Radiation exposure in pregnancy: need for awareness

INTRODUCTION

After the invention of the x-ray by Roentgen, modern medicine has come a long way in using radiation for the diagnosis and treatment of medical conditions.¹ Diagnosis in healthcare has seen a dramatic change in recent decades because of evidence-based practice. Growth in the utilization of non-invasive diagnostic imaging was seen from the mid to late 2000s followed by a reversal and flattening of growth after 2010.²

Radiation can be quantified using radioactivity, exposure, absorbed dose, and effective dose. Biological hazards can be of two types-deterministic effect, where dose above threshold causes cell death; stochastic effect, in which damage to cells occurs at any level of doses and no determined dose has been identified. Both deterministic and stochastic effects are seen in high-dose ionizing radiation, but low-dose has been shown to have mostly stochastic effects.^3,4

Ionizing radiation can cause serious consequences in the fetus like malformations, growth restrictions, neurological deficiencies, or cancer depending on the stage of fetal development.⁵ Spontaneous abortion of fetus occurs when exposed to radiation during the first two weeks of pregnancy while the mother is unaware of her pregnancy.⁶ A high done in the 2^nd trimester can lead to malignancy of childhood (1% increase in congenital abnormalities with every 10 rads increase). Hence, it is better to keep these radiation exposures to the bare minimum in pregnant women.⁶

Awareness about sources of radiation exposure among medical professionals can curtail needless imaging and its consequences in their patients.⁷ Studies have concluded that most of the public is not concerned about ionizing radiation from radiological procedures because of trust in doctors and their broad training in radiation protection.⁸

Patient awareness and knowledge of ionizing radiation exposure in recent studies report a lack of knowledge in the Indian population.^9,10

There are hardly any studies in India that assess the knowledge of pregnant women regarding radiation exposure and its ill effects on the fetus. We believe this study will highlight the awareness of women in our study sample and the need for an initiative by the government, hospital administration and doctors to increase health education regarding this in patients and the general public. Hence, aim to assess education level of pregnant women about radiation exposure during pregnancy.

Objective

The objectives of the study were to assess awareness about the ill effects of radiation exposure amongst pregnant women across socio-demographic parameters and to assess improvement in the awareness level post health education.

METHODS

A questionnaire-and interview-based interventional-sectional study was conducted for a period of three months on 404 pregnant women visiting the radiology department for antenatal ultrasound examination in a tertiary hospital-ESIC Model hospital, Rajajinagar, Bengaluru. The sample size was after assuming 50% of subjects were aware with relative precision of 5%, confidence interval 95% and keeping a 5% error margin. Ethical committee approval was obtained. Ethical committee approval no: No.532/L/11/12/Ethics/ESICMC &PGIMSR/Estt.Vol..IV.

Inclusion criteria

Subjects equal/ more than 18 years of age, self-reporting of pregnancy confirmed with results of a urine pregnancy test or previous scans and subjects who volunteered to provide informed consent included in study.

Exclusion criteria

Subjects lesser than 18 years of age and subjects who declined to participate in the study were excluded from the study.

Using a pre-designed questionnaire drafted by the authors, the subjects were assessed for awareness of risks of radiation exposure (x-ray, CT scan, ultrasonography, MRI) on the fetus. The questionnaire was framed by the authors as well as validated by experts in the particular field.

The questionnaire included that age, weeks of gestation, order of baby, number of antenatal visits, presence of any anomaly in previous baby, education of head of family, occupation, family income, history of previous abortions, if health education regarding radiation exposure was received during any antenatal visit, presence of any radiation exposure during previous pregnancies? presence of any radiation exposure during current pregnancy? presence of any knowledge on why radiation exposure should be avoided during pregnancy and if yes to the above question, what knowledge do they have? (Skin lesions, limb defects, cardiac or brain malformations, miscarriage, others).

