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Briggs 1 Cori Briggs English 2089 Professor Skutar December 3, 2015 Essay 4: Capstone Assignment An Argument on the Dangers of Radiologic Testing on Pregnant Women Hello, my name is Cori Briggs and I am currently a student aspiring for a career in the field of Radiologic Technology by working towards acceptance into the RT program here at UC Blue Ash. Radiologic imaging can be a very controversial topic and sometimes, that is what makes it so interesting, appealing, and ever changing. Radiology has certainly sparked a fair amount of arguments over its dangers; especially to patients with certain conditions, specifically pregnant patients. There is a great debate between the worlds of healthcare and parenting regarding diagnostic radiology and whether or not it is safe for expecting mothers. The safety of diagnostic imaging in pregnant women is a real concern due to the adverse effects it could have on both mother and fetus. Women have a stringent decision to make when faced with the choice of identifying their health issues and potentially harming their unborn child, I’m sure that some of us in this room have either been in a situation similar to this, or maybe we know someone who has had to make this decision in the past. Briggs 2 Diagnostic radiologic procedures such as x-rays, angiography, MRI, computed tomography, ventilation-perfusion lung scanning, ultrasound, fluoroscopy, etc.., all give great advantages to diagnosing ailments and determining severity. As beneficial as these procedures can be for the overall health of the patient, they also carry great risk that could alter a fetus’ growth and development. Often it becomes an argument of mother’s life versus baby’s life and determining that is the pit of the debate and controversy. Some strongly believe that mothers should ultimately not receive any type of exposure from radiologic imaging as they believe that the risks are too great. Many infer that the human fetus, because of its rapid progression from a single cell to a formed organism in nine months, is more sensitive to radiation than the adult. This inference is supported by the results of experiments in animal models, and experience with human populations that have been exposed to very high doses of radiation, such as atomic bombing victims. There is a strongly fueled fear of miscarriage, birth defects, slow mental development, childhood cancer and deformities, and other unfortunate risks, but fortunately, not all exposures to ionizing radiation result in these outcomes. The risk to the fetus is a function of gestational age at exposure and the radiation dose (Reiman). Before I lose anyone with lingo, discussion of the effects of radiation requires background knowledge of radiation nomenclature and dosimetry. The absorbed dose of radiation is the amount of energy deposited per kilogram of tissue and is measured in "rads." One rad is the energy transfer of 100 ergs per gram of any absorbing material. So here is how the relationships apply to diagnostic X-rays in soft tissue: 1 rad equals 0.01 gray (Gy), which is equal to 0.01 sievert (Sv), which is also equal to1 rem (roentgen-equivalent man) (Kruskal). Don’t worry, there will not be a pop-quiz over this information, I just find the Briggs 3 more background information I am able to relay, the better understanding there will be of what is being presented. Recommendations for termination of pregnancy at fetal doses of less than 100-150 mGy are not justified based upon radiation risk, according to ICRP 84 and Wagner and colleagues. At fetal doses above this level, the decision should be based upon the individual circumstances. This complicated issue involves much more than radiation protection considerations and requires the provision of counseling for the patient and her partner. At fetal doses in excess of 500 mGy, there can be significant fetal damage, the magnitude and type of which is a function of dose and stage of pregnancy (International Commission on Radiological Protection). As many publications and data resources have shown us, diagnostic x-ray exam radiation doses do not approach these levels. Personally, I trust in physicians’ opinions and I am confident that they would never suggest a treatment plan or explore and option that would not ultimately have more gain over loss. Healthcare professionals are fully trained and serving to help and heal, that is their job and ultimate goal. I believe a mother should keep the option to explore diagnostic radiologic imaging as long as all facets and risks are explained properly. A mother has every right to worry about her own health, as well as her child’s. Radiology does come with harmful risks, but the benefit can be so much greater. Conditions and ailments can be found and mapped almost painlessly, and treatment plans can be set into motion very quickly, potentially increasing quality of life. Unless a high number of diagnostic radiological exams of the pelvic area are performed during pregnancy, radiation from routine exams will not result in harmful Briggs 4 effects. Prenatal doses from properly performed diagnostic procedures present no measurable