The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the . The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized.

2010 (Res. 13)*

ACR–SPR PRACTICE GUIDELINE FOR THE SAFE AND OPTIMAL PERFORMANCE OF FETAL MAGNETIC RESONANCE IMAGING (MRI)

PREAMBLE

These guidelines are an educational tool designed to assist Therefore, it should be recognized that adherence to these practitioners in providing appropriate radiologic care for guidelines will not assure an accurate diagnosis or a patients. They are not inflexible rules or requirements of successful outcome. All that should be expected is that the practice and are not intended, nor should they be used, to practitioner will follow a reasonable course of action establish a legal standard of care. For these reasons and based on current knowledge, available resources, and the those set forth below, the American College of Radiology needs of the patient to deliver effective and safe medical cautions against the use of these guidelines in litigation in care. The sole purpose of these guidelines is to assist which the clinical decisions of a practitioner are called practitioners in achieving this objective. into question. I. INTRODUCTION The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by This guideline was developed and written collaboratively the physician or medical physicist in light of all the by the American College of Radiology (ACR) and the circumstances presented. Thus, an approach that differs Society for Pediatric Radiology (SPR). from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. Magnetic resonance imaging (MRI) is a proven, To the contrary, a conscientious practitioner may established imaging modality for evaluating fetal responsibly adopt a course of action different from that anomalies that are not well assessed with sonography [1- set forth in the guidelines when, in the reasonable 6]. MRI is used for problem-solving and only in select judgment of the practitioner, such course of action is circumstances for screening. Properly performed and indicated by the condition of the patient, limitations of interpreted, MRI not only contributes to diagnosis but available resources, or advances in knowledge or also serves as an important guide to treatment and technology subsequent to publication of the guidelines. delivery planning and counseling. However, sonography However, a practitioner who employs an approach is the screening modality of choice in the fetus. Fetal MRI substantially different from these guidelines is advised to should be performed only for a valid medical reason, and document in the patient record information sufficient to only after careful consideration of sonographic findings or explain the approach taken. family history of an abnormality for which screening with MRI might be beneficial. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, This guideline addresses the use of MRI in fetal alleviation, and treatment of disease. The variety and diagnosis. complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict While MRI is an effective noninvasive diagnostic test for with certainty a particular response to treatment. characterizing many fetal abnormalities, its findings may be misleading if not closely correlated with the clinical history and sonographic findings. Adherence to the

PRACTICE GUIDELINE Fetal MRI / 1 following guidelines will enhance the probability of b. Hemangiomas. appropriately diagnosing such abnormalities. c. Goiter. d. Teratomas. II. QUALIFICATIONS AND e. Facial clefts. RESPONSIBILITIES OF PERSONNEL 2. MRI can be helpful in assessing airway See the ACR Practice Guideline for Performing and obstruction that may impact parental counseling, Interpreting Magnetic Resonance Imaging (MRI). prenatal management, delivery planning, and postnatal therapy [41-45]. In addition, individuals interpreting fetal MRI should be familiar with fetal diagnosis, as it can differ from that of C. Thorax the newborn, pediatric, and adult population. 1. Masses in the thorax suspected or not adequately III. INDICATIONS assessed by sonography [46-48]. These include, but are not limited to: Primary indications for MRI include, but are not limited a. Congenital pulmonary airway to: malformations (including congenital cystic adenomatoid malformation, sequestration, A. Brain and Spine and congenital lobar emphysema.). b. Congenital diaphragmatic hernia. 1. Congenital anomalies of the brain suspected or c. Effusions. not adequately assessed by sonography [3,7-30]. 2. MRI can be used for volumetric assessment of These include but are not limited to: fetal lung parenchyma [49-52] particularly those a. Ventriculomegaly. at risk for secondary to b. Agenesis of the corpus callosum. , chest mass, or skeletal c. . dysplasias. d. Posterior fossa anomalies. e. Cerebral cortical malformations. D. Abdominal, Retroperitoneal, and Pelvic

In addition, MRI can be helpful in screening When an abdominal or pelvic mass is identified fetuses with a family risk for brain abnormalities sonographically, the etiology may remain uncertain due to such as tuberous sclerosis, corpus callosal limitations from fetal lie, maternal body habitus, dysgenesis, or . oligohydramnios, or small field of view. MRI can add additional information that may impact parental 2. Vascular abnormalities of the brain suspected or counseling, management, and delivery planning not adequately assessed by sonography [31,32]. [33,37,38,42,53-57]. This includes, but is not limited to: These include, but are not limited to: a. Vascular malformations. 1. Determining the etiology of an abdominal-pelvic b. . cyst. c. Infarctions. 2. Assessing the size and location of tumors such as d. Monochorionic twin pregnancy hemangiomas, neuroblastomas, sacrococcygeal complications. teratomas, and suprarenal or renal masses. 3. Assessing complex genitourinary anomalies, 3. Congenital anomalies of the spine suspected or including . not adequately assessed by sonography [18,33- 4. Assessing renal anomalies in cases of severe 40]. These include, but are not limited to: oligohydramnios. a. Neural tube defects. 5. Diagnosing bowel anomalies such as megacystis b. Sacrococcygeal teratomas. microcolon. c. Caudal regression/sacral agenesis. d. . E. Complications of Monochorionic Twins e. Vertebral anomalies. Delineation of vascular anatomy prior to laser treatment B. Skull, Face, and Neck of twins, assessment of morbidity after death of a monochorionic co-twin, and improved delineation of 1. Masses of the face and neck suspected or not anatomy in conjoined twins are areas where MRI may be adequately assessed by sonography [22,41-45]. useful [58,59] due to its high spatial resolution, contrast These include, but are not limited to: resolution, large field of view, and multiplanar imaging a. Venolymphatic malformations. capabilities. This additional information may impact

