Endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy
- Suku George, MD, MPH, FACP
Suku George, MD, MPH, FACP
- GI Specialists of Georgia
- Marc F Catalano, MD, FACG, FACP, FASGE, AGAF
Marc F Catalano, MD, FACG, FACP, FASGE, AGAF
- The University of Texas Health Science Center at Houston
- Professor of Medicine, Department of Internal Medicine, Division of Gastroenterology
- Director, Memorial Hermann Southeast Endoscopy & Chief of Therapeutic Endoscopy
- Director of UT-MHH Advanced Endoscopy Training Program
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
Pregnancy is associated with an increased risk of gallstone formation. Fortunately, complications due to cholelithiasis, such as cholecystitis, choledocholithiasis, and pancreatitis, are relatively uncommon, and in many cases can be managed conservatively [1-3]. (See "Gallstones in pregnancy" and "Intercurrent hepatobiliary disease during pregnancy" and "Epidemiology of and risk factors for gallstones".)
However, occasionally, patients develop complications related to gallstones that require intervention during pregnancy [1-3]. Although there are no precise estimates of the incidence, several reports have found that biliary tract disease (most commonly cholecystitis) represented one of the most frequent indications for non-obstetrical surgery during pregnancy [4-6].
A subset of patients requires endoscopic retrograde cholangiopancreatography (ERCP), most commonly for choledocholithiasis or presumed gallstone pancreatitis. Opinions regarding the safety of ERCP during pregnancy differ in various reports [7-13]. Major concerns surround issues related to radiation exposure to the fetus and the risk of the procedure on pregnancy outcome.
A general principle in the care of women with an acute biliary tract disorder during pregnancy is to provide the most conservative management possible with the hope of delaying intervention until after pregnancy or until the second trimester, when surgical intervention is relatively safest. (See "Management of the pregnant patient undergoing nonobstetric surgery".)
Few ERCP-related complications to the mother or fetus have been reported. Data on safety of ERCP in pregnancy are limited [14,15]. A literature review described complications that were reported during a total of 64 ERCPs performed during pregnancy (mostly described in case series of one to four patients) [11,16-38]. Of these procedures, 14 were done in the first trimester, 23 in the second, 19 in the third, and 8 unspecified. Therapeutic procedures included 56 sphincterotomies. Of 47 pregnancies that were followed to term, there were two premature births. Conservative treatment of a type I choledochal cyst resulted in cyst rupture at 18 weeks of gestation with subsequent peritonitis . Spontaneous abortion of the fetus occurred after surgery. A patient with a pancreatic pseudocyst who underwent diagnostic ERCP before EUS-guided cyst-gastrostomy has also been reported . (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)
- Hill LM, Johnson CE, Lee RA. Cholecystectomy in pregnancy. Obstet Gynecol 1975; 46:291.
- Glenn F, McSherry CK. Gallstones and pregnancy among 300 young women treated by cholecystectomy. Surg Gynecol Obstet 1968; 127:1067.
- Printen KJ, Ott RA. Cholecystectomy during pregnancy. Am Surg 1978; 44:432.
- Amos JD, Schorr SJ, Norman PF, et al. Laparoscopic surgery during pregnancy. Am J Surg 1996; 171:435.
- Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during pregnancy. Arch Surg 1996; 131:546.
- Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surv 1998; 53:566.
- Jamidar PA, Beck GJ, Hoffman BJ, et al. Endoscopic retrograde cholangiopancreatography in pregnancy. Am J Gastroenterol 1995; 90:1263.
- Sungler P, Heinerman PM, Steiner H, et al. Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy. Surg Endosc 2000; 14:267.
- Farca A, Aguilar ME, Rodriguez G, et al. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest Endosc 1997; 46:99.
- Tham TC, Vandervoort J, Wong RC, et al. Safety of ERCP during pregnancy. Am J Gastroenterol 2003; 98:308.
- Kahaleh M, Hartwell GD, Arseneau KO, et al. Safety and efficacy of ERCP in pregnancy. Gastrointest Endosc 2004; 60:287.
- Simmons DC, Tarnasky PR, Rivera-Alsina ME, et al. Endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy without the use of radiation. Am J Obstet Gynecol 2004; 190:1467.
- Howden JK, Baillie J. Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate pancreatitis: a prospective randomized trial. Gastrointest Endosc 2001; 53:834.
