Gastrointestinal endoscopy in the pregnant woman

Table 1 Unique features of endoscopy during pregnancy

1 Two or more patients at risk

2 Medications and anesthesia usually used may be contraindicated due to fetal risks

3 Patient position an issue in terms of placental blood flow

4 Greater concerns for blood pressure fluctuations due to concerns about placental perfusion

5 Greater concern for aspiration in later pregnancy

6 Disease states that may be exacerbated by pregnancy (GERD) or specific to pregnancy (hyperemesis gravidarum, gestational diabetes, third trimester liver syndromes-HELLP syndrome, etc.)

7 Deferral of procedure to more optimal times (e.g., defer procedure from second trimester to postpartum, with possible expedited delivery)

8 Duration of procedure prime concern

9 Obstetric input and monitoring usually necessary

10 Screening for malignancy and Barrett’s esophagus less of a concern

11 Avoidance of radiation-based and interventional ancillary procedures (computed tomography imaging, angiography)

12 Monopolar electrocautery (e.g., with sphincterotomy) may harm fetus

GERD: Gastroesophageal reflux disease.

Table 2 Fetal risks of endoscopic or peri-endoscopic medications used during pregnancy¹

Medication class	FDA category of safety in pregnancy	Medications
Proton pump inhibitors	B	Lansoprazole, Pantoprazole, Dexlansoprazole, Esmeprazole, Rebeprazole
	C	Omperazole
Histamine-2 antagonists	B	Cimetidine, Famotidine, Nizatidine, Ranitidine
Antiemetics	B	Odansetron, Metoclopramide, Diphenhydramine, Trimethobenzamide, Prochloropromazine, Doxyamine Succinate and Pyridoxine
	C	Promethazine
Prokinetic agents	B	Metoclopramide, Erythromycin
Anesthesia	B	Propofol, Ketamine
Narcotics	B	Meperidine
	B	Morphine, Fentanyl
Benzodiazepines	D	Diazepam, Midazolam
Reversal agents	B	Nalozone
	C	Flumazenil
Colonic preparations	C	Polyethylene glycol, Phosphate preparations2
Antispasmodic	B	Glucagon

¹FDA categorizations of drug safety during pregnancy accepted as guidelines in the current report and by the American Society for Gastrointestinal Endoscopy (ASGE[4]);

²This review does not recommend use of phosphate preparations during pregnancy. The ASGE recommends its use “with caution”[4]. FDA: United States Food and Drug Administration.

Table 3 Indications for esophagogastroduodenoscopy during pregnancy

Strong indications1
	Dysphagia > 1-2 wk, especially with diminished intake or weight loss
	Odynophagia > 1-2 wk
	Gross gastrointestinal hemorrhage with hematemesis and/or melena, especially if patient becomes hypotensive, requires blood products, or has a significant acute hemoglobin decline
	GI hemorrhage with strong clinical suspicion of varices
	Suggestion of malignancy on radiologic imaging studies (e.g., MRI)
	Possible gastric outlet obstruction (e.g., from peptic ulcer disease)
	Endoscopic therapy for continued UGI bleeding
	Balloon dilatation of symptomatic UGI stricture (e.g., endoscopic therapy for reflux stricture)
Moderate indications
	Recurrent nausea and emesis (including possible hyperemesis gravidarum) if patient > 16-18 wk pregnant and concern exists for peptic ulcer disease with inadequate patient response to > 2 wk of conservative therapy, including PPI
	Strong need for endoscopic placement of enteric tube (e.g., for hyperemesis or severe, prolonged, acute pancreatitis)
	Nausea and emesis after UGI surgery (including bariatric surgery) with concern for postsurgical stricture
Weak indications
	Hyperemesis gravidarum during first trimester
	Self-limited nausea, emesis or abdominal pain
	GERD symptoms, excluding dysphagia not responsive to empiric PPI therapy
	Routine endoscopic surveillance for higher risk patients (e.g., EGD for personal history of familial polyposis coli)-can be deferred until postpartum
	Iron deficiency anemia-should generally be deferred until postpartum

¹These recommendations incorporate the American Society for Gastrointestinal Endoscopy (ASGE) guidelines[4] as recommendations 1-4, and 7, but the current report adds recommendations 5, 6 and 8 that were not addressed in the ASGE guidelines. MRI: Magnetic resonance imaging; UGI: Upper gastrointestinal; GERD: Gastroesophageal reflux disease; EGD: Esophagogastroduodenoscopy; PPI: Proton pump inhibitor.

Table 4 Concerns about performance of endoscopic retrograde cholangiopancreatography during pregnancy

1 The procedure is technically challenging

2 The patient is normally placed in prone position for ERCP with consequently decreased placental perfusion for the significant duration of the procedure

3 The patient requires considerable anesthetic medications during ERCP due to discomfort during this particularly prolonged procedure

4 Patients often have preexisting pain and significant acute disease, such as gallstone pancreatitis or cholangitis

5 Fluoroscopy is usually required during ERCP with consequent fetal radiation exposure

6 Complications are more common in ERCP than in other endoscopic procedures and can potentially be severe (e.g., pancreatitis, cholangitis, hemorrhage)

7 Sphincterotomy entails monopolar electrocautery with current possibly traversing the fetus

8 Endoscopic sphincterotomy entails risks of postsphincterotomy bleeding or perforation

9 Repeat procedures may be required, such as ERCP for retained biliary stones or stent malfunction and cholecystectomy for gallstones

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 5 Recommendations for endoscopic retrograde cholangiopancreatography during pregnancy¹

1 Weigh conservative management and/or deferral. Radiation early in gestation is a particular concern. Second trimester may be optimal time

2 Consult with obstetrician

3 Consult with radiation physicist if feasible to calculate appropriate dosimetry

4 Obtain MRCP if useful and available

5 Employ experienced ERCP physician

6 Endoscopic ultrasound may obviate ERCP (if CBD gallstones are not extremely likely)

7 Shield fetus/Employ unit with highly collimated beam/Avoid continuous radiation

8 Employ tactics to minimize/obviate radiation: Aspirate bile/intraductal ultrasound/biliary balloon sweeps w/o fluoroscopy/cholangioscopy/biliary stent placement

9 Avoid taking hard copy radiographs of findings because these use greater amounts of radiation than fluoroscopy

10 Minimize monopolar cautery during sphincterotomy. Employ grounding pad so that electric current does not traverse uterus/fetus

¹These current recommendations incorporate the American Society for Gastrointestinal Endoscopy (ASGE) guidelines[4] as recommendations 1,2,5, and 7-10, but the current report adds recommendations 3 and 4 that were not addressed in the ASGE guidelines. ERCP: Endoscopic retrograde cholangiopancreatography; MRCP: Magnetic resonance cholangiopancreatography; CBD: Common bile duct.

Table 6 Basic principles of endoscopy during pregnancy

1 Weigh benefits of endoscopy versus conservative management

2 Defer endoscopy to second trimester or post-delivery when appropriate

3 Evaluate all proposed medications in terms of teratogenicity and abortifacient potential

4 Obtain consultation from obstetrics and preferably employ anesthesiologist

5 Position patient on left side. Avoid perturbations of blood pressure

6 Minimize drug administration and procedure time

7 For ERCP, minimize or obviate radiation (Table 5). Utilize radiation physicist and calculate dosimetry

8 Utilize bipolar electrocautery. Minimize monopolar use

ERCP: Endoscopic retrograde cholangiopancreatography.