2 / Fetal MRI PRACTICE GUIDELINE parental counseling, delivery planning, and postnatal There are theoretical RF power considerations that are management. greater at higher field strengths than at lower ones. Radiologists should be cognizant of the increased power F. Fetal Assessment deposition typically accompanying some higher field studies and ensure that they do not exceed established When a fetal abnormality is identified that may require guidelines. fetal surgery, MRI is a useful adjunct in confirming the diagnosis and planning potential surgical options [37,60- B. MRI contrast agents should not be routinely 64]. It is also important for screening the fetal brain both administered to pregnant patients. Gadolinium is a before and after surgical interventions. pregnancy class C drug, meaning that the safety in humans has not been proven. This document describes The high risk to mother and fetus of potential in-utero fetal MRI, but for completeness we will discuss use of surgery requires accurate assessment of all anomalies. gadolinium contrast agents in pregnancy. This includes, but is not limited to: There are no documented fetal indications for the use of 1. Meningomyelocele. MRI contrast, but there may be rare instances where 2. Sacrococcygeal teratomas. contrast is needed for assessing maternal anatomy or 3. Processes obstructing the airway, such as a neck pathology. mass or congenital high airway obstruction. 4. Complications of monochorionic twins needing The decision to administer contrast must be made on a surgery. case-by-case basis by the covering level 2 MR personnel 5. Chest masses. designated attending radiologist who will assess the risk- benefit ratio for that particular patient. The decision to IV. SAFETY GUIDELINES AND POSSIBLE administer a gadolinium-based MR contrast agent to CONTRAINDICATIONS pregnant patients should be accompanied by a well- documented and thoughtful risk-benefit analysis. This See the ACR Practice Guideline for Performing and analysis should be able to defend a decision to administer Interpreting Magnetic Resonance Imaging (MRI), the the contrast agent based on overwhelming potential ACR Guidance Document for Safe MR Practices [65], benefit to the patient or fetus outweighing the theoretic and the ACR Manual on Contrast Media [66]. but potentially real risks of long-term exposure of the developing fetus to free gadolinium ions. A. Pregnant patients – For additional information please see the ACR Practice Guideline for Imaging Pregnant or Studies have demonstrated that gadolinium-based MR Potentially Pregnant Adolescents and Women with contrast agents pass through the placental barrier and Ionizing Radiation. enter the fetal circulation [78,79]. From there, they are filtered in the fetal kidneys and then excreted into the Present data have not conclusively documented any amniotic fluid. In this location the gadolinium-chelate deleterious effects of MR imaging at 1.5 T on the molecules are in a relatively protected space and may developing fetus [67-77]. Therefore, no special remain in this amniotic fluid for an indeterminate amount consideration is recommended for any trimester in of time before finally being reabsorbed and eliminated. pregnancy. Pregnant patients can be accepted to undergo As with any equilibrium situation involving any MR scans at any stage of pregnancy if, in the dissociation constant, the longer the chelate molecule determination of a level 2 MR personnel-designated remains in this space, the greater the potential for attending radiologist [65], the risk-benefit ratio to the dissociation of the potentially toxic gadolinium ion from patient warrants that the study be performed. The its chelate molecule. It is unclear what impact such free radiologist should confer with the referring physician and gadolinium ions might have if they were to be released in document the following in the radiology report or the any quantity in the amniotic fluid. Certainly, deposition patients’ medical record: into the developing fetus would raise concerns of possible secondary adverse effects. The risk to the fetus with 1. The information requested from the MR study administration of gadolinium-based MR contrast agents cannot be acquired by ultrasonography. remains unknown and may be harmful. 2. The data are needed to potentially affect the care of the patient or fetus during the pregnancy. C. It is suggested that pregnant patients undergoing an 3. The referring physician does not feel it is prudent MRI examination have a discussion with the supervising to wait until the patient is no longer pregnant to physician concerning potential risks versus benefits of obtain these data. performing a fetal MRI. At this stage, the preponderance of research studies have failed to discover any

