Imaging of Pregnancy-related Vascular Complications

Published Online:https://doi.org/10.1148/rg.2017160128

This article describes physiologic vascular-related changes of pregnancy, radiation risks during gestation, and pregnancy-related vascular complications to help radiologists improve imaging examination selection, diagnosis, and clinical management.

Pregnancy results in substantial hemodynamic and prothrombotic changes that form the foundation for downstream vascular complications, both during pregnancy and in the postpartum period. In addition, several important risk factors, including older patient age, diabetes, and smoking, can increase the risk for vascular-related pregnancy complications. Because radiologists often play an important role in evaluation of the pregnant patient, understanding the pathophysiology of vascular-related complications in pregnancy and their imaging appearances is essential for diagnostic accuracy. The authors review relevant normal physiologic changes of pregnancy, pathophysiologic changes, and imaging features of vascular conditions that can manifest in conjunction with pregnancy. Particular attention is given to pertinent imaging information that radiologists should provide to referring clinicians to optimally affect the management of pregnant patients as well as women in the peripartum and postpartum stages. Among the complications discussed are preeclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; spontaneous coronary artery dissection; placental abruption; amniotic fluid embolism and acute pulmonary embolism; dural venous sinus thrombosis; ovarian vein thrombophlebitis; vasa previa; uterine arteriovenous malformations; heritable aortopathies; and hereditary hemorrhagic telangiectasia. To help radiologists avoid the use of unnecessary ionizing radiation in pregnancy, imaging examination selection and optimization are also reviewed. Radiologists should be familiar with the physiologic changes of pregnancy, radiation risks during gestation, and pregnancy-related vascular complications to improve imaging examination selection, diagnosis, and clinical management.

