable single-dose
threshold (mGy)
Vulnerable
Postconception age
~0
All stages??
Early Termination
~100
<2wks (postconception)
Malformation
~100
>2, <9 wk
Cretinism
I-131
Small head size
> 50
After thyroid function
commences ~ 8 wk
>2, <16 wk
IQ deficit
~100
>7, <16 wk
Severe mental
retardation
~150
>7, <16 wk
An exposure higher than
0.4 mGy (to the thyroid)
during gestation
occurred in mothers of
low-birth-weight infants.
Retrospective study:
women with low birth
weight babies are more
likely to have had dental
x-rays that resulted in
more than 0.4 mGy to
the thyroid.
© 2003 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Risks? What Risks?
Risks? What Risks?
Scientists present data in a variety of quanitiative ways that are useful to
scientists, but are frequently misused when communicating to a general
audience.
Mrs. Smith, the pelvic CT study for your kidney
Mrs. Smith, I know that you have heard that the
infection that you had two weeks ago, before we
radiation
you received
froma your
CT examination
Does quantifying
risk give
realistic
or a distorted
knew you were pregnant, has perhaps doubled the
may
have increased
the chances
thatshould
your child
perspective
on how much
someone
be
risk that your child will develop cancer before age 18.
could
develop
cancer,
concerned
about
it? but this risk is very small
and the likelihood of a normal outcome is nearly
the same as it is for any child. Without the
radiation 99.7%remain free of cancer. In your
case this might be around 99.4%.
Relative risk versus absolute risk ---- what is the difference in perspective?
Which explanation most appropriately conveys
the risk? Both are quantitatively correct.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Radiation and healthy children
Conceptus dose (mGy)
Probability of no
malformation (%)
Probability of no cancer
before age 19 y (%)
0
97
99.7
0.5
97
99.7
1.0
97
99.7
2.5
97
99.7
5
97
99.7
10
97
99.6
50
97
99.4
100
~ 97
99.1
Risk of cancer mortality ~1/17,000 per mGy dose to conceptus
From ICRP # 84
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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My clinical guidelines on risks
for patients
My clinical guidelines on risks
for patients
• Keep benefit/risk as high as reasonable achievable;
• At doses < 50 mGy to conceptus, risk results in
minimal potential harm, but should be avoided if
possible;
• At doses between 50 and 100 mGy risk is still
minimal on a measureable basis, but microscopic
changes in the cerebral cortex have been
documented when radiation is delivered in
vulnerable periods for cerebral development.
• At doses above 100 mGy risk thresholds are reached
and risks increase as dose increases.
• See ICRP 84 for details on risk.
• Keep benefit/risk as high as reasonable achievable;
• At doses < 50 mGy to conceptus, risk results in
minimal potential harm, but should be avoided if
possible;
• At doses between 50 and 100 mGy risk is still
minimal on a measureable basis, but microscopic
changes in the cerebral cortex have been
documented when radiation is delivered in
vulnerable periods for cerebral development.
• At doses above 100 mGy risk thresholds are reached
and risks increase as dose increases.
• See ICRP 84 for details on risk.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
My clinical guidelines on risks
for patients
My clinical guidelines on risks
for patients
• Keep benefit/risk as high as reasonable achievable;
• At doses < 50 mGy to conceptus, risk results in
minimal potential harm, but should be avoided if
possible;
• At doses between 50 and 100 mGy risk is still
minimal on a measureable basis, but microscopic
changes in the cerebral cortex have been
documented when radiation is delivered in
vulnerable periods for cerebral development.
• At doses above 100 mGy risk thresholds are reached
and risks increase as dose increases.
• See ICRP 84 for details on risk.
• Keep benefit/risk as high as reasonable achievable;
• At doses < 50 mGy to conceptus, risk results in
minimal potential harm, but should be avoided if
possible;
• At doses between 50 and 100 mGy risk is still
minimal on a measureable basis, but microscopic
changes in the cerebral cortex have been
documented when radiation is delivered in
vulnerable periods for cerebral development.
• At doses above 100 mGy risk thresholds are reached
and risks increase as dose increases.
