Ep. 288 Treating the Pregnant Patient with Dr. Nikki Keefe

In this episode, our host Dr. Ally Baheti interviews interventional radiologist Dr. Nikki Keefe about safety considerations for pregnant and breastfeeding IR patients. Dr. Keefe’s personal experience with pregnancy during her IR training sparked her interest in this topic. A lot of IR patients are pregnant or breastfeeding, so it is important to be cognizant of radiation and medication exposures and how they should be altered. She emphasizes the importance of establishing a protocol when these patients present. We review radiation doses of various IR procedures and risk stratification based on gestational age. At each stage of pregnancy, there are different risks of disruptions in organogenesis, effects on neural tube development, and predisposition to cancer. Elective procedures should usually be deferred until after delivery. The most common and necessary procedures performed in pregnant patients are PICC line placement, nephrostomy tube, and treatment of postpartum hemorrhage. Dr. Keefe also shares her tips for minimizing fluoroscopy time and deciding between different diagnostic imaging modalities that present both maternal and fetal radiation risks. Next, we discuss medication safety. Iodinated contrast is safe to give during pregnancy, while gadolinium is not. Sedation with opioids is generally safe, but their sustained use or administration around the perinatal period can cause neonatal withdrawal symptoms. Benzodiazepines can also be used for amnesia and anxiety reduction, and midazolam has a good safety profile and long half life. However, abnormally extended use of benzodiazepines can cause floppy infant syndrome (sedation, muscle laxity, failure to suckle). Dr. Keefe notes that pregnant patients have to start on higher doses than the standard, since they have higher blood volume and increased renal clearance of these medications. Lovenox is the safest known anticoagulant for pregnant women. Additionally, fetal heart monitoring should be performed before and after the procedure. Finally, we talk about specific cases of patient positioning when placing nephrostomy tubes, transhepatic access for gallbladder tubes, treatment of visceral artery aneurysms before pregnancy, and selection of  imaging modalities to detect pulmonary embolism.