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Available online at www.sciencedirect.com

www.elsevier.com/locate/semperi

Timing of MRI in pregnancy, repeat exams, access, and physician qualications

Deborah Levine, MD
Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA

A RT I C L E IN F O

A B S T R A C T
This review addresses specic questions regarding performance and utility of fetal MR. The

Keywords: MRI Fetus Pregnancy CNS abnormalities Prenatal diagnosis

specic issues addressed are (1) physician qualications; (2) MR safety; (3) access to fetal MR; (4) timing of MRI in pregnancy; (5) repeat exams; and (6) when MRI is most effective for prenatal diagnosis. Fetal MRI is a problem-solving tool used for specic indications that are driven by ultrasound or at times by family history. Fetal MR should always be performed with knowledge of the sonographic ndings from prior targeted scan. The best evidence for utility of MR is in assessment of CNS anomalies and assessment of the fetus with airway obstruction requiring decisions regarding mode of therapy. The type of information provided by MR can profoundly impact patient counseling and management. We recommend a team approach including specialists in obstetric imaging, fetal MRI, and postnatal care in interpreting MR so that the best information can be given to the pregnant patient. & 2013 Elsevier Inc. All rights reserved.

1. Sonography is the mainstay of fetal diagnosis

Sonography is the mainstay of fetal screening and diagnosis. MR is a problem-solving tool and is utilized when additional information is needed beyond that available with ultrasound. The sonogram that leads to an MR is optimally a targeted scan, performed to assess the anomaly suspected or in question.13 Communication with the ordering physician (typically an obstetrician) cannot be over-stressed. The images from the sonogram and knowledge of the anatomy and pathology in question are crucial for appropriate performance and interpretation of the MR examination.

(1) Knowledge of MR safety in order to have an informed discussion with the patient about the risks and benets of the examination. (2) Knowledge of the MR machine and how to optimize fetal images. Signal-to-noise ratio, eld of view, and image plane need to be optimized since each fetus/pregnant woman has a unique set of anatomy. Depending on imaging plane and fetal orientation scan factors frequently need to be changed during the exam for best depiction of fetal anatomy and pathology. The physician should have access to relevant ancillary studies (which should include a targeted sonogram) The physician interpreting the MRI scans must have a clear understanding and knowledge of the anatomy and pathophysiology relevant to the MRI examination since fetal diagnosis can differ from that of the newborn, pediatric, and adult population. A team approach is often needed, with contributions from individuals with expertise in obstetric imaging, fetal MR, as well as postnatal imaging and outcomes.

2.

Physician qualications

The physician qualications to perform the fetal MR examination include the following: 4

Some of the images used in this manuscript were supported by NIH 01998. E-mail address: dlevine@bidmc.harvard.edu 0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2013.06.011

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3.

Access

The qualications and team approach discussed above lead to the issue of suboptimal access nationwide to centers with fetal MR expertise. While tertiary care centers may have the expertise needed, the groups working as a team might not have been formed. Sites of expertise tend to be focused in academic centers, particularly those with expertise in obstetric and/or pediatric imaging. Outside of tertiary centers, specialists in fetal imaging with MR might not be available. Thus, while the hardware (1.5 T magnet) and surface coils and software (fast spin echo sequences) are widely available, the physician expertise to interpret the studies may be lacking.

The balance between needing information to decide on delivery mode and thus wanting to perform an exam as late in pregnancy as possible needs to be balanced with the threat of preterm labor in a pregnancy with a fetus with a neck mass obstructing the airway and causing polyhydramnios. Thus an initial exam in a fetus with a potential neck mass, imaging of the airway may be performed at 32 weeks, and if needed repeated later in gestation.

6. When MRI is most effective for prenatal diagnosis

There are many case series documenting utility of MR in a wide spectrum of abnormalities. The incremental benet of the MR exam depends on the quality of the sonogram to which it is being compared and the type of abnormality that is being assessed.

4.

Safety

MR is felt to be safe for use in pregnancy.47 The majority of studies on safety have been performed at 1.5 T and lower eld strengths. Pregnant patients can undergo MR scans at any stage of pregnancy if, in the opinion of the radiologist, the risk-benet ratio to the patient warrants that the study be performed. MR for fetal anatomy is typically performed after 20 weeks gestational age when the fetus is large enough for the anatomy to be well visualized. However, MR can be safely performed at any gestational age (for example if a patient is suspected to have appendicitis in the rst trimester and MR is available rather than CT if ultrasound has not depicted the appendix). MRI contrast agents should not be administered to pregnant patients for assessment of fetal abnormalities.8 Gadolinium is a pregnancy class C drug, meaning that the safety in humans has not been proven.

CNS abnormalities
MR is particularly benecial in documenting additional abnormalities beyond those identied by ultrasound in fetuses with cerebral ventriculomegaly11,12 and agenesis of the corpus callosum.1315 In these fetuses, MR at any age can show additional abnormalities, but the cortical abnormalities and heterotopias are best seen in the third trimester9 (Fig. 1). Another class of CNS abnormalities where MR is particularly useful is vascular abnormalities in the brain, where the extent of hemorrhage and/or infarction are incompletely depicted by ultrasound.16 MR can also be very helpful in screening for CNS abnormalities that may not be well depicted by ultrasound, such as tuberous sclerosis,1719 and can be helpful in screening for patients with a family history of specic types of lissencephaly.20,21 Other CNS abnormalities in which MR can be helpful if more information is needed beyond that available with ultrasound are variants of holoprosencephaly,22 posterior fossa anomalies where the true midline view of the vermis allows for optimal

5.

