Gastrointestinal endoscopy in the pregnant woman

Abstract

About 20000 gastrointestinal endoscopies are performed annually in America in pregnant women. Gastrointestinal endoscopy during pregnancy raises the critical issue of fetal safety in addition to patient safety. Endoscopic medications may be potentially abortifacient or teratogenic. Generally, Food and Drug Administration category B or C drugs should be used for endoscopy. Esophagogastroduodenoscopy (EGD) seems to be relatively safe for both mother and fetus based on two retrospective studies of 83 and 60 pregnant patients. The diagnostic yield is about 95% when EGD is performed for gastrointestinal bleeding. EGD indications during pregnancy include acute gastrointestinal bleeding, dysphagia > 1 wk, or endoscopic therapy. Therapeutic EGD is experimental due to scant data, but should be strongly considered for urgent indications such as active bleeding. One study of 48 sigmoidoscopies performed during pregnancy showed relatively favorable fetal outcomes, rare bad fetal outcomes, and bad outcomes linked to very sick mothers. Sigmoidoscopy should be strongly considered for strong indications, including significant acute lower gastrointestinal bleeding, chronic diarrhea, distal colonic stricture, suspected inflammatory bowel disease flare, and potential colonic malignancy. Data on colonoscopy during pregnancy are limited. One study of 20 pregnant patients showed rare poor fetal outcomes. Colonoscopy is generally experimental during pregnancy, but can be considered for strong indications: known colonic mass/stricture, active lower gastrointestinal bleeding, or colonoscopic therapy. Endoscopic retrograde cholangiopancreatography (ERCP) entails fetal risks from fetal radiation exposure. ERCP risks to mother and fetus appear to be acceptable when performed for ERCP therapy, as demonstrated by analysis of nearly 350 cases during pregnancy. Justifiable indications include symptomatic or complicated choledocholithiasis, manifested by jaundice, cholangitis, gallstone pancreatitis, or dilated choledochus. ERCP should be performed by an expert endoscopist, with informed consent about fetal radiation risks, minimizing fetal radiation exposure, and using an attending anesthesiologist. Endoscopy is likely most safe during the second trimester of pregnancy.

ACG Clinical Guideline: Liver Disease and Pregnancy

“…As outlined in the general endoscopy section above, endoscopy during pregnancy appears safe, but must be considered carefully in terms of the indication for endoscopy, the risks vs. benefi t evaluation and whether it will lead to management changes ( 15,173 ).…”

Diagnostic and Therapeutic Endoscopy in Pregnancy: When, Why and How?

“…The most common indication for upper GI endoscopy (UGIE) in pregnant woman are bleeding, abdominal pain and refractory vomiting [3]. The most common UGIE finding was reflux esophagitis followed by Mallory Weiss tear and peptic ulcers [9]. UGIE is safe for fetus when it is strongly indicated [10,11].…”

“…Out of various endoscopic hemostatic techniques available for nonvariceal upper GI bleed (NVUGB); there is insufficient data to recommend specific endotherapy in pregnancy [6,12]. Epinephrine injection is commonly done to control active GI bleed in the general population; but it may cause decreased uterine blood flow being categorized as category C drug [9,11]. Amniotic fluid can conduct electric current during electrocoagulation.…”

Endoscopic retrograde cholangiopancreatography

“…[3,4] Most of the studies on this topic are small sample size retrospective studies, and the general consensus is that the risks of ERCP in pregnant females are comparable to those in nonpregnant patients. [5] Therefore, the authors evaluated the large database (Nationwide inpatient sample database) of the years 2008 and 2009 of pregnant patients who underwent ERCP and compared the results and complications with age-matched nonpregnant controls. The controls were selected using stratified sampling using SAS 9.2 (SAS Institute, Inc., Cary, NC) whereby 3 nonpregnant control females were selected randomly for each pregnant female drawn from the same 5-year age group.…”