Ercp During Pregnancy: Is It Safe?

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to treat gallstones, which affect up to 5% to 12% of pregnant women. It involves using an endoscope to guide a small wire into the bile duct and remove the gallstones. While ERCP is generally considered safe and effective during pregnancy, there are potential risks to the fetus, such as radiation exposure, as well as to the mother, including pancreatitis, bleeding, and perforation. The procedure is typically performed during the second trimester, as the first and late third trimesters carry higher risks of obstetric complications and spontaneous abortion, respectively. Overall, ERCP is a valuable tool for managing gallstones during pregnancy, but it should be used judiciously and with appropriate modifications to ensure the safety of both the mother and fetus.

ERCP is considered safe and effective during pregnancy

Endoscopic retrograde cholangiopancreatography (ERCP) is generally considered safe and effective during pregnancy. However, it is important to note that there are potential risks associated with the procedure, and special considerations need to be made to ensure the safety of both the mother and fetus.

ERCP is a procedure used to treat pancreaticobiliary diseases, such as gallstone disease, which can occur in 3-12% of pregnancies. While most pregnant patients with gallstones do not require therapy, a small percentage may exhibit symptoms such as right upper quadrant discomfort, nausea, or cholecystitis. In these cases, ERCP can be a safe and effective treatment option.

The safety of ERCP during pregnancy has been demonstrated in several studies. One study reported on 17 ERCP procedures performed on 10 pregnant patients, with no maternal adverse events or fetal complications observed. Another study of 68 ERCPs on 65 pregnant women found that while post-ERCP pancreatitis occurred in 16% of patients, all cases were mild and there were no systemic or local complications.

To minimize risks to the fetus, strategies such as reducing fluoroscopy time or adopting non-radiation ERCP techniques are often employed. Lead shielding is also used to protect the fetus from radiation exposure. Overall, ERCP is considered a relatively safe and effective procedure during pregnancy when performed by experienced endoscopists with careful attention to detail.

It is important to note that ERCP should not be used as a diagnostic procedure during pregnancy, and non-invasive imaging modalities such as ultrasound or MRI should be used instead. ERCP is generally recommended during the second trimester, as it is considered the safest period for surgical interventions during pregnancy.

Hormonal changes during pregnancy increase the risk of gallstone formation

Pregnancy is a time of great hormonal change, and these changes can increase the risk of gallstone formation. The female body already has a higher risk of gallstone formation due to the presence of estrogen, and the hormonal changes during pregnancy can exacerbate this. Estrogen can cause cholesterol levels in bile to spike, leading to the development of gallstones. This is further compounded by weight gain and rapid weight loss after pregnancy, which are also risk factors.

The formation of gallstones is not helped by the fact that bile evacuation from the gallbladder slows down during pregnancy. This, combined with increased cholesterol levels in the bile, can lead to gallstone formation. The prevalence of gallstones in pregnancy ranges from 2-12%, and women are 2-3 times more likely than men to develop gallstones.

The good news is that gallstones can often be prevented during pregnancy with some simple lifestyle changes. Eating a high-fibre diet, choosing the right fats (monounsaturated and omega-3), and cutting back on sugar and refined carbohydrates can all help to reduce the risk of gallstone formation. Maintaining a healthy weight during pregnancy can also reduce the risk, as obesity is a major risk factor for gallstones.

While gallstones are a concern during pregnancy, they are not an inevitable part of the process. By taking some preventative measures, women can reduce their risk of developing gallstones and avoid the pain and potential complications that come with them.

ERCP is the standard of care for managing choledocholithiasis

Choledocholithiasis, or the presence of gallstones in the common bile duct, is a serious condition that can lead to life-threatening consequences such as cholangitis or gallstone pancreatitis. While surgical therapy has traditionally been the treatment of choice for gallstone disease, it is associated with an increased risk of fetal compromise during pregnancy.

Endoscopic retrograde cholangiopancreatography (ERCP) has emerged as an effective alternative therapeutic option for managing choledocholithiasis during pregnancy. ERCP is a technique that combines luminal endoscopy and fluoroscopic imaging to diagnose and treat conditions associated with the pancreatobiliary system.

During ERCP, a side-viewing duodenoscope is passed through the esophagus, stomach, and into the second portion of the duodenum, where the major duodenal papilla is identified and inspected for abnormalities. The papilla is the convergence point of the ventral pancreatic duct and the common bile duct, serving as a conduit for drainage of bile and pancreatic secretions into the duodenum.

After examining the papilla, selective cannulation of either the common bile duct or the ventral pancreatic duct is performed, and a cholangiogram or pancreatogram is obtained fluoroscopically by injecting radiopaque contrast material into the duct. ERCP is now primarily a therapeutic procedure, with abnormalities addressed using specialized accessories passed through the endoscope's working channel.

Therapeutic interventions for choledocholithiasis during pregnancy may include:

• Stone extraction using a balloon catheter
• Sphincterotomy
• Biliary stent placement
• Biliary stricture dilation
• Stone fragmentation using lithotripsy techniques

While ERCP carries a higher risk of serious complications compared to other endoscopic procedures, it can be safely performed during pregnancy when carried out by experienced practitioners with judicious use of fluoroscopy. Strategies to minimize radiation exposure to the fetus include reducing fluoroscopy time, using lead shielding, and adopting non-radiation ERCP techniques whenever possible.

