**Endoscopy in Pregnant Patients**

### Nurten Akyurek Savas

sociated with gender and histologic type.Lung Cancer. 2010 Aug;69(2):172-9. Epub

[117] Feng Q, Deftereos G, Hawes SE, Stern JE, Willner JB, Swisher EM, Xi L, Drescher C, Ur‐ ban N, Kiviat NB:DNA hypermethylation, Her-2/neu overexpression and p53 muta‐ tions in ovarian carcinoma.GynecolOncol. 2008 Nov;111(2):320-9. Epub 2008 Aug 30.

[118] Feng Q, Hawes SE, Stern JE, Dem A, Sow PS, Dembele B, Toure P, Sova P, Laird PW, Kivi‐ at NB:Promoter hypermethylation of tumor suppressor genes in urine from patients with cervical neoplasia.CancerEpidemiol Biomarkers Prev. 2007 Jun;16(6):1178-84.

2009 Nov 28.

320 Endoscopy

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53242

**1. Introduction**

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy. Though it is prudent to postpone the investigation to the third trimester or rather to the postpartum period; in certain clinical situations where therapeutic intervention is necessary, it offers a relatively safe alternative to radiologic or surgical intervention. There are a number of potential risks associated with endoscopy during pregnancy [1]:


The American Society for Gastrointestinal Endoscopy (ASGE) guidelines [2] list the follow‐ ing general principles guiding endoscopy in pregnancy (Table1).

Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esopha‐ gogastroduedenoscopy (EGD) seems to be relatively safe for the fetus and may be per‐ formed when strongly indicated during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) seems to be relatively safe during pregnancy and should be performed for strong indications (for exam‐ ple, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy in‐ clude the performance of endoscopy in hospital by an expert endoscopist and only when

strongly indicated, deferral of endoscopy to the second trimester whenever possible, and ob‐ stetric consultation.

The US Food and Drug Administration (FDA) lists 5 categories of drugs with regard to safe‐

administered during pregnancy, but the potential bene

This categorization indicates general risks based on four components: individual experimen‐ tal studies on drug risk in laboratory animals, number and quality of experimental studies, individual clinical studies on drug risk in humans, and number and quality of clinical stud‐ ies. FDA categorization is, nonetheless useful in clinical practice. Category A drugs are safe during pregnancy. Category B drugs may generally be used during pregnancy. Category C drugs may often be used if required during pregnancy. Category D drugs are relatively con‐ traindicated, and when used should be administered with extreme caution. Category X

There are no category A drugs used for endoscpy. For use during endoscopic procedures category B and, when necessary, category C drugs are recommended. Category D drugs may be used when benefits clearly outweigh the risks. These categories are of limited value for determining the safety of one- time use; therefore, consultation with an obstetrician re‐ garding medication should be considered. For most procedures the level of sedation should be anxiolysis or moderate sedation. İf deep sedation is necessary, it should be administered

Key data on safety of commonly used endoscopic medications are summarized in table 3.

to the fetus in any trimester of pregnancy

but remains a possibility

fits may outweigh the potential risk

any possible benefit to the patient

Adequate, well-controlled studies in pregnant women have failed to demonstrate a risk

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 323

Adequate, well-controlled studies in pregnant women have not shown increased risk of fetal abnormalities despite adverse findings in animals or, in the absence of adequate human studies, animal studies show no fetal risk. The chance of fetal harm is remote,

Adequate, well-controlled human studies are lacking, and animal studies have shown a risk to the fetus or are lacking as well. There is a chance of fetal harm if the drug is

Studies in humans, or investigational or postmarketing data, have demonstrated fetal risk. Nevertheless, potential benefits from the use of the drug may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or for serious disease for which safer drugs cannot be used or are ineffective

Studies in animals or humans, or investigational or postmarketing reports, have demonstrated positive evidence of fetal abnormalities or risk which clearly outweighs

ty during pregnancy [8] (Table 2).

**Category Risk Description**

studies show no risk

risk in humans

evidence of risk

d in pregnancy

**Table 2.** FDA categorization of drug safety during pregnancy

drugs are absolutely contraindicated during pregnancy [8].

A Controlled

B No evidence of

C Risk cannot be ruled out

X Contraindicate

by an anesthesiologist [2].

D Positive


### **2. Fetal safety of endoscopic medications**

One of the most important point in endoscopic procedures of pregnant patients is to avoid maternal hypoxia and hypotension which can cause placental hypoperfusion and potential fetal injury. Maternal oversedation with resulting hypoventilation or hypotension, or mater‐ nal positioning that might lead to inferior vena caval compression by the gravid uterus can lead to decreased uterine blood flow and fetal hypoxia. Other potential risks to the fetus in‐ clude teratogenesis (both from medication given to the mother and radiation exposure from fluoroscopy) and premature birth [1-6]. To prevent hypoxia and hypotension during the in‐ tervention, pregnant patients should be positioned in the left lateral position, prompt intra‐ venous hydration with normal saline or a similarly high osmolar solution should be made, use of analgesics and sedatives should be restricted if possible and in the case of necessity abortion of the endoscopic procedure should be considered [5,6].

Sedation in pregnancy has always been a challenge to anesthesiologists. No anesthetic drug, inhaled anesthetics, or local anesthetic has been proven to be teratogenic in humans. A nota‐ ble exception is benzodiazepine group, which has been linked to congenital anomalies. All agents that are administered during pregnancy must be used with caution and vigilence. It is clear that anesthetic effects on placental perfusion and the placental transfer of depressant drugs may influence the fetus [5,6,7].

During the endoscopic procedures in pregnant patients, anesthesiologic asistance is recom‐ mended in the first and third trimester because of the increaed risk of teratogenecity and the risk of premature labor, respectively [5].

The US Food and Drug Administration (FDA) lists 5 categories of drugs with regard to safe‐ ty during pregnancy [8] (Table 2).


**Table 2.** FDA categorization of drug safety during pregnancy

strongly indicated, deferral of endoscopy to the second trimester whenever possible, and ob‐

6 Position pregnant patients in left pelvic tilt or left lateral position to avoid vena cava or aortic compression 7 Presence of fetal heart sounds should be confirmed before sedation is begun and after the endoscopic

9 Endoscopy is contraindicated in obstetric complications such as placental abruption, imminent delivery, ruptured

One of the most important point in endoscopic procedures of pregnant patients is to avoid maternal hypoxia and hypotension which can cause placental hypoperfusion and potential fetal injury. Maternal oversedation with resulting hypoventilation or hypotension, or mater‐ nal positioning that might lead to inferior vena caval compression by the gravid uterus can lead to decreased uterine blood flow and fetal hypoxia. Other potential risks to the fetus in‐ clude teratogenesis (both from medication given to the mother and radiation exposure from fluoroscopy) and premature birth [1-6]. To prevent hypoxia and hypotension during the in‐ tervention, pregnant patients should be positioned in the left lateral position, prompt intra‐ venous hydration with normal saline or a similarly high osmolar solution should be made, use of analgesics and sedatives should be restricted if possible and in the case of necessity

Sedation in pregnancy has always been a challenge to anesthesiologists. No anesthetic drug, inhaled anesthetics, or local anesthetic has been proven to be teratogenic in humans. A nota‐ ble exception is benzodiazepine group, which has been linked to congenital anomalies. All agents that are administered during pregnancy must be used with caution and vigilence. It is clear that anesthetic effects on placental perfusion and the placental transfer of depressant

During the endoscopic procedures in pregnant patients, anesthesiologic asistance is recom‐ mended in the first and third trimester because of the increaed risk of teratogenecity and the

8 Obstetric support should be available in the event of a pregnancy-related complication

1 Always have a strong indication, particularly in high-risk pregnancies

2 Defer endoscopy to second trimester whenever possible 3 Use lowest effective dose of sedative medications 4 Whenever possible, use category A or B drugs

**Table 1.** General Principles guiding endoscopy in pregnancy (ASGE)

**2. Fetal safety of endoscopic medications**

abortion of the endoscopic procedure should be considered [5,6].

drugs may influence the fetus [5,6,7].

risk of premature labor, respectively [5].

stetric consultation.

322 Endoscopy

5 Minimize procedure time

membranes, or eclampsia

procedure

This categorization indicates general risks based on four components: individual experimen‐ tal studies on drug risk in laboratory animals, number and quality of experimental studies, individual clinical studies on drug risk in humans, and number and quality of clinical stud‐ ies. FDA categorization is, nonetheless useful in clinical practice. Category A drugs are safe during pregnancy. Category B drugs may generally be used during pregnancy. Category C drugs may often be used if required during pregnancy. Category D drugs are relatively con‐ traindicated, and when used should be administered with extreme caution. Category X drugs are absolutely contraindicated during pregnancy [8].

There are no category A drugs used for endoscpy. For use during endoscopic procedures category B and, when necessary, category C drugs are recommended. Category D drugs may be used when benefits clearly outweigh the risks. These categories are of limited value for determining the safety of one- time use; therefore, consultation with an obstetrician re‐ garding medication should be considered. For most procedures the level of sedation should be anxiolysis or moderate sedation. İf deep sedation is necessary, it should be administered by an anesthesiologist [2].

Key data on safety of commonly used endoscopic medications are summarized in table 3.


studies have raised possible associations between diazepam administration and mental re‐ tardation or neurologic defects,[14] cardiac defects [11] and Mobius syndrome (sixth and seventh nerve palsies) [15]. Diazepam is rated a category D drug during pregnancy, because of these potential associations its use during pregnancy is discouraged, particularly in the first trimester. Clinical data concerning fetal safety of midazolam are limited; however, the drug has not been associated with oral cleft palates. Administration of midazolam during labor has been reported to transiently depress neonatal neurobehavioral responsiveness [16,17]. Although rated a category D drug, since it has not been reported to be associated with congenital abnormalities, midazolam is the preferred benzodiazepine when meperi‐ dine is inadequate. Due to a similar mechanism of action as diazepam, midazolam use

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 325

should be restricted during pregnancy, especially during the first trimester [1,2,4,5].

ing the first trimester is inadequately studied [4,5,18].

Propofol is increasingly used for anesthesia at endoscopy in the general population. It is short –acting with a recovery period much shorter than with standard agents. However, as a result of a relatively narrow therapeutic index (defined as a ratio given by average toxic dose divided by average therapeutic dose) and the potential for respiratory depression which can cause respiratory arrest and even death if improperly monitored, it is generally administrated by anesthesiologists. Endoscopy socities have recommended the usage of this agent for difficult to sedate and complicated clinical situations. Propofol is rated a category B drug and it is considered relatively safe to use during pregnancy, although its safety dur‐

Ketamine is useful for endoscopy in patients who are expected to experience insufficient seda‐ tion from propofol. Like propofol, ketamine has a rapid onset of action and a short duration of effect. Although rated a category B drug during pregnancy, ketamine carries the caveats that fetal safety during the first trimester is unstudied and unknown in humans, and an extremely

Naloxone, a rapidly acting narcotic antagonist, crossing the placenta within 2 minutes of in‐ travenous administration, is occasionally administered during endoscopy to reverse narcotic overdose [2,4,20]. The drug is rated a category B drug during pregnancy. It should only be used in respiratory depression, systemic hypotension or unresponsiveness in a closely moni‐ tored setting during or after endoscopy. It should be administered during pregnancy in small, graded doses titrated to the desired effect. It should not be routinely administered af‐ ter endoscopy during pregnancy,since one neonatal fatality has been attributed to its use [21]. Naloxone is contraindicated in pregnant patients who are dependent on narcotics be‐ cause it can precipitate opiate withdrawal syndrome [22]. Flumazenil, a benzodiazepine an‐ tagonist, is used to reverse oversedation from benzodiazepines administered during endoscopy. It is rated a category C drug during pregnancy. The drug should only be used to reverse benzodiazepine overdose during pregnancy because its fetal risks are largely un‐ known, with only few case reports of use during pregnancy. Flumazenil overdose can cause maternal seizures, particularly when administrated to patients who are chronically habituat‐ ed to benzodiazepines. This overdose can be prevented by careful and slow titration and ad‐ ministration of minimal dosage of benzodiazepines required for endoscopy. [4,19,20,23].

high dose or prolonged administration of it during pregnancy may be unsafe [4,19].