PRACTICE GUIDELINE Fetal MRI / 3 reproducible harmful effects of exposure of the mother or and varied on a case-by-case basis when necessary. These developing fetus to the 3 T or weaker magnetic fields protocols should be reviewed and updated periodically. used in the routine clinical MR imaging process. However, far less is known about the potential effects, if Documentation that satisfies medical necessity includes 1) any, of the time varying gradient and/or radiofrequency fetal gestational age, and 2) relevant history (including magnetic fields used during actual scanning to potentiate sonographic findings and family history of pertinent image generation. Furthermore, the considerable majority abnormalities). Additional information regarding the of our data to date comes from research involving specific reason for the examination or a provisional magnetic fields of 1.5 T or less. Thus, we have less diagnosis would be helpful and may at times be needed to information regarding the potential safety issues that may allow for the proper performance and interpretation of the exist at higher field strength systems. These theoretical examination. risks should be carefully balanced against the potential benefits to the patient undergoing a magnetic resonance A. Patient Selection examination. A decision as to whether or not to proceed with the requested MRI study will need to be based on a The physician responsible for the examination should thorough and thoughtful evaluation of the potential and at supervise appropriateness of patient selection and times unknown risks of the MR examination versus the preparation and be available in person or by phone for potential benefits to the patient, as well as the risks consultation. Patients must be screened and interviewed associated with declining to do so. prior to the examination to exclude individuals who may be at risk by exposure to the MR environment. V. SPECIFICATIONS OF THE EXAMINATION Intravenous contrast should not be used for fetal MRI.

The supervising physician must have an understanding of Patients suffering from anxiety or claustrophobia may the indications, risks, and benefits of the examination, as require sedation or additional assistance. well as alternative imaging procedures. The physician must be familiar with potential hazards associated with Knowledge of the gestational age of the pregnancy is MRI. The physician should be familiar with relevant important for planning the examination and positioning of ancillary studies that the patient may have undergone. The the surface coil. physician performing MRI interpretation must have a clear understanding and knowledge of the anatomy and Prior to 20 weeks gestational age the fetal MRI study can pathophysiology relevant to the MRI examination. give limited diagnostic information due to the small size of the fetus and fetal movement. If the examination is The written or electronic request for fetal MRI limited by early gestational age then it may need to be examinations should provide sufficient information to repeated later. The need for early diagnosis should be demonstrate the medical necessity of the examination and balanced against the advantages of improved resolution allow for its proper performance and interpretation. later in pregnancy, with the choice dependent on the anomalies to be assessed. Fetal motion occurs constantly Documentation that satisfies medical necessity includes 1) during the examination. However, using single shot and/or 2) relevant history (including techniques or other rapid acquisition techniques, slices are known diagnoses). Additional information regarding the obtained in less than 1 second, and therefore images are specific reason for the examination or a provisional only degraded if motion occurs during image acquisition. diagnosis would be helpful and may at times be needed to Sequences may need to be repeated if motion degrades allow for the proper performance and interpretation of the the image of the region of interest. examination. B. Facility Requirements The request for the examination must be originated by a physician or other appropriately licensed health care Appropriate emergency equipment and must provider. The accompanying clinical information should be immediately available to treat adverse reactions be provided by a physician or other appropriately licensed associated with administered medications. The equipment health care provider familiar with the patient’s clinical and medications should be monitored for inventory and problem or question and consistent with the state scope of drug expiration dates on a regular basis. The equipment, practice requirements. (2006 - ACR Resolution 35) medications, and other emergency support must also be appropriate for the range of ages and sizes in the patient The supervising physician must also understand the pulse population. sequences to be used and their effect on the appearance of the images, including the potential generation of image artifacts. Standard imaging protocols may be established

4 / Fetal MRI PRACTICE GUIDELINE C. Examination Technique performed as part of a special fetal brain evaluation [80-82]. Depending on the size of the and fetal area of interest, either a torso or cardiac phased array surface coil 2. Fetal spine is placed over the gravid uterus. If the patient will not fit into the magnet with a surface coil, then a body coil can Imaging sequences should include axial, coronal, be used. The mother lies supine, or in the left lateral and sagittal single shot T2-weighted images of decubitus position. The maternal foot first position helps the fetal spine. Optimal slice thickness is 2 to 3 minimize claustrophobia. Maternal sedation is not mm, but in some patients a 4 to 5 mm slice necessary in the vast majority of cases. Scout images thickness may be needed because of signal-to- orthogonal to the gravid uterus are performed, and routine noise consideration. Additional sequences are thick (7 to 8 mm) slices axial to the gravid uterus may be rarely indicated in the spine evaluation, but may obtained with a single acquisition fast spin echo or other include a FLAIR or spoiled fast gradient echo appropriate sequences for a fetal overview. As stated sequence as noted above regarding brain previously, maternal intravenous contrast is not indicated evaluation. for fetal imaging. 3. Fetal face and neck Fetal MRI single shot acquisition sequences or other rapid acquisition sequences are employed to limit the effects of Imaging sequences should include axial, coronal, fetal motion. A T2-weighted spin echo single shot and sagittal single shot T2-weighted images of sequence reveals excellent anatomy. Fast acquisition T1- the fetal face and neck. A slice thickness range weighted images with gradient echo sequences are less of 3 to 5 mm should be used with knowledge of anatomically discriminating, but help to define certain signal-to-noise considerations, with earlier fetal tissue or fluid characteristics, such as fat, gestational age fetuses having thinner slices. The hemorrhage, liver, and meconium in bowel. It is preferred fast T1 gradient echo should be performed in the that fast gradient echo sequences be performed during a appropriate plane if there is suspicion of fat or breath-hold, or using respiratory trigger technique. Short hemorrhage. STIR images may provide tau inversion recovery (STIR) images may provide improved resolution of tissue characteristics in improved resolution of tissue characteristics when the masses such as teratomaa or venolymphatic water contents of structures are similar. Additional malformations. sequences such as fluid attenuated inversion recovery (FLAIR), steady-state free precession (SSFP) sequences Repeated sagittal images may be needed to (FIESTA, TrueFISP, bFFE), hydrography, BOLD visualize fluid in the oropharynx if a lesion of imaging, and echo planar imaging may be performed as the palate is suspected. needed. 4. Fetal thorax Field of view should be tailored to fetal (and maternal) size. Overlap of maternal onto maternal anatomy (“wrap- Imaging sequences should include axial, coronal, around” or spatial misregistration artifact) is allowable if and sagittal single shot T2-weighted images of fetal structures are well-visualized. the fetal thorax. The slice thickness range should be 3 to 5 mm. The fast T1 gradient echo can be 1. Fetal brain performed in the coronal or sagittal plane to evaluate the liver and meconium in cases of Imaging sequences should include axial, coronal, congenital diaphragmatic hernia. STIR images and sagittal single shot T2-weighted images of may provide improved resolution of tissue the fetal brain. Optimal slice thickness is 3 mm, characteristics in lesions such congenital but in some patients a 4 to 5 mm slice thickness pulmonary airway malformation in some may be needed because of signal-to-noise instances [47]. SSEP sequences (FIESTA, consideration. The fast T1 gradient echo should TrueFISP) can be used to further assess the heart be performed in the coronal or axial plane if and vascular masses. there is suspicion of fat or hemorrhage. Additional FLAIR sequences may be done to 5. Fetal abdomen suppress the bright signal of the cerebral spinal fluid in certain cases. The use of diffusion- Imaging sequences should include axial, coronal, weighted imaging (DWI) to evaluate metabolic and sagittal single shot T2-weighted images of or ischemic processes may occasionally be the fetal abdomen. The slice thickness range should be 3 to 5 mm. The fast T1 gradient echo

