Reprint from DANISH MEDICAL BULLETIN, Vol. 6, No. 4, June 1959
THERAPEUTIC ABORTION ON ACCOUNT OF X-RAY EXAMINATION DURING PREGNANCY
BY
ERLING HAMMER-JACOBSEN
N. OLAF MBLLERS BOGTRYKKERI Frederiksborggede 26 Kobenhavn K. 8966
001 lb31 PARTIAL DOCUMENT JUNE 1939 D,U'lSII ,IIEDICi\L BULLETIX 113
THERAPEUTLC~ABORTLOS ON ACCOC'NT OF X-RAY EXAMINATIOS DURING PREGSAXCI
By ERLING HAMMER-JACOBSEN
In recent years X-ray examination of pregnant the authors are of the opinion that smaller doses women has in some instances been either the sole will also cause injury to human beings, in whom or a contrilbutory indication for therapeutic abor- even small defects are recognized. However, doses tion. less than one r are assumed not to cause visible Eleven pregnant women had one or niore ab- injury. dominal X-ray examinations during the first three M' i 1 s o n (1954 found retardation of growth months of pregnancy. Therapeutic abortion mas at the rate of one to five per cent when exposing later pcrfornied in eight caFes while thrcc went pregnant rats to radiation with 12.5 r, the smallest to term. dose hitherto used in animal experiments. With a dose of 25 r retardation of growth and malforma- EARLIER STUDIES tions of the eyes were produced at the rate of It is not intended to make here a complete list six to twelve per cent and six per cent re- of studies previously published. This was recently, spect ively. and most thoroughly, done by Magnusson H i c k s (1954) showed that neuroblasts of (1955 and 1958), by G y 11 e n s t e e n (1955) and foetuses of rats and mice necrotized after a dose earlier by M u r p h y (1947). of 40 r. Previous studies of injury to the foetus due to Tahmisian & Wright (1958) found that irradiation almost exclusively originate from the the incidence of malformations in grasshoppers use of radiation doses of a quality and quantity increased from 50-SO per cent when the dose corresponding to those of radiation therapy. For rate was increased from one r/minute to 200 this reason it is difficult to apply conclusions r/minute. The total dose in both instances was drawn from these doses to the comparatively 250 r. For the purpose of radiography with small doses in diagnostic radiology, and more modern units and short exposures the dose rate animal experiments will be required using diag- may be, for example, 50-150 r/minute. nostic units and with foetal doses ranging from The United Nations' report (1958) mentions about one r to 10-20 r. that in vitro it has been possible to produce As the background radiation is about 0.1 r per changes in embryonal neiiroblasts by application annum a foetus after the normal term of preg- of a dose of one rad. The nature of the changes nancy will have received a presumably harmless was not described. dose of about 0.08 r, which should be considered in reIation to the doses mentioned later. Diugnostic Radiology. Murphy (1929) and Goldstein & hlur- .in inial Experiments. p h y (1929 a) discuss a wonian who had been By exposing pregnant mice to radiation, R u s- bubjected to two retrograde pyelographie5, with s e 1 1 Si R 11 s s e 11 (1950) produced iiia1Formi- several exposures, at her 5th-Gth week of preg- tions of the thoraco-luinbar skeleton. The smallest nancy. At the end of term she gave birth to a dose applied was 25 r, and this produced changes. mongoloid idiot who died a few days after Russell & Russell (1952 and 1956) and delivery. On a rough estimate the foetal dosc is RusselI (1954) proved that the earlier in assumed to havc been 5-25 r. pregnancy the radiation was given, the more K j e 11 b e r g (1942) mentions an instance of malformations would result from such radiation, 1iysterosaIpingoaral)hy in pregcancy. In spite of and that the period from the second till the sixth the application of 120 ccs. contrast agent the week of human pregnancy is particularly sensi- patient did not miscarry. There is no mention of tive. As the cffect of radiation varies continuously the child. with the dose, apparently without any threshold, V a 1 d e ni a r JI :I d s c n (1942), in his matcrial, From the Department of Radiology iiic,iition\ :I 2.5-ycar-old married wonian who was (Head: Professor Gregers Thornsen) qubiectccl to a hysterosalpingography in 1935, Rigshospitalet, University of Copenhagen, and eight days after her latest menstruation. The the Radium Centre, Copenhagen pregnancy had a normal course and the patient (Head : Professor Jens Nielsen) . gave birth to a healthy normal term infant. 114 DAXISH MEDICAL BULLETIX Tot 6 no 4
I3 9 r g e S i c I s c n (194G) mentions hvo cases rsaniin:itions \Yere pcrforincd tliiring tl~cfirst il;lic rll WN~) til( ( I 1' 11 \-s t crosall t ingogi~apliy iii prcgn ancy . One coni- or ~lrcg~la~icl-, tile cO11t1~)i Iilctcd her normal term, the other continued corrcsliunding figure \\-as only l\vo out of 93. iintil the eighth month n-hcn pregnancy \vas in- Even if tlie inaterial from the first half of prep- tcrrupted during eclampsia. In 1917 the same nancl- is small, the figures seein to emphasize atrtlior mentions that liysterosalpingoarapli~\vas the greater risk involved by irradiation in early performed in four pregnant patients. One of these pregnancy. aborted. but hardly due to the X-ray examination. Considering that 86 per cent of the sick infants The children are not mcntioned, but a follou--up died without having been exposed to pre-natal study together