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. 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) [11,14-36]. 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.
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- 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