PRACTICE GUIDELINE Fetal MRI / 5 can be performed in the coronal or sagittal plane well as to others in the immediate area. Screening forms to evaluate the liver, meconium, fat, or must also be provided to detect those patients who may be hemorrhage in certain cases [83]. STIR images at risk for adverse events associated with the MRI may provide improved resolution of tissue examination. characteristics in lesions of the solid organs, such as kidneys, liver, or adrenal glands. BOLD Equipment monitoring should be in accordance with the imaging can be used to screen for ACR Technical Standard for Diagnostic Medical Physics hemochromotosis [42,84]. Performance Monitoring of Magnetic Resonance Imaging (MRI) Equipment. 6. Fetal volumetry ACKNOWLEDGEMENTS Various studies have established MRI derived volumes and equations for weight [38,85-90]. This guideline was developed according to the process The most commonly used are lung volumes to described under the heading The Process for Developing predict hypoplasia. Fetal weight has also been ACR Practice Guidelines and Technical Standards on the estimated. The technique involves adding ACR web page (http://www.acr.org/guidelines) by the together measured areas obtained by drawing ACR Guidelines and Standards Committee of the free-form regions of interest on sequences that Commission on Pediatric Radiology in collaboration with allow complete imaging of the volume without the SPR. motion-induced artifact, and multiplying by slice thickness. Volume assessments should be Collaborative Drafting Committee reserved for specific indications. ACR VI. DOCUMENTATION Deborah Levine, MD, FACR, Co-Chair Dorothy I. Bulas, MD, FACR, Co-Chair Reporting should be in accordance with the ACR Practice Kimberly E. Applegate, MD, MS, FACR Guideline for Communication of Diagnostic Imaging Emanuel Kanal, MD, FACR Findings. Diane M. Twickler, MD, FACR

VII. EQUIPMENT SPECIFICATIONS SPR Christopher I. Cassady, MD The MRI equipment specifications and performance must Judy A. Estroff, MD meet all state and federal requirements. The requirements Elmar M. Merkle, MD include, but are not limited to, specifications of maximum Marta Hernanz-Schulman, MD, FACR static magnetic strength, maximum rate of change of the magnetic field strength (dB/dt), maximum radiofrequency Consultants power deposition (specific absorption rate), and Anthony J. Barkovich, MD maximum acoustic noise levels. Fergus V. Coakley, MD Orit A. Glenn, MD VIII. QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION Guidelines and Standards Committee - Pediatric CONTROL, AND PATIENT EDUCATION Marta Hernanz-Schulman, MD, FACR, Chair Taylor Chung, MD Policies and procedures related to quality, patient Brian D. Coley, MD education, infection control, and safety should be Seth Crapp, MD developed and implemented in accordance with the ACR Kristin L. Crisci, MD Policy on Quality Control and Improvement, Safety, Eric N. Faerber, MD, FACR Infection Control, and Patient Education appearing under Lynn A. Fordham, MD the heading Position Statement on QC & Improvement, Marguerite T. Parisi, MD Safety, Infection Control, and Patient Education on the Sudha P. Singh, MB, BS ACR web page (http://www.acr.org/guidelines). Donald P. Frush, MD, FACR, Chair, Commission

