Review article
Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy

https://doi.org/10.1016/j.ejogrb.2017.10.008Get rights and content

Abstract

Background

For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis.

Summary and key messages

This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits.

We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing “ERCP” with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.

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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