**Table 3.** Safety of anesthetics commonly used in gastrointestinal endoscopy

Meperidine, an opiate analgesic, was commonly used for gastrointestinal endoscopy in the general population, but has been replaced by short-acting analgesics due to theoretical con‐ cerns about toxicity, manifested as respiratory depression and seizures. Meperidine is rapid‐ ly transferred across the human placenta after intravenous administration, after that metabolized to normeperidine which has a long half-life. Repeated high dose and prolonged administration of meperidine can cause progressive accumulation of normeperidine, and produce toxic effects of maternal respiratory depression and seizures. Meperidine is rated a category B drug during pregnancy, but rated category D when used for prolonged periods (>36 h) at high doses at term. Meperidine use should be limited to 50–75 mg during routine endoscopy during pregnancy [4,5,9].

Fentanyl is a potent narcotic agonist with a rapid onset of action and a shorter patient recovery time than meperidine. It is an FDA category C drug during pregnancy. It appears safe when given in low doses (<125 mg) in patients undergoing endoscopy during pregnancy [2,4,5].

Benzodiazepines (diazepam and midazolam) are commonly administrated before gastroin‐ testinal endoscopy to reduce anxiety, induce brief amnesia, and produce muscle relaxation. Prolonged use of diazepam during early pregnancy has been associated with cleft palate malformations [4,11] but several large studies have not shown this association [12,13]. Some

studies have raised possible associations between diazepam administration and mental re‐ tardation or neurologic defects,[14] cardiac defects [11] and Mobius syndrome (sixth and seventh nerve palsies) [15]. Diazepam is rated a category D drug during pregnancy, because of these potential associations its use during pregnancy is discouraged, particularly in the first trimester. Clinical data concerning fetal safety of midazolam are limited; however, the drug has not been associated with oral cleft palates. Administration of midazolam during labor has been reported to transiently depress neonatal neurobehavioral responsiveness [16,17]. Although rated a category D drug, since it has not been reported to be associated with congenital abnormalities, midazolam is the preferred benzodiazepine when meperi‐ dine is inadequate. Due to a similar mechanism of action as diazepam, midazolam use should be restricted during pregnancy, especially during the first trimester [1,2,4,5].

**Drug FDA category in**

*Narcotics*

324 Endoscopy

*General anesthetics*

*Sedatives*

*Reversal agents*

**pregnancy**

Fentanyl C In low doses it is safe.

**key points regarding drug safety**

and seizures.

situations.

first trimester.

**Table 3.** Safety of anesthetics commonly used in gastrointestinal endoscopy

endoscopy during pregnancy [4,5,9].

Meperidine B, but D at term Repeated high dose and prolonged administration can cause respiratory depression

Propofol B Generally suggested to be used in difficult to sedate and complicated clinical

Ketamine B Human data is limited; animal data suggests prolonged usage is unsafe.

Diazepam D Some of congenital malformations and mental retardations are possibly associated

Midazolam D As a benzodiazepine member, its usage is restricted during pregnancy especially in

Naloxone B It is probably safe and should be used only in respiratory depression, systemic

Flumazenil C Its fetal risks are largely unknown, it should be given in small doses carefully.

Meperidine, an opiate analgesic, was commonly used for gastrointestinal endoscopy in the general population, but has been replaced by short-acting analgesics due to theoretical con‐ cerns about toxicity, manifested as respiratory depression and seizures. Meperidine is rapid‐ ly transferred across the human placenta after intravenous administration, after that metabolized to normeperidine which has a long half-life. Repeated high dose and prolonged administration of meperidine can cause progressive accumulation of normeperidine, and produce toxic effects of maternal respiratory depression and seizures. Meperidine is rated a category B drug during pregnancy, but rated category D when used for prolonged periods (>36 h) at high doses at term. Meperidine use should be limited to 50–75 mg during routine

Fentanyl is a potent narcotic agonist with a rapid onset of action and a shorter patient recovery time than meperidine. It is an FDA category C drug during pregnancy. It appears safe when given in low doses (<125 mg) in patients undergoing endoscopy during pregnancy [2,4,5].

Benzodiazepines (diazepam and midazolam) are commonly administrated before gastroin‐ testinal endoscopy to reduce anxiety, induce brief amnesia, and produce muscle relaxation. Prolonged use of diazepam during early pregnancy has been associated with cleft palate malformations [4,11] but several large studies have not shown this association [12,13]. Some

with diazepam usage so its usage is discouraged during pregnancy.

hypotension or unresponsiveness in a closely monitored pregnant after endoscopy.

Propofol is increasingly used for anesthesia at endoscopy in the general population. It is short –acting with a recovery period much shorter than with standard agents. However, as a result of a relatively narrow therapeutic index (defined as a ratio given by average toxic dose divided by average therapeutic dose) and the potential for respiratory depression which can cause respiratory arrest and even death if improperly monitored, it is generally administrated by anesthesiologists. Endoscopy socities have recommended the usage of this agent for difficult to sedate and complicated clinical situations. Propofol is rated a category B drug and it is considered relatively safe to use during pregnancy, although its safety dur‐ ing the first trimester is inadequately studied [4,5,18].

Ketamine is useful for endoscopy in patients who are expected to experience insufficient seda‐ tion from propofol. Like propofol, ketamine has a rapid onset of action and a short duration of effect. Although rated a category B drug during pregnancy, ketamine carries the caveats that fetal safety during the first trimester is unstudied and unknown in humans, and an extremely high dose or prolonged administration of it during pregnancy may be unsafe [4,19].

Naloxone, a rapidly acting narcotic antagonist, crossing the placenta within 2 minutes of in‐ travenous administration, is occasionally administered during endoscopy to reverse narcotic overdose [2,4,20]. The drug is rated a category B drug during pregnancy. It should only be used in respiratory depression, systemic hypotension or unresponsiveness in a closely moni‐ tored setting during or after endoscopy. It should be administered during pregnancy in small, graded doses titrated to the desired effect. It should not be routinely administered af‐ ter endoscopy during pregnancy,since one neonatal fatality has been attributed to its use [21]. Naloxone is contraindicated in pregnant patients who are dependent on narcotics be‐ cause it can precipitate opiate withdrawal syndrome [22]. Flumazenil, a benzodiazepine an‐ tagonist, is used to reverse oversedation from benzodiazepines administered during endoscopy. It is rated a category C drug during pregnancy. The drug should only be used to reverse benzodiazepine overdose during pregnancy because its fetal risks are largely un‐ known, with only few case reports of use during pregnancy. Flumazenil overdose can cause maternal seizures, particularly when administrated to patients who are chronically habituat‐ ed to benzodiazepines. This overdose can be prevented by careful and slow titration and ad‐ ministration of minimal dosage of benzodiazepines required for endoscopy. [4,19,20,23].

### **3. Upper gastrointestinal endoscopy**

Although it would be ideal to postpone all endoscopic procedures until after delivery, preg‐ nant patients can develop conditions that require urgent upper endoscopy. The most common indications for EGD in pregnant patients are significant or continued gastrointestinal hemor‐ rhage, dysphagia and refractory nausea and vomiting (Table 4). In a multicenter retrospective study of 83 pregnant women on safety and clinical efficacy of EGD in pregnant patients; endos‐ copy indications included gastrointestinal bleeding, abdominal pain and vomiting in decreas‐ ing order [24]. The Mallory-Weiss tear was an important cause of upper gastrointestinal bleeding in 14% of patients, the peptic ulcer was also responsible for 14% of gastrointestinal bleeding in those patients which is significantly lower than the reported frequencies in non pregnant patients. The diagnostic yield for upper gastrointestinal bleeding was 95% and there was no cases of premature labour or congenital fetal malformation. Labor was not induced in any of the patients and 95% of the patients gave birth to healthy infants. The four fetal deaths in the study were in all high risk patients and were unrelated to EGD. The mean Apgar scores of live born infants were not significantly different than control groups.

hyperemesis gravidarum, during pregnancy. In the presence of significant upper gastroin‐ testinal bleeding or severe nause and vomiting accompanied by abdominal pain or refracto‐ ry to medical treatment or signs of gastroduedenal obstruction, EGD may be appropriate to exclude significant peptic ulcer, gastric outlet obstruction or to treat bleeding site. According to the results of studies endoscopically the pregnant women has lower rate of peptic ulcer diseases but higher rate of reflux esophagitis compared to non pregnant patients, and the diagnostic yield of EGD for upper gastrointestinal bleeding during pregnancy is similar to that of EGD performed for the same indication in the general population of about 95% [30].

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 327

Acute nonvariceal upper GI bleeding (NVUGB) is a common clinical emergency leading to 50-160 hospitalizations per 100000 adults. Mortality may be as high as 10-14%, although this appears to be decreasing in many countries [31]. Endoscopy for the nonvariceal upper GI bleeding (NVUGB) allows assesment of the risk of rebleeding and enables therapeutic he‐ mostasis that reduces bleeding, the need for surgery, and mortality. The largest analysis of pregnant women for NVUGB is conducted by Geoffrey et al [32] in a population based study including 1210 pregnant women with NVUGB and 6050 nonpregnant women with NVUGB. Mallory-Weis tear was the most common identified cause of NVUGB in pregnant women, in contrast peptic ulcer diesase and gastritis were the predominant etiologies for NVUGB in nonpregnant patients. Pregnant women were less likely to require blood transfu‐ sion and were less likely to present with hypovolemic shock compared to nonpregnant women. EGD was performed substantially less frequently in pregnant women compared with nonpregnant women. The proportion of EGD's that led to therapeutic intervention was similar between pregnant and nonpregnant women, 8.9% vs 7.2% respectively. The mean in‐ terval from admission to EGD was longer for pregnant women compared with nonpregnant women. There were no in-hospital deaths among pregnant women with NVUGB, the pro‐ portions of pregnant and nonpegnant women requiring surgery for upper GI bleeding were not statistically different. Average hospital lenght of stay was shorter among pregnant wom‐ en compared with nonpregnant women. Although the rates of maternal mortality and fetal loss were well below 1% in both groups, fetal distress/complications were lower in the preg‐ nant group admitted with NVUGB, as was premature delivery. It can be concluded as; it is quite appropriate to defer endoscopy in a significant proportion of cases, who remain hemo‐

dynamically stable with self-limited NVUGB.

1 Significant or continued bleeding

7 Biliary or pancreatic ductal injury

5 Severe diarrhea with negative evaluation

**Table 4.** Indications for endoscopy in pregnancy (ASGE)

3 Dysphagia or odynophagia 4 Strong suspicion of colon mass

The indications of endoscopy in pregnacy is shown in table 4 [2].