with an estimation of the dose X-ray irradiation, and that 5 per cent of the niight be interesting. healthy infants had been exposed to irradiation H II 1 t 1, e r g (19491 nicntioiis n 25-ycar-old xvithout subsequent diseases, the irradiation can unmarried lvoman who twice had her abdomen only be the cause of some of the cases. It niight exposed to radiation from a ~~liotofluorographic be concluded that abdominal X-ray examination apparatus in the third month of her pregnancy is responsible for 14 per cent less i per cent = in order to induce abortion. These exposures were 7 per cent of Ieukaernia-cancer cases. given by a roentgen technician (the father of the Hoxvever, one may also make tlie following child) and each exposure lasted about five calculation: Out of 5G5 deaths per annum 40 iiiinutes during which the \voNiiian stood pressing (7 per cent) should he caused by abdominal her abdomcn against the roentgen tube. In the X-ray cxaniination (mainly pelvimetry and ab- fourth month of pregnancy an X-ray burn of the domen obstetric) in pregnancy. In England abdonien occurred. The patient gave birth to a 15 :ibout 12 inillion X-ray examinations are carrictl days premature infant weighing two kilos. Tlie out per annum at the hospitals (0 s b o r n c Sr child, who was followed up to the age of 13 S 111 i t 11 195G). 0.5-1 per cent of these are (Hu 1 t b e r g 19593, has an unusually small head. pelvimetry or obstetric examination of thr He is unable to read, and can only express him- abdomen = F0,OOO to 120,000 per anniini. In P self by sentences of not more than five words Sweden the corresponding figure is 0.4 per cent each. It has been recommended that he should (L a r s s o n 1958). be admitted to a home for imbeciles. There is no Thus one may estimate that only about 1/3-2j3 particular somatic disease. The foetal dose has per thousand of these examinations are causing not been recorded but is assumed to be of tlie leukaemia or cancer in the child. This figure order of 50-100 r. should be compared with the number of lives K a i s e r & 31 a r v i n (1957) counted the white sared by tlic information obtained by these S-rn). blood corpuscles in 22 newborn children whose examinations. The foetal doses have presu~iiably iiiotliers had been subjected to abdominal X-ray been of the order of two to ten r. esainination in the Stli-gth month of pregnancy In 1958 D e in p s t e r followed-up tlie childrcn with a foetal dose of 1.5-3 r. No difference was of 148 mothers in whom pelvimetry had been per- found in the number of blood corpuscles in formed in 1948. Out of 125 children traced 104 children exposed to X-rays and in the unexposed were alive and healthy. Among the 21 who died ones. there were no cases of Icukaemia or cancer. S t e 1s a r t, W c b b Sr H e w i t t (1958) carried oiit a Inrgc and c:ireful inrcstigation of the causes Radiotherapy. of Iculiacinia and cancer in infancy. The iiiothers Following r;itliothcsral)y sc~cr:il iiis1;iriccs or of 1,416 children who died in the years 19.53- foetuses initired by radiation - and also a fc\v 1'35.5, under the age of ten, of leukaemia (677 noriiial children - Iinvc Iwcn reported but Ilic c:ises) or cancer (739 cases) xvere intervie\vcd. foetal doses haw Iwcn of the order of soinc The control material was of an identical size. The hundred r and not at all coniparablc with diog- total nuntber of children who had died \vas 1,694 nostic radiology. 1mt only 1.41F cases were covered by tlic study. Robinson (1927), Goldstein Sr Slur- 4 significantly higher frequency of direct foetal 1) h y (1929 a and b), and ,IT 11 r p li y (1929), re- irradiation, virus infections, and threatened abor- port several cases in which mothers had had tions, was found amongst the dead children, and abdominal X-ray or radium treatment and then a high maternal age also seemed to increase the gave birth to children with various nialforma- risk of leukaemia in infancy. Among the dead tions (microcephaly, hydrocephaly, spina bifida. children there was also a higher post-natal frc- strabisnius, malformation of cranium and cxtremi- quency of X-ray csaminations, aciitc pulmonary ties). infections, and severe injuries. Jon cs and Sc il 1 (1944) report on 51; In tlie leukaemia-cancer group 1iY (15 per patients \vho during prcgnancy received radiuiii ccnt) of the niotliers - as against 93 (seven per or X-ray trc:ttiiicnt of cancer of the titerine CCY- cent) of the mothers of the control group - had vix. Among the children were found seven been si1 b j cc t e d lo abd o it I i n a1 S -ra y ex ani in at ion definitely abnormal and 12 definitely normal during pregnancy. Eighteen of the li8 X-ray ones. JUXE 1969 DANISH MEDICAL BULLETIN 115