Specific policies and procedures related to MRI safety Comments Reconciliation Committee should be in place with documentation that is updated Kimberly E. Applegate, MD, MS, FACR, Chair annually and compiled under the supervision and Anthony J. Barkovich, MD direction of the supervising MRI physician. Guidelines Leonard Berlin, MD, FACR should be provided that deal with potential hazards Dorothy I. Bulas, MD, FACR associated with the MRI examination of the patient as Christopher I. Cassady, MD

6 / Fetal MRI PRACTICE GUIDELINE Fergus Vincent Coakley, MD intracranial anomalies. Childs Nerv Syst 1990; 6:212- Judy A. Estroff, MD 215. Howard B. Fleishon, MD, MMM, FACR 12. Ghai S, Fong KW, Toi A, Chitayat D, Pantazi S, Donald P. Frush, MD, FACR Blaser S. Prenatal US and MR imaging findings of Orit A. Glenn, MD lissencephaly: review of fetal cerebral sulcal Marta Hernanz-Schulman, MD, FACR development. Radiographics 2006; 26:389-405. Emanuel Kanal, MD, FACR 13. Glenn OA, Norton ME, Goldstein RB, Barkovich AJ. Alan D. Kaye, MD, FACR Prenatal diagnosis of by fetal Paul A. Larson, MD, FACR magnetic resonance imaging in monochorionic cotwin death. J Ultrasound Med 2005; 24:711-716. Deborah Levine, MD, FACR 14. Greco P, Resta M, Vimercati A, et al. Antenatal Lawrence A. Liebscher, MD, FACR diagnosis of isolated lissencephaly by ultrasound and Elmar M. Merkle, MD magnetic resonance imaging. Ultrasound Obstet Daniel M. Schwartz, MD Gynecol 1998; 12:276-279. Diane M. Twickler, MD, FACR 15. Guo WY, Chang CY, Ho DM, et al. A comparative MR and pathological study on fetal CNS disorders. REFERENCES Childs Nerv Syst 2001; 17:512-518. 16. Hubbard AM, States LJ. Fetal magnetic resonance 1. Breysem L, Bosmans H, Dymarkowski S, et al. The imaging. Top Magn Reson Imaging 2001; 12:93-103. value of fast MR imaging as an adjunct to ultrasound 17. Levine D, Barnes P, Korf B, Edelman R. Tuberous in prenatal diagnosis. Eur Radiol 2003; 13:1538- sclerosis in the fetus: second-trimester diagnosis of 1548. subependymal tubers with ultrafast MR imaging. AJR 2. Frates MC, Kumar AJ, Benson CB, Ward VL, Am J Roentgenol 2000; 175:1067-1069. Tempany CM. Fetal anomalies: comparison of MR 18. Levine D, Barnes PD, Madsen JR, Abbott J, Mehta imaging and US for diagnosis. Radiology 2004; T, Edelman RR. Central 232:398-404. abnormalities assessed with prenatal magnetic 3. Glenn OA, Goldstein RB, Li KC, et al. Fetal resonance imaging. Obstet Gynecol 1999; 94:1011- magnetic resonance imaging in the evaluation of 1019. fetuses referred for sonographically suspected 19. Levine D, Barnes PD, Madsen JR, Li W, Edelman abnormalities of the corpus callosum. J Ultrasound RR. Fetal central nervous system anomalies: MR Med 2005; 24:791-804. imaging augments sonographic diagnosis. Radiology 4. Levine D, Barnes PD, Edelman RR. Obstetric MR 1997; 204:635-642. imaging. Radiology 1999; 211:609-617. 20. Limperopoulos C, Robertson RL, Estroff JA, et al. 5. Quinn TM, Hubbard AM, Adzick NS. Prenatal Diagnosis of inferior vermian hypoplasia by fetal magnetic resonance imaging enhances fetal magnetic resonance imaging: potential pitfalls and diagnosis. J Pediatr Surg 1998; 33:553-558. neurodevelopmental outcome. Am J Obstet Gynecol 6. Twickler DM, Magee KP, Caire J, Zaretsky M, 2006; 194:1070-1076. Fleckenstein JL, Ramus RM. Second-opinion 21. Okamura K, Murotsuki J, Sakai T, Matsumoto K, magnetic resonance imaging for suspected fetal Shirane R, Yajima A. Prenatal diagnosis of central nervous system abnormalities. Am J Obstet lissencephaly by magnetic resonance image. Fetal Gynecol 2003; 188:492-496. Diagn Ther 1993; 8:56-59. 7. Adamsbaum C, Moutard ML, Andre C, et al. MRI of 22. Poutamo J, Vanninen R, Partanen K, Ryynanen, the fetal posterior fossa. Pediatr Radiol 2005; Kirkinen P. Magnetic resonance imaging 35:124-140. supplements ultrasonographic imaging of the 8. Benacerraf BR, Shipp TD, Bromley B, Levine D. posterior fossa, pharynx and neck in malformed What does magnetic resonance imaging add to the fetuses. Ultrasound Obstet Gynecol 1999; 13:327- prenatal sonographic diagnosis of ventriculomegaly? 334. J Ultrasound Med 2007; 26:1513-1522. 23. Resta M, Greco P, D'Addario V, et al. Magnetic 9. Bouchard S, Davey MG, Rintoul NE, Walsh DS, resonance imaging in pregnancy: study of fetal Rorke LB, Adzick NS. Correction of hindbrain cerebral malformations. Ultrasound Obstet Gynecol herniation and anatomy of the vermis after in utero 1994; 4:7-20. repair of myelomeningocele in sheep. J Pediatr Surg 24. Revel MP, Pons JC, Lelaidier C, et al. Magnetic 2003; 38:451-458; discussion 451-458. resonance imaging of the fetus: a study of 20 cases 10. d'Ercole C, Girard N, Cravello L, et al. Prenatal performed without curarization. Prenat Diagn 1993; diagnosis of fetal corpus callosum agenesis by 13:775-799. ultrasonography and magnetic resonance imaging. 25. Simon EM, Goldstein RB, Coakley FV, et al. Fast Prenat Diagn 1998; 18:247-253. MR imaging of fetal CNS anomalies in utero. AJNR 11. Dinh DH, Wright RM, Hanigan WC. The use of Am J Neuroradiol 2000; 21:1688-1698. magnetic resonance imaging for the diagnosis of fetal 26. Sonigo P, Elmaleh A, Fermont L, Delezoide AL, Mirlesse V, Brunelle F. Prenatal MRI diagnosis of