2 Severe or refractory nausea and vomiting or abdominal pain

6 Biliary pancreatitis, choledocholithiasis, or cholangitis

In an other study conducted by Debby et al [25], 60 pregnant women underwent EGD for recurrent and intractable nausea and vomiting in their first trimester. In that study only 11 patients had the upper gastrointestinal bleeding, the other majority had only intractable nausea and vomiting. The diagnostic yield of EGD in those patients appeared higher for gastrointestinal bleeding than for intractable vomiting but the difference was not statistically significant. Since the endoscopic findings only minimally changed the clinical management of patients with nausea and vomiting the authors suggested the necessity of EGD for upper gastrointestinal bleeding but not nausea and vomiting or hyperemesis gravidarum. A mailed survey of over 3000 members of the American College of Gastroenterology, which included information over 73 upper endoscopies performed during pregnancy. Endoscopic diagnoses from these procedures included esophagitis, gastritis, ulcers, Mallory-Weis tears and normal findings in descending order. This survey reported no significant complications adversly affecting pregnancy [26].

The relationship between hyperemesis gravidarum and Helicabacter Pylori (H.Pylori) infec‐ tion is estimated by Bagis et all, in their study, H Pylori infection was histologically demon‐ strated in 95% of pregnant patients with hyperemesis gravidarum and 50% of control patients. In that study patients with hyperemesis gravidarum had more severe H. Pylori in‐ fection compared to controls with H.Pylori infection, as measured histologically by density of bacterial infiltration. Authors suggested the usage of H.Pylori diagnostic tests to be part of hyperemesis gravidarum investigation [27]. Upper gastrointestinal complaints, especially nause and vomiting, are very common in pregnants. During pregnancy with the effect of progesteron and estrogen and with a lesser effect of motilin hormone the lower esophageal sphincter (LES) tone, gastric and intestinal motility decrease, causing gastroesophageal re‐ flux disease (GERD) symptoms. As pregnancy progresses, the frequency of and intensity of GERD symptoms increase which is caused by gastrointestinal motility changes during preg‐ nancy and with a small contribution of physical effects of gravid uterus [28,29]. So as a con‐ clusion endoscopy is rarely helpful and rarely indicated for nausea and vomiting, or even hyperemesis gravidarum, during pregnancy. In the presence of significant upper gastroin‐ testinal bleeding or severe nause and vomiting accompanied by abdominal pain or refracto‐ ry to medical treatment or signs of gastroduedenal obstruction, EGD may be appropriate to exclude significant peptic ulcer, gastric outlet obstruction or to treat bleeding site. According to the results of studies endoscopically the pregnant women has lower rate of peptic ulcer diseases but higher rate of reflux esophagitis compared to non pregnant patients, and the diagnostic yield of EGD for upper gastrointestinal bleeding during pregnancy is similar to that of EGD performed for the same indication in the general population of about 95% [30].

Acute nonvariceal upper GI bleeding (NVUGB) is a common clinical emergency leading to 50-160 hospitalizations per 100000 adults. Mortality may be as high as 10-14%, although this appears to be decreasing in many countries [31]. Endoscopy for the nonvariceal upper GI bleeding (NVUGB) allows assesment of the risk of rebleeding and enables therapeutic he‐ mostasis that reduces bleeding, the need for surgery, and mortality. The largest analysis of pregnant women for NVUGB is conducted by Geoffrey et al [32] in a population based study including 1210 pregnant women with NVUGB and 6050 nonpregnant women with NVUGB. Mallory-Weis tear was the most common identified cause of NVUGB in pregnant women, in contrast peptic ulcer diesase and gastritis were the predominant etiologies for NVUGB in nonpregnant patients. Pregnant women were less likely to require blood transfu‐ sion and were less likely to present with hypovolemic shock compared to nonpregnant women. EGD was performed substantially less frequently in pregnant women compared with nonpregnant women. The proportion of EGD's that led to therapeutic intervention was similar between pregnant and nonpregnant women, 8.9% vs 7.2% respectively. The mean in‐ terval from admission to EGD was longer for pregnant women compared with nonpregnant women. There were no in-hospital deaths among pregnant women with NVUGB, the pro‐ portions of pregnant and nonpegnant women requiring surgery for upper GI bleeding were not statistically different. Average hospital lenght of stay was shorter among pregnant wom‐ en compared with nonpregnant women. Although the rates of maternal mortality and fetal loss were well below 1% in both groups, fetal distress/complications were lower in the preg‐ nant group admitted with NVUGB, as was premature delivery. It can be concluded as; it is quite appropriate to defer endoscopy in a significant proportion of cases, who remain hemo‐ dynamically stable with self-limited NVUGB.


The indications of endoscopy in pregnacy is shown in table 4 [2].

**Table 4.** Indications for endoscopy in pregnancy (ASGE)

**3. Upper gastrointestinal endoscopy**

326 Endoscopy

adversly affecting pregnancy [26].

live born infants were not significantly different than control groups.

Although it would be ideal to postpone all endoscopic procedures until after delivery, preg‐ nant patients can develop conditions that require urgent upper endoscopy. The most common indications for EGD in pregnant patients are significant or continued gastrointestinal hemor‐ rhage, dysphagia and refractory nausea and vomiting (Table 4). In a multicenter retrospective study of 83 pregnant women on safety and clinical efficacy of EGD in pregnant patients; endos‐ copy indications included gastrointestinal bleeding, abdominal pain and vomiting in decreas‐ ing order [24]. The Mallory-Weiss tear was an important cause of upper gastrointestinal bleeding in 14% of patients, the peptic ulcer was also responsible for 14% of gastrointestinal bleeding in those patients which is significantly lower than the reported frequencies in non pregnant patients. The diagnostic yield for upper gastrointestinal bleeding was 95% and there was no cases of premature labour or congenital fetal malformation. Labor was not induced in any of the patients and 95% of the patients gave birth to healthy infants. The four fetal deaths in the study were in all high risk patients and were unrelated to EGD. The mean Apgar scores of

In an other study conducted by Debby et al [25], 60 pregnant women underwent EGD for recurrent and intractable nausea and vomiting in their first trimester. In that study only 11 patients had the upper gastrointestinal bleeding, the other majority had only intractable nausea and vomiting. The diagnostic yield of EGD in those patients appeared higher for gastrointestinal bleeding than for intractable vomiting but the difference was not statistically significant. Since the endoscopic findings only minimally changed the clinical management of patients with nausea and vomiting the authors suggested the necessity of EGD for upper gastrointestinal bleeding but not nausea and vomiting or hyperemesis gravidarum. A mailed survey of over 3000 members of the American College of Gastroenterology, which included information over 73 upper endoscopies performed during pregnancy. Endoscopic diagnoses from these procedures included esophagitis, gastritis, ulcers, Mallory-Weis tears and normal findings in descending order. This survey reported no significant complications

The relationship between hyperemesis gravidarum and Helicabacter Pylori (H.Pylori) infec‐ tion is estimated by Bagis et all, in their study, H Pylori infection was histologically demon‐ strated in 95% of pregnant patients with hyperemesis gravidarum and 50% of control patients. In that study patients with hyperemesis gravidarum had more severe H. Pylori in‐ fection compared to controls with H.Pylori infection, as measured histologically by density of bacterial infiltration. Authors suggested the usage of H.Pylori diagnostic tests to be part of hyperemesis gravidarum investigation [27]. Upper gastrointestinal complaints, especially nause and vomiting, are very common in pregnants. During pregnancy with the effect of progesteron and estrogen and with a lesser effect of motilin hormone the lower esophageal sphincter (LES) tone, gastric and intestinal motility decrease, causing gastroesophageal re‐ flux disease (GERD) symptoms. As pregnancy progresses, the frequency of and intensity of GERD symptoms increase which is caused by gastrointestinal motility changes during preg‐ nancy and with a small contribution of physical effects of gravid uterus [28,29]. So as a con‐ clusion endoscopy is rarely helpful and rarely indicated for nausea and vomiting, or even

### **4. Therapeutic endoscopy**

### **4.1. Endoscopic hemostasis for variceal bleeding**

Patients with cirrhosis are not likely to become pregnant due to endocrine and metabolic im‐ balances. On the other hand, women with non-cirrhotic portal hypertension have normal fertility rates. The incidence of variceal bleeding during pregnancy may reach up to 45% with a mortality rate of 18-50% The variceal bleeding frequently occurs during the last two trimester of gestation. The possible explanation for the high severity of variceal bleeding in pregnancy seems to be related to the increase in water retention and cardiac output, typical of both pregnancy and cirrhosis. Women with esophageal varices or severe liver disease should be advised, in case of planning the pregnancy, about the high risk of both variceal bleeding and hepatic decompensation during pregnancy. Also patients who have esopha‐ geal varices should be informed about the benefits of β-adrenergic receptor antagonist ther‐ apy during pregnancy to reduce portal pressure.

five voluntary abortions. In that report two patients required EBL after failure of EIS to ob‐

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 329

In an another report 10 patients underwent EIS with absolute alcohol, 5 patients for active variceal bleeding and another 5 patients for the profilaxis of variceal bleeding. Hemostasis was achieved in 5 actively variceal bleeding patients. All 10 patients delivered healthy in‐ fants [44]. According to the reported studies as in the nonpregnant population, EBL seems to be a reasonable option for acute variceal bleeding as well as for the profilaxis of variceal bleeding. EIS could be a secondary choice for the acute variceal bleeding due to the probable

When the endoscopic and pharmacological theraphy fails; TIPS may be a rescue procedure in pregnant women with recurrent and difficult-to treat variceal bleeding. Several papers confirm the utility and efficacy of TIPS for variceal bleeding unresponsive to endoscopic and pharmacological treatment, however since adequate controlled trials are lacking, it should be limited to a selected group of patients. TIPS placement is associated with radiation expo‐ sure of both the patient and the medical staff, it usually requires prolonged fluoroscopy. In the literature there is a few case of TIPS placement in pregnancy in which between 5.2 mSv and 2.1 mGy fetal dose of radiation reported [35,45,46]. So pregnancy is not an absolute con‐ traindication for TIPS placement in the treatment of relapsing bleeding varices and may be a

Endoscopic hemostatic techniques for nonvariceal bleeding include injection therapy with saline, with adrenaline, sclerosants, thrombin, fibrin, cyanoacrilate, ablative therapy with thermocoagulation, electrocoagulation, photocoagulation, argon plasma coagulation, and mechanical compression with hemoclips, detachable snares, graspers, or sutures [47]. In spite of these numerous techniques, there are a few case reports on fetal safety of endoscopic hemostasis for NVUGB. In those case reports adrenalin injection, thermocoagulation and electrocoagulation was used for hemostasis. In only one of the pregnant patient the hemo‐ static procedures were unsuccesful so patient required surgery. The fetal outcomes were

Adrenalin is category C drug and can cause a decrease in uterine blood flow. Although there is limited data of case reports, no advers events from adrenaline injection were report‐ ed, in this case the benefits (cessation of hemorhage, prevention of rebleeding) would seem

Amniotic fluid can conduct electrical current to the fetus. During the electrocoagulation the grounding pad should be placed in such a position that the uterus is not between the electri‐ cal catheter and grounding pad. Bipolar electrocautery should be used to minimize the risk of 'stray' currents going through the fetus. Electrocautery is relatively safe when used for hemostasis[2]. Due to the limited data on hemostasis for nonvariceal bleeding in pregnant patients, the therapeutic technique choice is based on expert opinion and generally made ac‐

rescue procedure when medical and endoscopic treatments have failed.