Lacorn me (1931) and Hoh hs (1950) re- For the purpose of the calculations the foetal port on three normal children after radiotherapy dose has been assumed to be twice that of the of the abdomen of the mother in the 7nd--3rd, rectum (antero-posterior projection). 4th, and 5th month of pregnancy respectively. In patients Nos. I, 111, IV and VI1 dose nieasure- Injury to the foetus has been reported also after ments were made Lvith the actual X-ray units that atomic bomb explosions (Ya m a z a k i, \V r i g h t had been used when these patients were ex- 9r b’r i g h t 1954), and after experiments with amined. animals with rcidioacliLje isofopes (S i k o v, There is a very \vide scatter of both the Lo f s t r 0111 & Soonan 195s). The doses measured and the calculated doses. The iiiean have been of the order of 500--1,000 r and are value is the most probable dose but one cannot not comparable with the doses of diagnostic be certain that the patient in qiiestion has not radiology. received the maximum possible dose. The mas- Summing up one can say that we know very imum possible dose must be decisive when little about possible injuries to foetuses on account considering the indication for induced abortion. of the small radiation doses in diagnostic radio- The \vide scatter may be due to, among other 11)gy. The therapeutic abortions tnentionetl later factors, variable duration of fluoroscopy. (In \\.ere thuc perforliied on a very slight basis. CdSE HISTORIES The cases are presented in the order of the BI .ITER 1.1 L decreasing size of the calculated foetal dose. The present study coinprises 11 pregnant women who were subjected to one or more ab- I. 24 years old, married, first pregnancy. Always dominal X-ray examinations during the first regular menstruation. In 1954 the patient underwent three months of pregnancy (cf. Table 1). X-ray examination of abdomen, intestinal passage, 2 barium enemas, and intravenous pyelography, 4s- The X-ray examinations were performed in five 63 days after last regular menstruation. Foetal dose radiological departments in Copenhagen in the is calculated to be 3.7 r (1.1-18.9). ’The examination years 1954-195S. The inductions of abortion took place during an admission to a surgical depart- sere performed in two gynaecological depart- ment. ments and two stirgical departments in Copen- After discharge the patient was referred to the hagen. Five of the abortions were induced in the Institute of Human Genetics by her physician, with same gynaecological department. a view to ascertaining whether the S-ray examinations performed might be harmful to the foetus. As a The histories of the 11 patients and the three radiologist was of the opinion that the X-ray examina- children have been studied. For reasons of dis- tions could not be considered an indication for induced cretion the three children were not followed-up abortion the patient was allowed to continue to term. but in a few years it is intended to try to get Natural birth at expected date, 2050 g, 45 cm. One further information about the children. half of the placenta was said to be fibrously trans- formed. Premature looking child with the following Co[cic[ulion of foetal dose. diseases during the first 3?$ years after birth: 3 weeks old: strangulated hernia ing. dxt. 3 munths old: \Yith a view to calculation of foetal dose the strangulated hernia ing. sin. Following this two patients’ X-ray films have been studied. The pneumonia-type illnesses, From the age of two years technical data were received from the radio- asthma (asthma in the family). EEC at the age of logical departments in question: focus-filrn- two years: normal. .It the age of two years acute distance, thickness of the added aluminium appendicitis. The child could not sit until it was filtration of the tube, the tube voltage applied eight months old, walk until it was 18 months, or IkV), tube current (mA), time of exposure (sec) speak until it was two years old. Sot until it was and the total number of mAs. 3’1 years old did it develop and look like other Rectal or vaginal dose measurements in patients children of its age. Data available up to the age of four years. of various radiological departments have been used for the calculations. Some of the measure- 11. ?6 years old, married, tn.o normal deli1,eries ments have previously been reported (H a ni in e r- 1953 and 1955. An abortion 1934 in the 3rd month J a c o b s e n 1957 a, b). of pregnancy. During an admission to ;i medical de- partment in 1956 the pnticnt underwent S-ray ex- The vaginal dose is assumed to be equal to the amination of chest, barium enema, barium meul, in- dose in the uterus, that is, the foetal dose. In testinal passage and cholecystography ?l--37 days order to calculate the dose in the uterus in after her last menstruation. DurinS a previous ~reg- relation to the rectal dose, measurements have nancy her menstruation had been fairly regular dur- been made in a paraffin phantom (Ham mer- ing the first months. Bulo test positive. Foetal dose .lac o bs e n 19.57 a). ant1 Inter with Mix D calculated to be 1.7 r (0.5-6). phantom blocks, at the Radiophysical Laboratory The radiological departnient estimated a foetal of the Radium Centre. It is found that the dose dose of 5-10 r, and as the Institute of Hiiriian at a depth of 10 cm (“uterus”) is two or three Genetics stated that the possibility that the ir- tiines as large ;IS at a deptli of 15 cin (“rectuni”), radiation had injured the foetus could not bc \vhen using radiation of tliagnostic cluality. escltitletl, an abortion \vas intltrcefl abollt one 116 DARISH MEDICAL BULLETIN Vol 6 no 4 -~- month later, A foetus was not observed, but cartilage and foetal bone as well as other elements microscopy of the scrapings showed: “small from the foetus are seen: no malignancy.” pieces of necrobiotic decidua and villi chorii covered with a single layer epithelium and with 111. 39 gears old, unmarried, first pregnancy. Always natural vasofaction. In addition particles of foetal regular menstruation. During admission to a surgical
Table 1. X-ray esaniinafion during pregnancy.
