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CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2021; 12(03): 138-150
DOI: 10.1055/s-0041-1739567
Systematic Review

Endoscopy in Pregnancy: A Systematic Review

Partha Pal
1   Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
,
D. Nageshwar Reddy
1   Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
,
Manu Tandan
1   Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
› Author Affiliations Funding None.
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Abstract

Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy.

Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021.

Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy.

Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

Keywords

pregnancy - esophagogastroduodenoscopy - flexible sigmoidoscopy - colonoscopy - endoscopic retrograde cholangiopancreatography - endoscopic ultrasound


Publication History

Article published online:
17 November 2021

© 2021. Society of Gastrointestinal Endoscopy of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 Cappell MS. Risks versus benefits of gastrointestinal endoscopy during pregnancy. Nat Rev Gastroenterol Hepatol 2011; 8 (11) 610-634
    CrossrefPubMedGoogle Scholar
  • 2 de Lima A, Zelinkova Z, van der Woude CJ. A prospective study of the safety of lower gastrointestinal endoscopy during pregnancy in patients with inflammatory bowel disease. J Crohn’s Colitis 2015; 9 (07) 519-524
    CrossrefPubMedGoogle Scholar
  • 3 Bagis T, Gumurdulu Y, Kayaselcuk F, Yilmaz ES, Killicadag E, Tarim E. Endoscopy in hyperemesis gravidarum and Helicobacter pylori infection. Int J Gynaecol Obstet 2002; 79 (02) 105-109
    CrossrefPubMedGoogle Scholar
  • 4 Nguyen GC, Dinani AM, Pivovarov K. Endoscopic management and outcomes of pregnant women hospitalized for nonvariceal upper GI bleeding: a nationwide analysis. Gastrointest Endosc 2010; 72 (05) 954-959
    CrossrefPubMedGoogle Scholar
  • 5 Shergill AK, Ben-Menachem T, Chandrasekhara V. ASGE Standard of Practice Committee. et al Guidelines for endoscopy in pregnant and lactating women. Gastrointest Endosc 2012; 76 (01) 18-24 Erratum in: Gastrointest Endosc. 2013 May;77(5):833. PMID: 22579258
    CrossrefPubMedGoogle Scholar
  • 6 Cappell MS. Sedation and analgesia for gastrointestinal endoscopy during pregnancy. Gastrointest Endosc Clin N Am 2006; 16 (01) 1-31
    CrossrefPubMedGoogle Scholar
  • 7 Cappell MS, Colon VJ, Sidhom OA. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups. Am J Gastroenterol 1996; 91 (02) 348-354
    PubMedGoogle Scholar
  • 8 Debby A, Golan A, Sadan O, Glezerman M, Shirin H. Clinical utility of esophagogastroduodenoscopy in the management of recurrent and intractable vomiting in pregnancy. J Reprod Med 2008; 53 (05) 347-351
    PubMedGoogle Scholar
  • 9 Kochhar R, Kumar S, Goel RC, Sriram PV, Goenka MK, Singh K. Pregnancy and its outcome in patients with noncirrhotic portal hypertension. Dig Dis Sci 1999; 44 (07) 1356-1361
    CrossrefPubMedGoogle Scholar
  • 10 Kochhar R, Goenka MK, Mehta SK. Endoscopic sclerotherapy during pregnancy. Am J Gastroenterol 1990; 85 (09) 1132-1135
    PubMedGoogle Scholar
  • 11 Aggarwal N, Sawhney H, Vasishta K, Dhiman RK, Chawla Y. Non-cirrhotic portal hypertension in pregnancy. Int J Gynaecol Obstet 2001; 72 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 12 Mandal D, Dattaray C, Sarkar R, Mandal S, Choudhary A, Maity TK. Is pregnancy safe with extrahepatic portal vein obstruction? An analysis. Singapore Med J 2012; 53 (10) 676-680