**4.2. Endoscopic hemostasis for nonvariceal bleeding**

healthy infants without fetal malformations [24,25,47,48,49].

cording to the results of clinical studies of nonpregnant patients.

to outweigh the risks [1,2,29,50].

literate esophageal varices [43].

effects on fetal safety.

Both endoscopic injectional sclerotheraphy (EIS) and endoscopic band ligation (EBL) either prophylactic or urgent seem to be safe procedures during pregnancy. When bleeding is not arrested endoscopically in cirrhotic patients, an emergency transjugular intrahepatic porto‐ systemic shunt (TIPS) is indicated, but data regarding pregnant cirrhotic women are scarce [33-39]. Since there are only a few case reports regarding the treatment options for this clini‐ cal condition, the management of esophageal varices and their major life-threatining compli‐ cation – hemorhage during pregnancy is still under evaluation. In the early 80's EIS was generally accepted as the first line treatment procedure for bleeding esophageal varices. De‐ spite this fact, only few cases of EIS with conventional sclerosants (polidocanol, absolute al‐ chocol, sodium tetradecyl sulphate) were reported during pregnancy [36,38,39]. There are no studies regarding the effect of the conventional sclerosants on the fetus published in the literature, although the procedure is considered safe and effective to control active variceal bleeding. Vasoactive drugs used to achieve hemostasis are contraindicated during pregnan‐ cy, since these (vasopressin and terlipressin) may induce labor or fetal malformations [36]. Recently EBL was reported as an effective treatment option for active variceal hemorrhage as well as prophylaxis of this severe complication during pregnancy [36-39].

In early 90's EBL has been proven effective in controlling active hemorrhage and in long term prevention of recurrent bleeding. There are several case reports that describe successful hemostasis without fetal complications [40,41]. When EBL is used there is no risk of migra‐ tion of a toxic substance to placenta. Studies of EBL versus EST in nonpregnant patients have shown improved reduction in rebleeding and mortality with EBL [40,42]. But there are no studies directly comparing EBL to EST in pregnant patients.

In a study conducted by Aggarwal et al, 17 patients with noncirrhotic portal hypertension caused by extrahepatic portal vein obstruction or portal fibrosis, underwent EIS with either absolute alcohol or sodium tetradecyl sulphate for acute variceal bleeding without compli‐ cations during pregnancy. In that retrospective analysis pregnancy outcomes included six healthy full-term infants, two preterm deliveries, three stillbirths, one neonatal death, and five voluntary abortions. In that report two patients required EBL after failure of EIS to ob‐ literate esophageal varices [43].

In an another report 10 patients underwent EIS with absolute alcohol, 5 patients for active variceal bleeding and another 5 patients for the profilaxis of variceal bleeding. Hemostasis was achieved in 5 actively variceal bleeding patients. All 10 patients delivered healthy in‐ fants [44]. According to the reported studies as in the nonpregnant population, EBL seems to be a reasonable option for acute variceal bleeding as well as for the profilaxis of variceal bleeding. EIS could be a secondary choice for the acute variceal bleeding due to the probable effects on fetal safety.

When the endoscopic and pharmacological theraphy fails; TIPS may be a rescue procedure in pregnant women with recurrent and difficult-to treat variceal bleeding. Several papers confirm the utility and efficacy of TIPS for variceal bleeding unresponsive to endoscopic and pharmacological treatment, however since adequate controlled trials are lacking, it should be limited to a selected group of patients. TIPS placement is associated with radiation expo‐ sure of both the patient and the medical staff, it usually requires prolonged fluoroscopy. In the literature there is a few case of TIPS placement in pregnancy in which between 5.2 mSv and 2.1 mGy fetal dose of radiation reported [35,45,46]. So pregnancy is not an absolute con‐ traindication for TIPS placement in the treatment of relapsing bleeding varices and may be a rescue procedure when medical and endoscopic treatments have failed.

#### **4.2. Endoscopic hemostasis for nonvariceal bleeding**

**4. Therapeutic endoscopy**

328 Endoscopy

**4.1. Endoscopic hemostasis for variceal bleeding**

apy during pregnancy to reduce portal pressure.

Patients with cirrhosis are not likely to become pregnant due to endocrine and metabolic im‐ balances. On the other hand, women with non-cirrhotic portal hypertension have normal fertility rates. The incidence of variceal bleeding during pregnancy may reach up to 45% with a mortality rate of 18-50% The variceal bleeding frequently occurs during the last two trimester of gestation. The possible explanation for the high severity of variceal bleeding in pregnancy seems to be related to the increase in water retention and cardiac output, typical of both pregnancy and cirrhosis. Women with esophageal varices or severe liver disease should be advised, in case of planning the pregnancy, about the high risk of both variceal bleeding and hepatic decompensation during pregnancy. Also patients who have esopha‐ geal varices should be informed about the benefits of β-adrenergic receptor antagonist ther‐

Both endoscopic injectional sclerotheraphy (EIS) and endoscopic band ligation (EBL) either prophylactic or urgent seem to be safe procedures during pregnancy. When bleeding is not arrested endoscopically in cirrhotic patients, an emergency transjugular intrahepatic porto‐ systemic shunt (TIPS) is indicated, but data regarding pregnant cirrhotic women are scarce [33-39]. Since there are only a few case reports regarding the treatment options for this clini‐ cal condition, the management of esophageal varices and their major life-threatining compli‐ cation – hemorhage during pregnancy is still under evaluation. In the early 80's EIS was generally accepted as the first line treatment procedure for bleeding esophageal varices. De‐ spite this fact, only few cases of EIS with conventional sclerosants (polidocanol, absolute al‐ chocol, sodium tetradecyl sulphate) were reported during pregnancy [36,38,39]. There are no studies regarding the effect of the conventional sclerosants on the fetus published in the literature, although the procedure is considered safe and effective to control active variceal bleeding. Vasoactive drugs used to achieve hemostasis are contraindicated during pregnan‐ cy, since these (vasopressin and terlipressin) may induce labor or fetal malformations [36]. Recently EBL was reported as an effective treatment option for active variceal hemorrhage

as well as prophylaxis of this severe complication during pregnancy [36-39].

no studies directly comparing EBL to EST in pregnant patients.

In early 90's EBL has been proven effective in controlling active hemorrhage and in long term prevention of recurrent bleeding. There are several case reports that describe successful hemostasis without fetal complications [40,41]. When EBL is used there is no risk of migra‐ tion of a toxic substance to placenta. Studies of EBL versus EST in nonpregnant patients have shown improved reduction in rebleeding and mortality with EBL [40,42]. But there are

In a study conducted by Aggarwal et al, 17 patients with noncirrhotic portal hypertension caused by extrahepatic portal vein obstruction or portal fibrosis, underwent EIS with either absolute alcohol or sodium tetradecyl sulphate for acute variceal bleeding without compli‐ cations during pregnancy. In that retrospective analysis pregnancy outcomes included six healthy full-term infants, two preterm deliveries, three stillbirths, one neonatal death, and Endoscopic hemostatic techniques for nonvariceal bleeding include injection therapy with saline, with adrenaline, sclerosants, thrombin, fibrin, cyanoacrilate, ablative therapy with thermocoagulation, electrocoagulation, photocoagulation, argon plasma coagulation, and mechanical compression with hemoclips, detachable snares, graspers, or sutures [47]. In spite of these numerous techniques, there are a few case reports on fetal safety of endoscopic hemostasis for NVUGB. In those case reports adrenalin injection, thermocoagulation and electrocoagulation was used for hemostasis. In only one of the pregnant patient the hemo‐ static procedures were unsuccesful so patient required surgery. The fetal outcomes were healthy infants without fetal malformations [24,25,47,48,49].

Adrenalin is category C drug and can cause a decrease in uterine blood flow. Although there is limited data of case reports, no advers events from adrenaline injection were report‐ ed, in this case the benefits (cessation of hemorhage, prevention of rebleeding) would seem to outweigh the risks [1,2,29,50].

Amniotic fluid can conduct electrical current to the fetus. During the electrocoagulation the grounding pad should be placed in such a position that the uterus is not between the electri‐ cal catheter and grounding pad. Bipolar electrocautery should be used to minimize the risk of 'stray' currents going through the fetus. Electrocautery is relatively safe when used for hemostasis[2]. Due to the limited data on hemostasis for nonvariceal bleeding in pregnant patients, the therapeutic technique choice is based on expert opinion and generally made ac‐ cording to the results of clinical studies of nonpregnant patients.

#### **4.3. Percutaneous endoscopic gastrostomy**

During pregnancy, optimal nutrition is essential in order to minimize maternal and neonatal morbidity [51]. Nause and vomiting are seen in 80% of pregnancies but usually symptoms are mild and self limited. In case of severe hyperemesis gravidarum with dehydration and ketonuria, patients should be hospitalized and receive intravenous hydration and anti-emet‐ ic agents. When the hospitalization duration prolongs without oral intake then supportive nutrition with enteral feeding or total parenteral nutrition should be considereed [29]. Long term nasogastric feeding is limited by patient intolerability and nasal septal necrosis. Side effects of long term total parental nutrition limit its usage during pregnancy[52]. Thus per‐ cutaneous endoscopic gastrostomy (PEG) becomes an important option for long term enter‐ al feeding. However, concerns about uterine damage, fetal injury, premature labor, and infections have restricted the application of PEG tube placement in pregnant women. There were no major complications with PEG tube placement in the several reported cases in the literature [53-61]. PEG enteral nutritional support was provided for an average of 14 weeks in the literature. During the pregnancy PEG tube placement is a feasible procedure for opti‐ mal enteral nutrition in the critical care setting. It is also feasible to perform PEG tube place‐ ment in the third trimester of pregnancy. A potential problem with PEG during pregnancy is puncture of uterus or fetus instead of the stomach during transabdominal neddle inser‐ tion. This risk is reduced by demarcating the upper border of uterus before PEG by abdomi‐ nal ultrasonography and by inserting the PEG needle ≥5cm cephaled.

colonoscopy during pregnancy. Lower endoscopy should be avoided for weak indications during pregnancy and should be deferred until after the first trimester, or if possible, until

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 331

Although flexible sigmoidoscopy will be sufficient for most pregnant women, colonoscopy may be required when there is life-threatening colonic bleeding and when a cause has not been established by sigmoidoscopy. In late pregnancy, patients should not be placed in the decubitus or prone position during colonoscopy. External abdominal pressure should gener‐ ally be avoided; if pressure is required, it should be minimal and directed away from the

All avilable evidence suggests that sigmoidoscopy is safe during pregnancy and the indica‐ tions include rectal bleeding, chronic diarrhea, abdominal pain and rectal pain. Guidelines for colonoscopy in pregnancy are not readily available due to insufficient data, although studies which have been done demonstrate safety and efficacy of the procedure provided that obstetrical consultation and close monitoring take place. Colonoscopy is indicated for suspected colon cancer, uncontrolled severe hemorrhage or when necessary before colonic

The safety and efficacy of the flexible sigmoidoscopy during pregnancy has been studied in one case-controlled study of 45 patients undergoing 48 sigmoidoscopies [69]. The most com‐ mon clinical indication was hematochezia in 29 patients, diarrhea was the indication in 10 patients and abdominal pain was in 4 patients. The most common sigmoidoscopic diagnosis included reactivated or newly diagnosed inflamatory bowel disease, bleeding internal hem‐ orroids and other colitis. Among the 29 patients with hematochezia, 8 patients were de novo diagnosis or flare of ulcerative colitis, 7 patients were de novo diagnosis or flare of Crohn's disease, 3 patients with acute proctosigmoitidis, 2 patients were bleeding internal hemor‐ rhoids, 1 patient was pseudomembraneous colitis, and 1 patient was sigmoid adenoma. Hematochezia gave the highest diagnostic yield compared with the other clinical indica‐ tions. Excluding one unknown pregnancy outcome and four voluntary abortions, 38 (93%) of 41 pregnant patients who underwent sigmoidoscopy delivered healthy infants, including 27 at term. The mean Apgar score of live-born infants in this study was not statistically dif‐

Therapeutic changes because of the sigmoidoscopic findings occured in 24 patients, includ‐ ing changing or instituting medication for inflamatory bowel disease in 15 patients, steroid enemas for nonspesific proctitis in two patients, avoiding surgery in two patients, and hem‐

Other than this study there are individual case reports of sigmoidoscopy performed during pregnancy and a mailed survey study [26, 70-74]. Multiple case reports describing flexible sigmoidoscopy in pregnant patients showed the safety of this procedure. In the mailed sur‐ vey study; after contacting 3300 gastroenterologists, their responses indicated that there were no endoscopic complications in 13 pregnant women who underwent flexible sigmoi‐ doscopy. In addition all pregnancies resulted in healthy infants. Common themes among these reports include a relatively high diagnostic yield of flexible sigmoidoscopy when per‐

surgery in pregnant women as well as in general population [67,68].

ferent from the mean national Apgar score of live born infants.

orrhoidal treatment in two patients.

the postpartum period [66].

uterus.