increase in the risk of prenatal death, malformation, or impairment of mental development over the background incidence of these effects (Lester, Saldana, Wagner). People must keep in mind that there are many rules and guidelines set up to assess and rate the risk of exposure and harm from radiation in pregnant women and for their fetuses (Health Physics Society). Healthcare professionals would not advise something that they could not justify having the best possible outcome for each patient. Rights are still rights and a woman carrying a child still has the right and responsibility to protect and care for her own self. It is hoped that a patient would have strong trust and faith in their physician to provide them with the best possible information and healthcare options. Of course there are emergent situations, and these are instances when the pregnant person may not be able to make a coherent health decision, thus the decision could fall into the family’s or healthcare provider’s hands. I believe that making a decision out of raw emotion could be very dangerous and a medical opinion always needs to be considered. However, I do hope that families and loved ones choose to learn and research radiologic options available verses nixing the idea all together, as is could just save and/or prolong their loved one’s life and could very possibly cause little to no harm to the fetus, dependent on the situation of course. Again, healthcare professionals will always be available to guidance and consultation during these events. By no means am I naïve to the dangers present in the use of radiologic procedures in pregnancy cases. I understand the medical risks, and also realize the physiological torment it can have on expecting mothers in a position considering testing and treatment. There Briggs 5 very well have been cases when exposure has had negative outcomes for mother, fetus, or sometimes both. Let’s look at the real life advantages that come from having radiologic testing and procedures available as options in care when pregnant. Not just in life-or-death or any emergent situations. Let’s set aside the technical lingo, which I sincerely apologize for if anyone’s eyes glazed over at the sound of all of that, and talk about some of the reasons pregnant patients would be undergoing a radiologic procedure anyways. A female may be suffering from pneumonia and a chest x-ray will help diagnose this ailment. Pneumonia can limit the amount of oxygen the female is supplying the rest of her body, including her womb and fetus. Her extremities could develop edema and poor circulation, which could cause further complications, especially when carry a child. Fluid could also be settling in her lungs which can be very dangerous, for which she would need a clear image to determine what is there and how to develop a treatment plan before she or baby experience further complications. Dysphagia is a condition meaning difficulty swallowing; this can result from neurological trauma from a variety of circumstances. As I’m sure you all understand, if a patient is having difficulty swallowing this could result in lack of nutrients, aspiration in the wind pipe, and possible harm if a pregnant person is experiencing nausea, what we call morning sickness. In some cases, a feeding tube may need to be placed, and in others, thickener may need to be added to any liquids the patient ingests. Barium swallow test allows physicians to evaluate the swallowing difficulty and severity, while an x-ray can make sure there is not an obstruction. Sometimes guided fluoroscopy is used to aid doctors in the placement of tubing that can help the patient receive nutrients while a treatment plan is being worked. Briggs 6 Now yes, those are serious complications for anyone, much less a pregnant person, but let’s discuss a few more severe examples. Instances that are more “life-or-death”, if you will. Here’s a report for you: So as of 2011, only seven cases of pancreatic adenocarcinoma (basically, a type of cancer that forms in the mucus –secreting glands throughout the body) diagnosed in pregnant persons had been reported as of late 2011 (Stathis, Moore). There was a particular case of pancreatic adenocarcinoma covered, presenting clinically as acute pancreatitis in a pregnant patient. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic mass with an inflammatory component and multiple hyper-intense metastatic lesions in the liver. That means that the movement or spreading of the cancer caused lesions on the organ, in this case, the liver. The patient was initially treated for biliary pancreatitis, and pancreatic cancer was not suspected given her young age and absence of risk factors. A diagnosis of pancreatic cancer in a pregnant patient requires a high reason of suspicion, and pancreatitis can be a very common presentation. Essentially, this was a 25 year old Caucasian woman at 20 weeks gestation with no significant past medical history presenting with a five day history of epigastric pain, nausea, and an episode of emesis, normal vital signs. Sounds pretty routine, right? Well her physical examination revealed a gravid uterus and a mildly tender abdomen with