©RSNA, 2017

References

  • 1. Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ 3rd. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005;143(10):697–706. Crossref, MedlineGoogle Scholar
  • 2. Elliott CG. Evaluation of suspected pulmonary embolism in pregnancy. J Thorac Imaging 2012;27(1):3–4. Crossref, MedlineGoogle Scholar
  • 3. Tong V, Dietz P, Morrow B, et al. Trends in smoking before, during, and after pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000–2010. MMWR CDC Surveill Summ 2013;62(6):1–19. Google Scholar
  • 4. Silveira MF, Matijasevich A, Menezes AM, et al. Secular trends in smoking during pregnancy according to income and ethnic group: four population-based perinatal surveys in a Brazilian city. BMJ Open 2016;6(2):e010127. Crossref, MedlineGoogle Scholar
  • 5. Hunt KJ, Schuller KL. The increasing prevalence of diabetes in pregnancy. Obstet Gynecol Clin North Am 2007;34(2):173–199, vii. Crossref, MedlineGoogle Scholar
  • 6. Lynch CP, Baker N, Korte JE, Mauldin JG, Mayorga ME, Hunt KJ. Increasing prevalence of diabetes during pregnancy in South Carolina. J Womens Health (Larchmt) 2015;24(4):316–323. Crossref, MedlineGoogle Scholar
  • 7. Costantine MM. Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol 2014;5:65. Crossref, MedlineGoogle Scholar
  • 8. Gongora MC, Wenger NK. Cardiovascular complications of pregnancy. Int J Mol Sci 2015;16(10):23905–23928. Crossref, MedlineGoogle Scholar
  • 9. Bonica JJ. Maternal anatomic and physiological alterations during pregnancy and parturition. In: Bonica JJ, McDonald JS, eds. Principles and practice of obstetric analgesia. Baltimore, Md: Williams & Wilkins, 1995; 45–83. Google Scholar
  • 10. Weiss BM, Hess OM. Pulmonary vascular disease and pregnancy: current controversies, management strategies, and perspectives. Eur Heart J 2000;21(2):104–115. Crossref, MedlineGoogle Scholar
  • 11. Han L, Liu X, Li H, et al. Blood coagulation parameters and platelet indices: changes in normal and preeclamptic pregnancies and predictive values for preeclampsia. PLoS One 2014;9(12):e114488. Crossref, MedlineGoogle Scholar
  • 12. Groen RS, Bae JY, Lim KJ. Fear of the unknown: ionizing radiation exposure during pregnancy. Am J Obstet Gynecol 2012;206(6):456–462. Crossref, MedlineGoogle Scholar
  • 13. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. RadioGraphics 2007;27(6):1705–1722. LinkGoogle Scholar
  • 14. Tremblay E, Thérasse E, Thomassin-Naggara I, Trop I. Quality initiatives: guidelines for use of medical imaging during pregnancy and lactation. RadioGraphics 2012;32(3):897–911. LinkGoogle Scholar
  • 15. Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging 2013;37(3):501–530. Crossref, MedlineGoogle Scholar
  • 16. Hand JW, Li Y, Thomas EL, Rutherford MA, Hajnal JV. Prediction of specific absorption rate in mother and fetus associated with MRI examinations during pregnancy. Magn Reson Med 2006;55(4):883–893. Crossref, MedlineGoogle Scholar
  • 17. MacKay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obstet Gynecol 2001;97(4):533–538. MedlineGoogle Scholar
  • 18. Duley L. Pre-eclampsia, eclampsia, and hypertension. BMJ Clin Evid 2008;2008:1402–1420. MedlineGoogle Scholar
  • 19. Peters RM, Flack JM. Hypertensive disorders of pregnancy. J Obstet Gynecol Neonatal Nurs 2004;33(2):209–220. Crossref, MedlineGoogle Scholar
  • 20. Kronthal AJ, Fishman EK, Kuhlman JE, Bohlman ME. Hepatic infarction in preeclampsia. Radiology 1990; 177(3):726–728. LinkGoogle Scholar
  • 21. Schwartz RB, Feske SK, Polak JF, et al. Preeclampsia-eclampsia: clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy. Radiology 2000;217(2):371–376. LinkGoogle Scholar
  • 22. Zak IT, Dulai HS, Kish KK. Imaging of neurologic disorders associated with pregnancy and the postpartum period. RadioGraphics 2007;27(1):95–108. LinkGoogle Scholar
  • 23. Nakai A, Asakura H, Oya A, Yokota A, Koshino T, Araki T. Pulsed Doppler US findings of renal interlobar arteries in pregnancy-induced hypertension. Radiology 1999;213(2):423–428. LinkGoogle Scholar
  • 24. Murray D, O’Riordan M, Geary M, Phillips R, Clarke T, McKenna P. The HELLP syndrome: maternal and perinatal outcome. Ir Med J 2001;94(1):16–18. MedlineGoogle Scholar
  • 25. Rooholamini SA, Au AH, Hansen GC, et al. Imaging of pregnancy-related complications. RadioGraphics 1993;13(4):753–770. LinkGoogle Scholar
  • 26. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169(4):1000–1006. Crossref, MedlineGoogle Scholar
  • 27. Turgut A, Demirci O, Demirci E, Uludoğan M. Comparison of maternal and neonatal outcomes in women with HELLP syndrome and women with severe preeclampsia without HELLP syndrome. J Prenat Med 2010;4(3):51–58. MedlineGoogle Scholar
  • 28. Casillas VJ, Amendola MA, Gascue A, Pinnar N, Levi JU, Perez JM. Imaging of nontraumatic hemorrhagic hepatic lesions. RadioGraphics 2000;20(2):367–378. LinkGoogle Scholar