Education of subjects varied from demographic data, antenatal history of previous and present pregnancy was collected. Detailed health education was imparted by the author about the ill-effects of radiation exposure on growing fetuses and their understanding was reassessed using the same questionnaire after 1 month.

Post health education questionnaire- 1. Presence of any knowledge on why radiation exposure should be avoided during pregnancy, 2. If yes to the above question, what knowledge do they have? (Skin lesions, limb defects, cardiac or brain malformations, miscarriage, others), 3. What precaution will they take in present and future pregnancy?

The data was analyzed to evaluate the influence of socioeconomic status on their knowledge. Modified Kuppuswamy system of classification was used to classify the participants based on their level of education, income, and occupation.¹¹ This helped to gauge the knowledge regarding radiation exposure among pregnant women before and after health education. Using Chi square, t test and ANOVA both qualitative and quantitative data was analyzed and the p<0.05 was considered significant.

RESULTS

A total of 404 pregnant women were interviewed for the study. Among them, most participants belonged to the age group 25-30 years (n=175) which is 43.32%, whereas only one was from the age group 40-45 years (Table 1).

Considering socioeconomic status, around 60% of them belonged to upper-lower socioeconomic status. It was observed that almost negligible subjects were from the upper or lower class (Table 1). The socio-demographic distribution of the study population is represented in Table 1.

The details of antenatal history are represented in Table 2. It shows that the nearly same number of the participants (Table 2) had the order of baby 1 (46.5%) and 2 (47.7%). Most (47.5%) of them belonged to the 3^rd trimester and least (12.8%) from the 1^st trimester (Table 2). About 1% of the study group had radiation exposure in the present or previous pregnancy due to various reasons (Table2). It was observed that only n=110 of the study population received health education regarding radiation exposure from the health care professional (Table 2).

Assessment of the factors affecting the awareness of radiation exposure among pregnant women is shown in Table 3. It can be observed that a significantly higher number of pregnant women belonging to the age group above 30 (46.8%) had awareness compared to their counterparts (29.5%). Most of the women who had awareness were either having their 1^st (n=59) or 2^nd (n=69) child. Although the number of women who had awareness about radiation exposure increased from 1st to 2^nd and 2^nd to 3^rd trimester, it was statistically insignificant. Around 26.5%, 35%, 81.4% of the pregnant women belonging to upper lower, lower-middle, and upper-middle-class had awareness regarding the matter respectively. But this was not statistically significant for consideration.

Health education had a major impact on the awareness of radiation exposure in study groups as shown in Table 4. A total of n=133 subjects had some knowledge about the matter before health education, whereas n=403 of them knew a health talk. This change was found to be statistically significant.

DISCUSSION

Ionizing radiation can damage the living tissue at a cellular level and can cause structural impairment to the DNA.¹ The conceptus, during its early stages of development, is considerably more vulnerable to radiation.¹² Although studies have shown that risk to the fetus by radiographic, fluoroscopic examination is minimal, it is still advisable to avoid unnecessary and unintended radiation exposure in pregnancy.^13,14 When significantly higher radiation (>500 mGy) has been exposed to the conceptus, it could lead to childhood malignancies, growth retardation, severe mental retardation, microcephalus, seizures, and intrauterine death.^12,14-16 Therefore, the knowledge of radiation exposure in pregnancy is vital.

The present study aimed at assessing the knowledge regarding radiation exposure in pregnant women and educating them regarding the same. Our study pointed out the inadequacy of health education regarding radiation exposure. The absence of significant difference in the awareness regarding radiation exposure between the parity and weeks of gestation was probably due to the lack of health education during the antenatal visits in previous or present pregnancy. The results of the present study could not be compared to the previous studies due to lack of literature. Though, a previous study on awareness of dental imaging in pregnancy conducted on women across all age groups pointed out that 91% had poor knowledge.¹⁷