- Friedel D, Stavropoulos S, Iqbal S, Cappell MS. Gastrointestinal endoscopy in the pregnant woman. World J Gastrointest Endosc 2014; 6:156.
- 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; 14:107.
- Baillie J, Cairns SR, Putman WS, Cotton PB. Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 1990; 171:1.
- Nesbitt TH, Kay HH, McCoy MC, Herbert WN. Endoscopic management of biliary disease during pregnancy. Obstet Gynecol 1996; 87:806.
- al Karawi M, Mohamed SA. Therapeutic endoscopic retrograde cholangiopancreatography with ultra-short fluoroscopy: report of two cases. Endoscopy 1997; 29:S31.
- Axelrad AM, Fleischer DE, Strack LL, et al. Performance of ERCP for symptomatic choledocholithiasis during pregnancy: techniques to increase safety and improve patient management. Am J Gastroenterol 1994; 89:109.
- Barthel JS, Chowdhury T, Miedema BW. Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy. Surg Endosc 1998; 12:394.
- Berger Z. Endoscopic papillotomy without fluoroscopy in pregnancy. Endoscopy 1998; 30:313.
- Binmoeller KF, Katon RM. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointest Endosc 1990; 36:607.
- Eichenberg BJ, Vanderlinden J, Miguel C, et al. Laparoscopic cholecystectomy in the third trimester of pregnancy. Am Surg 1996; 62:874.
- Freistühler M, Braess A, Petrides AS. [Ultrasound-controlled endoscopic papillotomy in pregnancy in severe biliary pancreatitis]. Z Gastroenterol 1999; 37:27.
- Friedman RL, Friedman IH. Acute cholecystitis with calculous biliary duct obstruction in the gravid patient. Management by ERCP, papillotomy, stone extraction, and laparoscopic cholecystectomy. Surg Endosc 1995; 9:910.
- Goldschmiedt M, Wolf L, Shires T. Treatment of symptomatic choledocholithiasis during pregnancy. Gastrointest Endosc 1993; 39:812.
- Kim SY, Wong DKH. ERCP in the management of pancreaticobiliary disease during pregnancy. Gastrointest Endosc 1996; 43:385.
- Llach J, Bordas JM, Ginès A, et al. Endoscopic sphincterotomy in pregnancy. Endoscopy 1997; 29:52.
- Martins L, Rodrigues R, Meirinho M. [Acute pancreatitis and pregnancy]. Acta Med Port 1997; 10:715.
- Parada AA, Gonçalves MO, Tafner E, et al. Endoscopic papillotomy under ultra-sonographic control. Int Surg 1991; 76:75.
- Rahmin MG, Hitscherich R, Jacobson IM. ERCP for symptomatic choledocholithiasis in pregnancy. Am J Gastroenterol 1994; 89:1601.
- Uomo G, Manes G, Picciotto FP, Rabitti PG. Endoscopic treatment of acute biliary pancreatitis in pregnancy. J Clin Gastroenterol 1994; 18:250.
- Zágoni T, Tulassay Z. Endoscopic sphincterotomy without fluoroscopic control in pregnancy. Am J Gastroenterol 1995; 90:1028.
- Bagci S, Tuzun A, Erdil A, et al. Treatment of choledocholithiasis in pregnancy: a case report. Arch Gynecol Obstet 2003; 267:239.
- Andreoli M, Sayegh SK, Hoefer R, et al. Laparoscopic cholecystectomy for recurrent gallstone pancreatitis during pregnancy. South Med J 1996; 89:1114.
- Gamberdella FR. Pancreatic carcinoma in pregnancy: a case report. Am J Obstet Gynecol 1984; 149:15.
- Comitalo JB, Lynch D. Laparoscopic cholecystectomy in the pregnant patient. Surg Laparosc Endosc 1994; 4:268.
- Wishner JD, Zolfaghari D, Wohlgemuth SD, et al. Laparoscopic cholecystectomy in pregnancy. A report of 6 cases and review of the literature. Surg Endosc 1996; 10:314.
- Hewitt PM, Krige JE, Bornman PC, Terblanche J. Choledochal cyst in pregnancy: a therapeutic dilemma. J Am Coll Surg 1995; 181:237.
- Ryan ME. Endoscopic management of a pancreatic pseudocyst during pregnancy. Gastrointest Endosc 1992; 38:605.
- Tang SJ, Mayo MJ, Rodriguez-Frias E, et al. Safety and utility of ERCP during pregnancy. Gastrointest Endosc 2009; 69:453.
