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Safety of gadolinium during pregnancy

Facundo Garcia-Bournissen, MD, Alon Shrim, MD, Gideon Koren, MD, FRCPC

March 2006

ABSTRACT

QUESTION

A pregnant patient who underwent magnetic resonance imaging (MRI) because of an acute abdomen, was told that MRI contrast agents (ie, gadolinium-based contrast agents) are contraindicated during pregnancy. What is the risk to her baby?

ANSWER

Current radiology practices and recommendations discourage the use of gadolinium-based contrast agents during pregnancy because their safety for the fetus has not yet been proven. In line, however, with the European Society of Radiology guidelines and based on the available evidence, gadolinium-based contrast agents appear to be safe in pregnancy. Gadolinium use should be considered when the diagnostic study is important for the health of the mother.

QUESTION

Une patiente enceinte a subi un examen à l'aide de l'imagerie par résonance magnétique (IRM) en raison d'un abdomen aigu. On lui a dit que les agents de contraste en IRM (p. ex. les agents de contraste à base de gadolinium) sont contre-indiqués durant la grossesse. Quels sont les risques pour son nouveau-né?

RÉPONSE

Les pratiques et les recommandations actuelles en radiologie ne sont pas favorables à l'utilisation des agents de contraste à base de gadolinium durant la grossesse parce que leur innocuité pour le foetus n'a pas encore été éprouvée. Par ailleurs, si l'on se fonde sur le guide de pratique de la Société européenne de radiologie et les données scientifiques accessibles, les agents de contraste à base de gadolinium semblent sûrs durant la grossesse. On devrait envisager recourir au gadolinium lorsque l'étude diagnostique est importante pour la santé de la mère.


Magnetic resonance imagining (MRI) is considered safe during pregnancy, as magnetic energy has been shown not to be harmful for the developing fetus.1,2

On the other hand, most radiology service providers consider gadolinium-based contrast agents for MRI (eg, gadopentetate, gadodiamide, gadolinium DPTA, gadoterate meglumine) to be relatively or absolutely contraindicated during pregnancy; these paramagnetic agents are not recommended by the Food and Drug Administration because they cross the placenta and their long-term effects are unknown. All pregnant patients are expected to consult their obstetricians before undergoing MRI examination.

Gadolinium-based contrast agents are excreted almost exclusively by the kidneys through glomerular filtration. Their volume of distribution is equal to the volume of extracellular water, and binding to plasma proteins is negligible. These agents possess a very high safety index in human beings.3

Although there have not been any long-term animal studies to evaluate the carcinogenic potential of gadolinium-based contrast agents, no carcinogenic or mutagenic effects have been observed and no teratogenic or other long-term effects occurred in mice exposed in utero to gadolinium-based contrast agents.4-7 Pregnant mice exposed to MRI with and without gadolinium had no differences in litter size, number of live offspring, fetal weight, morphology, or development, compared with unexposed controls.4

Gadolinium-based contrast agents have been detected in the placenta in animals and human beings.8-10 In women during the second and third trimesters of pregnancy, uptake of gadolinium-based contrast agents by the placenta was sufficient for MRI imaging.11,12 These agents have also been observed in animals, and occasionally in human beings, to cross the placenta into the fetal circulation and to be excreted by the fetal kidneys, appearing in the fetal bladder only minutes after administration to the mother.3,13,14 Gadolinium-based contrast agents are believed to diffuse from the fetus back to the mother, given the high clearance rate observed in fetal rats.15

Inadvertent exposure
Inadvertent human exposure during the first trimester of pregnancy has not been associated with adverse effects in the fetus.16,17 Reports on use of gadolinium-based contrast agents during the second or third trimester are not rare,10-13,18 underscoring the usefulness of these agents in diagnosing various conditions. No harm to the fetus has been documented in these circumstances.

Guidelines
The European Society of Radiology has issued a guideline19 discussing gadolinium use during pregnancy. Their conclusion is that gadolinium is probably safe during pregnancy, as excessive quantities are not expected to cross the placenta or to be toxic to the fetus if they do.19 These guidelines also state that, given that gadolinium is mainly distributed in extracellular water and rapidly eliminated by the kidney, in the unlikely event that some gadolinium reached the baby, it would be rapidly eliminated into urine.19

Conclusion
Current radiology practices and recommendations discourage the use of gadolinium-based contrast agents during pregnancy because their safety for the fetus has not been proven. Yet available evidence suggests it is unlikely that these compounds have an adverse effect on the developing fetus; therefore, their use should not be limited, particularly given the important clinical reasons for MRI examinations during pregnancy (eg, to rule out serious abdominal diseases).

