The first step in keeping prenatal radiation exposure to a minimum is to identify pregnant women. The referring doctors and the radiologists should survey all women and girls of childbearing potential, whether they are pregnant or may be pregnant. The results of the survey should be documented (§12 of Austrian Medical Radiation Protection Regulation) [2].

All women and children of childbearing age (recommendation 11-55 years old) should be asked whether they are pregnant, if menstruation is overdue and if menstruation is not overdue, but pregnancy is possible. The questionnaire we designed in five different languages is presented in Figure1.

Pictograms can also remind women to think about whether they could be pregnant. Figure 2 and 3, designed by the European committee Directorate-General Environment Nuclear Safety and Civil Protection [6; 7], hang in all the waiting rooms and dressing rooms in our department.

It is safe to assume that a woman in menopause, after hysterectomy, or bilateral ovariectomy, and in the first 10 days of the cycle, assuming a stable cycle, is not pregnant. But, women can still be pregnant even if they are using a contraception method, or, in the case of adolescents, if they declare they are not sexually active. The questioning should be therefore discreet. Pregnancy tests are not reliable for the first 10 days and cause additional costs.

An example of a case where a woman denied she was pregnant is presented in Figure 4.

Procedure in the case of a probably pregnant or a certainly pregnant patient

The indication for an exam associated with a radiation exposure during the pregnancy should be strictly justified by clinicians and radiologists (double justification) after considering the effectiveness, the benefits, and the risks of the available alternative methods that carry no or less radiation exposure. The decision-making process should be documented. The patient should be advised about the possible risks. She is always the only one who decides whether she will accept the possible risks. Then, the assignment of the radiologist is the optimization of the examination by involving physicists and radiographers (Figure 5).

In emergencies, the pregnant women’s life has a higher priority than the radiation protection of the unborn child. In the case of an emergency, the pregnant woman’s life should be saved, because saving the pregnant woman’s life indirectly saves the unborn child's life. The exposure parameters of the examination should be recorded to estimate the unborn child's exposure dose.

Table 5 lists some indications that require a radiological diagnosis or an intervention during pregnancy, including recommended modalities, modified based on Hojreh et al [1].

Table 5: Some indications that require a radiological diagnosis or an intervention during pregnancy, including recommended modalities [1]. Adapted/translated by permission from [Springer Nature]: [Sprinegr Nature] [Der Radiologe][Schutz des ungeborenen Lebens bei diagnostischen und interventionellen radiologischen Verfahren, Hojreh A, Prosch H, Karanikas G, Homolka P, Trattnig S], [Copyright © 2015, Springer Nature](2015)

1=Ultrasound; 2=Magnetic resonance imaging; 3=Magnetic resonance cholangiopancreatography; 4=Endoscopic retrograde cholangiopancreatography; 5=Cerebral computed tomography; 6=CT-angiography

Procedure in the case of unintentional radiation to an unborn child

If an unborn child is irradiated unintentionally, the individual risk should be estimated from the exposure data with the help of medical physicists and the patient should be advised in the context of a multidisciplinary process that involves the gynecologist (Figure 6) [1].

Prenatal influence of iodine-based contrast media on the unborn child

In exceptional circumstances, when radiographic examination is essential, iodine-based contrast media may be given to a pregnant female [27]. After the administration of iodine-based contrast media to the mother during pregnancy, thyroid function should be checked in the neonate during the first week [27].