Faculty Bibliography

Maternal cardiopulmonary arrest (MCPA) is a catastrophic event that can cause significant morbidity and mortality. A prepared, multidisciplinary team is necessary to perform basic and advanced cardiac life support specific to the anatomic and physiologic changes of pregnancy. MCPA is a challenging clinical scenario for any provider. Overall, it is an infrequent occurrence that involves 2 patients. However, key clinical intervention performed concurrently can save the life of both mother and baby.

Acute pelvic pain in premenopausal women frequently poses a diagnostic dilemma. These patients may exhibit nonspecific signs and symptoms such as nausea, vomiting and leukocytosis. The cause of pelvic pain includes a myriad of diagnostic possibilities such as obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The choice of the imaging modality is usually determined by a suspected clinical differential diagnosis. Thus the patient should undergo careful evaluation and the suspected differential diagnosis should be narrowed before an optimal imaging modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice, to assess for pelvic pain, when an obstetric or gynecologic etiology is suspected and computed tomography is often more useful when gastrointestinal or genitourinary pathology is thought to be more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies owing to its lack of ionizing radiation.The American College of Radiology Appropriateness Criteria(R) are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

BACKGROUND: Cardio-pulmonary resuscitation guidelines during pregnancy recommend placing the hands 2-3 cm higher on the sternum than in non-pregnant individuals. This recommendation is based on the presumption that the heart is displaced superiorly by the diaphragm during the third trimester. Whether there is true cardiac displacement due to the expanding uterus in pregnancy remains unknown. OBJECTIVE: To determine if there is vertical displacement of the heart during pregnancy using cardiac magnetic resonance imaging (CMR). STUDY DESIGN: A total of 34 healthy female volunteers aged 18 to 35 years were prospectively enrolled between 2010-2012 at two tertiary care centres. All participants were evaluated using CMR in the half left lateral decubitus position during the third trimester of pregnancy and again at a minimum of 3 months post-partum (surrogate for the non-pregnant state). Superior displacement of the heart was determined by measuring the distance between the inferior aspect of the clavicular heads and the coronary sinus at both time points. RESULTS: The study population included 34 females (mean age 29 +/- 3 years, BMI of 24 +/- 4 kg/m2). The mean gestational age at third trimester imaging was 237 +/- 16 days (34 weeks +/- 16 days) and mean number of days for postpartum imaging (baseline) was 107 +/- 25 days (16 weeks +/- 25 days). There was no statistical difference between the cardiac position at baseline (10.1 +/- 1.2 cm) and during the third trimester (10.3 +/- 1.1 cm) (p = 0.22). CONCLUSION: Contrary to popular assumption, there is no significant vertical displacement of the heart in the third trimester of pregnancy relative to the non-pregnant state. Accordingly, there is no need to alter hand placement for chest compressions during CPR in pregnancy.

Appropriate imaging for women undergoing infertility workup depends upon the clinician's suspicion for potential causes of infertility. Transvaginal US is the preferred modality to assess the ovaries for features of polycystic ovary syndrome (PCOS), the leading cause of anovulatory infertility. For women who have a history or clinical suspicion of endometriosis, which affects at least one third of women with infertility, both MRI and pelvic US can provide valuable information. If tubal occlusion is suspected, whether due to endometriosis, previous pelvic inflammatory disease, or other cause, hysterosalpingogram (HSG) is the preferred method of evaluation. To assess for anatomic causes of recurrent pregnancy loss (RPL) such as Mullerian anomalies, synechiae, and leiomyomas, saline infusion sonohysterography, MRI and 3-D US are most appropriate. Up to 10% of women suffering recurrent pregnancy loss have a congenital Mullerian anomaly. When assessment of the pituitary gland is indicated, MRI is the imaging exam of choice.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Endometrial cancer is the most common gynecologic and the fourth most common malignancy in women in the United States. Cross-sectional imaging plays a vital role in pretreatment assessment of endometrial cancers and should be viewed as a complementary tool for surgical evaluation and planning of these patients. Although transvaginal US remains the preferred examination for the screening purposes, MRI has emerged as the modality of choice for the staging of endometrial cancer and imaging assessment of recurrence or treatment response. A combination of dynamic contrast-enhanced and diffusion weighted MRI provides the highest accuracy for the staging. Both CT and MRI perform equivalently for assessing nodal involvement or distant metastasis. PET-CT is more appropriate for assessing lymphadenopathy in high-grade FDG-avid tumors or for clinically suspected recurrence after treatment. An appropriate use and guidelines of imaging techniques in diagnosis, staging, and detection of endometrial cancer and treatment of recurrent disease are reviewed.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Vaginal bleeding occurring in the second or third trimesters of pregnancy can variably affect perinatal outcome, depending on whether it is minor (i.e. a single, mild episode) or major (heavy bleeding or multiple episodes.) Ultrasound is used to evaluate these patients. Sonographic findings may range from marginal subchorionic hematoma to placental abruption. Abnormal placentations such as placenta previa, placenta accreta and vasa previa require accurate diagnosis for clinical management. In cases of placenta accreta, magnetic resonance imaging is useful as an adjunct to ultrasound and is often appropriate for evaluation of the extent of placental invasiveness and potential involvement of adjacent structures. MRI is useful for preplanning for cases of complex delivery, which may necessitate a multi-disciplinary approach for optimal care.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Imaging is used to detect and characterize adnexal masses and to stage ovarian cancer both before and after initial treatment, although the role for imaging in screening for ovarian cancer has not been established. CT and MRI have been used to determine the resectability of tumors, the candidacy of patients for effective cytoreductive surgery, the need for postoperative chemotherapy if debulking is suboptimal, and the need for referral to a gynecologic oncologist. Radiographic studies such as contrast enema and urography have been replaced by CT and other cross-sectional imaging for staging ovarian cancer. Contrast-enhanced CT is the procedure of choice for preoperative staging of ovarian cancer. MRI without and with contrast may be useful after equivocal CT, but is usually not the best initial procedure for ovarian cancer staging. Fluorine-18-2-fluoro-2-deoxy-D-glucose-PET/CT may not be needed preoperatively, but its use is appropriate for detecting and defining post-treatment recurrence. Ultrasound is useful for evaluating adnexal disease, but has limited utility for staging ovarian cancer. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.