NO. ot day, Foetus mt abortion Cue No. (Year) Total mAm .Iter 1811 Induced abortion Foetal dau rnenivud or delivery or X-my examination. child at birth period
I. (1954) ? 48-63 Delivery 2,050 g, 4.5 cm. Abdomen > 9,000 mds (normal) 9 months’ pregnancy. Intest. passage 3.7 r So malformations. Barium enema (1.1-18.9) Half the placenta had undergone Barium enema fibrous degeneration. I. v. pyelography
11. (1956) ? 21-37 Induced Micr. exam.: Normal placental tissue. Chest > 5,OOO mAs abortion Foetal cartilage and hone without Barium enema 1.7 r ni a 1 igna ncy. Barium meal (0.5-6.0) Intest. passage Cholecystography
111. (1958) Approx. 42-49 Induced Grossly normal. No bony deformities Barium enema 2,500 m.4s abortion on X-ray examination. Cholecystography 1.5 r Barium meal ( 0.4-3 .O
IV. (1956) Approx. .i8 Delivery 3,800 g. 53 cm. Lumbar spine 1,800 m.4s (normal) 9 months’ pregnancy. Thoracic spine 0.6 r Lumbar myelocele. (0.07-1.6) 1’. (1957) Approx. 15-16 Induced Sot examined Lumbar spine 840 mAs abortion 0.4 r (0.05-1.2)
VI. (1958) Approx. 11-18 Induced Micr. exam. of curettings showed Lumbar spine 1,020 m.4s (35) abortion normal placental tissue. Foetus not Thoracic spine 0.4 r observed. Pelvis (0.07-1.1)
VII, (1958) Approx. 88 Induced Grossly normal. hlicr. exam. of cere- I. v. pyelography 1,200 m.4s a bortion bral tissue, placenta and urnl~ilical 0.4 r cord normal. (0.245)
VIII. (1958) Approx. 27-21 Delivery ?,is0 g, 50 cm. Lumbar spine 200 m.4s (normal) 9 months’ pregnancy. 0.09 r Normal child. (0.01-0.2)
IX. (1956) Approx. 36 Induced Grossly normal. Jlier. report has Hysterosalpingography 300 mAs (7) abortion disappeared. 0.06 r ( 0.02-0.2 )
X. (1957) Approx. 21 Induced Sot examined. Hysterosalpingography 230 m.4s (i-I4 abortion 0.05 r (0.01-0.1)
XI. (1957) Approx. 35 Induced Sot examined. Hysterosalpingography I50 mAs (11) abortion 0.03 r , (0.01-0.08) .IU,YE 1959 DhXISH MEDICAL BVLLETIN 117 __ __. __ -
9 department the patient underwent barium enema, department. As it has been considered dcsirclblc cholecystography. and barium meal, 42-49 days after not to contact the patient, information about thc latest regular menstruation, and 16-23 days after child after its first birthday is not available. a very shortlasting and slight menstruation two days before scheduled time. V. 31 years old, married, one normal prcjinancv The patient has given the exact dates of coitus three years earlier. Always regular menstrii.it ion. which took place only once every month. On this During treatment at n physiotherapy clinic the Irimhr account one is in the rare position of being able spine was X-rayed 15-16 days after latest regular to establish with reasonable probability, that the menstruation. Foetal dose: 0.4 r (0.05-12). 98 days barium enema was made on the 25th day after after the latest menstruation the following statement conception, cholecystography on the 31st and was entered in the journal of the physiotherapy clinic, “The patient turns out to be in the third month of barium meal examination on the 32nd day. pregnancy”. The patient petitioned the Danish Mothers’ Aid Centre (D.M.A.C.) in Copenhagen for a thera- The patient was then admitted to 3 gyn:icc.olo- peutic abortion, as she had read in “Readers gical department and because of the risk IILICto Digest” that an X-ray esamination may cause an irradiation, abortion was induced 135 (la! T .iili,i. abnornial development of the foetus. Further she latest menstruation. Unfortunately thc r~~~~~u\, stated that as she was 39 years old, she was afraid measuring 30 cm, was not examined. of having a mongoloid child, that she lived alone
without any possibility of being married to the VI. 22 years old, unmarried. At the age of 211 ,111 father of the child, and that her financial posi- abortion in the third month. At the age of ‘?I*)iic tion was difficult. Phantom- and patient-dose normal delivery. Always irregular menstruation : 3 measurements were made with the same X-ray days/?-6 weeks. During admission to a gynaecolsicic..oI unit, letting the physician in charge of the department the thoracic spine, the lumbar spine .iii~I fluoroscopy of the patient make a fluoroscopy of pelvis were X-rayed because of an earlier diayiitlwfl another patient, and a foetal dose of 1.5 r (0.4-3) onsetting ankylosing spondylitis. The X-ray ex3ni I 11.1- was calculated. The barium enema accounted for tions were made about five weeks after her !.I!, \t menstruation of normal duration, and It13
admitted to this material because of diagnostic nurse became aware that the patient was ;p:< :’: G ’ irradiation of abdomen in early pregnancy. and the examination \vas discontinued. Foc~i.~~’ .-*. Normal delivery at term, 3500 g, 53 cm. Con- 0.4 1‘ (0.2-0.5). genital 4 x 5 cm myelocele of the lumbar region. Three weeks later the patient petitioni*ll 1!3~. The myelocele epithelized spontaneously after one D. 11. A. C. in Copenhagen for a therapeutic. .I!~s r year, but the motor development has been slow tion on account of a chronic bladder infl and it is probable that sphincter vesicae does not tion and of varicose veins, because it 7 $1 function normally. Cranial circumference a couple soon after her last child’s birth, and on i!nt of centimetres larger than normal. X-ray examina- of lack of living accomodation. She had tric.tI tion of cranium (age: 14 days) shows a peculiar induce abortion by means of pills. On rt,rli~t,\l
coarse netting, probably due to lack of calcifica- the radiological department in question ;.I\ 11 !hi*
tion. The spine seems to be normal, but laminae information that “injury to the foetus in ” 1. are not seen clearly in the region of the third above patient can not be left out of consi1tL.i I,. :I
lumbar vertebra. The child has been in hospital for certain, but the risk is considered tal !I*, and treated as an outpatient at a neurosurgical slight”. At the recommendation of the D. ?I. \ 1:. 118 DANISH MEDICAL BULLETIN 1-016 no 4 abortion \vas induced on a medical and eugenic indication in the 1Sth \veek of pregnancy. Foetus measured 33 cm and \vas autopsied at the Pathological-Anatoniical Institute of the Uni- versity of Copenhagen. The niacroscopic esaniina- tion sho\ved natural conditions. On niicroscopy of the umbilical cord, both cerebral hemispheres and the occipital lobe, the brain strni, and medulla spinalis. nothing abnormal \vas observed. Micro- scopy of tlie placenta slio\\-ed “flakes of decidua tissue and homogeneous eosinophilic stained ilia t t er, c alci f icd hcr c :in (i there” , otherwise nothing pathological. I). D.: “Foetal brain tissue I’ without pathological changes. Placenta tissue ii without definite pathological changes, yet slio\v- ing calcifications. Thus no signs of radiation- injury”.