This raises a question as to who must provide awareness and education on the radiation exposure and risks to pregnant women. Previous studies have shown that there is no consensus on the subject if radiologists, radiographers/ technologists, or referring physicians must provide health education.¹⁸ Some studies have also reported the lack of knowledge among healthcare professionals.^19,20 But attending health education programs has shown increased awareness levels in them.²¹ However, all of them agree that education and awareness must take place.¹⁸ Healthcare professionals must inform the patients on the benefits and risks of radiation exposure based on evidence-based guidelines.^18,22 Both the referring physician and the imaging personnel must strive to educate pregnant women on this issue. Although radiation is essential for certain lifesaving diagnostics, conservative management is proven to be the ideal way.¹⁴ Hence authors believe that as soon as the woman is deemed pregnant, this knowledge on radiological modalities can help in safe pregnancy.

In this study, after assessing the knowledge and awareness of radiation exposure, the pregnant women were educated regarding the same. They were made aware of the differences in various modalities of imaging and the radiation exposure concerning each modality. They were educated that (a) ultrasound was a must to assess the growth and development of the conceptus and was harmless during pregnancy; (b) the risk of high radiation exposure and its sequelae concerning the gestational age; (c) to consult the physician before undergoing x-ray for conditions such as toothache, cough or fracture during pregnancy; (d) emphasis on disease prevention to avoid the need for imaging modalities such as x-ray and CT scan; (e) to avoid accidental radiation exposure when visiting the hospital or accompanying others for procedures; (f) imaging with radiation exposure may be required when it plays a crucial role for the survival of mother or baby.

The participants were reassessed after the education. It was observed that there was a significant increase in awareness of the issue after the intervention (p<0.0001). A post health education assessment revealed that 99.75% (n=403) of participants were aware of the impact of radiation exposure in pregnancy and had the insight to avoid unnecessary radiation exposure. Therefore, a simple intervention regarding the issue during antenatal visits could bring about a significant improvement in the well-being of both pregnant women and conceptus.

Limitations

There is a need for constant monitoring and audit to ensure the knowledge being imparted to the pregnant women on their antenatal visits. Without this continued effort, the purpose can be not relevant. Hence, doctors in the radiology department need to take active participation in taking the project ahead. The education level of the participants was not taken into consideration for the study, instead Socioeconomic status was measured.

CONCLUSION

There is a lack of knowledge in pregnant women regarding the radiation, imaging modality, and its impact on the conceptus. There is a need for better communication regarding the issue between health professionals and pregnant women. Educating pregnant women on potential sequelae of radiation exposure helps them make informed decisions and avoid accidental exposure, thereby improving the quality of health care.

