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ABM Clinical Protocol #31: Radiology and Nuclear Medicine Studies in Lactating Women


Abstract

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Introduction

BREASTFEEDING WOMEN MAY be required to undergo diagnostic imaging and/or nuclear medicine procedures at any point during lactation. Many women report being incorrectly instructed to discard (“pump and dump”) their breast milk or stop breastfeeding after procedures. We seek to provide guidelines and recommendations regarding the safety of common imaging and nuclear medicine procedures performed during lactation. Although the vast majority of circumstances do not require interruption of breastfeeding, certain exceptions do exist and will be reviewed. A summary of recommendations is provided in Table 1 .

Table 1
Common Nuclear Medicine Imaging Agents and Recommendations for Breastfeeding
Imaging agent Breastfeeding interruption

  • Noncontrast radiographs

  • Nonvascular administration of iodinated contrast

  • CT with iodinated intravenous contrast

  • MRI with gadolinium-based intravenous contrast

  • Nuclear medicine imaging

  • PET

  • Bone scan

  • Thyroid imaging

    • I-131

    • I-123

    • Technetium-99m pertechnetate

  • No

  • No

  • No

  • No

  • No

  • No

  • Cessation for this infant

  • Recommendations vary, up to 3 weeks

  • Up to 24 hours, depending on dose

  • Renal imaging

    • Tc-99m DTPA

    • Tc-99m MAG3

    • Tc-99m DMSA

    • Tc-99m glucoheptonate

  • Cardiac imaging

    • Tc-99m Sestamibi

    • Tc-99m Tetrofosmin

  • MUGA

    • Tc-99m RBCs in vitro

    • Tc-99m RBCs in vivo

  • VQ scan

    • Tc-99m MAA

  • Breast imaging

    • Screening or diagnostic mammography

    • Ultrasound

    • MRI with gadolinium-based intravenous contrast

  • 12 hours

  • No

  • No

  • No

CT , computed tomography; MRI , magnetic resonance imaging; MUGA , multigated acquisition scan; Tc-99m MAA , technetium-99m macroaggregated albumin; PET , positron emission tomography; Tc-99m MAG3 , technetium-99m mertiatide; Tc-99m DMSA , technetium-99m succimer; VQ , ventilation-perfusion.

a The International Atomic Energy Administration recommends withholding breastfeeding for 4 hours or one feeding to account for any external radiation and free Tc99m pertechnetate in the product.

It should be noted that breastfeeding mothers involved in the care of patients undergoing nuclear medicine procedures and/or imaging studies and procedures should take standard precautions. However, due to the fact that these health care workers are not directly ingesting, inhaling, or receiving intravenous radiopharmaceuticals and/or contrast, no interruption in breastfeeding is required. Should a mother have an unexpected exposure, the institutional Radiology Safety Officer (RSO) should be contacted. Other sources for recommendations regarding unintended health care exposures include MotherToBaby.org and Infantrisk.com

Recommendations

Breast imaging

Several organizations, including the American College of Radiology (ACR), have made recommendations regarding breast imaging in pregnant and lactating women.

Screening

The ACR states that initiation or continuation of screening mammography should be considered dependent on the patient’s individual risk and expected duration of lactation. This includes average risk women of age ≥40 years as well as some intermediate- to high-risk women of age <40 years.

There is no contraindication to obtaining a mammogram during lactation. Nursing or expressing milk before mammography is recommended to decrease parenchymal density, thereby improving the sensitivity of mammography. Ultrasound may also be used as a supplemental screening modality in conjunction with mammography. The physiologic increased vascularity caused by lactation results in marked increase in background parenchymal enhancement of the breast on magnetic resonance imaging (MRI). For high-risk women breastfeeding for short periods of time, MRI should be performed 3 months after cessation of lactation. For high-risk women who plan to breastfeed for longer periods of time, MRI may be considered in addition to mammography for screening.

Diagnostic

Diagnostic breast imaging during lactation is the same as that for nonlactating women. For diagnostic evaluation of an area of palpable concern or persistent bloody nipple discharge, ultrasound is often the initial imaging modality. If ultrasound is either negative or demonstrates suspicious findings, additional imaging with mammography may be indicated.

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