hypoactive bowel sounds. However, right upper quadrant ultrasound revealed a normal gallbladder without stones and no common bile duct dilatation. Her lab work did show some abnormalities, especially regarding her white blood cell count. Our patient was admitted to the hospital for acute pancreatitis, and was initially managed with a nothing-by-mouth status (also known as NPO), intravenous hydration (fluids via IV), and medication for abdominal pain. Sounds unfortunate, yet Briggs 7 routine, right? Well, over the first few days of her stay she had modest clinical improvement, and her amylase and lipase were trending down, this was good. However, she remained symptomatic with episodes of abdominal pain, nausea and vomiting getting worse and worse. Both an MRI and MRCP were performed and revealed a peripancreatic mass that was attributed to inflammatory changes from acute pancreatitis, meaning her condition did start out as mild as it seemed, but transformed from there. Now, had those images never been obtained she would not have gotten an accurate diagnoses and would have gotten much worse instead of better. Five days later endoscopic ultrasound (EUS) revealed sludge in the gallbladder and apparent inflammatory mass changes in the head of the pancreas. After receiving antibiotics for five days, a repeat MRI and MRCP were performed and revealed increasing biliary sludge with common bile duct dilatation and multiple small hyperintensities scattered throughout the liver, interpreted as cysts or hemangiomas. On her 27th day as an inpatient, our patient underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed a short stricture of the distal common bile duct. Biliary sphincterotomy (meaning the bile duct sphincter was removed) and placement of a common bile duct stent were performed to relieve obstruction from the narrow space. She also underwent a cholecystectomy just shortly after her initial surgery. These procedures did go well, although the patient presented to the hospital after discharge with persistent abdominal pain. She underwent a repeat panel of complete biochemical studies and another MRI of the abdomen. The studies were suggestive of metastatic pancreatic adenocarcinoma which was later confirmed by liver biopsy (Perera, Dinushi, Kandavar, Palacios). Briggs 8 Now, I will inform you of the outcome…Physicians decided to administer corticosteroids to the mother to enhance fetal lung maturity and to proceed with delivery at 30 weeks via cesarean section – this was necessary in order to facilitate treatment after delivery (Perera, Dinushi, Kandavar, Palacios). Both mother and baby’s lives are always considered in these cases. The circumstances call for tough decisions, but, after all she had gone through, the patient delivered a viable neonate, what we in the medical field call a baby! Sadly, the patient succumbed to her pancreatic cancer a short two weeks after delivery. The moral of this case’s example is not to upset you or to highlight any dangers of radiologic imaging, this was to serve as a real life, although thankfully rare, situation. This 25 year old mother could have gone on thinking she was just suffering from acute pancreatitis had she refused radiologic testing. Thankfully, she was willing to consider and later opt in for these tests, which believe it or not, did ultimately save a life. I understand her outcome was not ideal, but think about this: she was able to live longer than she possibly could have without seeking proper treatment, she was able to deliver her baby in a safe place verses the possibility of delivering prematurely at home during complications from her cancer; she was also able to witness her child’s birth and make a connection, although very brief. These are absolutely amazing opportunities that arose from a tragically unfortunate circumstance. There are groups that offer a sense of community and support during pregnancy, as well as all kinds of tragedies and illness, maybe you or your loved ones have joined or started one at some point in time. Our very own campus even has a few great groups students are encouraged to join. These groups are a sounding board to voice concerns, gain advice and helpful information, as well as rally against or for causes that hit close to home Briggs 9 with its members. I will never, in any way, bash support groups. I am just here defending the radiologic benefits that some rally so hard to oppose. When a pregnant person is experiencing a medical issue, their minds are already scattered with worry, fear, protective instinct, and conflict while trying to gather the information that is put in front of them. Trying to digest all things at once is certainly stressful and exhausting. It is completely natural and respected to have certain ideas in mind for how you’d like to protect your child during gestational stages; however, somethings don’t always go as planned. Meaning, a person may want to go the natural route when sick with a cold or virus, or during delivery, but often times, circumstances call for medications and procedures that are immensely necessary for ensuring a safe outcome for both mother and child. Being taught or swayed in the direction