Gadolinium-enhanced magnetic resonance imaging during pregnancy may increase risk of perinatal death

EBM Focus - Volume 11, Issue 37

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Reference - JAMA 2016 Sep 6;316(9):952 (level 2 [mid-level] evidence)

  • The risks for the fetus associated with gadolinium-enhanced magnetic resonance imaging (MRI) during pregnancy are not completely understood.
  • In a retrospective cohort study of 1,424,105 maternal-child pairs, gadolinium-enhanced MRI at any time during pregnancy was associated with an increased risk of perinatal death (stillbirth or neonatal death).
  • These findings support the American College of Obstetricians and Gynecologists (ACOG) recommendations to limit use of gadolinium-enhanced MRI during pregnancy.

The risks for the fetus associated with exposure to gadolinium as part of MRI imaging are not well understood. ACOG recommends the use of gadolinium-enhanced MRI only in situations where “it significantly improves diagnostic performance and is expected to improve fetal or maternal outcome” (Obstet Gynecol 2016 Feb;127(2):e75). The potential for extended exposure of the fetus to gadolinium through continuous cycling of the compound from the amniotic fluid to the developing kidneys and back again is of concern, as gadolinium exposure has been reported to increase the risk for nephrogenic systemic fibrosis (NSF) in some patients with kidney disease (FDA Press Release 2010 Sep 9).

A recent retrospective cohort study involving over 1.4 million maternal-child pairs evaluated adverse outcomes in children up to 4 years old following exposure to gadolinium-enhanced MRI during pregnancy compared to those without any MRI exposure. Due to the difficulty of diagnosing NSF in children, diagnoses of any rheumatologic disease, inflammatory disease, or infiltrative skin condition were also evaluated. In this study, 397 maternal-child pairs were exposed to gadolinium-enhanced MRI during pregnancy. Pregnancies for which a congenital anomaly was diagnosed prior to first trimester MRI were excluded. Women exposed to gadolinium-enhanced MRI had more prenatal visits as well as higher rates of obesity, cancer, kidney disease, stroke, Crohn disease or ulcerative colitis, seizure disorder, and deliveries after 2008 compared to women without MRI exposure. The analyses were adjusted for these and other baseline characteristics.

Maternal-child pairs exposed to gadolinium-enhanced MRI during pregnancy had an increased risk of perinatal death (stillbirth or neonatal death) compared to those without any MRI exposure (adjusted relative risk 3.7, 95% CI 1.55-8.85). There was also an increased risk (adjusted hazard ratio 1.36, 95% CI 1.09-1.69) of any rheumatologic disease, inflammatory disease, or infiltrative skin condition such as arthritis, vasculitis, bone disorder, dermatitis, or connective tissue calcification. No association was found between gadolinium-enhanced MRI exposure and congenital anomaly without chromosomal disorder, or nephrogenic systemic fibrosis-like connective tissue or skin disease. In this study, the authors also evaluated the risk of adverse outcomes in a group exposed to first trimester MRI, either with or without gadolinium contrast. However, combining maternal-child pairs that had gadolinium exposure and those that did not confounds the data and prohibits any meaningful interpretation of risks associated with first trimester MRI that are independent of gadolinium risk.

The findings indicate that gadolinium exposure during pregnancy may not only increase the risk of perinatal death, but may also increase the risk of other adverse outcomes. The results of this study support the existing ACOG recommendations that exposure to gadolinium-enhanced MRI during pregnancy should be avoided unless it will clearly improve maternal or fetal outcomes.

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