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Appropriateness Criteria

Variant 1: Known or suspected multiple gestations. Monochorionic or dichorionic. First trimester. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pregnant uterus transabdominal Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 7
References Study Quality
9 (32861686) 4
27 (29115085) 4
24 (27180271) Good
28 (21308842) 3
35 (31710737) 3
34 (24585501) 4
33 (27622859) 3
32 (27363529) 3
31 (26466907) 3
30 (25989950) 3
29 (23754823) 4
US pregnant uterus transvaginal Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 2 3 1
References Study Quality
9 (32861686) 4
24 (27180271) Good
US assessment for TTTS Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 0 2 3 0 0 0 0 0
References Study Quality
9 (32861686) 4
US cervix transvaginal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 3 3 1 0 0 0 0 0
References Study Quality
25 (26363481) 3
26 (28942691) 4
US duplex Doppler fetal middle cerebral artery Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
US duplex Doppler fetal umbilical artery Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 1 0 0 0 0 0 0
References Study Quality
9 (32861686) 4
US echocardiography fetal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 1 1 1 0 0 0 0 0
References Study Quality
9 (32861686) 4
US pregnant uterus biophysical profile Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 0 0 0 0 0 0
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
MRI fetal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
Variant 2: Multiple gestations. Monochorionic or dichorionic. First trimester. First trimester ultrasound performed. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pregnant uterus transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 0 2 7
References Study Quality
40 (24371108) 3
39 (27766995) 4
38 (21234973) 4
37 (31773823) 3
33 (27622859) 3
16 (34839475) 4
15 (32852128) 4
14 (31788879) 3
9 (32861686) 4
5 (31697621) 4
US pregnant uterus transvaginal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 5 2 1 2
US cervix transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 0 0 4 4 2 0 0 0
References Study Quality
25 (26363481) 3
26 (28942691) 4
US echocardiography fetal May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 0 2 5 1 3 0 0 0
References Study Quality
16 (34839475) 4
15 (32852128) 4
US assessment for TTTS Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 1 2 2 1 0 1 0 0
References Study Quality
9 (32861686) 4
33 (27622859) 3
36 (17444560) 3
US duplex Doppler fetal middle cerebral artery Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 1 0 0 0 1 0 0 0
References Study Quality
9 (32861686) 4
US duplex Doppler fetal umbilical artery Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 7 1 1 0 0 0 0 0 1
References Study Quality
9 (32861686) 4
US pregnant uterus biophysical profile Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 0 0 0 0 0 0
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
MRI fetal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
Variant 3: Multiple gestations. Dichorionic twins or multichorionic higher order multiples. Second trimester anatomy examination. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US cervix transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 3 1 2
References Study Quality
43 (31878811) 4
44 (27133011) 4
US echocardiography fetal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 3 1 4 1
References Study Quality
46 (22713497) 4
US pregnant uterus transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 9
References Study Quality
5 (31697621) 4
41 (30308091) 4
47 (26428508) 4
US duplex Doppler fetal umbilical artery May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 4 2 0 0 0
US pregnant uterus transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 0 7 1 0 1
US assessment for TTTS Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 1 2 1 0 1 0 0 0
US duplex Doppler fetal middle cerebral artery Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 2 5 0 0 1 0 0 0
References Study Quality
45 (19012187) 4
US pregnant uterus biophysical profile Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 1 2 0 1 1 0 0 0
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
MRI fetal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 2 0 2 0 1 0 0 0
Variant 4: Multiple gestations. Monochorionic twins. Second trimester anatomy examination. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US assessment for TTTS Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 7
References Study Quality
9 (32861686) 4
12 (27561094) 3
US cervix transvaginal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 3 3 2 1
References Study Quality
43 (31878811) 4
44 (27133011) 4
48 (30107361) 3
47 (26428508) 4
49 (20516671) 4
US duplex Doppler fetal umbilical artery Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 6
References Study Quality
9 (32861686) 4
US echocardiography fetal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 6
References Study Quality
9 (32861686) 4
52 (23223160) 4
53 (25560113) 4
US pregnant uterus transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 9
References Study Quality
58 (20215730) 3
57 (31875322) 3