• See ICRP 84 for details on risk.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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My clinical guidelines on risks
for patients
My clinical guidelines on risks
for workers
• Keep benefit/risk as high as reasonable achievable;
• At doses < 50 mGy to conceptus, risk results in
minimal potential harm, but should be avoided if
possible;
• At doses between 50 and 100 mGy risk is still
minimal on a measureable basis, but microscopic
changes in the cerebral cortex have been
documented when radiation is delivered in
vulnerable periods for cerebral development.
• At doses above 100 mGy risk thresholds are reached
and risks increase as dose increases.
• See ICRP 84 for details on risk.
• Keep benefit/risk as high as reasonable
achievable;
• Carcinogenic risk is only important
risk;
• Manage all benefit/risk from the start of
employment.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Procedures to Manage Risks
------
Procedural Tasks
Be Prepared
Prepare policies and procedures for all employees and
have special policies regarding pregnant employees;
Advise workers about the radiation environment in
which they will be working, the likely doses to which
they will be exposed, the regulatory philosophy
about their exposures and the measures that can be
taken to optimize their benefit/risk;
Prepare policies and procedures for pregnant patients;
Advise medical personnel about the need to screen for
pregnancy and advise them on how it must be done
and the procedures to implement the policies.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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7
It would be nice if the sign
mentioned that this must
occur before the patient
has the examination!
This would be better phrased as “…before any medications, inocculations or
tests are started.”
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Procedures to Manage Risks
Prepare-screen
Policies and procedures on screening
How to screen
Ages to screen
Exams for which screening applies
Minors and guardians
Actions if pregnant or potentially pregnant.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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{Potential} Guidelines for Our Hospital regarding the radiography and pregnancy in girls and women from the
ages of 12 – 50 years who are to undergo x-rays of the abdomen, pelvis or radionuclide studies.
•Know and understand the policies of Our Hospital regarding screening procedures for potential pregnancy in women
between the ages of 12 and 50 years.
•Never perform the screening interrogatories in an area where members of the public are present or where there are
other individuals who are not essential to the procedure.
•Always be polite when escorting a patient to the examination suite.
•When a guardian is present::
If a guardian is with the patient who is between 12 – 17 years of age and the guardian does not ask to attend the
procedure, then escort the patient to the procedure room.
If the guardian requests to attend the procedure, advise the guardian that that is possible but that you will first have
to prepare the patient privately for the procedure. Advise the guardian that this is a matter of medical protocol and
that the guardian will be asked to attend the examination once the patient is ready.
If the guardian objects, call the radiologist. If the guardian agrees, then proceed to escort the patient to the
examination suite.
•When in the privacy of the examination room or in a very soft tone of voice when at the bedside of the patient,
address the patient as follows:
“Before we proceed with your x-rays (or scan) there are few questions I must ask you. These questions are of a
personal nature but are medically necessary before we can proceed. We need your full and open cooperation in this
matter. Is that OK?” (If “not OK”, call the radiologist.)
•When the patient consents to this introductory statement, proceed to ask:
“My first question is: Could you be pregnant?”
•Write the response in the patient’s record and proceed to the next question:
“The last question is: What was the date of your last normal and complete menstrual cycle?”(The words “normal
and complete” are necessary because women in early pregnancy can have minor discharge as a result of
implantation.)
•If a young patient does not appear to understand the question, call the radiologist. Write the response to this question
in the record and then politely thank the patient for her cooperation.
•Now proceed to carry out the appropriate actions as outlined in the policies and procedures. If it is OK to proceed with
the examination and a guardian is waiting, send for the guardian to attend the procedure. If there is some delay due to
a potential for pregnancy, advise the guardian that the radiologist is consulting with the referring physician to
determine the most proper examination to perform.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Can the results of a pregnancy test be used in
lieu of screening interogatories?
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{Potential} Guidelines for Our Residents in Radiology on the Management and Counseling of Pregnant
Patients Who Require Diagnostic X-Ray Imaging of the Abdomen or Pelvis, Radionuclide Studies, or
Fluoroscopically Guided Therapeutic Procedures
•Know and understand the policies of Our Hospital regarding screening of women between the ages 12 and 50 years
for pregnancy prior to diagnostic x-ray imaging of the abdomen or pelvis, radionuclide studies, and fluoroscopically
guided therapeutic procedures.
