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Monitor TIS up to 10 weeks post-LMP, TIB thereafter.

RECOMMENDED

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1 Radiology

1.2 Abdominal Ultrasound

The two major bioeffects from ultrasound (US) are thermal and nonthermal. Nonthermal effects (measured by mechanical index) are secondary to the wave’s alternating positive and negative pressures (direct effect). This affects tissues containing gas pockets, such as the lung and intestine. In other tissues, there is no evidence that the diagnostic US produces nonthermal damage without gas-lled contrast agents [9]. Single beam modes (A-mode, M-mode, and spectral pulsed Doppler) have a greater potential for nonthermal hazards than scanned modes (B-mode, Color Doppler), although the use of a narrow write-zoom box increases this potential for scanning modes [9].

The energy absorption in tissue primarily leads to a rise in temperature (thermal effects measured with thermal index—TI). The temperature elevation depends on the spatial-peak temporal average intensity (ISPTA), the US frequency, the dwell time along the beam axis, the width of the beam, the tissue properties, and patient characteristics. The US Food and Drug Administration (FDA) has proposed an upper limit of 720mW/cm2 for the spatial-peak temporal average intensity of the US beam for an obstetric US [10]. The British Medical Ultrasound Society made similar recommendations based on thermal indices (Fig.1.1).

According to the available evidence, exposure to

the diagnostic US during pregnancy appears to be

safe. (International Society of Ultrasound in

Obstetrics and Gynecology 2009 [11])

The British Medical Ultrasound Society neonatal cranial examinations via the fontanelle safety guidelines incorporate a limit for the TI in conjunction with the duration of the neonatal cranial scan. They suggest that scanning time should be restricted for any value TI >0.7. For a TI=2.3, the duration of such scans should be limited to 4min, and the neonatal brain scan is not recommended for a TI >3 (Fig.1.2). During neonatal cranial scans, the transducer remains stationary over the fontanelle with minimal movement. Therefore, signicantly elevated temperatures are more likely [12].

A temperature elevation of 4°C, maintained for ≥5min, is potentially hazardous to a fetus or embryo. Some diagnostic US equipment, operating in spectral pulsed Doppler mode, can produce temperature rises over 4°C in bone, with an associated risk of high temperatures developed in adjacent soft tissues by conduction [9]. From the transvaginal US, the temperature rise in fetal tissue is 0.5–1°C at 1cm depth (Fig.1.3). The contribution to tissue heating at 2cm and deeper is negligible [14]. Neonatal cranial scans are carried out within 10–15 MHz compared with the

2.5–5MHz used for obstetric/fetal applications.

Up to 8weeks after conception, organogenesis occurs. This is when cell damage might lead to fetal anomalies or subtle developmental changes. The brain and spinal cord continue to develop through to the neonatal period. The presence of bone within the beam greatly increases the likely temperature rise due to direct absorption in the bone itself and heat conduction

Fig. 1.1 Recommended maximum scanning times for obstetric examinations conducted with different displayed Thermal Indices (TI) [13]

THERMAL INDEX

RECOMMENDED RANGE PROVIDED ADEQUATE IMAGES CAN BE OBTAINED

(especially in 1st trimester)

Unlimited time observe ALARA

0.5

OBSTETRIC SCANNING

1.0

0.7

<60

mins

Recommended scanning time limits for these TIs

1.5 2.0 2.5 3.0

<30

mins

< 15

mins

(observe ALARA)

mins

min

NOT

for OB scanning

Monitor TIC. MI>0.7 should be used with caution in the presence of contrast agents

RECOMMENDED

1.2 Abdominal Ultrasound

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Fig. 1.2 Thermal hazard risk should be reduced when exposing the head, brain, or spine of any fetus or neonate

THERMAL INDEX

NEONATAL trans-cranial & spinal SCANNING

0.5

1.0

1.5 2.0 2.5 3.0

to diagnostic ultrasound [13]

0.7

RECOMMENDED RANGE PROVIDED ADEQUATE IMAGES CAN BE OBTAINED

Unlimited time observe ALARA

<60

mins

<30

mins

Recommended scanning time limits for these TIs

<15

mins

(observe ALARA)

mins

min

NOT

for Scanning of Central nervous system

thermal hazards since the lens and the aqueous and vitreous liquids have no cooling blood supply. This applies to the eye of a person of any age (e.g., a child or adult) and a fetus, although a fetal eye is better cooled due to a liquid environment [13].