    PubMedGoogle Scholar
  • 13 Keepanasseril A, Gupta A, Ramesh D, Kothandaraman K, Jeganathan YS, Maurya DK. Maternal-fetal outcome in pregnancies complicated with non-cirrhotic portal hypertension: experience from a tertiary centre in South India. Hepatol Int 2020; 14 (05) 842-849
    CrossrefPubMedGoogle Scholar
  • 14 Dhiman RK, Biswas R, Aggarwal N, Sawhney H, Chawla Y. Management of variceal bleeding in pregnancy with endoscopic variceal ligation and N-butyl-2-cyanoacrylate: report of three cases. Gastrointest Endosc 2000; 51 (01) 91-93
    CrossrefPubMedGoogle Scholar
  • 15 Vosko S, Cohen DL, Neeman O, Matalon S, Broide E, Shirin H. Achalasia during pregnancy: proposed management algorithm based on a thorough literature review. J Neurogastroenterol Motil 2021; 27 (01) 8-18
    CrossrefPubMedGoogle Scholar
  • 16 Patel V, Nicar M, Emmett M. et al Intestinal and renal effects of low-volume phosphate and sulfate cathartic solutions designed for cleansing the colon: pathophysiological studies in five normal subjects. Am J Gastroenterol 2009; 104 (04) 953-965
    CrossrefPubMedGoogle Scholar
  • 17 Neri I, Blasi I, Castro P, Grandinetti G, Ricchi A, Facchinetti F. Polyethylene glycol electrolyte solution (Isocolan) for constipation during pregnancy: an observational open-label study. J Midwifery Womens Health 2004; 49 (04) 355-358
    CrossrefPubMedGoogle Scholar
  • 18 Rottenstreich M, Mosmar K, Ehrlich Z, Kitroser E, Grisaru-Granovsky S. Flexible endoscopic decompression for treatment of sigmoid volvulus in pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 242: 184-185
    CrossrefPubMedGoogle Scholar
  • 19 Cappell MS, Colon VJ, Sidhom OA. A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups. Dig Dis Sci 1996; 41 (12) 2353-2361
    CrossrefPubMedGoogle Scholar
  • 20 Ko MS, Rudrapatna VA, Avila P, Mahadevan U. Safety of flexible sigmoidoscopy in pregnant patients with known or suspected inflammatory bowel disease. Dig Dis Sci 2020; 65 (10) 2979-2985
    CrossrefPubMedGoogle Scholar
  • 21 Cappell MS, Fox SR, Gorrepati N. Safety and efficacy of colonoscopy during pregnancy: an analysis of pregnancy outcome in 20 patients. J Reprod Med 2010; 55 (3-4) 115-123
    PubMedGoogle Scholar
  • 22 Seubert DE, Puder KS, Goldmeier P, Gonik B. Colonoscopic release of the incarcerated gravid uterus. Obstet Gynecol 1999; 94 (5 Pt 1) 792-794
    CrossrefPubMedGoogle Scholar
  • 23 De Lima A, Galjart B, Wisse PH, Bramer WM, van der Woude CJ. Does lower gastrointestinal endoscopy during pregnancy pose a risk for mother and child? - a systematic review. BMC Gastroenterol 2015; 15: 15
    CrossrefPubMedGoogle Scholar
  • 24 Brent RL. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks. Semin Oncol 1989; 16 (05) 347-368
    PubMedGoogle Scholar
  • 25 Tham TC, Vandervoort J, Wong RC. et al Safety of ERCP during pregnancy. Am J Gastroenterol 2003; 98 (02) 308-311
    CrossrefPubMedGoogle Scholar
  • 26 Samara ET, Stratakis J, Enele Melono JM, Mouzas IA, Perisinakis K, Damilakis J. Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial?. Gastrointest Endosc 2009; 69 (04) 824-831
    CrossrefPubMedGoogle Scholar
  • 27 Friedel D, Stavropoulos S, Iqbal S, Cappell MS. Gastrointestinal endoscopy in the pregnant woman. World J Gastrointest Endosc 2014; 6 (05) 156-167
    CrossrefPubMedGoogle Scholar
  • 28 Inamdar S, Berzin TM, Sejpal DV. et al Pregnancy is a risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography in a national cohort study. Clin Gastroenterol Hepatol 2016; 14 (01) 107-114