•Any life-saving emergency procedure should be done without delay, regardless of pregnancy.
•For patients known to be pregnant, reasonable consideration must first be given to alternative examinations that do not
require the use of ionizing radiation, i.e., ultrasound or MR.
•If an alternative examination is not possible, consider modifying the examination to obtain an adequate diagnosis. Or,
consider another type of x-ray examination that uses less radiation than the one ordered. Such a modification must not
compromise the diagnostic adequacy, lest the study need to be repeated and unnecessarily expose the patient to even
more radiation.
•Verbally counsel the patient about the need for the study. Advise her that a benefit-risk assessment has been made
and, in the best medical judgment of the physicians, the medical benefits of performing the examination outweigh any
potential risks to the child.
•For single pass CT studies of the abdomen-pelvis, the dose to the conceptus is not likely to exceed 4 rad (40 mGy) for
studies performed at proper technique and is likely to be less than this. For this level of dose, there are no known risks
to the development of the child. The only potential risk is for radiation-induced neoplasm (including cancer) that may
develop later in life. This risk is very small and the likelihood of this not occurring exceeds 99% of the normal likelihood
of remaining healthy. For pelvic CT, dosimeters should be placed anteriorly and posteriorly on the patient at the level of
the conceptus if time permits. Obtain them from the radiation safety office.
•In pregnant patients who require CT of the pelvis, a single pass of the pelvis should be all that is needed. Any request
for dual pass must be carefully and cautiously considered. If two or more passes over the pelvis are involved, a more
involved assessment of dose and risk is required.
•All planar diagnostic procedures deliver much less radiation to the baby than single-pass CT, except on occasion for
fluoroscopy of the pelvis. Therefore there are no additional concerns for planar studies.
•For pelvic angiography dosimeters should be placed anteriorly and posteriorly on the patient at the level of the
conceptus. Obtain them from the radiation safety office.
•Notate the results of all counseling in the patient’s chart.
My policy is this:
Pregnancy tests are not required and are not
a part of the standard of care for
radiography.
If results of any recent pregnancy test are
positive for pregnancy, consult with the
radiologist before proceeding.
If results of any recent pregnancy test are
negative, disregard the results and proceed
with interrogatories.
Pregnancy tests are required for all
administrations of I-131 and therapeutic
radionuclides administered IV or per os.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Procedures to Manage Risks
Prepare-Monitor doses
Know doses ahead of time:
Collect data at routine physics inspections
regarding conceptus doses from particular
examinations
Educate fluoroscopists of management of
doses, especially during pregnancy
Report conceptus doses for average patient
from single pass CT of the pelvis
Take action if protocols deliver
unnecessarily high doses.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Measure
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Corrected
kV
mA
Time (s)
Slice Interval
(mm)
Helical
Pitch
FOV (cm)
Dose(mR)
Dose (mrad)
Head (holder)
120
200
1
5
No
1
25
81.4
2920
Head (holder)
140
170
1
5
Yes
1
25
98.1
3519
Head (holder)
140
170
1
5
No
1
25
98.1
3519
Head (holder)
120
300
1
5
No
1
25
122
4376
Head (holder)
120
280
1
5
No
1
25
114
4089
Head (holder)
120
170
1
5
No
1
25
69.2
2482
Head (holder)
120
200
1
10
No
1
25
161
2888
Head (holder)
120
200
1
7
No
1
25
113
2895
Head (holder)
120
200
1
3
No
1
25
51.3
3067
Head (holder)
120
200
1
1
No
1
25
17.8
3193
Table (Head ph)
120
250
1
5
No
1
36
104
3731
Conceptus
120
250
1
5
No
1
36
104
2574
Exam
37
Note: conceptus dose is based on contiguous scanning, divide by pitch to obtain
dose when pitch different from 1.0.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Pregnant
Patient
My guidelines for workers
Prepare-Advise
Pregnant
Patient
• Prepare policies and procedures for your facility
• Counseling on risks should occur before pregnancy
occurs (e.g., at pre-employment, orientation, or in
educational setting);
• Dose monitoring should start before employee
becomes pregnant;
• Employee is advised at pre-employment, oreintation,
or in educational setting, that she must report a
pregnancy to the RSO before any special measures
can be taken to assist her in optimizing her
benefit/risk for her condition;
• Male employees are included in counseling on risks
and advised of policy about their obligation to pitch
in when readjustment of schedules may be
necessary.