VIII. 25 years old, married, previously two abortions. During treatment at a physiotherapy clinic the lumbar Fig. 1. spine was X-rayed 27-21 days after latest menstrua- Case no. IS. Hysferosnlpingogru1,hy tion. Foetal dose: 0.09 r (0.01-0.2). Pregnancy. In view of tlic radiation hazard a gynaecologist stated that he considered induced abortion ab- that tissue \vas sent for liistological rsamination solutely indicated. Another gynaecologist and two but the rcport of thc niicroscopic examination radiologists on the other hand stated that there has be en ni i s 1ai (1. was no indication for induced abortion. It was then decided to let the patient complete the preg- S. 31 years old, one natural birth 10 years ago. nancy. The patient has not been informed about Referred to a gynaecological department for metror- the considerations. rhagia. Menstruations previously regular, but of vari- able intensity, and at varying intervals the last three Sornial delivery eight months and 26 days after months. H?sterosalpinjiography was performed aliout the first day of the latest menstruation. Child three weeks after latest menstruation of a moderntc without malformations: 2750 g, 50 cm. Sormal and short-lasting char:icter, 1-? weeks after a \cry development. Data available up to tlie age of five faint and short-lasting bleeding. Foetal dose: 0.05 r inon t lis. (0.01-0.1 1. The uterine ca!ity was about 10 cm x The follo\ving patients are three married women 10 cm and there was an clearing at the ccntre who \v ere ex p os e d to h y s t er 0sa1 pin gogr a phy at and to the right, :timost the size of a hen’s egg. a gynaecology department with subsequent thera- Radiological diagnosis: “It must be a pregnancy at peutic abortion at the decision of the gynaecology about the 3rd month”. Subsequently evacuatio uteri was performed “as the patient by now has got o department. One miglit at first think that the de- rather high X-ray dose”. Some ahortion tissue which partment had considered the possible risk in- was not microscolrically esninincd \vas removed. volved by the contrast injection in uterus as well as the possible radiation hazard; but it is stated XI. 32 years old, two normal dcli\crics 13 and G that the contrast injection was not taken into years carlier. Rcferrcd to :I g?nnccologir:il tlcliartnicnt consideration. for observation fnr cancer nf the utcrus. Irregular menstruation for two to three months. Hvstero- IS. ?1 years old, first pregnancy. Menstruation salpingography was performed 35 days after latest during the last year somewhat irregular, 4-5 days/ menstruation of natural intensity, 11 days after a 4-7 veeks. On account of dysmenorrhoea a hystero- sparse and short-1:isting (1 ‘I. days) nienstruation. salpingography was performed 36 days after the latest Foetal dose is calrulatcd to be 0.03 r ~O.~ll-~l.O~I. The menstruation of regular intensity, scven days after a uterine cavity \vas considerably enlarged with a large slight bleeding. Foetal dose: 0.06 r (0.02--0.2!. (Six round defcct in thc right 11alf. Itadiolofiical diagnosis: k films without fluoroscopyl. Radiological description “Fibroma uteri? I’rcgnancy:‘”. Bufo test p0sitij.c. (Fig. li: “;\ round smooth cavity of the size of a “In addition it turns iiut that thc patient has had grape-fruit, iii which the right uterine corner may rubella. On account of this and on account of the Le discerned, is filled, but the greater part of the S-ray esamination it is thought thcrc must be an in- interior of this cavity is filled by a globular, slightly dication for indurcd abortion”. E\.:icuotio uteri \vas humpy clearing going from the left side and located then performed and foctiis and pl:iccnta were rcnio! cd, at anterior or posterior xvall. Radiological diagnosis: hut not examined Pregnancy”. Bufo test positive. In viov of the radiation hazard abortion was It is characteristic of thcse threc patients that induced 11 days after thc X-ray examination. they all had had irregular mcnstruation and all A 15 ciii long foetus \vas deliycred, showing \vere in the second to third month of pregnancy. nothing abi1~Jl’iii;l~~ii;ic.~-osco~~ic~rll~. It i.; stated They \vcrc‘ all gyn:icccilogically exaininctl prior to JUNE 19.59 DANISH MEDICAL BULLETlY 119 the X-ray examination without their pregnancy 1. Injurious foetal dose. being detected. Further it is paradoxical that the Russell & Russell (1956) are of the pregnancy was diagnosed by X-ray examination opinion, as previously mentioned, that doses be- and that the pregnancy was then intcrrupted on low one r may be presumed to produce no account of the X-ray examination. nieasurable adverse effects. The International Commission on Radiological Finally, as a curiosity, a case encountered once Protection 1957 recommends that pregnant womcn by the D. 11. A. C. will be discussed. A woman are not occupationally exposed to irradiation but applied for induced abortion because her husband that no special precautionary nieasures need to had been exposed to several X-ray examinations be taken if the maximum perniissible Xveekly dose in regions near to the gonads. The patient iq not is not exceeded. For the first four months of included in the relevant material as the problem pregnancy this corresponds to a foetal dose of is of a genetic nature and does not directly con- about one r. (Skin dose: 300 nir/\veek). cern foetal injuries. On this basis one might suggest the following 43 years old, married, three children IS, 15 and 11 general lines for the first four months of years old, applied to the D. 11. .I. C. for induced abor- pregnancy: tion as she thought she was too old to hove a child, Foetal doses of less than about one r, accord- :ind that she \vas not strong enough. There are three ing to our present knowledge, are presumed to cases of diabetes and one case of insanity in the cause no noticeable injury, and consequently patient’s family. After careful investigation the provide indication for therapeutic abortion. application was refused. no The application was renewed and this time she Foetal doses between about one r and about claimed that her husband had been exposed to 10 r are assumed, in some instances, to caiise 20-30 intravenous pyelographies during recent injuries in the form of diseases, malformations, years. .A gonad dose of 13-40 r was estimated and slow development or reduced resistance, especial- the Institute of Human Genetics stated on this ly when the irradiation occurs between the second basis that there was an eugenic indication for and sixth week. Doses should be individually therapeutic abortion. i\ closer investigation re- evaluated after measurements with the X-ray units vealed, hoivever, that only 12 intravenous pyelo- in question. If there are additional indications, graphies and one barium meal examination, to- therapeutic abortion should be assumed advisable. gether with two abdominal survey pictures were Foetal doses above about 10 r are assumed to undergone. On this basis the application was once involve a rather great probability of foetal injury. more rejected by the “Naevnet angaende Svanger- In such cases induction of abortion should there- skabsafbrydelse” (Council on Therapeutic Abor- fore be the general rule. tion), stating that “one has insufficient basis for These limits are thought of as a suggestion for assuming that X-ray doses like those of the present discussion. The limits are not sharply defined case may involve obvious risk of serious foetal ones, they should be open for individualization. in jury”. More animal experiments with doses ranging from one r to 10-20 r will perhaps afford a basis for Normal delivery at term. Fully developed child : determination as to whether there is a threshold 3900 g, 52 cni. Sornial physical and mental de- velopment. Information available up till age of dose and establish the dependency between dose 13 months. and incidence of disease or malformation. Studies of larger clinical materials may likewise lead to more definite rules. DISCUSSION During the last five months of pregnancy it seems as if the foetus will withstand rather The aim of the casuistic material produced is considerable doses, of the order occurring in to draw attention to this new indication for thera- pelvimetry. peutic abortion. On the other hand it is not in- If abortion is performed, the foetus should tended to try to either prove or disprove that the always be microscopically esamined. When birth diseases in the children of patients I and IV are follows irradiation of a foetus with doses exceed- due to X-ray irradiation at the foetal stage. ing about one r the development of the child It is desirable to invite reports on similar cases should be kept under observation. and to arrange at the Institute of Human Genetics G~ central registration of patients who are exposed 2. Has induced abortion been justified in the to irradiation during the first half of pregnancy. cases submitted? Three questions may be raised for discussion: These abortions, induced on account of the 1) What foetal doses are injurious? radiation hazard, were performed according to 2) Has therapeutic abortion been jtistified in the the “eugenic” indication of the Pregnancy .ict: cases submitted‘! “TVhere therc is an obvious risk that the child, 3) How can irradiation of pregnant women be on account of hereditary taint, or for reasons of avo id e d .? injury or disease contracted at the foetal stage, 120 DAXISH MEDJCAL BULLETIX Tot 8 no 4
\vi11 be suffering from insanity, imbecility, other time the chance of an undiscovered pregnancy is severe mental defects, epilepsy, or serious and in- but small. After the sixth week there need not curable abnormality or bodily disease”. be any doubt of pregnancy and irradiation should It appears from the material that therc has been therefore be avoided according to general considerable uncertainty as to the evaluation of practice. This suggestion was mentioned in an the risk and the indication for abortion. editorial of Ugeskr. Laeger 1956, by Brpn d- In accordance xvith the above mentioned pre- s t e d (1956), Hammer-Ja c o b s e n (195ia), liminary lines one might think that patient No. I Buhl (1957), Martin (1957) and Dupont should have had her pregnancy interrupted. (1958). Patient KO.IV should also perhaps have had her In order also to avoid irradiation in women pregnancy interrupted, if there were additional with ovulation early in the cycle, and with a indications. On the other hand it must be agreed special view to the irregularly menstruating pa- that patient KO. VI11 should be allowed to continue tients mentioned in this material, the follolving her pregnancy. modification of the suggestion is proposed: - Regarding the abortions induced it seems that In fertile women X-ray examination of the the indication was reasonable in patient Nr. 111, abdomen should be performed only during the and perhaps also in case No. 11. The same applies first ten days following a regular menstruation to patient No. VII, where the medical indication of normal intensity and duration. seems to haw been predominant, and patient This rule should be introduced as a routine No. VI who was unmarried and had one child. rule by all radiological departments, practising On the other hand there seems to be no reason radiologists and chiropractors. The physician to induce abortion in patients Nos. V, IX, X and referring the