References

  1. De Wilde JP, Rivers AW, Price DL. A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 2005;87:335-53.
  2. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR imaging in obstetrics. Radiographics 2002;22:563-82.
  3. Shellock FG, Kanal E. Safety of magnetic resonance imaging contrast agents. J Magn Reson Imaging 1999;10:477-84.
  4. Rofsky NM, Pizzarello DJ, Weinreb JC, Ambrosino MM, Rosenberg C. Effect on fetal mouse development of exposure to MR imaging and gadopentetate dimeglumine. J Magn Reson Imaging 1994;4:805-7.
  5. Soltys RA. Summary of preclinical safety evaluation of gadoteridol injection. Invest Radiol 1992;27(Suppl 1):S7-11.
  6. Morisetti A, Bussi S, Tirone P, de Haen C. Toxicological safety evaluation of gadobenate dimeglumine 0.5 M solution for injection (MultiHance), a new magnetic resonance imaging contrast medium. J Comput Assist Tomogr 1999;23(Suppl 1):S207-17.
  7. Wible JH Jr, Galen KP, Wojdyla JK. Cardiovascular effects caused by rapid administration of gadoversetamide injection in anesthetized dogs. Invest Radiol 2001;36:292-8.
  8. Salomon LJ, Siauve N, Balvay D, Cuenod CA, Vayssettes C, Luciani A, et al. Placental perfusion MR imaging with contrast agents in a mouse model. Radiology 2005;235:73-80.
  9. Lam G, Kuller J, McMahon M. Use of magnetic resonance imaging and ultrasound in the antenatal diagnosis of placenta accreta. J Soc Gynecol Investig 2002;9:37-40.
  10. Palacios Jaraquemada JM, Bruno C. Gadolinium-enhanced MR imaging in the differential diagnosis of placenta accreta and placenta percreta. Radiology 2000;216:610-1.
  11. Marcos HB, Semelka RC, Worawattanakul S. Normal placenta: gadolinium-enhanced dynamic MR imaging. Radiology 1997;205:493-6.
  12. Spencer JA, Tomlinson AJ, Weston MJ, Lloyd SN. Early report: comparison of breath-hold MR excretory urography, Doppler ultrasound and isotope renography in evaluation of symptomatic hydronephrosis in pregnancy. Clin Radiol 2000;55:446-53.
  13. Novak Z, Thurmond AS, Ross PL, Jones MK, Thornburg KL, Katzberg RW. Gadolinium-DTPA transplacental transfer and distribution in fetal tissue in rabbits. Invest Radiol 1993;28:828-30.
  14. Chapon C, Franconi F, Roux J, Le Jeune JJ, Lemaire L. Prenatal evaluation of kidney function in mice using dynamic contrast-enhanced magnetic resonance imaging. Anat Embryol (Berl) 2005;209:263-7.
  15. Okazaki O, Murayama N, Masubuchi N, Nomura H, Hakusui H. Placental transfer and milk secretion of gadodiamide injection in rats. Arzneimittelforschung 1996;46:83-6.
  16. Barkhof F, Heijboer RJ, Algra PR. Inadvertent i.v. administration of gadopentetate dimeglumine during early pregnancy. AJR Am J Roentgenol 1992;158:1171.
  17. Shoenut JP, Semelka RC, Silverman R, Yaffe CS, Micflikier AB. MRI in the diagnosis of Crohn's disease in two pregnant women. J Clin Gastroenterol 1993;17:244-7.
  18. Leyendecker JR, Gorengaut V, Brown JJ. MR imaging of maternal diseases of the abdomen and pelvis during pregnancy and the immediate postpartum period. Radiographics 2004;24:1301-16.
  19. Webb JA, Thomsen HS, Morcos SK. The use of iodinated and gadolinium contrast media during pregnancy and lactation. Eur Radiol 2005;15:1234-40.

Motherisk questions are prepared by the Motherisk Team at the Hospital for Sick Children in Toronto, Ont. Dr Garcia-Bournissen and Dr Shrim are members and Dr Koren is Director of the Motherisk Program. Dr Koren is supported by the Research Leadership for Better Pharmacotherapy during Pregnancy and Lactation and, in part, by a grant from the Canadian Institutes of Health Research. He holds the Ivey Chair in Molecular Toxicology at the University of Western Ontario in London.

Published Motherisk Updates are available on the College of Family Physicians of Canada website (www.cfpc.ca).

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