ACKNOWLEDGEMENTS

Author would like to thank to all the participants for investing their precious time in the study. Also, grateful for the department of community medicine for their guidance and input for statistical analysis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Donya M, Radford M, ElGuindy A, Firmin D, Yacoub MH. Radiation in medicine: Origins, risks, and aspirations. Glob Cardiol Sci Pract. 2014;2014(4):437-48.
2. 2. Hong AS, Levin D, Parker L, Rao VM, Ross-Degnan D, Wharam JF. Trends in diagnostic imaging utilization among Medicare and commercially insured adults from 2003 through 2016. Radiology. 2020;294(2):342-50.
3. 3. Arnout E. Awareness of biological hazards and radiation protection techniques of dental imaging- A questionnaire based cross-sectional study among Saudi dental students. J Dent Health Oral Disord Ther. 2014;1(2):62-5.
4. 4. Ramanathan S, Ryan J. Radiation awareness among radiology residents, technologists, fellows and staff: where do we stand? Insights Imaging. 2015;6(1):133-9.
5. 5. Laura. Report No. 174 – Preconception and Prenatal Radiation Exposure: Health Effects and Protective Guidance (2013). Ncrponline.org. 2018. Available at: https://ncrponline.org/shop/reports/report-no-174-preconception-and-prenatal-radiation-exposure-health-effects-and-protective-guidance-2013/. Accessed on 25 May 2021.
6. 6. Razi T, Bazvand L, Ghojazadeh M. Diagnostic dental radiation risk during pregnancy: Awareness among general dentists in Tabriz. J Dent Res Dent Clin Dent Prospects. 2011;5(2):67-70.
7. 7. Arslanoğlu A, Bilgin S, Kubal Z, Ceyhan MN, Ilhan MN, Maral I. Doctors’ and intern doctors’ knowledge about patients’ ionizing radiation exposure doses during common radiological examinations. Diagn Interv Radiol. 2007;13(2):53-5.
8. 8. Evans KM, Bodmer J, Edwards B, Levins J, O’Meara A, Ruhotina M et al. An exploratory analysis of public awareness and perception of ionizing radiation and guide to public health practice in Vermont. J Environ Public Health. 2015;2015:476495.
9. 9. Sharma SR, Karjodkar FR, Sansare KP, Saalim M, Mishra ID, Johaley S et al. Attitude and awareness of general population towards radiation hazards and safety: An institutional study. Indian J Dent Res. 2019;30(1):27-30.
10. 10. Kotian RP, Sukumar S, Kotian SR, David LR. Perception of Radiation Awareness among Patients in South Indian population A Qualitative Study. Indian J Appl Res. 2013;2(11).
11. 11. Modified Kuppuswamy scale for socioeconomic status of the Indian family-Update based on New CPI (IW) series from September 2020. J Family Med Prim Care. 2021;10(5):2048-9.
12. 12. Shaw P, Duncan A, Vouyouka A, Ozsvath K. Radiation exposure and pregnancy. J Vasc Surg. 2011;53(1):28S-34S.
13. 13. Yoon I, Slesinger TL. Radiation Exposure in Pregnancy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.
14. 14. McCollough CH, Schueler BA, Atwell TD, Braun NN, Regner DM, Brown DL et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27(4):909–17; discussion 917-8.
15. 15. Vadachia Y, Els H, Andronikou S. Accuracy of patients’ self-reporting of pregnancy and awareness of risks to the fetus from X-ray radiation. S Afr Med J. 2008;98(11):862-4.
16. 16. Centers for Disease Control and Prevention. Radiation and Pregnancy: Information for clinicians; CS303779-A. Available at: https://www.cdc.gov/nceh/radiation/emergencies/pdf/303779-A_2019_Radiation-and-Pregnancy_508.pdf. Accessed on 2019, April 29.
17. 17. Bahanan L, Tehsin A, Mousa R. Women’s awareness regarding the use of dental imaging during pregnancy. BMC Oral Health. 2021;21:357.
18. 18. Ribeiro A, Husson O, Drey N, Murray I, May K, Thurston J et al. Ionising radiation exposure from medical imaging-A review of Patient’s (un) awareness. Radiography (Lond). 2020;26(2):e25-30.
19. 19. Almohiy H. Knowledge and awareness of ionizing radiation risks among Saudi Obstetricians. J Radiat Res Appl Sci. 2020;13(1):542-5.
20. 20. Khamtuikrua C, Suksompong S. Awareness about radiation hazards and knowledge about radiation protection among healthcare personnel: A quaternary care academic center-based study. SAGE Open Med. 2020;8:2050312120901733.
21. 21. Prasad M, Gupta R, Patthi B, Singla A, Pandita V, Kumar JK et al. Imaging more imagining less: An insight into knowledge, attitude and practice regarding radiation risk on pregnant women among dentists of Ghaziabad-A cross sectional study. J Clin Diagn Res. 2016;10(7):ZC20-5.
22. 22. Lee CI, Haims AH, Monico EP, Brink JA, Forman HP. Diagnostic CT scans: assessment of patient, physician, and radiologist awareness of radiation dose and possible risks. Radiology. 2004;231(2):3938.