patient for X-ray examination should SI. In patient No. XI it should be mentioned, how- state the latest date of menstruation in the refer- ever, that the patient stated she had had rubella ence, and the nurse should cheek that no more during pregnancy. However, a specified time or than ten days have passed. any verification of rubella is nct mentioned. If the possibility of pregnancy cannot be es- All cases should perhaps hare been submitted eluded, X-ray examination should be avoided or to the D. M. A. C. for decision. postponed until the last five months of pregnancy. Only vitally indicated examinations should bc 3. How can irradiation of pregnant women be exempted from this rule. avo id ed ? It might be thought that observation of this rule Through the years several authors have warned would cause too much disturbance in the daily against irradiation in early pregnancy. Already in routine. Against this it must be pointed out that 1935 Bstergaard Christensen stated: it affects only about 3 per cent of all X-ray cs- “Considering the very great and disastrous sensi- aminations (male + female). Approx. % mill. tivity to radiation of the young foetus, it cannot X-ray examinations of women are carried out per beforehand be left out of question that even diag- year in hospitals and by practising radiologists nostic doses may be dangerous when applied to (Ham m e r - J a c o b s e n 1958). Through in- the female pelvic region during early pregnancy”. vestigations to be published later it can be cal- In 1958 B r Z n d s t e d stated: “In the future culated that about 30,000 abdominal X-ray examin- it will require an enormous effort of vigilant ations of nomen 15-39 years old (excl. pelvime- control to protect, not only pregnant women, but try and abdomen obstetric) are carried out. About also potential mothers, against the radiation 300 of these women are in their first month of hazards” . pregnancy. As about 4,000 legal abortions are induced in .4pproxiniately every fifteenth reference of a Denmark per year (Berthelsen & 0ster- woman to X-ray csamination will involvc con- gaard 1958) the patients mentioned here do sideration of the latest nicnstruation in relation to not represent any quantitatively great problem. the X-ray examination. But as the prablem is fundamental and its treat- Many radiological departments are already ob- ment may create a precedent it has been found serving this rule where hysterosalpingography is reasonable to deal with it. concerned. Considering this, no inconreniencc The most important conclusion must therefore should be necessary in trying to have the rule be the necessity for the establishment of a simple observed. Even in the largest radiological depart- measure of precaution that will prevent irradia- ment in Denmark the number of these patients tion of foetuses in early stages. will hardly exceed ten a day (outpatients + in- As most women in the early part of the period patients). The problem will in particular concern especially sensitive to radiation (second to sixth outpatients. week) may not yet have realised their pregnancy, Russell & Russell (1952) suggest that ir- CONCLUSION radiation of pelvis in women at the reproductive Very little is known about the possible injurious age should be restricted to the two weeks imme- effect of small radiation doses on foetuses in early diately follo\ving menstruation, as during that pregnancy. It will be necessary to carry out more
001 Ib45 .IU,YE 1959 DANISH MEDICAL BULLETIN 121
animal experiments with foetal doses ranging from References: one r to 10-20 r and to follow-up children 1) Editoral. Ugeskr. Lager 1936, 118: 880-881. cxposed to irradiation in the first half of pregnan- 2) Symposium of Radiation and other Deleterious CY. .igents on Embryonic Development. J. Cell. Comp. Irradiation of the foetus should as far as Physiol. 1954, 43: Suppl. 1, pp. 337. possible be avoided during the first half of 3) Berthelsen, H. G. b E. @stergnard: Ugcskr. Lreger 1958, 120: 1005-1009. pregnancy, as long as we do not know more 4) Brlndsted, H. V.: Atomalderen og vor biologiske about these matters. fremtid. (The Atomic Age and our Biological Fu- It is suggested that the following rule should ture). Copenhagen 1956, pp. 83. be introduced as a routine: - 5) Brpndsted, H. V.: Ugeskr. Lreger 1958, 140: 1-10. In fertile women abdominal X-ray examination 6) Buhl, J.: Undersagelse over de striledoser, pa- should only be performed during the first ten tienter modtager ved nogle kliniske rantgenunder- s@gelser, en vurdering af deres biologiske betyd- days following a regular menstruation of normal ning og forslag til deres aedbringelse. Copenhagen intensity and drrration. 1957. Prize paper in Clinical Medicine, University If this rule is observed the problem of thera- of Copenhagen 1956. Records of the University peutic abortion on account of X-ray examination of Copenhagen. during pregnancy may be avoided in the majority 7) Dempster, W. H.: Lancet 1938, 11: 169. of cases. 8) Dupont, A.: Nord. rned. 1958, 60: 1574-1576. 9) Goldstein, L. C D. P. Murphy: Am. J. Roentgenol. a, 2’: 322-331. SUMMARY 1!)Y 10) Goldstein. L. C D. P. Murphy: Am. .J. Obst. Gynec. I’rcvious 9tudics on radiation injury to the 19?9b, 15: 189-195, 281. foetus are reviewed. Very little is known about 11) Gullensten, L.: Nord. med. 1958, 59: 846, 1501. possible injuries due to the small radiation doses 12) Hammer-Jaeobsen, E.: Undersagelse over de stri- in diagnostic radiology. ledoser, patienter modtager ved nogle kliniskc Eleven pregnant wonicn had one or more ab- r@ntgenundersagelser, en vurdering af deres bio- tloniinal X-ray examinations during the first three logiske bctydning og forslng til deres nedhringelse. months of pregnancy. Subsequently, 8 had thera- Copenhagen 1957 a. Prize paper in Clinical Medi- peutic abortion, whereas 3 went to term. The case cine, University of Copenhagen 1956. Records of the University of Copenhagen. histories are reported. The calculated foctal tloscs 131 ffammer-.lacob.sen. E.: Ugeskr. I-ccycr 1967 11, ll!k range from 0.03 to 3.7 r (0.01-18.9). 