    CrossrefPubMedGoogle Scholar
  • 29 Jamidar PA, Beck GJ, Hoffman BJ. et al Endoscopic retrograde cholangiopancreatography in pregnancy. Am J Gastroenterol 1995; 90 (08) 1263-1267
    PubMedGoogle Scholar
  • 30 Farca A, Aguilar ME, Rodriguez G. de la Mora G, Arango L. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest Endosc 1997; 46 (01) 99-101
    PubMedGoogle Scholar
  • 31 Kahaleh M, Hartwell GD, Arseneau KO. et al Safety and efficacy of ERCP in pregnancy. Gastrointest Endosc 2004; 60 (02) 287-292
    CrossrefPubMedGoogle Scholar
  • 32 Gupta R, Tandan M, Lakhtakia S, Santosh D, Rao GV, Reddy DN. Safety of therapeutic ERCP in pregnancy - an Indian experience. Indian J Gastroenterol 2005; 24 (04) 161-163
    PubMedGoogle Scholar
  • 33 Sharma SS, Maharshi S. Two stage endoscopic approach for management of choledocholithiasis during pregnancy. J Gastrointestin Liver Dis 2008; 17 (02) 183-185
    PubMedGoogle Scholar
  • 34 Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos. Gastrointest Endosc 2008; 67 (02) 364-368
    CrossrefPubMedGoogle Scholar
  • 35 Tang SJ, Mayo MJ, Rodriguez-Frias E. et al Safety and utility of ERCP during pregnancy. Gastrointest Endosc 2009; 69 (3 Pt 1) 453-461
    CrossrefPubMedGoogle Scholar
  • 36 Bani Hani MN, Bani-Hani KE, Rashdan A, AlWaqfi NR, Heis HA, Al-Manasra AR. Safety of endoscopic retrograde cholangiopancreatography during pregnancy. ANZ J Surg 2009; 79 (1-2) 23-26
    CrossrefPubMedGoogle Scholar
  • 37 Daas AY, Agha A, Pinkas H, Mamel J, Brady PG. ERCP in pregnancy: is it safe?. Gastroenterol Hepatol (N Y 2009; 5 (12) 851-855
    PubMedGoogle Scholar
  • 38 García-Cano J, Pérez-Miranda M, Pérez-Roldán F. et al ERCP during pregnancy. Rev Esp Enferm Dig 2012; 104 (02) 53-58
    CrossrefPubMedGoogle Scholar
  • 39 Zhou Y, Zhang X, Zhang X. et al ERCP in acute cholangitis during third trimester of pregnancy. Hepatogastroenterology 2013; 60 (125) 981-984
    PubMedGoogle Scholar
  • 40 Ersoz G, Turan I, Tekin F, Ozutemiz O, Tekesin O. Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy. Surg Endosc 2016; 30 (01) 222-228
    CrossrefPubMedGoogle Scholar
  • 41 Konduk BT, Bayraktar O. Efficacy and safety of endoscopic retrograde cholangiopancreatography in pregnancy: a high-volume study with long-term follow-up. Turk J Gastroenterol 2019; 30 (09) 811-816
    CrossrefPubMedGoogle Scholar
  • 42 Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009; 15 (29) 3649-3652
    CrossrefPubMedGoogle Scholar
  • 43 Brewer Gutierrez OI, Godoy Brewer G, Zulli C. et al Multicenter experience with digital single-operator cholangioscopy in pregnant patients. Endosc Int Open 2021; 9 (02) E116-E121
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Polydorou A, Karapanos K, Vezakis A. et al A multimodal approach to acute biliary pancreatitis during pregnancy: a case series. Surg Laparosc Endosc Percutan Tech 2012; 22 (05) 429-432
    CrossrefPubMedGoogle Scholar
  • 45 Huang P, Zhang H, Zhang XF, Zhang X, Lü W, Fan Z. Comparison of endoscopic retrograde cholangiopancreatography performed without radiography and with ultrasound-guidance in the management of acute pancreaticobiliary disease in pregnant patients. Chin Med J (Engl 2013; 126 (01) 46-50
    PubMedGoogle Scholar
  • 46 Sethi S, Thosani N, Banerjee S. Radiation-free ERCP in pregnancy: a “Sound” approach to leaving no stone unturned. Dig Dis Sci 2015; 60 (09) 2604-2607
    CrossrefPubMedGoogle Scholar