PEG tube placement should be reserved only for severe refractory cases where the nutrition of the mother and the fetus is at risk. The pregnant should be informed about the risks of the procedure and potential placental injury. If possible less invasive alternative techniques as nasoenteric feeding tube or peripherally inserted catheter for parenteral nutrition should be attempted if this is not succesful or is refused by the patient, PEG tube placement should be considered.

#### **4.4. Percutaneous endoscopic gastrojejunostomy**

Percutaneous endoscopic gastrojejunostomy( PEGJ) is a feeding tube placement in to the je‐ jenum via a gastrostomy. This placement enables food to be delivered more distally to de‐ crease the sensation of nausea, vomiting and risk of aspiration. PEGJ indications are similar to PEG indications with additional risk of aspiration. In case of refractory nause and vomit‐ ing in the presence of PEG tube feeding, PEG tube can be converted to PEGJ. There are only few case reports of PEGJ for hyperemesis gravidarum and one patient with coma from mas‐ sive stroke [62-65]. As in the PEG, PEGJ can be considered in very severe hyperemesis gravi‐ darum refractory to medical treatment and the other noninvasive treatment modalities.

### **5. Sigmoidoscopy/ colonoscopy**

Most pregnant patients are young, healthy women and the gestational period is only 40 weeks in duration, because of that; it is unusual for them to need flexible sigmoidoscopy or colonoscopy during pregnancy. Lower endoscopy should be avoided for weak indications during pregnancy and should be deferred until after the first trimester, or if possible, until the postpartum period [66].

**4.3. Percutaneous endoscopic gastrostomy**

330 Endoscopy

considered.

During pregnancy, optimal nutrition is essential in order to minimize maternal and neonatal morbidity [51]. Nause and vomiting are seen in 80% of pregnancies but usually symptoms are mild and self limited. In case of severe hyperemesis gravidarum with dehydration and ketonuria, patients should be hospitalized and receive intravenous hydration and anti-emet‐ ic agents. When the hospitalization duration prolongs without oral intake then supportive nutrition with enteral feeding or total parenteral nutrition should be considereed [29]. Long term nasogastric feeding is limited by patient intolerability and nasal septal necrosis. Side effects of long term total parental nutrition limit its usage during pregnancy[52]. Thus per‐ cutaneous endoscopic gastrostomy (PEG) becomes an important option for long term enter‐ al feeding. However, concerns about uterine damage, fetal injury, premature labor, and infections have restricted the application of PEG tube placement in pregnant women. There were no major complications with PEG tube placement in the several reported cases in the literature [53-61]. PEG enteral nutritional support was provided for an average of 14 weeks in the literature. During the pregnancy PEG tube placement is a feasible procedure for opti‐ mal enteral nutrition in the critical care setting. It is also feasible to perform PEG tube place‐ ment in the third trimester of pregnancy. A potential problem with PEG during pregnancy is puncture of uterus or fetus instead of the stomach during transabdominal neddle inser‐ tion. This risk is reduced by demarcating the upper border of uterus before PEG by abdomi‐

PEG tube placement should be reserved only for severe refractory cases where the nutrition of the mother and the fetus is at risk. The pregnant should be informed about the risks of the procedure and potential placental injury. If possible less invasive alternative techniques as nasoenteric feeding tube or peripherally inserted catheter for parenteral nutrition should be attempted if this is not succesful or is refused by the patient, PEG tube placement should be

Percutaneous endoscopic gastrojejunostomy( PEGJ) is a feeding tube placement in to the je‐ jenum via a gastrostomy. This placement enables food to be delivered more distally to de‐ crease the sensation of nausea, vomiting and risk of aspiration. PEGJ indications are similar to PEG indications with additional risk of aspiration. In case of refractory nause and vomit‐ ing in the presence of PEG tube feeding, PEG tube can be converted to PEGJ. There are only few case reports of PEGJ for hyperemesis gravidarum and one patient with coma from mas‐ sive stroke [62-65]. As in the PEG, PEGJ can be considered in very severe hyperemesis gravi‐ darum refractory to medical treatment and the other noninvasive treatment modalities.

Most pregnant patients are young, healthy women and the gestational period is only 40 weeks in duration, because of that; it is unusual for them to need flexible sigmoidoscopy or

nal ultrasonography and by inserting the PEG needle ≥5cm cephaled.

**4.4. Percutaneous endoscopic gastrojejunostomy**

**5. Sigmoidoscopy/ colonoscopy**

Although flexible sigmoidoscopy will be sufficient for most pregnant women, colonoscopy may be required when there is life-threatening colonic bleeding and when a cause has not been established by sigmoidoscopy. In late pregnancy, patients should not be placed in the decubitus or prone position during colonoscopy. External abdominal pressure should gener‐ ally be avoided; if pressure is required, it should be minimal and directed away from the uterus.

All avilable evidence suggests that sigmoidoscopy is safe during pregnancy and the indica‐ tions include rectal bleeding, chronic diarrhea, abdominal pain and rectal pain. Guidelines for colonoscopy in pregnancy are not readily available due to insufficient data, although studies which have been done demonstrate safety and efficacy of the procedure provided that obstetrical consultation and close monitoring take place. Colonoscopy is indicated for suspected colon cancer, uncontrolled severe hemorrhage or when necessary before colonic surgery in pregnant women as well as in general population [67,68].

The safety and efficacy of the flexible sigmoidoscopy during pregnancy has been studied in one case-controlled study of 45 patients undergoing 48 sigmoidoscopies [69]. The most com‐ mon clinical indication was hematochezia in 29 patients, diarrhea was the indication in 10 patients and abdominal pain was in 4 patients. The most common sigmoidoscopic diagnosis included reactivated or newly diagnosed inflamatory bowel disease, bleeding internal hem‐ orroids and other colitis. Among the 29 patients with hematochezia, 8 patients were de novo diagnosis or flare of ulcerative colitis, 7 patients were de novo diagnosis or flare of Crohn's disease, 3 patients with acute proctosigmoitidis, 2 patients were bleeding internal hemor‐ rhoids, 1 patient was pseudomembraneous colitis, and 1 patient was sigmoid adenoma. Hematochezia gave the highest diagnostic yield compared with the other clinical indica‐ tions. Excluding one unknown pregnancy outcome and four voluntary abortions, 38 (93%) of 41 pregnant patients who underwent sigmoidoscopy delivered healthy infants, including 27 at term. The mean Apgar score of live-born infants in this study was not statistically dif‐ ferent from the mean national Apgar score of live born infants.

Therapeutic changes because of the sigmoidoscopic findings occured in 24 patients, includ‐ ing changing or instituting medication for inflamatory bowel disease in 15 patients, steroid enemas for nonspesific proctitis in two patients, avoiding surgery in two patients, and hem‐ orrhoidal treatment in two patients.

Other than this study there are individual case reports of sigmoidoscopy performed during pregnancy and a mailed survey study [26, 70-74]. Multiple case reports describing flexible sigmoidoscopy in pregnant patients showed the safety of this procedure. In the mailed sur‐ vey study; after contacting 3300 gastroenterologists, their responses indicated that there were no endoscopic complications in 13 pregnant women who underwent flexible sigmoi‐ doscopy. In addition all pregnancies resulted in healthy infants. Common themes among these reports include a relatively high diagnostic yield of flexible sigmoidoscopy when per‐ formed during pregnancy for strong indications, clinically important changes in therapy re‐ sulting from sigmoidoscopic diagnosis, a relatively high rate of favorable fetal outcomes, poor fetal outcomes generally occuring only in very sick mothers and unrelated to sigmoi‐ doscopy etiologically or temporally, and a low rate of congenital anomalies.

ative colitis, ischemic colitis, Crohns colitis, and lymphocytic colitis. Colonoscopy led to significant therapeutic changes in 7 (35%) patients. Two mothers experienced minor colono‐ scopic complications of mild, transient hypotension. Study patients had relatively favorable fetal outcomes: 18 relatively healthy infants, 1 involuntary abortion, and 1 infant born with a

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 333

In a mailed survey of 3300 gastroenterologists 13 colonoscopies were performed without complications [26]. This study was retrospective, and subject to biases relating to recall and dependence on voluntary reporting. In an other study Cappell and co workers [69] retro‐ spectively examined eight pregnant women undergoing colonoscopies at 10 different medi‐ cal centers. Excluding one elective abortion and one fetal demise unrelated to the colonoscopy occuring 4 months later, six healthy infants were born. There was no difference

There are several case reports about colonoscopy during pregnancy [80-88], fetal outcomes after colonoscopy included 8 healthy babies, 2 stillbirth unrelated to the colonoscopy (in mothers with either metastatic colon cancer or massive lower gastrointestinal hemorrhage

Given the limited data on its safety and the potential to cause significant adverse events, co‐ lonoscopy should be reserved to strong indications or life-threatining emergencies during second trimester. But in case of suspicion of colon cancer, evaluation of colonic mass or co‐ lonic stricture of unknown etiology, for severe uncontrolled colonic hemorrhages, for colon‐ ic pseudoobstruction when the alternative is surgical decompression and when required before urgent colonic surgery, colonoscopy should be considered even in the first and third trimester. Colonoscopy should generally be deferred in any trimester of pregnancy until af‐ ter delivery for elective indications, such as surveillance for prior history of colon cancer or

Therapeutic colonoscopy includes hemostasis of lower gastrointestinal bleeding, colono‐ scopic polypectomy, and colonic stenting. As mentioned in the hemostasis for NVUGB sec‐ tion,injection therapy with saline, with adrenaline, sclerosants, thrombin, fibrin, cyanoacrilate, ablative therapy with thermocoagulation, electrocoagulation, photocoagula‐ tion, argon plasma coagulation, and mechanical compression with hemoclips, detachable

Epinephrine is commonly used to treat gastrointestinal bleeding and achieves hemostasis through its vasoconstrictive effects. There are numerous studies about the fetal safety of epi‐ nephrine administration during labor which established its fetal safety so it is commonly added to spinal epidural anesthesia. Although in the report of Briggs and colleagues' [10], there was no congenital defect in 35 infants with first trimester in utero exposure of epi‐ nephrine, there is a case report of fatal intracranial hemorrhage in an infant during child‐

snares, graspers, or sutures are used during lower gastrointestinal bleeding [47].

in outcomes based on the trimester during which colonoscopy was performed.

requiring emergency colonic surgery), and one unknown fetal outcome.

congenital defect (septum secundum cardiac defect).

colonic polyps.