PRACTICE GUIDELINE Fetal MRI / 7 fetal cerebral tuberous sclerosis. Pediatr Radiol 1996; anomalies. Eur J Obstet Gynecol Reprod Biol 2001; 26:1-4. 96:173-178. 27. Sonigo PC, Rypens FF, Carteret M, Delezoide AL, 42. Coakley FV, Hricak H, Filly RA, Barkovich AJ, Brunelle FO. MR imaging of fetal cerebral Harrison MR. Complex fetal disorders: effect of MR anomalies. Pediatr Radiol 1998; 28:212-222. imaging on management--preliminary clinical 28. Stazzone MM, Hubbard AM, Bilaniuk LT, et al. experience. Radiology 1999; 213:691-696. Ultrafast MR imaging of the normal posterior fossa 43. Kathary N, Bulas DI, Newman KD, Schonberg RL. in fetuses. AJR Am J Roentgenol 2000; 175:835-839. MRI imaging of fetal neck masses with airway 29. Tilea B, Delezoide AL, Khung-Savatovski S, et al. compromise: utility in delivery planning. Pediatr Comparison between magnetic resonance imaging Radiol 2001; 31:727-731. and fetopathology in the evaluation of fetal posterior 44. Ogura T, Hamada H, Obata-Yasuoka M, et al. fossa non-cystic abnormalities. Ultrasound Obstet Antepartum assessment of fetal cystic lymphangioma Gynecol 2007; 29:651-659. by magnetic resonance imaging. Gynecol Obstet 30. Whitby E, Paley MN, Davies N, Sprigg A, Griffiths Invest 2002; 53:237-239. PD. Ultrafast magnetic resonance imaging of central 45. Tsuda H, Matsumoto M, Yamamoto K, et al. nervous system abnormalities in utero in the second Usefulness of ultrasonography and magnetic and third trimester of pregnancy: comparison with resonance imaging for prenatal diagnosis of fetal ultrasound. Bjog 2001; 108:519-526. teratoma of the neck. J Clin Ultrasound 1996; 31. Brunel H, Girard N, Confort-Gouny S, et al. Fetal 24:217-219. brain injury. J Neuroradiol 2004; 31:123-137. 46. Hubbard AM. Magnetic resonance imaging of fetal 32. de Laveaucoupet J, Audibert F, Guis F, et al. Fetal thoracic abnormalities. Top Magn Reson Imaging magnetic resonance imaging (MRI) of ischemic brain 2001; 12:18-24. injury. Prenat Diagn 2001; 21:729-736. 47. Levine D, Barnewolt CE, Mehta TS, Trop I, Estroff 33. Avni FE, Guibaud L, Robert Y, et al. MR imaging of J, Wong G. Fetal thoracic abnormalities: MR fetal : diagnosis and imaging. Radiology 2003; 228:379-388. assessment. AJR Am J Roentgenol 2002; 178:179- 48. Matsuoka S, Takeuchi K, Yamanaka Y, Kaji Y, 183. Sugimura K, Maruo T. Comparison of magnetic 34. Beuls EA, Vanormelingen L, van Aalst J, et al. In resonance imaging and ultrasonography in the vitro high-field magnetic resonance imaging- prenatal diagnosis of congenital thoracic documented anatomy of a fetal myelomeningocele at abnormalities. Fetal Diagn Ther 2003; 18:447-453. 20 weeks' gestation. A contribution to the rationale of 49. Barnewolt CE, Kunisaki SM, Fauza DO, Nemes LP, intrauterine surgical repair of . J Estroff JA, Jennings RW. Percent predicted lung Neurosurg 2003; 98:210-214. volumes as measured on fetal magnetic resonance 35. Fitzmorris-Glass R, Mattrey RF, Cantrell CJ. imaging: a useful biometric parameter for risk Magnetic resonance imaging as an adjunct to stratification in congenital diaphragmatic hernia. J ultrasound in oligohydramnios. Detection of Pediatr Surg 2007; 42:193-197. sirenomelia. J Ultrasound Med 1989; 8:159-162. 50. Gorincour G, Bouvenot J, Mourot MG, et al. Prenatal 36. Glenn OA, Barkovich J. Magnetic resonance imaging prognosis of congenital diaphragmatic hernia using of the fetal brain and spine: an increasingly important magnetic resonance imaging measurement of fetal tool in prenatal diagnosis: part 2. AJNR Am J lung volume. Ultrasound Obstet Gynecol 2005; Neuroradiol 2006; 27:1807-1814. 26:738-744. 37. Hedrick HL, Flake AW, Crombleholme TM, et al. 51. Ward VL, Nishino M, Hatabu H, et al. Fetal lung Sacrococcygeal teratoma: prenatal assessment, fetal volume measurements: determination with MR intervention, and outcome. J Pediatr Surg 2004; imaging--effect of various factors. Radiology 2006; 39:430-438; discussion 430-438. 240:187-193. 38. Kirkinen P, Partanen K, Merikanto J, Ryynanen M, 52. Williams G, Coakley FV, Qayyum A, Farmer DL, Haring P, Heinonen K. Ultrasonic and magnetic Joe BN, Filly RA. Fetal relative lung volume: resonance imaging of fetal sacrococcygeal teratoma. quantification by using prenatal MR imaging lung Acta Obstet Gynecol Scand 1997; 76:917-922. volumetry. Radiology 2004; 233:457-462. 39. Mangels KJ, Tulipan N, Tsao LY, Alarcon J, Bruner 53. Cassart M, Massez A, Metens T, et al. JP. Fetal MRI in the evaluation of intrauterine Complementary role of MRI after sonography in myelomeningocele. Pediatr Neurosurg 2000; 32:124- assessing bilateral urinary tract anomalies in the 131. fetus. AJR Am J Roentgenol 2004; 182:689-695. 40. Okamura M, Kurauchi O, Itakura A, Naganawa S, 54. Hata K, Hata T, Kitao M. Antenatal diagnosis of Watanabe Y, Mizutani S. Fetal sacrococcygeal sacrococcygeal teratoma facilitated by combined use teratoma visualized by ultra-fast T2-weighted of Doppler sonography and MR imaging. AJR Am J magnetic resonance imaging. Int J Gynaecol Obstet Roentgenol 1991; 156:1115-1116. 1999; 65:191-193. 55. Poutamo J, Vanninen R, Partanen K, Kirkinen P. 41. Bekker MN, van Vugt JM. The role of magnetic Diagnosing fetal urinary tract abnormalities: benefits resonance imaging in prenatal diagnosis of fetal of MRI compared to ultrasonography. Acta Obstet Gynecol Scand 2000; 79:65-71.