Doppler US can produce high intensities and should be used judiciously, keeping the exposure time and acoustic output to the lowest level possible [15]. European Federation of Societies for Ultrasound in Medicine and Biology (EFSUM) statements from 2019 for Doppler use in preg-

Fig. 1.3 Temperature rise variation prediction in a niteelement model after 200s. The upper segment represents the transducer, and the lower segment represents the tissue mimic. Heat is applied to a thin layer in between, representing the transducer lens. The aspect ratio of the transducer aperture is 3:1, smaller in the direction perpendicular to the image plane. The temperature scale is in °C. (Reproduced with permission from [14])

Table 1.2 Recommended safety limits for obstetric scans more than 10weeks gestational age

TIB Recommended scanning time

0.7–1.0 Restrict time to 60min

1.1–1.5 Restrict time to 30min

1.6–2.0 Restrict time to 15min

2.1–2.5 Restrict time to 4min

2.6–3.0 Restrict time to 1min >3.0 Scanning of the fetus is not recommended;

however, briey

Reproduced with permission from [17] TIB thermal index for bone

nancy up to 14weeks are [16]:

• Pulsed Doppler (spectral, power, and color ow imaging) US should not be used routinely,

• When performing Doppler US, the displayed TI ≤1.0, and exposure time should be kept as short as possible (usually less than 5–10min) and should not exceed 60min,

• There are unlikely fetal safety implications when scanning maternal uterine arteries in the rst trimester if the embryo/fetus lies outside the Doppler US beam.

Table 1.2 shows the advised TI for bone levels

and recommended safety limits for obstetric from bone to adjacent tissues. The following table identies the relevant landmarks in early pregnancy. The eye is particularly vulnerable to

scans more than 10weeks gestational age accord-

ing to the British Medical Ultrasound Society

from 2020.

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1 Radiology

1.3 Abdominal CT

Exposure to less than 5 rad (50 mGy), which includes most imaging radiation doses, is not associated with an increase in fetal anomalies or pregnancy loss (Table 1.3) [7, 18]. Also, fetal risks during normal pregnancy include a 3% risk of spontaneous birth defects, a 15% risk of spontaneous abortion, a 4% risk of prematurity and growth retardation, and a 1% risk of mental retardation [19]. This should be explained to the future mother.

CT is used when the US examination is not diagnostic and unequivocal. The risk and benets should be weighed for every pregnant patient.

It is preferable to use the multidetector-row CT with the high-speed mode in pregnancy since it has half the radiation dose of the high-quality mode, and its scanning parameters are identical. Radiation exposure in these settings is 300mrad, below an accepted safe level of radiation exposure in pregnancy of 5 rad. The radiation may increase the background incidence of cancers before the age of 20 by 0.06%/rad delivered to the fetus [4, 20]. These are the results of

15–20years ago. The consequences of newer CT modules with lesser radiation will be evident in the following decades. Table1.3 shows potential dose-dependent radiation effects during fetal development.

Lack of understanding of radiation effects on the fetus causes unnecessary anxiety in pregnant patients and clinicians exposed to diagnostic radiation and may lead to unnecessary pregnancy termination. Family physician perceptions from 2004 of teratogenic risk associated with undergoing plain radiography and CT during early pregnancy showed that 3% would recommend pregnancy termination after the rst trimester CT and 0.5% following radiography in the rst trimester; 12% were unsure if pregnancy termination was needed after radiography; and 19% were unsure about a need for CT examination. Also, 8% of obstetricians would recommend pregnancy termination after the rst trimester CT examination [21]. A further decrease in radiation is a lowdose CT. In 2004, the largest single radiation dose was 1.372rad, signicantly lower than an average of 2.2 rad for detecting urinary stones [22].