**7. Therapeutic colonoscopy**

Studies suggested that sigmoidoscopy during pregnancy does not induce labor or cause congenital malformations, it is not contraindicated, and should be considered in medically stable patients with important indications. Sigmoidoscopy should be performed with mater‐ nal monitoring by electrocardiography and pulse oximetry, after obstetrical consultation and after medical stabilization. Medical stabilization may require blood transfusions and supplemental oxygenation [4,66,68]. Sigmoidoscopy is not recommended during pregnancy for indications of a change in bowel habits, abdominal pain, a family history of colon cancer, and routine screening or surveillance. In these cases, sigmoidoscopy is best deferred until at least 6 weeks postpartum [67, 68].

Little is known about the safety or otherwise of bowel cleansing agents during pregnancy. Studies have shown that the systemic absorbtion of Polyethylene glycol is minimal and the problems with abdominal bloating and gas are less common as compared to other laxatives [75] But since polyethylene glycol solutions have not been studied during pregnancy, there‐ fore it is a category C drug during pregnancy. Sodium phosphate solutions (also category C) may cause fluid and electrolyte disturbance, and therefore probably best avoided during pregnancy. Also it was published that newborns were shown to manifest bone deminerali‐ zation and bone growth failure because of maternal phosphate overload [76], although a one time use in pregnancy has not shown to be detrimental. Another consideration when using phosphosoda preperations is the risk of phosphate nephropathy [77] which has been report‐ ed in selected cases. As for bowel preperation for flexible sigmoidoscopy, phosphate enemas should be relatively safe, but have not been studied in pregnancy. Tap water enemas may be sufficient. In a study [78] of the preference of gastroenterologist and obstetricians of bowel cleansing agent for sigmoidoscopy and colonoscopy in the same hospital, it was shown that 50% of gastroenterologist prefer to use polyethylene glycol solutions and 50% avoid use of fleet phosphosoda. Twent percent of obstetricians seem to prefer fleet phosphosoda, and 26% avoid polyethylene glycol solutions which is exact opposite of gastroenterologist. Both groups prefer fleet enema the most (51%), while magnesium citrate is used least often (38%).

### **6. Colonoscopy**

There are insufficient data regarding the safety of performing colonoscopy during pregnan‐ cy. The largest case control study of 20 patients [79]; there were 20 pregnant patients under‐ going colonoscopy and 20 pregnant controls who were matched for colonoscopy but who did not undergo colonoscopy. Colonoscopy indications in the study patients included diar‐ rhea, hematochezia, bloody diarrhea, abdominal pain, and other reasons. Colonoscopy was performed in the second trimester in the majority of patients (n=16) with only 4 patients un‐ dergoing the procedure in the first and third trimester. Colonoscopic diagnoses were; ulcer‐ ative colitis, ischemic colitis, Crohns colitis, and lymphocytic colitis. Colonoscopy led to significant therapeutic changes in 7 (35%) patients. Two mothers experienced minor colono‐ scopic complications of mild, transient hypotension. Study patients had relatively favorable fetal outcomes: 18 relatively healthy infants, 1 involuntary abortion, and 1 infant born with a congenital defect (septum secundum cardiac defect).

In a mailed survey of 3300 gastroenterologists 13 colonoscopies were performed without complications [26]. This study was retrospective, and subject to biases relating to recall and dependence on voluntary reporting. In an other study Cappell and co workers [69] retro‐ spectively examined eight pregnant women undergoing colonoscopies at 10 different medi‐ cal centers. Excluding one elective abortion and one fetal demise unrelated to the colonoscopy occuring 4 months later, six healthy infants were born. There was no difference in outcomes based on the trimester during which colonoscopy was performed.

There are several case reports about colonoscopy during pregnancy [80-88], fetal outcomes after colonoscopy included 8 healthy babies, 2 stillbirth unrelated to the colonoscopy (in mothers with either metastatic colon cancer or massive lower gastrointestinal hemorrhage requiring emergency colonic surgery), and one unknown fetal outcome.

Given the limited data on its safety and the potential to cause significant adverse events, co‐ lonoscopy should be reserved to strong indications or life-threatining emergencies during second trimester. But in case of suspicion of colon cancer, evaluation of colonic mass or co‐ lonic stricture of unknown etiology, for severe uncontrolled colonic hemorrhages, for colon‐ ic pseudoobstruction when the alternative is surgical decompression and when required before urgent colonic surgery, colonoscopy should be considered even in the first and third trimester. Colonoscopy should generally be deferred in any trimester of pregnancy until af‐ ter delivery for elective indications, such as surveillance for prior history of colon cancer or colonic polyps.

### **7. Therapeutic colonoscopy**

formed during pregnancy for strong indications, clinically important changes in therapy re‐ sulting from sigmoidoscopic diagnosis, a relatively high rate of favorable fetal outcomes, poor fetal outcomes generally occuring only in very sick mothers and unrelated to sigmoi‐

Studies suggested that sigmoidoscopy during pregnancy does not induce labor or cause congenital malformations, it is not contraindicated, and should be considered in medically stable patients with important indications. Sigmoidoscopy should be performed with mater‐ nal monitoring by electrocardiography and pulse oximetry, after obstetrical consultation and after medical stabilization. Medical stabilization may require blood transfusions and supplemental oxygenation [4,66,68]. Sigmoidoscopy is not recommended during pregnancy for indications of a change in bowel habits, abdominal pain, a family history of colon cancer, and routine screening or surveillance. In these cases, sigmoidoscopy is best deferred until at

Little is known about the safety or otherwise of bowel cleansing agents during pregnancy. Studies have shown that the systemic absorbtion of Polyethylene glycol is minimal and the problems with abdominal bloating and gas are less common as compared to other laxatives [75] But since polyethylene glycol solutions have not been studied during pregnancy, there‐ fore it is a category C drug during pregnancy. Sodium phosphate solutions (also category C) may cause fluid and electrolyte disturbance, and therefore probably best avoided during pregnancy. Also it was published that newborns were shown to manifest bone deminerali‐ zation and bone growth failure because of maternal phosphate overload [76], although a one time use in pregnancy has not shown to be detrimental. Another consideration when using phosphosoda preperations is the risk of phosphate nephropathy [77] which has been report‐ ed in selected cases. As for bowel preperation for flexible sigmoidoscopy, phosphate enemas should be relatively safe, but have not been studied in pregnancy. Tap water enemas may be sufficient. In a study [78] of the preference of gastroenterologist and obstetricians of bowel cleansing agent for sigmoidoscopy and colonoscopy in the same hospital, it was shown that 50% of gastroenterologist prefer to use polyethylene glycol solutions and 50% avoid use of fleet phosphosoda. Twent percent of obstetricians seem to prefer fleet phosphosoda, and 26% avoid polyethylene glycol solutions which is exact opposite of gastroenterologist. Both groups prefer fleet enema the most (51%), while magnesium citrate is used least often (38%).

There are insufficient data regarding the safety of performing colonoscopy during pregnan‐ cy. The largest case control study of 20 patients [79]; there were 20 pregnant patients under‐ going colonoscopy and 20 pregnant controls who were matched for colonoscopy but who did not undergo colonoscopy. Colonoscopy indications in the study patients included diar‐ rhea, hematochezia, bloody diarrhea, abdominal pain, and other reasons. Colonoscopy was performed in the second trimester in the majority of patients (n=16) with only 4 patients un‐ dergoing the procedure in the first and third trimester. Colonoscopic diagnoses were; ulcer‐

doscopy etiologically or temporally, and a low rate of congenital anomalies.

least 6 weeks postpartum [67, 68].

332 Endoscopy

**6. Colonoscopy**

Therapeutic colonoscopy includes hemostasis of lower gastrointestinal bleeding, colono‐ scopic polypectomy, and colonic stenting. As mentioned in the hemostasis for NVUGB sec‐ tion,injection therapy with saline, with adrenaline, sclerosants, thrombin, fibrin, cyanoacrilate, ablative therapy with thermocoagulation, electrocoagulation, photocoagula‐ tion, argon plasma coagulation, and mechanical compression with hemoclips, detachable snares, graspers, or sutures are used during lower gastrointestinal bleeding [47].

Epinephrine is commonly used to treat gastrointestinal bleeding and achieves hemostasis through its vasoconstrictive effects. There are numerous studies about the fetal safety of epi‐ nephrine administration during labor which established its fetal safety so it is commonly added to spinal epidural anesthesia. Although in the report of Briggs and colleagues' [10], there was no congenital defect in 35 infants with first trimester in utero exposure of epi‐ nephrine, there is a case report of fatal intracranial hemorrhage in an infant during child‐ birth after excessive in utero epinephrine [89]. Because of the epinephrine's α adrenergic effect of decreasing uterine blood flow, it is a category C during pregnancy and its dosage should be kept low during pregnancy.

cated during pregnancy. But it is more likely to be incomplete when done during pregnancy

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 335

Pregnancy is associated with an increased risk of gallstone formation. Fortunately, compli‐ cations due to cholelithiasis, such as cholecystitis, choledocholithiasis and pancreatitis are relatively uncommon and in many cases can be managed conservatively. However occasion‐ ally patients develop complications related to gallstones that require intervention during pregnancy. 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

A subset of patients requires ERCP, most commonly for choledocholithiasis or presumed gallstone pancreatitis. Opinions regarding the safety of ERCP during pregnancy differ in various reports, reflecting the relatively limited data. Major concerns surround issues relat‐ ed to radiation exposure to the fetus and the risk of procedure on pregnancy outcome.

A general principle in the care of the women with an acute biliary tract disorder during pregnancy is to provide the most conservative management possible with the hope of delay‐ ing intervention until after pregancy or until the second trimester, when surgical interven‐ tion is relatively safer. There are numerous reports about ERCP during pregnancy especially

The largest series in the literature included 65 pregnant patients [100]; the most common in‐ dications for ERCP during pregnancy were recurrent biliary colic, abnormal liver function tests, and a dilated bile duct on ultrasound. Sixty eight ERCP was performed on 65 pregnant patients, 17 pregnants were in the first trimester, 20 pregnants were in the second trimester and 31 pregnants were in the third trimester. The median fluoroscopy time was 1.45 mi‐ nutes. Almost all patients underwent a therapeutic procedure. Post ERCP pancreatitis devel‐ oped in 11 patients (16%), none of whom had a severe course. Most patients achieved a term pregnancy (89%), there were no fetal deaths, perinatal deaths, or evident congenital malfor‐

Another series of 23 patients included 20 of whom underwent a therapeutic ERCP while three underwent a diagnostic ERCP only [101]. One patient developed post ERCP pancreati‐ tis (after each of her three ERCP). There was one spontaneous abortion and one neonatal death 26 hours after delivery. The neonatal death and post-ERCP pancreatitis were in the same patient who undergone three ERCPs (twice during the first and one during the third trimesters) with pancreatic duct stenting for stenosis of pancretaic orifice after a previous

Shelton et al in a retrospective series of 21 cases of ERCP with sphincterotomy reported suc‐ cessful extraction of stones in 14 women and successful removal of sludge in 7 women. There was one maternal complication of pancreatitis. There were 17 healthy babies deliv‐ ered at term; One preterm, low birth weight baby, and 3 unknown fetal outcomes [102].

mations. Only 5 babies (8%) were born prematurely or with low birth weight.

frequent indications for non-obstetrical surgery during pregnancy [95-99].

because of slowed intestinal transit time during pregnancy.

