Radiation risk

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Radiation risk in medical field

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Pregnancy and Medical Radiation : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Pregnancy and Medical Radiation Bandar Al-Bahouth BSc, MSc Chief Technologist & RPO

Contents : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Contents Introduction Fetal radiation risks Informed consent, notices, pregnancy determination Fetal doses from procedures Pregnant workers Research involving radiation during pregnancy Issues regarding termination of pregnancy

Introduction : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Introduction Thousands of pregnant women are exposed to ionising radiation each year Lack of knowledge is responsible for great anxiety and probably unnecessary termination of pregnancies For most patients, radiation exposure is medically appropriate and the radiation risk to the fetus is minimal

Example: justified use of CT Pregnant female, was in motor vehicle accident : 

Example: justified use of CT Pregnant female, was in motor vehicle accident Fetal skull ribs Blood outside uterus Fetal dose 20 mGy

3 minute CT exam and taken to the operating room. She and the child survived : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— 3 minute CT exam and taken to the operating room. She and the child survived Free blood Kidney torn off aorta (no contrast in it) Splenic laceration

Fetal radiation risk : 

Fetal radiation risk There are radiation-related risks throughout pregnancy that are related to the stage of pregnancy and absorbed dose Radiation risks are most significant during organogenesis and in the early fetal period, somewhat less in the 2nd trimester, and least in the 3rd trimester Less Least Most risk

Radiation-induced malformations : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Radiation-induced malformations Malformations have a threshold of 100-200 mGy or higher and are typically associated with central nervous system problems Fetal doses of 100 mGy are not reached even with 3 pelvic CT scans or 20 conventional diagnostic x-ray examinations These levels can be reached with fluoroscopically guided interventional procedures of the pelvis and with radiotherapy

Central nervous system effects : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Central nervous system effects During 8-25 weeks post-conception the CNS is particularly sensitive to radiation Fetal doses in excess of 100 mGy can result in some reduction of IQ (intelligence quotient) Fetal doses in the range of 1000 mGy can result in severe mental retardation and microcephaly, particularly during 8-15 weeks and to a lesser extent at 16-25 weeks

Slide 9: 

Heterotopic gray matter (arrows) near the ventricles in a mentally retarded individual occurring as a result of high dose in-utero radiation exposure

Slide 10: 

Frequency of microcephaly as a function of dose and gestational age occurring as a result of in-utero exposure in atomic bomb survivors (Miller 1976) Dose (cGy)

Leukaemia and cancer… : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Leukaemia and cancer… Radiation has been shown to increase the risk for leukaemia and many types of cancer in adults and children Throughout most of pregnancy, the embryo/fetus is assumed to be at about the same risk for carcinogenic effects as children

Leukaemia and cancer (cont’d) : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Leukaemia and cancer (cont’d) The relative risk may be as high as 1.4 (40% increase over normal incidence) due to a fetal dose of 10 mGy For an individual exposed in utero to 10 mGy, the absolute risk of cancer at ages 0-15 is about 1 excess cancer death per 1,700

Probability of bearing healthy children as a function of radiation dose : 

Probability of bearing healthy children as a function of radiation dose

Pre-conception irradiation : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Pre-conception irradiation Pre-conception irradiation of either parent’s gonads has not been shown to result in increased risk of cancer or malformations in children This statement is from comprehensive studies of atomic bomb survivors as well as studies of patients who had been treated with radiotherapy when they were children

Informed consent and understanding : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Informed consent and understanding The pregnant patient or worker has a right to know the magnitude and type of potential radiation effects that might result from in-utero exposure Communication should be related to the level of risk. Communication that risk is negligible is adequate for very low dose procedures (<1 mGy to the fetus) If fetal doses are above 1 mGy, a more detailed explanation should be given

Exposure of pregnant patients : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Exposure of pregnant patients In some circumstances, the exposure is inappropriate and the unborn child may be at increased risk of harm to health Prenatal doses from most properly performed diagnostic procedures present no measurably increased risk of prenatal death, malformation, or mental impairment Higher doses such as those from therapeutic procedures can result in significant fetal harm

Medical radiation procedures : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Medical radiation procedures All medical practices (occupational and patient-related) should be justified (more benefit than risk) Medical exposures should be justified for each patient before they are performed After it is decided to do a medical radiation procedure, the fetal radiation dose should be reduced while still obtaining the required diagnostic information