Table 1.3 Potential in utero-induced radiation effects

Conception age <50mGy 50–100mGy >100mGy

Before conception 1st–2nd week None Probably none Possible spontaneous abortion 3rd–8th week None Potential effects are uncertain and

9th–15th week

16th–25th week >25th week None None None applicable to diagnostic medicine

Reproduced with permission from [7]

None None None

Possible malformations increase as the dose too subtle to be clinically detectable

None Potential effects are uncertain and

too subtle to be clinically detectable

None None IQ decits are not detectable at diagnostic dosed

increases

Risk of diminished IQ or mental retardation,

increasing in frequency and severity with

increasing dose

1.4 Abdominal MRI

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1.4 Abdominal MRI

MRI offers superior contrast resolution relative to any other available imaging modality. It detects small amounts of uid and mild inammation even without IV contrast, by employing T2-weighted sequences. MRI is the diagnostic method of choice when the radiation risk or potential nephrotoxicity of iodine-based contrast agents is a major concern. Noncontrast MRI is benecial as a radiation-free modality for populations more vulnerable to ionizing radiation— specically pediatric and pregnant patients. No evidence exists on specic consequences of noncontrast MRI on children or fetuses exposed during any trimester [23, 24] and pregnant adult patients [24].

The disadvantages of MRI are primarily the increased cost and relatively limited availability of MRI equipment or trained personnel compared to US or CT, especially in emergency settings. MRI is not free of theoretical risks, including (1) the potential biological effects of the static and time-varying magnetic elds, (2) the heating effects of the radiofrequency pulses (>1.5T), and (3) the acoustic noise generated by the spatial encoding gradients [25]. However, no reports of adverse effects from MRI during pregnancy on the developing conceptus exist [26].

Radiofrequency energy in MRI deposits as heat in the tissues. Therefore, all MRI machines monitor the specic absorption rate to comply with safety guidelines. With a limited ability to regulate temperature independently, the developing embryo and fetus depend entirely on the mother’s thermoregulatory capacity. As a general rule, maternal core body temperature increases of ∼2 °C above normal for extended periods, 2–2.5 °C above normal for 0.5–1 h, or ≥4 °C above normal for 15min have resulted in developmental abnormalities in animal models [27]. Corresponding specic absorption rate (SAR) values that would be necessary to cause such temperature elevations in a healthy adult female would be in the range of ≥15W/kg (whole-body average or WBA), with ∼4 W/kg required to increase core temperature 1 °C. A conservative estimate of 1.5W/kg WBA (1/10th the threshold

to protect against measurable temperature increases) would seem sufcient to protect against any signicant blood ow reduction to the pregnant mother’s embryo or fetus [27]. This is more than three times above the current WBA limit for occupational exposure (0.4 W/kg) as outlined in IEEE C95.1-2005 and ICNIRP-1998 international safety standards for radiofrequency exposures. The maximum localized specic absorption rate occurs in the mother, with approximately 50% in the fetus, and no studies have demonstrated the effects on the fetus [28, 29]. Specic recommendations for MRI use in pregnancy are:

• When scanning a pregnant woman, if the fetus or maternal abdomen is not the target organ, the fetus should be kept out of the transmit eld of the RF coil if possible,

• Care must be taken when scanning fetuses with poor placental function, such as fetal growth restriction. It should be noted that maternal heat stress has been reported to reduce placental perfusion,

• Care must be taken when scanning pregnant women with conditions leading to impaired thermoregulation. Unless the clinical situation dictates that the scan is urgent, it would be prudent not to scan pregnant women who are febrile.

Exposure to 1.5T noncontrast MRI during pregnancy had no harmful effects on longterm neurodevelopmental outcomes [30].

The patient should be informed that there are

no known harmful effects from the use of MR imaging at 1.5T or lower magnetic eld strengths [25] and that there is a lack of experience with the use of eld strengths greater than 2.5T, and these should be avoided [25]. Despite obvious improvements in the image quality at 3 T, the specic absorption rate usually increases signicantly [31]. Two-channel radiofrequency (RF) shim- ming can improve imaging without increasing the specic absorption rate for fetal MRI at 3T [31].

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1 Radiology

Absolute contraindications for MR include

[32]:

• metal implants not made of titanium,

• metal implants of unknown composition,

• gadolinium administration during the rst trimester.

The intermediate and lowest-risk gadolinium-

based contrast media may be given to pregnant women in the lowest dose required to provide essential diagnostic information [33]. Gadolinium-based MR contrast agents pass through the placenta to fetal circulation. The fetal kidneys then excrete the contrast material into the amniotic uid, where the agent can remain for an indeterminate amount of time. No large, wellcontrolled studies have been performed to document the presence or absence of adverse fetal effects resulting from maternal gadolinium administration. Therefore, the potential risks to the fetus remain unknown [32]. Rapid-sequence MRI is preferable to conventional MRI due to its shorter exposure [34].