**9.1. Endoscopic retrograde cholangiopancreatography**

for the last ten years.

surgical sphincteroplasty.

Electrocautery is also another method of providing hemostasis during lower gastrointestinal bleeding, also used for performing polypectomy or hot biopsy. Using electrocautery to le‐ sions may occasionally be required during pregnancy and has been safely performed with‐ out detectable advers effcts to fetus. However, because amniotic fluid has been demonstrated to conduct electrical current, externally placed grounding pad should be placed close to the electrical catheter, devices should use bipolar currents. Polyp removal if not bleeding, should be postponed after pregnancy [4, 5, 66].

Colonic tattooing is done with Indian ink and methylene blue in nonpregnant patients. Indi‐ an ink has been shown to persist for the entire life of patient. There have ben no reports of long term complications of Indian ink tattooing. Methylene blue tattooing during pregnancy is not been studied but there are reports of examination of Metylene blue during amniocent‐ esis and in detection of ruptured membranes. In these reports fetal death, jejunal atresia, is reported which labels Metylene blue as teratogenic. Although safety of colonic injection is not studied; its usage should be avoided during pregnancy [66, 90, 91].

### **8. Enteroscopy**

Enteroscopy takes a very long time of procedure with a long time of anesthesia. There is no case report of enteroscopy during pregnancy, so the fetal safety of enteroscopy could not be predicted.

### **9. Video capsule endoscopy**

Video capsule endoscopy (VCE) represents a significant advance in the investigation of small bowel diseases. The main indications are obscure gastrointestinal hemorrhages, Crohn's disease, celiac disease, small bowel tumors and polyposis syndromes. The main contraindications are known or suspected gastrointestinal obstruction, strictures, fistulas, cardiac pacemakers and swallowing disorders [92]. During pregnancy the growing gravid uterus pushes and compresses the gastrointestinal tract, and gastrointestinal motility de‐ creases due to inhibition of intestinal smooth muscle by gestational progestin. These effects raise the theoretical concerns regarding capsule impaction during pregnancy [4,93]. Al‐ though according to the FDA, pregnancy is a relative contraindication for VCE [92]; there is a report of VCE usage in a young acute bleeding pregnant patient in whom endoscopy and colonoscopy revealed no lesion other than fresh blood exiting the terninal ileum. On VCE an actively bleeding jejunal lesion was shown of which pathology was jejunal carcinoid tumor. Patient and fetus did well after surgery [94]. From this report, it can be concluded that VCE may be considerable during pregnancy for strong indications, it is not absolutely contraindi‐ cated during pregnancy. But it is more likely to be incomplete when done during pregnancy because of slowed intestinal transit time during pregnancy.

### **9.1. Endoscopic retrograde cholangiopancreatography**

birth after excessive in utero epinephrine [89]. Because of the epinephrine's α adrenergic effect of decreasing uterine blood flow, it is a category C during pregnancy and its dosage

Electrocautery is also another method of providing hemostasis during lower gastrointestinal bleeding, also used for performing polypectomy or hot biopsy. Using electrocautery to le‐ sions may occasionally be required during pregnancy and has been safely performed with‐ out detectable advers effcts to fetus. However, because amniotic fluid has been demonstrated to conduct electrical current, externally placed grounding pad should be placed close to the electrical catheter, devices should use bipolar currents. Polyp removal if

Colonic tattooing is done with Indian ink and methylene blue in nonpregnant patients. Indi‐ an ink has been shown to persist for the entire life of patient. There have ben no reports of long term complications of Indian ink tattooing. Methylene blue tattooing during pregnancy is not been studied but there are reports of examination of Metylene blue during amniocent‐ esis and in detection of ruptured membranes. In these reports fetal death, jejunal atresia, is reported which labels Metylene blue as teratogenic. Although safety of colonic injection is

Enteroscopy takes a very long time of procedure with a long time of anesthesia. There is no case report of enteroscopy during pregnancy, so the fetal safety of enteroscopy could not be

Video capsule endoscopy (VCE) represents a significant advance in the investigation of small bowel diseases. The main indications are obscure gastrointestinal hemorrhages, Crohn's disease, celiac disease, small bowel tumors and polyposis syndromes. The main contraindications are known or suspected gastrointestinal obstruction, strictures, fistulas, cardiac pacemakers and swallowing disorders [92]. During pregnancy the growing gravid uterus pushes and compresses the gastrointestinal tract, and gastrointestinal motility de‐ creases due to inhibition of intestinal smooth muscle by gestational progestin. These effects raise the theoretical concerns regarding capsule impaction during pregnancy [4,93]. Al‐ though according to the FDA, pregnancy is a relative contraindication for VCE [92]; there is a report of VCE usage in a young acute bleeding pregnant patient in whom endoscopy and colonoscopy revealed no lesion other than fresh blood exiting the terninal ileum. On VCE an actively bleeding jejunal lesion was shown of which pathology was jejunal carcinoid tumor. Patient and fetus did well after surgery [94]. From this report, it can be concluded that VCE may be considerable during pregnancy for strong indications, it is not absolutely contraindi‐

should be kept low during pregnancy.

**8. Enteroscopy**

**9. Video capsule endoscopy**

predicted.

334 Endoscopy

not bleeding, should be postponed after pregnancy [4, 5, 66].

not studied; its usage should be avoided during pregnancy [66, 90, 91].

Pregnancy is associated with an increased risk of gallstone formation. Fortunately, compli‐ cations due to cholelithiasis, such as cholecystitis, choledocholithiasis and pancreatitis are relatively uncommon and in many cases can be managed conservatively. However occasion‐ ally patients develop complications related to gallstones that require intervention during pregnancy. 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 [95-99].

A subset of patients requires ERCP, most commonly for choledocholithiasis or presumed gallstone pancreatitis. Opinions regarding the safety of ERCP during pregnancy differ in various reports, reflecting the relatively limited data. Major concerns surround issues relat‐ ed to radiation exposure to the fetus and the risk of procedure on pregnancy outcome.

A general principle in the care of the women with an acute biliary tract disorder during pregnancy is to provide the most conservative management possible with the hope of delay‐ ing intervention until after pregancy or until the second trimester, when surgical interven‐ tion is relatively safer. There are numerous reports about ERCP during pregnancy especially for the last ten years.

The largest series in the literature included 65 pregnant patients [100]; the most common in‐ dications for ERCP during pregnancy were recurrent biliary colic, abnormal liver function tests, and a dilated bile duct on ultrasound. Sixty eight ERCP was performed on 65 pregnant patients, 17 pregnants were in the first trimester, 20 pregnants were in the second trimester and 31 pregnants were in the third trimester. The median fluoroscopy time was 1.45 mi‐ nutes. Almost all patients underwent a therapeutic procedure. Post ERCP pancreatitis devel‐ oped in 11 patients (16%), none of whom had a severe course. Most patients achieved a term pregnancy (89%), there were no fetal deaths, perinatal deaths, or evident congenital malfor‐ mations. Only 5 babies (8%) were born prematurely or with low birth weight.

Another series of 23 patients included 20 of whom underwent a therapeutic ERCP while three underwent a diagnostic ERCP only [101]. One patient developed post ERCP pancreati‐ tis (after each of her three ERCP). There was one spontaneous abortion and one neonatal death 26 hours after delivery. The neonatal death and post-ERCP pancreatitis were in the same patient who undergone three ERCPs (twice during the first and one during the third trimesters) with pancreatic duct stenting for stenosis of pancretaic orifice after a previous surgical sphincteroplasty.

Shelton et al in a retrospective series of 21 cases of ERCP with sphincterotomy reported suc‐ cessful extraction of stones in 14 women and successful removal of sludge in 7 women. There was one maternal complication of pancreatitis. There were 17 healthy babies deliv‐ ered at term; One preterm, low birth weight baby, and 3 unknown fetal outcomes [102].

Another series described long term follow up of 18 pregnant women who underwent biliary sphincterotomy for common bile duct stones during pregnancy (first trimester 4, second 6, third 8) [103]. Despite short term complications (one with postsphincterotomy bleedings, one with mild post ERCP pancreatitis and preterm labor), no long term maternal complica‐ tions were seen after a median of six years (range 1-11 year). Only 11 of the 18 families were retrospectively contacted; all 11 babies were healthy on follow up at a mean of 6 years post‐ partum. Only one mother had preterm delivery.

Data from studies of animals and nuclear bomb survivors suggest that the period of major organogenesis, between the 8th and 15th weeks of gestation, is the most sensitive for growth retardation, which may be observed with exposures of 200-250mrem. Exposures greater than 100mrem occuring later, during neuron development and migration, may be associated with microcephaly, seizures, decline in mental ability, and childhood cancer [107]. During the whole of gestation, the maxium permitted dose of ionizing radiation to the fetus is

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 337

Lead shielding should be used to minimize radiation exposure to the uterus. The lead apron shield must be placed underneath the patient and not draped over the abdomen since the radiation source is underneath the patient when using the standard fluoroscopy C-arm [109]. External shielding can not elimineta fetal exposure due to internally scattered radia‐ tion. Even though the fetus can be shielded, efforts should be made to avoid performing ERCP during the first trimester. While harmful effects of radiation exposure are unlikely to develop below a certain threshold of radiation dose, the threshold associated with a risk of

Though a majority of investigators have reported no immediate complication in newborn, because of low dose radiation exposure, no one has looked 10-20 years after the exposure,

ERCP without fluoroscopy has been reported in some studies [102,111] in the last years. Sharma and Maharshi [110] described a two step procedure with biliary sphincterotomy and stenting without fluoroscopy or ultrasound (US) asistance as a first step and definitive ERCP with stone extraction after delivery. In another series [102] it is described as; endoscopist controls wire –guided cannulation first; then the cannule is not advanced in to the duct un‐ less the endoscopist is confident that the bile duct has been cannulated, as assesssed by the presence of bile flowing around the wire from the papillary orifice. Once biliary cannulation is confirmed, a standard wire-guided biliary sphincterotomy is performed using the papillo‐ tome. While the bile is not seen flowing around the guidewire, instead of advancing the catheter to aspirate fluid, a 5F 2 cm stent is inserted over the wire and the drainage from the stent is observed. The color of draining fluid is used to assess whether the stent is in the bile duct or the pancreatic duct. If the stent reveals bile flow, a stent –guided biliary sphincterot‐ omy using a needdle-knife is performed. The stent is removed after biliary sphincterotomy. Even though the introduction of ERCP without fluoroscopy, ERCP should be avoided for weak indications such as preoperative cholangiography in patients with a low probability of having choledocholithiasis. Women of childbearing age should be asked about the possibili‐ ty of pregnancy and a pregnancy test should be ordered based on clinical history. Other methods of diagnosis that do not involve radiation should be considered, magnetic reso‐ nance cholangiopancreatography (MRCP) can provide diagnostic information for a variety of hepatobiliary conditions while endoscopic ultrasonography (EUS) is highly sensitive and spesific for choledocholithiasis. MRCP for the detection of common bile duct stone and sub‐ sequent extraction without using fluoroscopy has been reported in some newly published case reports. In a study conducted by Oto et al [111], the role of MRCP in the evaluation of pregnant patients with acute pancreaticobiliary disease is investigated; 18 pregnant patients

childhood cancers such as leucemia is not known precisely.

from that point; ERCP without fluoroscopy is investigated.