The decision to perform ERCP during pregnancy should be carefully considered, weighing the risks and benefits for both the mother and fetus. Overall, ERCP is now considered a relatively safe and effective procedure during pregnancy for managing choledocholithiasis.

Radiation exposure risks to the fetus

Radiation exposure during pregnancy can have an impact on embryonic and fetal development, depending on the dose and gestational age at which the exposure occurs. Potential radiation exposure risks to the fetus can be divided into four categories: intrauterine fetal death, malformations and disturbances of growth and development, mutagenic, and carcinogenic effects.

Radiation-induced damage can result in fetal growth restriction and congenital malformations, often associated with intellectual disability, as well as the possibility of increased cancer risk. Although the risk of developing cancer from radiation is low, it is a stochastic effect with no clear radiation threshold level defined.

The American College of Obstetricians and Gynecologists states that exposure to less than 5 rad or 50 mGy does not appear to be associated with an increased rate of fetal anomalies or pregnancy loss. Fetal malformations, growth retardation, and intrauterine death have a threshold conceptus dose of 100-200 mGy. These doses are not typical for general diagnostic radiology, particularly when the fetus lies outside of the primary beam, as with ERCP.

In a study by Samara et al., fetal dose exposure was found to occasionally exceed 50 mGy, ranging from 3.4 to 55.9 mGy. These findings highlight the importance of dose-reduction techniques and safe and effective fluoroscopy use. Strategies to reduce radiation exposure to the fetus include limiting fluoroscopy time, using low-dose settings, lead shielding, and patient positioning to allow for anterior-posterior beam projection.

Overall, while ERCP is considered relatively safe and effective during pregnancy, the potential risks of radiation exposure to the fetus should be carefully considered and mitigated through appropriate techniques and precautions.

Special considerations and modifications of ERCP during pregnancy

When performing ERCP during pregnancy, there are several special considerations and modifications that should be made to ensure the safety of both the mother and the fetus. Here are some key aspects to consider:

• Timing of the Procedure: It is generally recommended to delay the procedure until after pregnancy or at least until the second trimester, as this is considered the safest period for surgical interventions. ERCP during the first trimester should be avoided if possible due to the risk of spontaneous abortion. Similarly, elective ERCP during the late third trimester should be deferred until after delivery to minimize the risk of fetal loss and birth-related complications.
• Informed Consent: The patient and their family should be extensively counselled about the procedure, including its indications, steps, expected benefits, and potential risks for both the mother and the fetus. It is essential to obtain written informed consent from the patient and involve their spouse/significant other and additional family members to build trust and relieve anxiety.
• Patient Positioning: During the procedure, the patient can be placed in a left pelvic tilt, left lateral position, or supine position to avoid vena cava or aortic compression. The standard prone position can be used early in pregnancy or during the second trimester but should be avoided in the later stages of pregnancy.
• Radiation Shielding: Lead shields should be placed underneath the patient's abdomen to reduce radiation exposure to the fetus, as the x-ray beam originates from below the patient. The value of placing a second lead shield over the patient's abdomen is unproven and is left to the endoscopist's discretion.
• Maternal-Fetal Monitoring: Astute monitoring is recommended throughout the procedure, documenting fetal heart tones before sedation and immediately after completion. In the first and second trimesters, the procedure can be performed in a GI endosuite, while in the third trimester, it is generally preferred to have it done in an operating room with obstetrics support in case of labour or other complications.
• Medications and Sedation: Glucagon, a category B drug, can be safely used to reduce intestinal contractions during ERCP. For visualizing the biliary tree, diatrizoate (category D) is used as a contrast agent. While transient fetal hypothyroidism is a theoretical risk, there is no convincing evidence to avoid its use, especially when weighing the potential consequences of maternal cholangitis. Sedative medications such as meperidine (Category B), propofol (Category B), fentanyl (Category C), and midazolam (Category D) are generally considered safe during pregnancy.
• Rectal Indomethacin: Rectal indomethacin is the standard of care for preventing post-ERCP pancreatitis, but there is limited data on its use in pregnant women. Its use should be decided on a case-by-case basis, considering the degree of difficulty of biliary cannulation and other procedural factors.
• Multidisciplinary Approach: A multidisciplinary team, including an experienced endoscopist, anesthesia professionals, obstetricians, and surgeons, should be involved in the procedure to manage any potential peri-procedural pregnancy-related issues effectively.
• Modified ERCP Techniques: Modifications to the ERCP technique aim to minimize procedure time and fluoroscopy exposure. This includes minimizing overall fluoroscopy time, using short taps of fluoroscopy, avoiding hard copy images, utilizing the last-image hold feature, and collimating the x-ray beam to the smallest field possible. Radiation-free ERCP techniques, such as using a choledochoscope or empirical bile aspirate-guided techniques, have been successful in various case reports and series.

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