Gastrointestinal endoscopy in pregnancy

Table 1 General principles for endoscopy in pregnant women¹

1	Always have a strong indication, particularly in high-risk pregnancies
2	Endoscopy should be postponed to second trimester whenever possible
3	Lowest effective dose of sedative medications should be used
4	Especially category A or B drugs should be used
5	Procedure time should be very short
6	To avoid vena caval or aortic compression, pregnant women should be positioned in the left pelvic tilt or left lateral position
7	Fetal heartbeat should be detected before sedation and also after the endoscopic procedure
8	Obstetric support should be available whenever pregnancy-related complications occur
9	Placental abruption, imminent delivery, ruptured membranes, or eclampsia are defined as obstetric complications of endoscopy

¹Based on Qureshi et al[2] (2005).

Table 2 United States food and drug administration categorization of drug safety during pregnancy¹

Category	Risk	Description
A	No risk has been shown in controlled studies	Sufficient, well-controlled studies have not demonstrated a risk to the fetus in any trimester of pregnancy
B	No risk in humans	Sufficient, well-controlled studies have not demonstrated an increased risk of fetal abnormalities despite adverse findings in animals or, in the absence of adequate human studies, animal studies show no fetal risk. The chance of fetal harm is very low but still is a possibility
C	Risk cannot be ruled out	Sufficient, no well-controlled human studies, where animal studies have shown a risk to the fetus. There is a chance of fetal harm if the drug is administered during pregnancy, but the potential benefits should be considered and may outweigh the potential risk
D	Positive evidence of risk	Studies in humans, or investigational or postmarketing data, have demonstrated fetal risk. Nevertheless, potential benefits from the use of the drug may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or for serious disease for which safer drugs cannot be used or are ineffective
X	Contraindicated in pregnancy	Studies in animals or humans (investigational or postmarketing reports) have demonstrated positive evidence of fetal abnormalities or risk that clearly outweighs any possible benefit to the patient

¹Adapted from Food and Drug Administration (1980)[8].

Table 3 Safety of anesthetics commonly used in gastrointestinal endoscopy

Drug	FDA category in pregnancy	Key points about drug safety
Narcotics
Meperidine	B, but D at term	Repeated use of high dose and prolonged administration can cause respiratory depression and seizures
Fentanyl	C	It is safe in low doses
Propofol	B	Generally suggested for use in patients who are sedated with difficulty and in complicated clinical situations
General anesthetics
Ketamine	B	Data are limited with humans; animal data suggest prolonged use is not safe
Sedatives
Diazepam	D	Some congenital malformations and mental retardation may be associated with diazepam, the use of diazepam during pregnancy is restricted
Midazolam	D	As a benzodiazepine member, its use is restricted during pregnancy, especially in the first trimester
Reversing agents
Naloxone	B	It probably is safe but should be used only in respiratory depression, systemic hypotension, or unresponsiveness in a closely monitored pregnant woman after endoscopy
Flumazenil	C	Fetal risks are unknown, but it should be given carefully in small doses

FDA: United States Food and Drug Administration.

Table 4 Indications for endoscopy in pregnancy

No.	Indication
1	Major or continued bleeding
2	Severe or refractory nausea and vomiting or abdominal pain
3	Dysphagia or odynophagia
4	High suspicion of colonic mass
5	Severe diarrhea with negative evaluation
6	Biliary pancreatitis, CBD stones, or cholangitis
7	Biliary or pancreatic ductal injury

Based on American Society for Gastrointestinal Endoscopy.