Timing of MR

There is no single optimal time to perform MR, as each individual patient will have needs that depend on the time of sonographic diagnosis and personal desire to have as much information as soon as possible. Since many anomalies are discovered at the time of routine anatomic survey at 18 20 weeks gestational age, this is often the time that MR examinations are requested. In general, we avoid performing MR examinations at o18 weeks gestational age since fetal size limits the assessment. Examinations performed at 2022 weeks frequently give the additional information needed to more completely characterize abnormalities that were not well documented with ultrasound. However, if information about cerebral cortical development or information about airway impingement prior to delivery is needed, these studies are best performed in the third trimester.9 However, not all cases re-scanned in the third trimester will offer new information. In a study by Grifths et al.10 of fetuses with ventriculomegaly who initially underwent MR at 2024 weeks, and then repeat MR at 3032 weeks, only 1 of 40 fetuses had additional abnormality found.

Fig. 1 T2-weighted MR of 35-week gestational age fetus with dysgenesis of the corpus callosum and small heterotopias (proven postnatally). The heterotopias (arrows) were not seen on ultrasound performed the same day.

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Fig. 2 Three sagittal images from T2-weighted MR of 32-week-gestational age fetus with predominately exophytic sacrococcygeal teratoma (arrow). The small intra-pelvic extent (small arrow on B) was depicted on MR and not on ultrasound.

characterization of the abnormality,23,24 and cortical migrational abnormalities such as may be present after infection with CMV or toxoplasmosis.25,26

8.

Face and neck

7.

Spine abnormalities

Most neural tube defects are well characterized by ultrasound. However, if a patient is considering in utero surgery for a neural tube defect, MR can be helpful to screen for other CNS abnormalities, to better depict the Chiari II malformation, and to exclude a lipomyelomeningocele.2730 MR has also been shown to be particularly helpful in assessing the intra-pelvic component of sacrococcygeal teratomas, which aids in patient counseling in considering the type of surgery needed28,3134 (Fig. 2) and the potential impact on surrounding organs. In other rare spinal abnormalities such as caudal regression syndrome, sacral agenesis, or sirenomelia35 MR can be used if the diagnosis is unclear by ultrasound,36 for example in patients with anhydramnios or large body habitus limiting fetal assessment.

MR is particularly helpful to assess for the extent of masses within the neck and face, and in particularly to assess for airway impingement that might affect mode of delivery (C-section and ex-utero intrapartum treatment [EXIT]32,37,38 (Fig. 3) procedure) or for masses obstructing the lower airway a procedure EXIT to extracorporeal membrane oxygenation (ECMO). Although some centers recommend MR for assessment of the soft palate in fetuses39,40 with facial clefts, this is not routinely recognized as an indication for MR.

9.

Thorax

MR in the thorax is used to characterize chest masses such as congenital pulmonary adenomatoid malformation (CPAM spectrum which includes cystic adenomatoid malformations, sequestration, and congenital lobar over-ination) and congenital diaphragmatic hernias.41,42 The need for MR in these cases is dependent on the type of information desired by the

Fig. 3 Two sagittal images from T2-weighted MR of large face and neck mass in 22-week-gestational age fetus. The MR shows the extent of the tumor (arrow) in the face and illustrated the distended oropharynx (small arrow). Images such as these are very helpful to allow for parents and referring clinicians to understand the extent of the tumor since the anatomy that they are visualization is more easily understand by non-sonographers.

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clinicians for counseling patients regarding treatment, prognosis, and outcome.43,44

10. Abdominal, retroperitoneal, and pelvic abnormalities

There are a variety of lesions in the abdomen and pelvis where MR can aid in clarifying diagnosis. However, the MR is only indicated in those cases where a more precise diagnosis could change counseling or management. Examples of types of lesions that may be claried by MR include the following: Determine the etiology of an abdominal-pelvic mass/cyst. Assess size and location of tumors such as hemangiomas, neuroblastomas, sacrococcygeal teratomas, and suprarenal or renal masses.45 Assess complex genitourinary anomalies such as Cloaca malformation.46 Assess renal anomalies in cases of severe oligohydramnios.47 Diagnose bowel anomalies associated with unexplained bowel dilatation or microcolon.46

11.

Complications in monochorionic twins

At some centers, MR is performed prior to laser or radiofrequency ablation for treatment of twin-twin transfusion or acardiac twins. In these cases, MR can aid in dening vascular anatomy and assess for anomalies in the twins.48 In monochorionic twins, after the demise of a co-twin, MR can aid in characterization of the sequelae of the profound hypoperfusion experienced by the surviving twin.49 Since infarcts may take up to 2 weeks to become morphologically apparent on imaging, it is benecial to wait at least 2 weeks after the documented twin demise to perform the MR exam. In cases of conjoined twins, MR is very helpful in allowing for a large eld of view of the twins for planning for delivery and depiction of shared organs.49

12.

Summary

Fetal MRI is a problem-solving tool used for specic indications that are driven by ultrasound or at times by family history. The type of information provided by MR can profoundly impact patient counseling and management. We recommend a team approach in interpreting MR so that the best information can be given to the pregnant patient.

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