  • 47 Götzberger M, Pichler M, Gülberg V. Contrast-enhanced US-guided ERCP for treatment of common bile duct stones in pregnancy. Gastrointest Endosc 2012; 76 (05) 1069-1070
    CrossrefPubMedGoogle Scholar
  • 48 Vohra S, Holt EW, Bhat YM, Kane S, Shah JN, Binmoeller KF. Successful single-session endosonography-based endoscopic retrograde cholangiopancreatography without fluoroscopy in pregnant patients with suspected choledocholithiasis: a case series. J Hepatobiliary Pancreat Sci 2014; 21 (02) 93-97
    CrossrefPubMedGoogle Scholar
  • 49 Bar-Meir S, Rotmensch S. Investigation of obstructive jaundice by an ultra-thin-caliber endoscope: a new technique for potential use in pregnancy. Am J Obstet Gynecol 1984; 150 (08) 1003-1004
    CrossrefPubMedGoogle Scholar
  • 50 Baillie J, Cairns SR, Putman WS, Cotton PB. Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 1990; 171 (01) 1-4
    PubMedGoogle Scholar
  • 51 Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy. Gastroenterol Clin North Am 2003; 32 (01) 123-179
    CrossrefPubMedGoogle Scholar
  • 52 Baron TH, Schueler BA. Pregnancy and radiation exposure during therapeutic ERCP: time to put the baby to bed. ? Gastrointest Endosc 2009; 69 (04) 832-834
    CrossrefPubMedGoogle Scholar
  • 53 Binmoeller KF, Katon RM. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointest Endosc 1990; 36 (06) 607-609
    CrossrefPubMedGoogle Scholar
  • 54 Nesbitt TH, Kay HH, McCoy MC, Herbert WN. Endoscopic management of biliary disease during pregnancy. Obstet Gynecol 1996; 87 (5 Pt 2) 806-809
    PubMedGoogle Scholar
  • 55 Rahmin MG, Hitscherich R, Jacobson IM. ERCP for symptomatic choledocholithiasis in pregnancy. Am J Gastroenterol 1994; 89 (09) 1601-1602
    PubMedGoogle Scholar
  • 56 Girotra M, Jani N. Role of endoscopic ultrasound/SpyScope in diagnosis and treatment of choledocholithiasis in pregnancy. World J Gastroenterol 2010; 16 (28) 3601-3602
    CrossrefPubMedGoogle Scholar
  • 57 Lee JJ, Lee SK, Kim SH. et al Efficacy and safety of pancreatobiliary endoscopic procedures during pregnancy. Gut Liver 2015; 9 (05) 672-678
    PubMedGoogle Scholar
  • 58 Roumieu F, Ponchon T, Audra P, Gaucherand P. Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences. Eur J Obstet Gynecol Reprod Biol 2008; 140 (01) 141-142
    CrossrefPubMedGoogle Scholar
  • 59 Chong VH. EUS complements ERCP during pregnancy. Gastrointest Endosc 2009; 70 (06) 1285-1286 author reply 1286–1287
    CrossrefPubMedGoogle Scholar
  • 60 Magno-Pereira V, Moutinho-Ribeiro P, Macedo G. Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. Eur J Obstet Gynecol Reprod Biol 2017; 219: 35-39
    CrossrefPubMedGoogle Scholar
  • 61 Hogan RB, Ahmad N, Hogan RB II. et al Video capsule endoscopy detection of jejunal carcinoid in life-threatening hemorrhage, first trimester pregnancy. Gastrointest Endosc 2007; 66 (01) 205-207
    CrossrefPubMedGoogle Scholar
  • 62 Van Bodegraven AA, Böhmer CJ, Manoliu RA. et al Gallbladder contents and fasting gallbladder volumes during and after pregnancy. Scand J Gastroenterol 1998; 33 (09) 993-997
    CrossrefPubMedGoogle Scholar
  • 63 Aicart Ramos M, Volpato N, López San Román A. Retained capsule in Crohn’s disease: what happens if i get pregnant?. J Crohn’s Colitis 2015; 9 (06) 516
    CrossrefPubMedGoogle Scholar
  • 64 Ryan ME. Endoscopic management of a pancreatic pseudocyst during pregnancy. Gastrointest Endosc 1992; 38 (05) 605-608
    CrossrefPubMedGoogle Scholar
  • 65 Gyokeres T, Topa L, Marton I, Pap A. Endoscopic cystogastrostomy during pregnancy. Gastrointest Endosc 2001; 53 (04) 516-518
    CrossrefPubMedGoogle Scholar