- Gupta R, Tandan M, Lakhtakia S, et al. Safety of therapeutic ERCP in pregnancy - an Indian experience. Indian J Gastroenterol 2005; 24:161.
- Petersen BT. Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis During Pregnancy: More Questions Than Answers From Administrative Databases. Clin Gastroenterol Hepatol 2016; 14:115.
- Basso L, McCollum PT, Darling MR, et al. A study of cholelithiasis during pregnancy and its relationship with age, parity, menarche, breast-feeding, dysmenorrhea, oral contraception and a maternal history of cholelithiasis. Surg Gynecol Obstet 1992; 175:41.
- Moon JH, Cho YD, Cha SW, et al. The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US. Am J Gastroenterol 2005; 100:1051.
- Baillie J. ERCP during pregnancy. Am J Gastroenterol 2003; 98:237.
- Siegel JH, Cohen SA. ERCP in a pregnant patient. Am J Gastroenterol 1994; 89:1596.
- 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; 67:364.
- Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy. Gastroenterol Clin North Am 2003; 32:123.
- ASGE Standard of Practice Committee, Shergill AK, Ben-Menachem T, et al. Guidelines for endoscopy in pregnant and lactating women. Gastrointest Endosc 2012; 76:18.
- Hoffman BJ, Cunningham JT. Radiation exposure to the pregnant patient during ERCP (abstract). Gastrointest Endosc 1992; 38:A109.
- Dumonceau JM, Garcia-Fernandez FJ, Verdun FR, et al. Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) guideline. Endoscopy 2012; 44:408.
- Smith I, Gaidhane M, Goode A, Kahaleh M. Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter? World J Gastrointest Endosc 2013; 5:148.
- Di Leo M, Arcidiacono PG. Fetal radiation exposure: Is monitoring really needed? World J Gastrointest Endosc 2013; 5:366.
- Axelrad AM, Fleischer D. ERCP in a pregnant patient. Response to Drs. Siegel and CohenD. (Letter). Am J Gastroenterol 1994; 89:1596.
- Sharma SS, Maharshi S. Two stage endoscopic approach for management of choledocholithiasis during pregnancy. J Gastrointestin Liver Dis 2008; 17:183.
- Chen CP, Wang KG, Su TH, Yang YC. Acute pancreatitis in pregnancy. Acta Obstet Gynecol Scand 1995; 74:607.
- Ramin KD, Ramin SM, Richey SD, Cunningham FG. Acute pancreatitis in pregnancy. Am J Obstet Gynecol 1995; 173:187.
- Swisher SG, Hunt KK, Schmit PJ, et al. Management of pancreatitis complicating pregnancy. Am Surg 1994; 60:759.
- Wilkinson EJ. Acute pancreatitis in pregnancy: a review of 98 cases and a report of 8 new cases. Obstet Gynecol Surv 1973; 28:281.
- Block P, Kelly TR. Management of gallstone pancreatitis during pregnancy and the postpartum period. Surg Gynecol Obstet 1989; 168:426.
- Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335:909.
- Tranter SE, Thompson MH. Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 2002; 89:1495.
- Jackson H, Granger S, Price R, et al. Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 2008; 22:1917.
- STRATEGIES TO MINIMIZE RADIATION RISK TO THE FETUS
- Preprocedure interventions
- - Avoid ERCP for weak indications
- - Inquire about pregnancy
- - Consider other imaging tests
- - Fully inform patient and document
- - Choose a highly-experienced endoscopist
- - Avoid fluoroscopy
- Intraprocedural interventions
- - Medicines used in ERCP
- - Proper shielding
- - Consider patient positioning
- - Minimize procedure time
- - Consider involvement of an anesthesiologist
- - Request obstetrical consultation
- - Minimize fluoroscopy time
- Use fetal radiation exposure monitoring
- Generous sphincterotomy
- Avoid pancreatic endotherapy
- Precut papillotomy
- Stenting or sphincterotomy or both
- Use of peroral choledoscopy to confirm ductal clearance
- ACUTE BILIARY PANCREATITIS
- Is endoscopic sphincterotomy sufficient?
- Is sphincterotomy needed in patients without choledocholithiasis?
- Is cholecystectomy needed after delivery?
- Is there a role for ursodeoxycholic acid?
- SUMMARY AND RECOMMENDATIONS