  • 29. 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(5):1301–1316. LinkGoogle Scholar
  • 30. Sheikh AS, O’Sullivan M. Pregnancy-related spontaneous coronary artery dissection: two case reports and a comprehensive review of literature. Heart Views 2012;13(2):53–65. Crossref, MedlineGoogle Scholar
  • 31. Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature. Catheter Cardiovasc Interv 2001;52(1):88–94. Crossref, MedlineGoogle Scholar
  • 32. Appleby CE, Barolet A, Ing D, et al. Contemporary management of pregnancy-related coronary artery dissection: a single-centre experience and literature review. Exp Clin Cardiol 2009;14(1):e8–e16. MedlineGoogle Scholar
  • 33. Kim JJ, Dillon WP, Glastonbury CM, Provenzale JM, Wintermark M. Sixty-four-section multidetector CT angiography of carotid arteries: a systematic analysis of image quality and artifacts. AJNR Am J Neuroradiol 2010;31(1):91–99. Crossref, MedlineGoogle Scholar
  • 34. McMahon MA, Squirrell CA. Multidetector CT of aortic dissection: a pictorial review. RadioGraphics 2010;30(2):445–460. LinkGoogle Scholar
  • 35. Merz W, Rüland A, Hippe V, et al. Pregnancy in Budd-Chiari syndrome: case report and proposed risk score. Medicine (Baltimore) 2016;95(22):e3817. Crossref, MedlineGoogle Scholar
  • 36. Ren W, Li X, Jia J, Xia Y, Hu F, Xu Z. Prevalence of Budd-Chiari syndrome during pregnancy or puerperium: a systematic review and meta-analysis. Gastroenterol Res Pract 2015;2015:839875. Crossref, MedlineGoogle Scholar
  • 37. Raszeja-Wyszomirska J, Mieżyńska-Kurtycz J, Marlicz W, Lawniczak M, Wójcicki M. Primary Budd-Chiari syndrome: a single center experience. Hepatogastroenterology 2012;59(118):1879–1882. MedlineGoogle Scholar
  • 38. Mukund A, Gamanagatti S. Imaging and interventions in Budd-Chiari syndrome. World J Radiol 2011;3(7):169–177. Crossref, MedlineGoogle Scholar
  • 39. Masselli G, Brunelli R, Di Tola M, Anceschi M, Gualdi G. MR imaging in the evaluation of placental abruption: correlation with sonographic findings. Radiology 2011;259(1):222–230. LinkGoogle Scholar
  • 40. Elsayes KM, Trout AT, Friedkin AM, et al. Imaging of the placenta: a multimodality pictorial review. RadioGraphics 2009;29(5):1371–1391. LinkGoogle Scholar
  • 41. Raptis CA, Mellnick VM, Raptis DA, et al. Imaging of trauma in the pregnant patient. RadioGraphics 2014;34(3):748–763. LinkGoogle Scholar
  • 42. Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med 2002;21(8):837–840. Crossref, MedlineGoogle Scholar
  • 43. Wei SH, Helmy M, Cohen AJ. CT evaluation of placental abruption in pregnant trauma patients. Emerg Radiol 2009;16(5):365–373. Crossref, MedlineGoogle Scholar
  • 44. Kopelman TR, Berardoni NE, Manriquez M, et al. The ability of computed tomography to diagnose placental abruption in the trauma patient. J Trauma Acute Care Surg 2013;74(1):236–241. Crossref, MedlineGoogle Scholar
  • 45. Montagnana M, Cervellin G, Franchini M, Lippi G. Pathophysiology, clinics and diagnostics of non-thrombotic pulmonary embolism. J Thromb Thrombolysis 2011;31(4):436–444. Crossref, MedlineGoogle Scholar
  • 46. West M. Amniotic fluid embolism: a historical perspective in diagnosis and management. BJOG 2016;123(1):110. Crossref, MedlineGoogle Scholar
  • 47. Han D, Lee KS, Franquet T, et al. Thrombotic and nonthrombotic pulmonary arterial embolism: spectrum of imaging findings. RadioGraphics 2003;23(6):1521–1539. LinkGoogle Scholar
  • 48. Lussana F, Coppens M, Cattaneo M, Middeldorp S. Pregnancy-related venous thromboembolism: risk and the effect of thromboprophylaxis. Thromb Res 2012;129(6):673–680. Crossref, MedlineGoogle Scholar
  • 49. National Clinical Guideline Centre. Venous thromboembolism: reducing the risk of venous thromboembolism in patients admitted to hospital—NICE clinical guidelines. 2010;92. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0051769/. Accessed April 2016. Google Scholar
  • 50. Freeman LM, Stein EG, Sprayregen S, Chamarthy M, Haramati LB. The current and continuing important role of ventilation-perfusion scintigraphy in evaluating patients with suspected pulmonary embolism. Semin Nucl Med 2008;38(6):432–440. Crossref, MedlineGoogle Scholar
  • 51. Leung AN, Bull TM, Jaeschke R, et al. American Thoracic Society documents: an official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline— Evaluation of Suspected Pulmonary Embolism in Pregnancy. Radiology 2012;262(2):635–646. LinkGoogle Scholar
  • 52. Shah M, Agarwal N, Gala NB, Prestigiacomo CJ, Gandhi CD. Management of dural venous sinus thrombosis in pregnancy. Eur J Vasc Endovasc Surg 2014;48(4):482. CrossrefGoogle Scholar
  • 53. Piazza G. Cerebral venous thrombosis. Circulation 2012;125(13):1704–1709. Crossref, MedlineGoogle Scholar