56 (29024208) 3
55 (24011780) 3
54 (25925425) 4
49 (20516671) 4
41 (30308091) 4
9 (32861686) 4
US duplex Doppler fetal middle cerebral artery May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 1 7 0 1 1
References Study Quality
51 (31605505) 4
50 (31277521) 4
20 (-3120926) 4
9 (32861686) 4
3 (26094734) 2
US pregnant uterus transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 0 6 2 0 1
MRI fetal without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 2 4 0 0 0
US pregnant uterus biophysical profile Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 1 1 0 0 0 0 0
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 1 0 0 0 0 0 0
Variant 5: Multiple gestations. Dichorionic twins or multichorionic higher order multiples. Growth and antepartum surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US pregnant uterus transabdominal Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 9
US cervix transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 1 0 0 3 3 2 0 1
References Study Quality
43 (31878811) 4
US duplex Doppler fetal middle cerebral artery May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 1 3 3 3 0 0 0
US duplex Doppler fetal umbilical artery May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 3 4 0 1 0
US echocardiography fetal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 2 2 4 2 0 0 0
US pregnant uterus biophysical profile May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 6 3 1 1 0
References Study Quality
62 (17154226) 3
63 (26453124) 3
US pregnant uterus transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 3 2 0 1
US assessment for TTTS Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 2 1 2 0 1 0 0 0
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 0 0 0 0 0 0 0
MRI fetal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 2 1 1 0 1 0 0 0
Variant 6: Multiple gestations. Monochorionic twins. Growth and antepartum surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US assessment for TTTS Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 6
References Study Quality
9 (32861686) 4
12 (27561094) 3
13 (30306664) 4
US duplex Doppler fetal middle cerebral artery Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 3 1 2
References Study Quality
3 (26094734) 2
9 (32861686) 4
50 (31277521) 4
51 (31605505) 4
US duplex Doppler fetal umbilical artery Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 6
References Study Quality
9 (32861686) 4
42 (27062653) 3
US pregnant uterus transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 9
References Study Quality
9 (32861686) 4
12 (27561094) 3
US cervix transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 6 0 0 0
References Study Quality
43 (31878811) 4
US echocardiography fetal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 2 3 1 1 2
References Study Quality
9 (32861686) 4
12 (27561094) 3
US pregnant uterus biophysical profile May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 2 5 3 1 0
References Study Quality
62 (17154226) 3
63 (26453124) 3
US pregnant uterus transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 1 5 2 0 1
MRI fetal without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 2 1 0 2 4 1 0 0 0
References Study Quality
17 (25377504) 3
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
Variant 7: Multiple gestations. Dichorionic or multichorionic higher order multiples or monochorionic gestations. Known abnormality or discordance between fetuses (fluid, size, weight). Growth and antepartum surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler fetal middle cerebral artery Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 4 1 1
References Study Quality
3 (26094734) 2
51 (31605505) 4
72 (30125414) 3
73 (30207009) 3
74 (22418955) 4
US duplex Doppler fetal umbilical artery Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 3 2 3
References Study Quality
42 (27062653) 3
77 (20878679) 3
76 (21962139) 3
75 (32573847) 3
70 (14533898) 4
US pregnant uterus biophysical profile Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 4 3 0 2
US pregnant uterus transabdominal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 9
References Study Quality
9 (32861686) 4
83 (29363848) 4
84 (24751835) M
4 (29287298) 4
58 (20215730) 3
US assessment for TTTS May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 3 4 0 0
References Study Quality
71 (32832884) 3
70 (14533898) 4
69 (23617829) 4
12 (27561094) 3
9 (32861686) 4
5 (31697621) 4
4 (29287298) 4
US cervix transvaginal May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 2 4 5 0 0 0
References Study Quality
43 (31878811) 4
US echocardiography fetal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 3 4 1 0 1
References Study Quality
32 (27363529) 3
52 (23223160) 4
82 (27813120) 3
81 (23495173) 3
80 (27150066) 3
79 (21998013) 3
78 (24919586) 3
58 (20215730) 3
22 (-3196434) 4
US pregnant uterus transvaginal May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 7 1 0 0
MRI fetal without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 3 2 3 0 0
References Study Quality
68 (32358676) 3
67 (29688161) 3
66 (31220847) 3
65 (26268524) 3
18 (28444780) 3
17 (25377504) 3
MRI fetal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.