Informed consent should be signed by the patient. The safety of MRI for the fetus has not been proved (US FDA guidelines and the American College of Radiology).

1.5 MRCP

The European Society of Urogenital Radiology (ESUR) established its Contrast Media Safety Committee in 1994. Table1.4 presents the ESUR guidelines (version 10.0) from 2018 on using iodine-based and gadolinium-based contrast media during pregnancy [35].

IV iodinated contrast crosses the placenta and

is classied as an FDA category B drug. A known risk is free iodine uptake by the fetal thyroid gland early in pregnancy, potentially inducing a hypothyroid state. Animal studies with IV iodinated contrast have shown no fetal risk, but without controlled studies on pregnant women, theoretical risks remain [36]. American College

Table 1.4 ESUR guidelines for using iodinated and gadolinium contrast media during pregnancy and lactation

Iodine-based contrast media

Pregnancy In exceptional

circumstances, when radiographic Examination is essential, iodinebased contrast media may be given to the pregnant female b) Following administration of iodine-based contrast media to the mother during pregnancy, thyroid function should be checked in the neonate during the rst week

Lactation Breastfeeding may

be continued normally when iodine-based contrast media is given to the mother

Pregnant or Lactating mother with renal Impairment

Reproduced with permission from [35]

Follow ESUR guidelines for contrast media administration when renal function is impaired. No additional precautions are necessary for the fetus or neonate

Gadolinium-based contrast media

(a) When there is a very strong indication for enhanced MR, the smallest possible dose of a macrocyclic gadolinium contrast agent may be given to the pregnant female (b) Following administration of gadolinium-based agents to the mother during pregnancy, no neonatal tests are necessary Breastfeeding may be continued normally when macrocyclic gadolinium-based contrast agents are given to the mother Do not administer gadolinium-based contrast agents

of Radiology Committee on Drugs and Contrast Media claims that iodinated contrast medium

does not affect thyroid function test results in patients with a normally functioning thyroid gland. Multiple studies have shown that a single dose of iodinated contrast medium administered to a pregnant mother does not affect neonatal thyroid function [37].

An additional concern about the safety of MRCP in the rst trimester exists because radiofrequency pulses result in energy deposition and potentially result in tissue heating (see Sect. 1.4).

1.8 ERCP

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1.6 Nuclear Medicine Examinations

Many nuclear medicine examinations do not require routine pregnancy testing (Table1.5), and most examinations are not indicated in an emergency.

Table 1.5 Diagnostic nuclear medicine examinations that do NOT require routine pregnancy testing

Radiopharmaceutical Type of scan

Single photon emitters

99mTc-DTPA Renal scan, ventilation, gastric

emptying, VP/VA shunt 99mTc-MDP Bone scan 99mTc-sulfur colloid Gastric emptying, bone marrow

mapping, Splenule / splenosis

localization, sentinel node

localization, lymphoscintigraphy 99mTc-Pertechnetate Thyroid scan, Meckel’s

diverticulum 99mTc-MAA Lung perfusion, right-to-left

shunt assessment, liver shunt

assessment 99mTc-labelled RBC 99mTc-HIDA Cholecystitis, bile leak,

99mTc-Sestamibi Cardiac stress test, parathyroid

99mTc- HMPAO Brain death scan 111In-WBC Infection, inammatory bowel

111In-Octreoscan Neuroendocrine tumor imaging 111In-DTPA Cisternography, CSF leak 133Xe Lung ventilation 67Ga Spine infection

201TI

133Xe Ventilation

Positron emitters

18F-FDG Tumor imaging 68Ga-DOTATATE Neuroendocrine tumor imaging

Reproduced with permission from [7]

Not commonly used

GI bleeding, MUGA,

hemangioma

functional gallbladder disorder

localization, molecular breast

imaging

disease

Cardiac perfusion scan stress/

rest

1.7 Radiologic Interventional Techniques

Radiologic interventional techniques are increasingly used. The advantage is minimal invasiveness, while the disadvantage is ionizing radiation. All principles for CT (see Sect. 1.3) or MRI (see Sect. 1.4) use should be applied.