8 / Fetal MRI PRACTICE GUIDELINE 56. Saguintaah M, Couture A, Veyrac C, Baud C, Quere intensity level during obstetric echo-planar magnetic MP. MRI of the fetal . Pediatr resonance imaging. Br J Radiol 1995; 68:1090-1094. Radiol 2002; 32:395-404. 71. Kanal E, Gillen J, Evans JA, Savitz DA, Shellock 57. Toma P, Lucigrai G, Marzoli A, Lituania M. Prenatal FG. Survey of reproductive health among female MR diagnosis of metastatic adrenal neuroblastoma with workers. Radiology 1993; 187:395-399. sonography and MR imaging. AJR Am J Roentgenol 72. Kok RD, de Vries MM, Heerschap A, van den Berg 1994; 162:1183-1184. PP. Absence of harmful effects of magnetic 58. Kline-Fath BM, Calvo-Garcia MA, O'Hara SM, resonance exposure at 1.5 T in utero during the third Crombleholme TM, Racadio JM. Twin-twin trimester of pregnancy: a follow-up study. Magn transfusion syndrome: cerebral ischemia is not the Reson Imaging 2004; 22:851-854. only fetal MR imaging finding. Pediatr Radiol 2007; 73. Levine D, Zuo C, Faro CB, Chen Q. Potential heating 37:47-56. effect in the gravid uterus during MR HASTE 59. Zoppini C, Vanzulli A, Kustermann A, Rizzuti T, imaging. J Magn Reson Imaging 2001; 13:856-861. Selicorni A, Nicolini U. Prenatal diagnosis of 74. Merkle EM, Dale BM, Paulson EK. Abdominal MR anatomical connections in conjoined twins by use of imaging at 3T. Magn Reson Imaging Clin N Am contrast magnetic resonance imaging. Prenat Diagn 2006; 14:17-26. 1993; 13:995-999. 75. Myers C, Duncan KR, Gowland PA, Johnson IR, 60. Coakley FV. Role of magnetic resonance imaging in Baker PN. Failure to detect intrauterine growth fetal surgery. Top Magn Reson Imaging 2001; 12:39- restriction following in utero exposure to MRI. Br J 51. Radiol 1998; 71:549-551. 61. Hayakawa M, Seo T, Itakua A, et al. The MRI 76. Schwartz JL, Crooks LE. NMR imaging produces no findings of the right-sided fetal lung can be used to observable mutations or cytotoxicity in mammalian predict postnatal mortality and the requirement for cells. AJR Am J Roentgenol 1982; 139:583-585. extracorporeal membrane oxygenation in isolated 77. Shellock FG, Crues JV. MR procedures: biologic left-sided congenital diaphragmatic hernia. Pediatr effects, safety, and patient care. Radiology 2004; Res 2007; 62:93-97. 232:635-652. 62. Hu LS, Caire J, Twickler DM. MR findings of 78. Magnevist. Product Information. Berlex complicated multifetal gestations. Pediatr Radiol Laboratories; 2000. 2006; 36:76-81. 79. Runge VM. Safety of approved MR contrast media 63. Hubbard AM, Crombleholme TM, Adzick NS. for intravenous injection. J Magn Reson Imaging Prenatal MRI evaluation of giant neck masses in 2000; 12:205-213. preparation for the fetal exit procedure. Am J 80. Agid R, Lieberman S, Nadjari M, Gomori JM. Perinatol 1998; 15:253-257. Prenatal MR diffusion-weighted imaging in a fetus 64. Mota R, Ramalho C, Monteiro J, et al. Evolving with . Pediatr Radiol 2006; indications for the EXIT procedure: the usefulness of 36:138-140. combining ultrasound and fetal MRI. Fetal Diagn 81. Baldoli C, Righini A, Parazzini C, Scotti G, Triulzi F. Ther 2007; 22:107-111. Demonstration of acute ischemic lesions in the fetal 65. Kanal E, Barkovich AJ, Bell C, et al. ACR guidance brain by diffusion magnetic resonance imaging. Ann document for safe MR practices: 2007. AJR Am J Neurol 2002; 52:243-246. Roentgenol 2007; 188:1447-1474. 82. Brugger PC, Stuhr F, Lindner C, Prayer D. Methods 66. American College of Radiology. Manual on Contrast of fetal MR: beyond T2-weighted imaging. Eur J Media. Radiol 2006; 57:172-181. http://www.acr.org/SecondaryMainMenuCategories/ 83. Farhataziz N, Engels JE, Ramus RM, Zaretsky M, quality_safety/contrast_manual.aspx. Accessed Twickler DM. Fetal MRI of urine and meconium by September 11, 2009. gestational age for the diagnosis of genitourinary and 67. Baker PN, Johnson IR, Harvey PR, Gowland PA, gastrointestinal abnormalities. AJR Am J Roentgenol Mansfield P. A three-year follow-up of children 2005; 184:1891-1897. imaged in utero with echo-planar magnetic 84. Marti-Bonmati L, Baamonde A, Poyatos CR, resonance. Am J Obstet Gynecol 1994; 170:32-33. Monteagudo E. Prenatal diagnosis of idiopathic 68. Chew S, Ahmadi A, Goh PS, Foong LC. The effects neonatal hemochromatosis with MRI. Abdom of 1.5T magnetic resonance imaging on early murine Imaging 1994; 19:55-56. in-vitro embryo development. J Magn Reson Imaging 85. Baker PN, Johnson IR, Gowland PA, et al. Fetal 2001; 13:417-420. weight estimation by echo-planar magnetic resonance 69. Clements H, Duncan KR, Fielding K, Gowland PA, imaging. Lancet 1994; 343:644-645. Johnson IR, Baker PN. Infants exposed to MRI in 86. Gong QY, Roberts N, Garden AS, Whitehouse GH. utero have a normal paediatric assessment at 9 Fetal and fetal brain volume estimation in the third months of age. Br J Radiol 2000; 73:190-194. trimester of human pregnancy using gradient echo 70. Glover P, Hykin J, Gowland P, Wright J, Johnson I, MR imaging. Magn Reson Imaging 1998; 16:235- Mansfield P. An assessment of the intrauterine sound 240.

