of: • Avoiding questions that might confuse minors or be objectionable to parents or guardians • Providing a stricter method of screening for some of the higher dose procedures. The pregnancy test should be ordered by the appropriate clinician. If a pregnancy test is refused, this should be documented in the patient’s medical record and the radiologist should be notified. E. Deciding to Proceed with the Examination If a patient can reasonably attest that she is not pregnant (for example, she is not sexually active, is on birth control, or she is biologically incapable of conceiving), then the examination can be performed. When the patient does not meet these criteria, and when the need for the examination is not critically urgent, the technologist should contact the radiologist or nuclear medicine physician for further guidance or follow procedural instructions previously defined in a written protocol developed by the radiologist or physician [1]. If pregnancy is established, the patient should be informed in a timely manner. While it is preferable that the referring physician inform the patient, this might not be practical, and the radiologist or nuclear medicine physician should ensure that the patient is informed. The patient, referring physician, and radiologist/nuclear medicine physician can then make decisions on the optimal patient management and imaging needs. If the procedure is of a critically urgent nature and pregnancy status cannot be verified, a note should be entered in the patient’s record that verification of pregnancy status was waived because of the critically urgent nature of the study [19]. Documentation that is consistent with institutional policies should be entered in the patient’s medical record, indicating the circumstances of the waiver and the physician who directed the waiver. For some procedures that are expected to deliver relatively high doses to a conceptus, a pregnancy test should be obtained within 72 hours prior to commencement of the procedure unless medical exigencies prevent it. If a patient is found to be pregnant, the procedure might be modified, canceled, or substituted with appropriate alternative imaging that does not use ionizing radiation. If so, the referring provider should be notified. IV. IMAGING THE PREGNANT PATIENT A. Patient Consent For an imaging examination of the abdomen or pelvis using ionizing radiation, obtaining consent from a patient known to be pregnant is an essential component of providing comprehensive medical care in certain situations. This process requires: 1) a realistic overview of the limited risk to the patient and conceptus from the examination, and 2) the beneficial role of this imaging procedure in maternal or fetal health evaluation. Whether particular institutions use written consent forms or verbal consent, this interaction should be documented in the patient’s medical record and in compliance with state law. The written consent form should be retained in the medical record. The format of the consent may vary based on the clinical situation and local institutional guidelines. Because a detailed quantitative list of risks may be beyond the comprehension of some patients, some institutions prefer a limited consent process in which generalized benefits and risks to the pregnant patient and conceptus are described (see Appendix C). Other facilities might prefer a uniformly detailed, numerically oriented consent form that lists the radiation risks and potential adverse effects. Regardless of the format, the information communicated should accurately convey the benefits and risks posed by the procedure, in language understandable to the layperson. Conveying information in a positive, rather than negative, format is useful in helping a patient understand an accurate perspective of risk. Rather than telling the patient what the likelihood is that her child could develop PRACTICE PARAMETER 8 Pregnant or Potentially Pregnant Patients cancer later in life, the message with a positive, accurate perspective is that the cancer risk is small and that the likelihood the child will remain healthy with no adverse radiation effects is only slightly different from that of any other child (see Appendix C for sample consent form). B. Preplanning The most effective way to limit radiation exposure to the pregnant patient is by eliminating unjustified scans, utilizing alternative modalities (ie, ultrasound and MRI) and, in cases when a modality utilizing ionizing radiation is the appropriate modality, tailoring the examination to the clinical question for the patient using the lowest possible dose (optimization). For this to be achieved, discussion between the referring physician and the radiologist or the nuclear medicine physician may need to take place. The imaging technologist and the imaging physician should work together to assure the best benefit/risk for the patient and conceptus. Establishment of guidelines for imaging acute disease processes in pregnant patients can expedite patient evaluation. It is best to have written imaging protocols in place before imaging pregnant patients to insure uniform and optimized patient care. Protocols may be based on accumulated experience, literature reviews, and respected medical points of view. When necessary, dose estimation can be facilitated by documenting relevant technique factors [18] and machine-recorded dose surrogates, eg, kerma-area product (also known as dose-area product) and cumulative reference-point air kerma [20]. For nuclear medicine procedures, the conceptus dose can be estimated from published tables of organ doses per unit of administered activity by radiopharmaceutical [21]. For radiological examinations, the highest radiation exposure to the conceptus occurs when the abdominal/pelvic region is exposed to the primary x-ray beam. Radiation exposure parameters may be reduced and a certain degree of compromise in image quality is acceptable; nevertheless, the quality cannot decrease beyond a certain level required for diagnosis. The exposure parameters should be determined prior to scanning by radiologists in collaboration with a qualified medical physicist. Nearly all abdominal/pelvic radiologic procedures can be