1.8 ERCP

1.8.1 Radiation

The rst report of ERCP during pregnancy in 1990 included ve successful cases of biliary sphincterotomy and gallstone extraction for choledocholithiasis or cholangitis [38]. Hoffman and Cunningham, in 1992, reported four pregnant women who underwent ERCP during the rst trimester. Radiation exposure after appropriate abdominal shielding is well below levels at which damage to the fetus can occur [39]. The radiation used during ERCP is 18–310mrad [40, 41]. The

American College of Obstetricians and Gynecologists (ACOG) states that risks for fetal

anomalies, growth restriction, or abortions are not increased with radiation exposure of less than 5rad, a level above the exposure range for diagnostic procedures [42]. Radiation risk is greatest during the rst trimester. Fluoroscopy generally delivers a radiation dose of up to 20rads/min, but varies depending on the X-ray equipment, patient positioning, and patient size. The fetus should be shielded during cholangiography. Other alternatives to uoroscopy include intraoperative US and choledochoscopy. Recently, more ERCP procedures have been performed without uoroscopy to eliminate the radiation risk [43, 44], mainly as a two-stage approach. Biliary drainage is done in the rst ERCP, primarily used during

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1 Radiology

the third trimester when the completion of pregnancy is near. Biliary sphincterotomy with the small incision as a rst-stage ERCP avoids biliary AP caused or aggravated by stent-induced pancreatic duct obstruction and dislodgement or early fall-off of the plastic stent due to the large incision. Then after delivery, the second ERCP with the denitive extraction of calculi under uoroscopic control is performed [43]. Even though the risks to the fetus during the second and the third trimester for radiation exposure are low, it is recommended to protect the uterus with a lead shield.

ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy- related complications but not fetal and pregnancy-related complications [45].

1.8.2 Techniques

Solely diagnostic ERCP is not recommended during pregnancy [46].

In the general population, diagnostic ERCP is not recommended and has been replaced by less invasive tests such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) [47].

Eliminating radiation exposure can be accomplished by cannulating the CBD with a sphincterotome over a guidewire that can be xed in place, sphincterotomy, exchanging the sphincterotome for an extraction balloon catheter over the guidewire, and sweeping the bile duct without a cholangiogram to extract any stones. This technique does not provide real-time information regarding the anatomy of the ductal system and documentation of stone clearance [44]. Another

option is capturing uoroscopic images with a videoendoscopy, providing a safer ERCP procedure than spot radiography [48]. The third option is sphincterotomy under US guidance [49]. US-guided ERCP showed a higher rate of stone clearance in comparison to empirical nonradiation- ERCP (89% vs. 60%, P <0.05) and lower complication rates (14% vs. 3%, P<0.05) [50]. EUS can be carried out in the same session before ERCP to determine the number, size, and site of stones [51]. Another way to conrm biliary cannulation and stone clearance without radiation is by inserting a choledochoscope through the working channel of EGD to visualize the bile duct [52] directly.

The bile aspiration after deep cannulation enables conrmation of selective CBD cannulation and endoscopic sphincterotomy without radiographic control, including US [53]. One modication includes CBD cannulation with a double-lumen sphincterotome. With deep cannulation, the bile conrms the CBD position. After deep CBD cannulation, the guidewire is passed, and a complete biliary sphincterotomy is done over the guidewire. When deep CBD cannulation is not possible, after two attempts, the conventional sphincterotome is removed and needleknife sphincterotomy is performed. Once the biliary orice is identied, a complete biliary sphincterotomy is performed using a conventional double-lumen sphincterotome after conrming the location inside CBD.After the biliary sphincterotomy, a Zag guidewire is left in place, and a 7Fr double pigtail stent is placed in the CBD.Patients are kept nil orally for 6h after the procedure, and IV uids and IV cefotaxime 1g bid are given for 1day, followed by oral antibiotics for 5–7days. After delivery, all the patients are subjected to denitive ERCP. Biliary stents are removed, and a cholangiogram is obtained. All small stones are removed with a Dormia basket. For retaining large stones, mechanical lithotripsy is used. Patients with multiple large stones undergo surgery [54]. The aspiration technique avoids pancreatography. Fluoroscopy time should be as short as possible (<1min), and spot radiographs should be avoided if possible [55].

