European Journal of Obstetrics & Gynecology and Reproductive Biology
Review articleDemystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy
Introduction
Women are about twice as likely to develop choledocholithiasis compared to men, regardless of the prevalence of cholelithiasis [1]. This discrepancy is more pronounced at younger ages, with a significant reduction in the woman-to-man ratio as the age progresses [2], reflecting the magnitude of the effect of pregnancy and sex hormones.
The litogenicity of female sex hormones is reinforced by studies in which estrogens have been administered to men. In a study with patients with prostatic adenocarcinoma, there was an increase in hepatic cholesterol secretion that resulted in an increase in both bile cholesterol saturation and rate of gallstone formation during estrogen treatment [3]. Also, in men with acute myocardial infarction, estrogens increased the risk of biliary lithiasis more than twice [4].
Pregnancy is a major risk factor for biliary lithiasis. The risk increases with frequency and number of pregnancies and reduces with breastfeeding [5]. The risk increases up to 10 times in multiparous compared to nulliparous [6]. During pregnancy there is a decrease in gallbladder motility and a breakdown of cholesterol in bile. These changes are induced by estrogen which increases cholesterol secretion and progesterone which reduces the secretion of bile acids and delays the emptying of the gallbladder. There is also a relative overproduction of hydrophobic bile acids (chenodeoxycholate) which reduces bile's ability to solubilize cholesterol [1], [7].
In a prospective ultrasound study with more than 3200 pregnant women without lithiasis (baseline ultrasound), lithiasis or new bile sludge was observed in 7.1% up to the second trimester, 7.9% up to the third trimester and 10.2% up to 6 weeks postpartum. Of the pregnant women with lithiasis or biliary sludge, only 1.2% developed symptoms of biliary pathology [8]. Up to 10% of symptomatic pregnant women develop serious complications such as acute cholecystitis, choledocholithiasis or pancreatitis [9].
Risks of ERCP in pregnancy include risks of sedation, radiation or electrocautery to the fetus, as well as technical difficulties related to the changing maternal anatomy and an increased risk to post-ERCP pancreatitis. Therefore we reviewed each potential risk based on the best available evidence to date.
Section snippets
Endoscopic retrograde cholangiopancreatography (ERCP): patient selection and indications
ERCP is currently established as an essentially therapeutic technique and, in pregnancy, it becomes even more pressing that it is performed for this purpose alone. In this population, it is indicated, as treatment in biliary pancreatitis, symptomatic choledocholithiasis and cholangitis or in the lesions of the pancreatic or biliary duct [10]. The usual risks associated with ERCP, such as perforation, infection, hemorrhage and pancreatitis can have important consequences to both mother and
Risks of radiation exposure and strategies of reduction
Fluoroscopy radiation may have both stochastic effects and deterministic effects. The formers, do not present a dose threshold, the likelihood of developing deleterious effects is proportional to the dose but its severity is dose-independent (e.g. leukemia). In the latters, the dose and severity threshold are proportional to the dose (e.g. cataracts) [12]. Hence the concept “as low as reasonably achievable” radiation has emerged [13]. In fact, the European Society of Digestive Endoscopy (ESGE)
ERCP complications
A retrospective cohort study of the National Inpatient Sample with 907 pregnant and 2721 non-pregnant women demonstrated that there was no difference in rates of perforation, infection and bleeding of ERCPs performed in pregnant women. Post-ERCP pancreatitis (PEP) occurred in 12% of pregnant women vs. 5% non-pregnant. Pregnancy was an independent risk factor (OR 2.8, CI 2.1–3.8) for PEP [22]. The pregnancy group had less pancreatic stents placed than the control group, which was statistically
Non-radiation ERCP
In a retrospective study, 21 ERCPs without fluoroscopy were analyzed in pregnant women [24]. A previous imaging study was performed (all had abdominal ultrasound, 6 echoendoscopy (EUS) and 4 magnetic resonance cholangiopancreatography (MRCP)). The bile cannulation was confirmed by the observation of bile around the guidewire (with forward and backward movements). When bile was not visible, a 5 French (Fr) 2 cm stent was placed. In the case of drainage of bile by the stent, sphincterotomy was
ERCP timing
There is the generic recommendation to avoid endoscopy in the first trimester whenever possible [10]. In ERCP, there has also been worries during the first trimester. In a retrospective review of 68 ERCPs performed in 65 pregnant patients, there were no perforation, sedation adverse events, postsphincterotomy bleeding, cholangitis, or procedure-related maternal or fetal deaths. However, women submitted to ERCP in the first trimester had the lowest percentage of term pregnancies (73%), the
Cholecystectomy
Surgery during pregnancy increases the risk of fetal loss. Therefore, the indication is usually limited to urgent situations as acute cholecystitis. The second trimester is considered to be the optimal time for cholecystectomy, with the lowest risk for fetal morbity [33]. However, there are also several studies demonstrating the safety in urgent cases during the first trimester [34]. Surgery in the third trimester was generally limited for fear of induction of preterm labor (up to 40% in
Conclusion
ERCP can be performed in pregnancy safely and effectively in women who have a clear indication. There are multiple strategies for reducing maternal and fetal risks associated with this technique.
EUS can eliminate the need for ERCP and its risks in pregnant women with no concrete evidence of choledocholithiasis, and even plan the best approach in those that present previous evidence by specifying the number, size and location of the lithiasis. EUS-CPRE thus presents itself as the ideal approach
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Cited by (19)
Surgery A survey of patients' perceptions and experiences of intervention for gallstone disease during pregnancy
2022, HeliyonCitation Excerpt :After appendectomies, cholecystectomy is the second most common procedure, with an incidence of 0.05% and an increasing trend [1, 2]. Previously avoided because of safety concerns, endoscopic retrograde cholangiopancreatography (ERCP) has recently become more frequently used during pregnancy [3, 4]. Gallstone complications such as cholecystitis, pancreatitis or choledocholithiasis are potentially dangerous to the fetus.
American Society for Gastrointestinal Endoscopy radiation and fluoroscopy safety in GI endoscopy
2021, Gastrointestinal EndoscopyCitation Excerpt :Therapeutic ERCP is relatively safe and effective during pregnancy when performed by an experienced endoscopist and optimal during the second trimester of pregnancy. Several case series have reported no increase in birth defects, preterm deliveries, or abortion in pregnant women who undergo ERCP.67-70 The fetus should be shielded with a radiation protection apron between the x-ray tube and the patient’s abdomen.
Challenges encountered in the management of gall stones induced pancreatitis in pregnancy
2019, International Journal of SurgeryCitation Excerpt :Although these reports were generally based on single centre experiences that involved small number of patients, they could perhaps pave the way for larger future studies. On the other hand, radiation exposure of less than 50 mGy during pregnancy had not been reported to cause any foetal complications, keeping in mind that ERCP is associated with an estimated foetal radiation exposure at a much smaller value of 0.40 mGy [23,28,46]. A recently published systematic review has tabled a list of excellent recommendations to minimize the radiation effect of fluoroscopy during therapeutic ERCP in pregnant patients [47].
Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)
2020, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :Overall, pregnant patients with cholangitis are treated similar to non-pregnant patients [67]. Stone extraction for cholangitis can be achieved safely by ERCP with fetal shielding [70]. Intraoperative common bile duct exploration is an uncommon procedure requiring specialized surgical skills, and has been reported only in few cases but with good fetal and maternal outcomes [68].
Choledocholithiasis in pregnancy. Case report
2019, Clinica e Investigacion en Ginecologia y Obstetricia