Evaluation of potentially pregnant patients : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Evaluation of potentially pregnant patients In females of child-bearing age, an attempt should be made to determine who is, or could be, pregnant, prior to radiation exposure

Notices : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Notices A missed period in a regularly menstruating woman should be considered due to pregnancy, until proven otherwise Notices regarding pregnancy should be posted in patient waiting areas, such as If it is possible that you might be pregnant, notify the physician or other staff before your x-ray examination, treatment, or before being injected with a radioactive material

Approximate fetal doses from conventional x-ray examinations : 

Approximate fetal doses from conventional x-ray examinations

Approximate fetal doses from fluoroscopic and computed tomography procedures : 

Approximate fetal doses from fluoroscopic and computed tomography procedures

Higher dose procedures : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Higher dose procedures Radiation therapy and interventional fluoroscopically-guided procedures may give fetal doses in the range of 10-100 mGy or more depending on the specifics of the procedure After such higher dose medical procedures have been performed on pregnant patients, fetal dose and potential fetal risk should be estimated by a knowledgeable person

Nuclear medicine and pregnant patients… : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Nuclear medicine and pregnant patients… Most diagnostic procedures are done with short-lived radionuclides (such as technetium-99m) that do not cause large fetal doses Often, fetal dose can be reduced through maternal hydration and encouraging voiding of urine Some radionuclides do cross the placenta and can pose fetal risks (such as iodine-131)

Nuclear medicine and pregnant patient (cont’d) : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Nuclear medicine and pregnant patient (cont’d) The fetal thyroid accumulates iodine after about 10 weeks gestational age High fetal thyroid doses from radioiodine can result in permanent hypothyroidism If pregnancy is discovered within 12 h of radio-iodine administration, prompt oral administration of stable potassium iodine (60-130 mg) to the mother can reduce fetal thyroid dose. This may need to be repeated several times

Approximate whole body fetal dose (mGy) from common nuclear medicine procedures : 

Approximate whole body fetal dose (mGy) from common nuclear medicine procedures

Nuclear medicine and breast feeding : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Nuclear medicine and breast feeding A number of radionuclides are excreted in breast milk. It is recommended that breast feeding is suspended as follows: Completely after 131I therapy 3 weeks after 131I, 125I, 67Ga, 22Na, and 201Tl 12 h after 131I hippurate and all 99mTc compounds except as below: 4 h after 99mTc red cells, DTPA, and phosphonates

Research on pregnant patients : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Research on pregnant patients Research involving radiation exposure of pregnant patients should be discouraged

Radiation exposure of pregnant workers : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Radiation exposure of pregnant workers Pregnant medical radiation workers may work in a radiation environment as long as there is reasonable assurance that the fetal dose can be kept below 1 mGy during the pregnancy 1 mGy is approximately the dose that all persons receive annually from penetrating natural background radiation

Termination of pregnancy… : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Termination of pregnancy… High fetal doses (100-1000 mGy) during late pregnancy are not likely to result in malformations or birth defects since all the organs have been formed A fetal dose of 100 mGy has a small individual risk of radiation-induced cancer. There is over a 99% chance that the exposed fetus will NOT develop childhood cancer or leukaemia

Termination of pregnancy (cont’d) : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Termination of pregnancy (cont’d) Termination of pregnancy at fetal doses of less than 100 mGy is NOT justified based upon radiation risk At fetal doses between 100 and 500 mGy, decisions should be based upon individual circumstances 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

Risks in a pregnant population not exposed to radiation : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Risks in a pregnant population not exposed to radiation Risks: Spontaneous abortion > 15% Incidence of genetic abnormalities 4-10% Intrauterine growth retardation 4% Incidence of major malformation 2-4%

Slide 32: 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Unnecessary examination (justification) Unnecessary exposure (optimization) Inadequate examination, which can lead to incorrect or incomplete diagnosis PROTECTION FROM WHAT?

Slide 33: 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— PLEASE DON’T SHOOT ME…!

Web sites for additional information on radiation sources and effects : 

INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION —————————————————————————————————————— Web sites for additional information on radiation sources and effects European Commission (radiological protection pages): europa.eu.int/comm/environment/radprot International Atomic Energy Agency: www.iaea.org International Commission on Radiological Protection: www.icrp.org United Nations Scientific Committee on the Effects of Atomic Radiation: www.unscear.org World Health Organization: www.who.int

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