References

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1.8.3 Contrast Agents

Among other considerations for ERCP in pregnancy, contrast agents containing iodine, such as diatrizoate, can cause hypothyroidism in the baby. Risks may be minimized by using low concentrations of diatrizoate, especially the water- soluble form, thus limiting the number of intraductal injections and avoiding unnecessary pancreatography [56]. Guidelines for contrast media use during pregnancy are listed in Table 2.2.

1.8.4 Maternal andFetal Outcomes

Nonradiation techniques may decrease the risk of nonpregnancy-related outcomes but do not impact fetal or pregnancy-related outcomes [45]. The long-term outcome in children born after radiation exposure during ERCP was unremarkable [57].

1.9 Endovascular Techniques

Endovascular techniques have been increasingly used in the pregnant population. Most procedures include interventions in the upper maternal abdomen because the fetus can be protected from radiation exposure by a lead apron [58, 59].

1.10 Intraoperative Cholangiography

Fetal radiation exposure in routine IOC is equivalent to 0.5rad, well below the threshold dose of 5–10rad recommended in pregnancy. Therefore, it is considered safe, primarily when used with uterine shielding [60]. A shield to cover the fetus is recommended in all trimesters [61, 62].

References

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2. Bochicchio GV, Napolitano LM, Haan J, Champion H, Scalea T.Incidental pregnancy in trauma patients. J Am Coll Surg. 2001;192(5):566–9.

3. Drost TF, Rosemurgy AS, Sherman HF, Scott LM, Williams JK. Major trauma in pregnant women: maternal/fetal outcome. J Trauma. 1990;30(5):574–8.

4. Doll R, Wakeford R.Risk of childhood cancer from fetal irradiation. Br J Radiol. 1997;70:130–9.

5. Osei EK, Faulkner K.Fetal doses from radiological examinations. Br J Radiol. 1999;72(AUG):773–80.

6. Eskandar O, Eckford S, Watkinson T.Safety of diagnostic imaging in pregnancy. Part 1: X-ray, nuclear medicine investigations, computed tomography and contrast media. Obstetr Gynaecol. 2010;12(2):71–8.

7. Radiology AC of ACR-SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. American College of Radiology; 2018.

8. Measurements NC on RP and Medical radiation exposure of pregnant and potentially pregnant women. Bethesda; 1997.

9. Society TBMU.Statement on the use, and potential hazards of diagnostic ultrasound; 2012.

10. Barnett S.Routine ultrasound scanning in rst trimester: what are the risks? Semin Ultrasound CT MRI. 2002;23:387–91.

11. Torloni MR, Vedmedovska N, Merialdi M, Betrán AP, Allen T, González R, etal. Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis. Ultrasound Obstet Gynecol. 2009;33(5):599–608.

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bmus.org/static/uploads/resources/BMUS-SafetyGuidelines-2009-revision-FINAL-Nov-2009.pdf.

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16. Safety EC for MU. Statment on the safe use of Doppler ultrasound during scans at 11–14 weeks (or earlier in pregnancy). 2019.

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guidelines/safety- statements/statement- on- the- safeuse- of- doppler- in- fetal- second- and- third- trimesterultrasound- examinations/.

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20. International Commission on Radiological Protection. Pregnancy and medical radiation. Ann ICRP. 2000;30:1–42.

21. Rathnapalan N, Chandra K, etal. Physicians perception of teratogenic risk associated with radiography and CT during early pregnancy. Am J Roentgenol. 2004;182:1107–9.

22. McAleer SJ, Loughlin KR.Nephrolithiasis and pregnancy. Curr Opin Urol. 2004;14(2):123–7.

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24. Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG, Froelich JW, etal. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37:501–30.

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28. Gowland P, De Wilde J. Temperature increase in the fetus due to radio frequency exposure during magnetic resonance scanning. Phys Med Biol. 2008;53(21):L15.

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31. Yetisir F, Abaci Turk E, Guerin B, Gagoski BA, Grant PE, Adalsteinsson E, etal. Safety and imaging performance of two-channel RF shimming for fetal MRI at 3T.Magn Reson Med. 2021;86(5):2810–21.

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