2 79-2 90. The author makes the following preliminary 14) HammerJacobsen, E.: Die Hiiufigkeit ron Runt- suggestions about irradiation during the first four genuntersuchungen in Diinernark. Discussion to months of pregnancy: Foetal doses below about lecture by Sehaaf 1958. 40. Tagung der Deutsehen one r do not indicate induction of abortion. Foetal Rontgengesellschaft, Bremen 1958. ‘To be published doses between about one r and about ten r indicate in the congress procedures. therapeutic abortion only in the presence of ad- 15) Hicks, S. P.: J. Cell. Comp. Physiol. 1954 43: ditional indications. Foetal doses above about 10 Suppl. 1, 151-178. r presumably always indicate abortion. 16) Hobbs, A. A. Jr.: Radiology 1960, .j+: 242-?46. 17) Hollaender, A. (ed.): Radiation Biology. Val. I: One of the pregnancies that was carried to term High Energy Radiation, .\.IC (;ran.-Hill, Sew Ynrli ought to have been interrupted. Four of the in- 1954. duced abortions ought not to have been perform- 18) Hultberg, S.: Acta. radiol. 1949, 3%: 17-27. cd. 19) Hultberg, S.: Personal communication, 1959. X-ray examinations of the abdomcn should not 20) International Commission on Radiological Pro- he performed during the first four months of tection: Report on Amendments During 1956 to pregnancy. the Recommendations of the International Com- mission on Radiological Protection. Acta radiol. In order to avoid irradiation in the early stages 1957, 48: 493-495. of pregnancy, the following routine precaution is 21 J International Cornmission on Radiological Pro- suggested: In fertile women X-ray examination of tection and International Commission on Radio- the abdomen should be carried out only during lngicaf Units and Measurements: Exposure of >Ian the first ten days after a regular menstrual period to Ionizing Radiation from Medical Procedures. of normal intensity and duration. .in Enquiry into Methods of Evaluation. Physics in Medicine and Biology 1957, 2: 107-151. I am greatly indebted to Professor Tage Kemp, ??) Jones. W. N. Jr. C W. Xeill, Jr.: Am. J. Obst. C the Institute of Human Genetics and Eugenics of the Cynec. 1944. 45: 447-463. University of Copenhagen, to chief physician H. 23) Kaiser, I. H.: b J. F. Marvin: Radiology 1957, 63: H o f f rn e y e r, ~IBdrehjaelpsinstitutionen i KBbenhavn 249-250. ithe Danish Mothers’ did Centre, Copenhagen), and 24) Kjellberg, S. R.: Hystero-salpingo-pelvigraphie. to the heads of various anonymous mentioned depart- Acta radiol. 1942, suppl. 43 (Thesis). ments, for kind permission to publish abstracts from 25) Lacomme, .If.: Bull. SOC.obstct. gynecol. de Paris their case histories. 1931. 20: 457-460.
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26) Larsson, Lars-Eric: Radiation Doses to the Gonads 41) Russell, L. U. S; It-. L. Russell: Hazards [(I 1111 of Patients in Swedich Roentgen Diagnostics. Acta Embryo and Fetus from Ionizing Radiatiun iri radiol. 1958, suppl. 157 (Thesis]. Proceedings of the International Conference UII 27) Madsen, J'.: Kliniske studier over Hysterosalpingo- the Peaceful Uses of Atomic Energy. $01. 11 grafi. Vniversitetsforloget .4arhus 1912. P. 65. United Sations Sen. Tork 1956, p. li5-173. (Thesis). 42) Schaof: Ergebnisse der Befragung eines repra.cn- 28) Jfagnusson, 1Y.: Sord, med. 1955, 53: 3. tativen Bevijlkerungsquerschnitts iiber die H.iu- 29) Yaynusson, W.: Srensko LHkartidn. 1958, 55: 2399. figkeit ron Rontgenuntersuchungen. 10. 'l'agun': 30) Marlin, J. H.: Proc. Coll. Radiol. Australia 1957, der Deutschen Rontgengesellschaft, Brernen I !l:,X 1: 103-112. To be published in the congres procedure>. 31) Medical Research Council: The Hazards to Man 13) Sikou, M. R.. J. E. Lofstrom 6 T. R. .\c,r,n,rri of Suclear and Allied Radiations. Her Majesty's Effect of Maternally Administered P-32 nil FC(~! Stationary Office, London 1956. Development. Second United Nations 1ntern:it 1t111:il 32) Murphy, D. P.: Am, J. Obst. 6 Gynec. 1929, 18: Congress on the Peaceful Uses of Atomic Etit,ii: 179-187, 288. 1958. 33) Murphy, D. P.: Congenital Malformations. J. B. 14) Stewart, d., J. Webb S; D. Heuiitt: Brit. \lr(l. I Lippincott Co. Philadelphia 1917. 1958, I: 1499-1508. 31) Xielsen, B.: Nord. med. 1916, 31: 2131-2134. 45) Tahrnisian, T. A'. 6 B. J. Wrighf; ?Jcdicni SCU,, 35) Sielsen, B.: Acta rndiol. 1947, 28: 185-198. February 10, 1958, p. 6. 36) Osborn, S. 8. 8: E. E. Smith: Lancet 1956, 270: 46) United Xations: Report of the United S.iticjii, 919-953. Scientific Committee on the Effects of \tt1iiit< 37) Robinson, M. R.: Am. J. Roentgenol. 1927, 18: Radiation. Supplement No. 17 (.+/38381. l't111~1 1-25. Nations, New Tork 1958 p. 40. 38) Russell, L. B.: The Effects of Radiation on hlam- 47) Wilson, J. G.: J. Cell. Comp. Physiol. l!l:t~. i I malian Prenatal Development. In,; Radiation Bio- Suppl. 1, 11-37. logy, .Ed: :by A. 'Hollaender, vol.; 1: Mc Craw-Hill, 18) Yarnaiaki, J. S., S. 1V. Wright 8: P. M. \\.rj,)/if
Kew Tork 1954, p. 861-918. J. Cell. Comp. Physiol. 1954, 43: Suppl. I. ( - 39) Russell, L. B. 6 W.L. Russell: Genetics 1950, 35: 328. 689. 49) Osteryaard Christensen, L.: Straalegenetik 1,; I. 40) Russell, L. E. 6 W.L. Russell: Radiology 1952, 58: nisk RQntgenvirksomhed. I<. Engsigs Bogli.i~i4~~I. 369-377. Aalborg (Thesis) 1935.
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