Not for patients!
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Professional Counseling—the patient
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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•To: Dr. Noname
•CONFIDENTIAL
•Re: Shesa Patient
•On 2 May 2005 I was provided by your assistant , Dr. Resident, documentation on radiologic examinations that the
above patient underwent on 30 February 2005. These included :
•One nuclear medicine bone scan involving 21.3 mCi of 99m-Tc HDP
•Several CT scans of the following:
•Scout image (missing, but presumably of the head)
•CT imaging of the head involving a volume about 13-cm long of contiguous slices consisiting of 3-mm and 5-mm
thickness at 3-mm and 5-mm intervals. Technique was 140 kVp, 170 mA, 2 seconds per rotation.
•Scout image of the torso, excluding the uterus.
•CT scan without contrast involving a volume about 23-cm long of contiguous 10-mm images acquired at 10-mm
intervals. Technique was 120 kVp, 180 mA, 1 second per rotation. Volume was from top of hips to just above the
diaphragm.
•First phase contrast involving a volume spanning 32 cm in length from about 5 cm above pelvic bone to superior
aspect of lungs. Technique was 120 kVp, 180 mA, 1 second per rotation, pitch of 2:1.
•Second contrast phase spanning a volume of 26 cm in length from top of hip bone to top of diaphragm.
Technique same as above.
•Third phase contrast from about 3-cm above hip bone for 22 cm.
•Another scout (missing, presumably of the head)
•A head series, I believe (missing)
•A retrospective series (missing)
•This patient is an average size patient with abdominal dimensions of about 24 cm x 30 cm. It is my understanding that
the patient was about 4 weeks from her last LMP when these studies were acquired. None of the above series directly
irradiated the uterus. Therefore the entire dose from the CT scans was from scattered radiation. The most inferior scan
was about 10 cm from the top of the uterus. Please note that I do not have dosimetry information about the CT scanner
in question. Most of these GE scanners result in similar outputs, but to provide a more confidient set of calculations, I
would need to have dose data on the scanner in question. Based on experience with another GE scanner, I estimate
the dose to the uterine area to be about 0.76 rad (7.6 mGy). Providing for a conservative potential error of a factor of
two in the estimate, the dose would have been below 1.5 rad (15 mGy). The majority of the dose to the uterus is from
radioactivity in the uterus and in the urinary bladder from the Nuclear bone scan.
Caution : Always separate your medical physics services from the physician’s
medical care services. I strongly recommend that it be made perfectly clear to
all parties ahead of time that as a medical physicist you are not a medical
doctor and all medical advice should be requested of a responsible physician.
• It is the physician’s role to counsel pregnant patients
ahead of time;
• Physicist monitors doses in real-time if appropriate;
• Physicist determines doses when necessary and
files a dose report with the appropriate physician;
• Report to your client along proper channels;
• Consult with referring physicians or radiologists on
information they request about dose and risk;
• Physician to file information in patient’s record.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
Woman
Resident
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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My guidelines for
counseling pregnant
workers
• Benefits are decided by the worker, not the
employer--worker decides if she wants to
avoid radiation areas altogether;
• Review history of pelvic exposures and
advise of nature of risk and risk levels;
• Counsel on behavior to keep doses well
managed;
• Provide extra shielding if desired;
• Provide realtime monitors if desired.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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6 lbs.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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12
10 lbs.
14 lbs.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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Educational objectives of this course
To develop a working perspective on the
risks involved with radiation exposure to
the pregnant individual.
To itemize procedural tasks necessary to
properly manage and monitor radiation
delivery.
To review professional counseling and
the role of the medical physicist in the
management of patients and personnel.
© 2004 by Louis K. Wagner, Ph.D. Reproduction not permitted without the written consent of the author.
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