Consent for abdominopelvic CT during pregnancy
UCSF Departments of Radiology and Obstetrics, Gynecology and Reproductive Sciences
Your doctor has asked the Radiology Department to perform a CT of your abdomen or pelvis (CT stands for Computed Tomography – you may have also heard it called a “CAT scan”). CT uses x-rays to evaluate your internal organs. Because you are pregnant, this will expose your baby to radiation. Exposure to radiation can be harmful during pregnancy, and this form will explain the benefits and risks involved.
Benefit of performing CT
The benefit of the study is that your doctor will use the results to better diagnose and manage your condition. CT is often the best way to diagnose a wide range of problems in the abdomen and pelvis, including appendicitis, diverticulitis, and the effects of trauma. Failure to diagnose and treat such conditions could result in harm to you or your baby.
Risk of organ damage to your baby
Very high doses of radiation can damage your baby’s developing organs, particularly in the early part of pregnancy (between weeks 4 and 17). However, research indicates the radiation your baby will get from this CT scan is too low to cause any damage to their developing organs.
Risk of childhood cancer in your baby
Studies have shown that the risk of your baby dying from cancer as a child may be as much as doubled due to the radiation received during this CT scan. In practice, the risk is probably lower because every effort is made to keep the amount of radiation as low as possible. It should also be noted that very few children die from cancer, so that even a doubling of the risk is still a very small risk. To put the risk in perspective, the excess risk of fatal childhood cancer (1 in 2000) is equivalent to driving 20,000 miles in a car or living in New York City for 3 years.
Risk of intravenous contrast
Some CT scans are performed with the use of intravenous contrast (X-ray dye), in order to acquire more information. The use of intravenous contrast has not been shown to be harmful to your baby. The contrast does contain iodine, which might interfere with your baby’s thyroid gland. Because of this, it is important for your baby’s thyroid gland to be checked after birth, but this test is routinely performed anyway on ALL babies born in California.
Alternatives to CT
In some cases, alternative examinations are performed, such as an ultrasound or MRI, because these examinations do not involve radiation. However, your doctor feels a CT exam would be the most valuable. You should discuss the advantages and disadvantages of other tests or approaches with your doctor.
By signing this document, you are indicating that you understand the risks, benefits, and alternatives to this examination and agree to proceed.
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Physician Patient
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Witness Date
Note: This form is not required for CT pelvimetry (minimal radiation dose and risk)
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