Gastrointestinal Endoscopy in Pregnant and Lactating Women: Emerging Standard of Care to Guide Decision-Making

Abstract

Endoscopic procedures generally are considered to be low-risk modalities, being performed on an on-demand basis in many ambulatory endoscopy centers and hospitals. However, the safety and efficacy of gastrointestinal endoscopy in pregnancy has not been well studied. In pregnancy, the risks to the fetus and mother are numerous and the magnitude of this risk will differ depending on trimester, the disease process being addressed, the underlying health and status of the maternofetal unit, and the nature of the endoscopic intervention being contemplated. Given the difficulties in performing prospective studies in the pregnant patient, these risks have not been well-quantified. Decision-making in practice is at times highly individualized. The obstetrician and endoscopist may therefore need to rely on prudent practice based on personal experience in conjunction with recognized underlying basic principles and consensus guidelines, rather than hard scientific data, to guide decision-making and advising patients. The purpose of this review is to make those caring for pregnant patients aware of the clinical considerations necessary to ensure a successful outcome and to provide guidance with respect to what is now considered to be the standard of care when managing pregnant and lactating patients in whom an endoscopic procedure is being contemplated.

ACG Clinical Guideline: Liver Disease and Pregnancy

“…Oversedation, resulting in hypotension or hypoxia, or positioning that compresses the inferior vena cava can lead to decreased uterine blood fl ow and fetal hypoxia. Th us, the patient should be positioned in the left lateral position to avoid vascular compression and aggressively managed with respect to intravenous hydration ( 11 ). Other concerns include teratogenicity of medications and radiation exposure.…”

Risks versus benefits of gastrointestinal endoscopy during pregnancy

“…■ Patient should lie in the left lateral position during EGD because of increased risk of regurgitation of gastric contents and aspiration during pregnancy ■ In late pregnancy, avoid placing the patient in the prone or supine position during the procedure or during postprocedural recovery because placental blood flow may be compromised in these positions due to compression of the inferior vena cava or aorta by the gravid uterus ■ Perform endoscopy during pregnancy at a hospital endoscopy suite rather than at an ambulatory center *Based on data from a number of sources. 4,7,94,158,225,[243][244][245][246] Recent technologies may improve fetal safety of endoscopy during pregnancy. Thinner endoscopes may permit intubation with minimal anesthesia and with reduced mechanical pressure on the uterus.…”

“…Previous recommendations regarding endoscopy during pregnancy have been outlined in a number of review articles published between 1998 and 2007; 4,7,94,158,225,[243][244][245][246] and in guidelines endorsed by the American Society for Gastrointestinal Endoscopy published in 2005. 247 General measures to improve the safety of endoscopy during pregnancy, based on this article and previously published literature, are listed in Box 2.…”

“…The enlarged gravid uterus can compress the colon and distort normal colonic landmarks at colonoscopy. 158 Despite this technical difficulty, cecal in tubation may be frequently achieved during pregnancy. …”

Gastrointestinal endoscopy in the pregnant woman

“…About 20000 GI endoscopies are performed annually on pregnant women in America, including > 12000 esophagogastroduodenoscopies (EGDs), > 1000 endoscopic retrograde cholangiopancreatographies (ERCPs), and several thousand sigmoidoscopies or colonoscopies [1] . About 0.4% of all endoscopies are performed during pregnancy [1][2][3] . The risks during pregnancy to the mother and fetus from common procedures, including upper and lower endoscopy, have not been well validated, and decisions regarding procedure performance are usually made on an individual basis based on professional society guidelines [4] .…”