PRACTICE GUIDELINE Fetal MRI / 9 87. Kok RD, van den Berg PP, van den Bergh AJ, Nijland R, Heerschap A. Maturation of the human fetal brain as observed by 1H MR spectroscopy. Magn Reson Med 2002; 48:611-616. 88. Uotila J, Dastidar P, Heinonen T, Ryymin P, Punnonen R, Laasonen E. Magnetic resonance imaging compared to ultrasonography in fetal weight and volume estimation in diabetic and normal pregnancy. Acta Obstet Gynecol Scand 2000; 79:255- 259. 89. Zaretsky M, Ramus R, McIntire D, Magee K, Twickler DM. MRI calculation of lung volumes to predict outcome in fetuses with genitourinary abnormalities. AJR Am J Roentgenol 2005; 185:1328- 1334. 90. Zaretsky MV, Reichel TF, McIntire DD, Twickler DM. Comparison of magnetic resonance imaging to ultrasound in the estimation of birth weight at term. Am J Obstet Gynecol 2003; 189:1017-1020.

*Guidelines and standards are published annually with an effective date of October 1 in the year in which amended, revised or approved by the ACR Council. For guidelines and standards published before 1999, the effective date was January 1 following the year in which the guideline or standard was amended, revised, or approved by the ACR Council.

Development Chronology for this Guideline 2010 (Resolution 13)

10 / Fetal MRI PRACTICE GUIDELINE