  • 54. Leach JL, Fortuna RB, Jones BV, Gaskill-Shipley MF. Imaging of cerebral venous thrombosis: current techniques, spectrum of findings, and diagnostic pitfalls. RadioGraphics 2006;26(1 suppl 1):S19–S41; discussion S42–S43. LinkGoogle Scholar
  • 55. Cantú C, Barinagarrementeria F. Cerebral venous thrombosis associated with pregnancy and puerperium: review of 67 cases. Stroke 1993;24(12):1880–1884. Crossref, MedlineGoogle Scholar
  • 56. Kolluru A, Lattupalli R, Kanwar M, Behera D, Kamalakannan D, Beeai MK. Postpartum ovarian vein thrombosis presenting as ureteral obstruction. BMJ Case Rep 2010;2010:1–3. CrossrefGoogle Scholar
  • 57. Khlifi A, Kebaili S, Hammami M, et al. Postpartum ovarian vein thrombophlebitis: report of a case and review of the literature. N Am J Med Sci 2010;2(8):389–391. Crossref, MedlineGoogle Scholar
  • 58. Kubik-Huch RA, Hebisch G, Huch R, Hilfiker P, Debatin JF, Krestin GP. Role of duplex color Doppler ultrasound, computed tomography, and MR angiography in the diagnosis of septic puerperal ovarian vein thrombosis. Abdom Imaging 1999;24(1):85–91. Crossref, MedlineGoogle Scholar
  • 59. Royal College of Obstetricians and Gynaecologists. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management—Green-top Guideline No. 27. 3rd ed. May 1, 2011. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_27.pdf. Accessed April 2016. Google Scholar
  • 60. Gagnon R, Morin L, Bly S, et al. Guidelines for the management of vasa previa. J Obstet Gynaecol Can 2009;31(8):748–760. Crossref, MedlineGoogle Scholar
  • 61. Moshiri M, Zaidi SF, Robinson TJ, et al. Comprehensive imaging review of abnormalities of the umbilical cord. RadioGraphics 2014;34(1):179–196. LinkGoogle Scholar
  • 62. Sellers F, Palacios-Marqués A, Moliner B, Bernabeu R. Uterine arteriovenous malformation. BMJ Case Rep 2013;2013. doi:10:1136/bcr-2012-008443. Google Scholar
  • 63. Tullius TG Jr, Ross JR, Flores M, Ghaleb M, Kupesic Plavsic S. Use of three-dimensional power Doppler sonography in the diagnosis of uterine arteriovenous malformation and follow-up after uterine artery embolization: case report and brief review of literature. J Clin Ultrasound 2015;43(5):327–334. Crossref, MedlineGoogle Scholar
  • 64. Alessandrino F, Di Silverio E, Moramarco LP. Uterine arteriovenous malformation. J Ultrasound 2013;16(1):41–44. Crossref, MedlineGoogle Scholar
  • 65. Mishina M, Hasegawa J, Nakamura M, Ichizuka K, Sekizawa A, Okai T. Sonohysterography is a useful diagnostic approach for uterine arteriovenous malformation. J Obstet Gynaecol Res 2014;40(6):1811–1813. Crossref, MedlineGoogle Scholar
  • 66. Cura M, Martinez N, Cura A, Dalsaso TJ, Elmerhi F. Arteriovenous malformations of the uterus. Acta Radiol 2009;50(7):823–829. Crossref, MedlineGoogle Scholar
  • 67. Coulon C. Thoracic aortic aneurysms and pregnancy. Presse Med 2015;44(11):1126–1135. Crossref, MedlineGoogle Scholar
  • 68. Wanga S, Silversides C, Dore A, de Waard V, Mulder B. Pregnancy and thoracic aortic disease: managing the risks. Can J Cardiol 2016;32(1):78–85. Crossref, MedlineGoogle Scholar
  • 69. European Society of Gynecology (ESG); Association for European Paediatric Cardiology (AEPC); German Society for Gender Medicine (DGesGM); et al. ESC Guidelines on the Management of Cardiovascular Diseases during Pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32(24):3147–3197. Crossref, MedlineGoogle Scholar
  • 70. Begbie ME, Wallace GM, Shovlin CL. Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): a view from the 21st century. Postgrad Med J 2003;79(927):18–24. Crossref, MedlineGoogle Scholar
  • 71. Wain K, Swanson K, Watson W, Jeavons E, Weaver A, Lindor N. Hereditary hemorrhagic telangiectasia and risks for adverse pregnancy outcomes. Am J Med Genet A 2012; 158A(8):2009–2014. Crossref, MedlineGoogle Scholar
  • 72. Shovlin CL, Sodhi V, McCarthy A, Lasjaunias P, Jackson JE, Sheppard MN. Estimates of maternal risks of pregnancy for women with hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): suggested approach for obstetric services. BJOG 2008;115(9):1108–1115. Crossref, MedlineGoogle Scholar
  • 73. Sierra A, Burrel M, Sebastia C, et al. Utility of multidetector CT in severe postpartum hemorrhage. RadioGraphics 2012;32(5):1463–1481. LinkGoogle Scholar
  • 74. Ianora AA, Memeo M, Sabba C, Cirulli A, Rotondo A, Angelelli G. Hereditary hemorrhagic telangiectasia: multi-detector row helical CT assessment of hepatic involvement. Radiology 2004;230(1):250–259. LinkGoogle Scholar
  • 75. Narsinh KH, Ramaswamy R, Kinney TB. Management of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia patients. Semin Intervent Radiol 2013;30(4):408–412. Crossref, MedlineGoogle Scholar

Article History

Received: May 04 2016
Revision requested: Sept 06 2016
Revision received: Oct 4 2016
Accepted: Oct 24 2016
Published online: July 11 2017
Published in print: July 2017