of fearing medical technology during these times could be hindering when real scenarios are played out. We can all agree that medical emergencies or all medical issues really, are frightening for all of us to some degree or another. If you have been pregnant you understand the worry and concern that comes with the territory for both yourself and baby. With so many possibilities of complications, including: shoulder dystocia, multiple pregnancies, cardiac arrhythmias, fetal cardiac anomalies, malignant disease, neurologic disorders, abdominal pain, hyperemesis, trauma, etc., it is very important to understand who is in your corner should something similar effect you during pregnancy. A patient will be cared for and after by many faces in a hospital, treatment center or physician office. These faces are highly skilled and trained for wat they do and the care they provide will always be tailored to each patient specifically (James, Steer). Each physician, surgeon, pharmacist, and radiation therapist acquires at least two degrees, not to mention multiple Briggs 10 certificates, during their 8-12 years of college education combined with residencies and medical or pharmacy school. Becoming a radiologist requires four years of undergraduate school, four years of medical school and at least four years in a radiology residency program (Ahlqvist). The technologists administering tests and procedures complete intensive 2-4 year programs, and are all tested by state boards as well. Depending on the specific modality they choose to peruse, that could require an additional 1-2 years training and testing (Lau, Pérez, Applegate, Rehani, Ringertz, Robert). So think about it, every single person involved in a pregnant woman’s radiologic testing and treatment plan are extremely qualified, and above all, they are human! Living, breathing, walking, talking, people that have real compassion and empathy, all with the single goal and responsibility to take CARE of you and to keep you safe. I am a strong advocator for patient education, and I strongly believe that our minds should remain open for the possibility of the unknown. Physicians encourage patients to do their research, voice their opinions and concerns about their care and treatment, as well as seek advice and resources whenever necessary. Medical personal and healthcare professionals are here to save lives not endanger them, and the roles they fill are multifaceted to say the least. Medical and technological advancements are being made every day. More and more resources are being verified and produced for patients, and clinical education training is becoming more and more rigorous - All to ensure the best possible education and care for our patients. Radiologic testing and procedures are always preformed with proper precautions and carefully consulted before decisions are made. There would never be a time when a pregnant person would be exposed to anything harmful without thorough evaluation of outcomes. Radiologic technology is an advanced Briggs 11 and tremendously genius resource our world benefits from greatly. Please remember, your healthcare is your decision, and there are professionals to help guide you in your treatment with your absolute safety in mind. Thank you very much for the opportunity to present this topic to you today. I truly hope I have facilitated a fresh outlook on radiologic testing during pregnancy. Briggs 12 Works Cited Ahlqvist, Jan B, Nilsson, Tore A, Hedman, Leif R, Desser, Terry S, Dev, Parvati, Johansson, Magnus, Youngblood, Patricia L, Cheng, Robert P, Gold,Garry E. "A Randomized Controlled Trial on 2 Simulation-Based Training Methods in Radiology: Effects on Radiologic Technology Student Skill in Assessing Image Quality." Simulation in Healthcare: Journal of the Society for Simulation in Healthcare 8.6 (2013): 382. Web. 1 Dec. 2015. Health Physics Society. Hps.org. 13 Aug. 2014. Web. 15 Nov. 2015. International Commission on Radiological Protection. Pregnancy and Medical Radiation. Oxford: Pergamon Press; ICRP Publication 84; 2000. James, D. K, Steer,Philip J. High Risk Pregnancy: Management Options. St. Louis, MO: Saunders/Elsevier, 2011. Web. 1 Dec. 2015. Kruskal, Jonathan MD, PhD. Www.uptodate.com. 10 Jan. 2015. Web. 13 Nov. 2015. Lau, Lawrence S., Pérez, Maria, Applegate, Kimberly E., Rehani, Medan N. , Ringertz, Hans F., Robert, George. (2011) Global Quality Imaging: Improvement Actions. Journal of the American College of Radiology 8, 330-334. Web. 1 Dec. 2015 Perera, Dinushi, Ramprasad Kandavar, and Enrique Palacios. "Pancreatic adenocarcinoma presenting as acute pancreatitis during pregnancy: clinical and radiologic manifestations." The Journal of the Louisiana State Medical Society 163.2 (2011) Expanded Academic ASAP. Web. 28 Nov. 2015 Reiman, Robert E. Www.safety.duke.edu. 29 Feb. 2012. Web. 13 Nov. 2015. Briggs 13 Stathis A, Moore MJ. Advanced pancreatic carcinoma: current treatment and future challenges. Nat Rev Clinical Oncology 2011;7:163-172. 1 Dec. 2015 Wagner LK, Lester RG, Saldana LR. Exposure of the pregnant patient to diagnostic radiations: A guide to medical management, 2nd ed. Madison WI: Medical Physics Publishing; 1997.