500rems [108].

Kahaleh et al reported a total of 17 pregnant patients underwent ERCP; of which 15 had ra‐ diation dosimetry measured. Mean fluoroscopy time was 14 seconds (1-48seconds), mean estimated fetal radiation exposure was 40mrad (1-180mrad). Complications were reported as; postsphincterotomy bleeding in one patient, which was controlled by placement of he‐ moclip, and post-ERCP pancreatitis in one patient. All infants delivered had Apgar scores of 8 or greater. Thirteen of 15 patients who delivered were contacted, and they confirmed that their child was in good health. [104].

In an another series of 15 patients, the incidence of complications (7%) was no different than the rate of complications observed in nonpregnant patients. [105]. There were no serious ad‐ verse outcomes to the fetus or mother.

Different from the aforementioned reports, Farca et al reported a prospective study ≥10 ther‐ apeutic ERCP during pregnancy [106]. In this study a single 10F stent was placed without sphincterotomy, all patients had uncomplicated pregnancies and delivered healthy infants. All underwent ERCP with sphincterotomy and stent extraction postpartum; 8 had stones ex‐ tracted. In two patients, the single 10F stent remained in place for 7 and 8 months, respec‐ tively; no one developed cholangitis.

During the ERCP in pregnancy the perceived risk of radiation exposure is much greater than the actual risk, but a full explanation of these risks to the pregnant patient and her fam‐ ily is more credible if given prior to exposure. Patients should be fully informed, back‐ ground population risks for miscarriage, congenital anomalies, genetic disease, and the growth restriction are approximately 20, 4, 10 and 10 percent, respectively. Potential radia‐ tion exposure risks to the fetus can be divided into four categories: intrauterine fetal death, malformations, disturbance of growth and development, mutagenic and carcinogenic ef‐ fects.

Ionizing radiation is measured in special units, rad (radiation absorbed dose) and rem (radi‐ ation equivalent man) and in the international units, gray (Gy) and sievert (Sv)

(1 rad = 1rem = 0.01Gy = 0.01Sv). The avarage person in United States receives about 360 mrem of ionizing radiation annually, of which about 60 mrem comes from man-made sour‐ ces, including medical exposures such as diagnostic radiographs. The rem is a unit used to measure the effect of radiation on the human body is referred to as the ' effective dose equivalent'. Fetal radiation exposure can result in developmental abnormalities, particularly if exposure is during the first trimester when organogenesis occurs. High radiation exposure may result in fetal wastage. Although estimates vary, it is recommended that fetal radiation exposure not exceed 100mrem during the first trimester [104].

Data from studies of animals and nuclear bomb survivors suggest that the period of major organogenesis, between the 8th and 15th weeks of gestation, is the most sensitive for growth retardation, which may be observed with exposures of 200-250mrem. Exposures greater than 100mrem occuring later, during neuron development and migration, may be associated with microcephaly, seizures, decline in mental ability, and childhood cancer [107]. During the whole of gestation, the maxium permitted dose of ionizing radiation to the fetus is 500rems [108].

Another series described long term follow up of 18 pregnant women who underwent biliary sphincterotomy for common bile duct stones during pregnancy (first trimester 4, second 6, third 8) [103]. Despite short term complications (one with postsphincterotomy bleedings, one with mild post ERCP pancreatitis and preterm labor), no long term maternal complica‐ tions were seen after a median of six years (range 1-11 year). Only 11 of the 18 families were retrospectively contacted; all 11 babies were healthy on follow up at a mean of 6 years post‐

Kahaleh et al reported a total of 17 pregnant patients underwent ERCP; of which 15 had ra‐ diation dosimetry measured. Mean fluoroscopy time was 14 seconds (1-48seconds), mean estimated fetal radiation exposure was 40mrad (1-180mrad). Complications were reported as; postsphincterotomy bleeding in one patient, which was controlled by placement of he‐ moclip, and post-ERCP pancreatitis in one patient. All infants delivered had Apgar scores of 8 or greater. Thirteen of 15 patients who delivered were contacted, and they confirmed that

In an another series of 15 patients, the incidence of complications (7%) was no different than the rate of complications observed in nonpregnant patients. [105]. There were no serious ad‐

Different from the aforementioned reports, Farca et al reported a prospective study ≥10 ther‐ apeutic ERCP during pregnancy [106]. In this study a single 10F stent was placed without sphincterotomy, all patients had uncomplicated pregnancies and delivered healthy infants. All underwent ERCP with sphincterotomy and stent extraction postpartum; 8 had stones ex‐ tracted. In two patients, the single 10F stent remained in place for 7 and 8 months, respec‐

During the ERCP in pregnancy the perceived risk of radiation exposure is much greater than the actual risk, but a full explanation of these risks to the pregnant patient and her fam‐ ily is more credible if given prior to exposure. Patients should be fully informed, back‐ ground population risks for miscarriage, congenital anomalies, genetic disease, and the growth restriction are approximately 20, 4, 10 and 10 percent, respectively. Potential radia‐ tion exposure risks to the fetus can be divided into four categories: intrauterine fetal death, malformations, disturbance of growth and development, mutagenic and carcinogenic ef‐

Ionizing radiation is measured in special units, rad (radiation absorbed dose) and rem (radi‐

(1 rad = 1rem = 0.01Gy = 0.01Sv). The avarage person in United States receives about 360 mrem of ionizing radiation annually, of which about 60 mrem comes from man-made sour‐ ces, including medical exposures such as diagnostic radiographs. The rem is a unit used to measure the effect of radiation on the human body is referred to as the ' effective dose equivalent'. Fetal radiation exposure can result in developmental abnormalities, particularly if exposure is during the first trimester when organogenesis occurs. High radiation exposure may result in fetal wastage. Although estimates vary, it is recommended that fetal radiation

ation equivalent man) and in the international units, gray (Gy) and sievert (Sv)

exposure not exceed 100mrem during the first trimester [104].

partum. Only one mother had preterm delivery.

their child was in good health. [104].

verse outcomes to the fetus or mother.

tively; no one developed cholangitis.

fects.

336 Endoscopy

Lead shielding should be used to minimize radiation exposure to the uterus. The lead apron shield must be placed underneath the patient and not draped over the abdomen since the radiation source is underneath the patient when using the standard fluoroscopy C-arm [109]. External shielding can not elimineta fetal exposure due to internally scattered radia‐ tion. Even though the fetus can be shielded, efforts should be made to avoid performing ERCP during the first trimester. While harmful effects of radiation exposure are unlikely to develop below a certain threshold of radiation dose, the threshold associated with a risk of childhood cancers such as leucemia is not known precisely.

Though a majority of investigators have reported no immediate complication in newborn, because of low dose radiation exposure, no one has looked 10-20 years after the exposure, from that point; ERCP without fluoroscopy is investigated.

ERCP without fluoroscopy has been reported in some studies [102,111] in the last years. Sharma and Maharshi [110] described a two step procedure with biliary sphincterotomy and stenting without fluoroscopy or ultrasound (US) asistance as a first step and definitive ERCP with stone extraction after delivery. In another series [102] it is described as; endoscopist controls wire –guided cannulation first; then the cannule is not advanced in to the duct un‐ less the endoscopist is confident that the bile duct has been cannulated, as assesssed by the presence of bile flowing around the wire from the papillary orifice. Once biliary cannulation is confirmed, a standard wire-guided biliary sphincterotomy is performed using the papillo‐ tome. While the bile is not seen flowing around the guidewire, instead of advancing the catheter to aspirate fluid, a 5F 2 cm stent is inserted over the wire and the drainage from the stent is observed. The color of draining fluid is used to assess whether the stent is in the bile duct or the pancreatic duct. If the stent reveals bile flow, a stent –guided biliary sphincterot‐ omy using a needdle-knife is performed. The stent is removed after biliary sphincterotomy.

Even though the introduction of ERCP without fluoroscopy, ERCP should be avoided for weak indications such as preoperative cholangiography in patients with a low probability of having choledocholithiasis. Women of childbearing age should be asked about the possibili‐ ty of pregnancy and a pregnancy test should be ordered based on clinical history. Other methods of diagnosis that do not involve radiation should be considered, magnetic reso‐ nance cholangiopancreatography (MRCP) can provide diagnostic information for a variety of hepatobiliary conditions while endoscopic ultrasonography (EUS) is highly sensitive and spesific for choledocholithiasis. MRCP for the detection of common bile duct stone and sub‐ sequent extraction without using fluoroscopy has been reported in some newly published case reports. In a study conducted by Oto et al [111], the role of MRCP in the evaluation of pregnant patients with acute pancreaticobiliary disease is investigated; 18 pregnant patients underwent MRCP for the indications of right upper quadrant pain, cholangitis, jaundice and pancreatitis. Fifteen of the 18 patients were also evaluated with abdominal US. Biliary dilata‐ tion was detected in 8 patients with US, but the cause of biliary dilatation could not be deter‐ mined by US in 7 patients. MRCP demonstrated the etiology in four of these patients (choledocholithiasis, Mirizzi syndrome, choledochal cysts, and intrahepatic biliary stones) and excluded obstructive pathology in the other four patients. MRCP was unremarkable in the 7 patients who had no biliary dilatation on US. Three patients underwent only MRCP; two had choledocholithiasis, and one had cholelithiasis and pancreatitis. While this study suggests that MRCP may be very helpful diagnostically for acute pancreatobiliary disease in the pregnant population, this study does not give any information about the fetal outcomes, including the incidence of congenital amlformations after MRCP during pregnancy.

report, EUS was performed for acute pancreatitis of unknown etiology in 3 pregnant pa‐ tients. Biliary pancreatitis without common bile duct stones found in 2 patients and pancrea‐ titis due to unspecified pancreatic anomaly was found in one pregnant patient. There were no reported maternal complications in this study with 2 healthy infants but one fetal death

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 339

One may argue that EUS will prolong the overall time for a procedure. However, when EUS is normal, ERCP interventions can be avoided. In addition, EUS may provide other useful information. In experienced hands, the added time for EUS can be only a few minutes. So further studies are required to assess the role of EUS in the management of pregnant pa‐ tients. However, it would seem acceptable to perform EUS when choledocholithiasis is a

The SpyGlass system is a recently developed system for performing cholangioscopy, pan‐ creatoscopy. The main advantage over standard ERCP is that with the SpyGlass system the scope can be inserted directly into the bile duct and the pathology can be directly visualized, rather than using radiographs to visualize the bile ducts. This direct visualization allows the endoscopists to obtain a targetted biopsy, if needed, or to use electrohydraulic lithotripsy to crush stones under direct vision. This technique has been applied to 7 pregnant patients in the literature, five patients underwent choledochoscopy using spyscopy after ERCP, sphinc‐ terotomy, and balon sweeps; this procedure confirmed the removal of all choledochal stones in those patients. In one patient this technique is used to show residual 2 mm common bile duct stones after balon sweeping at ERCP, and in the remainig patient it has been used to show the sludge coming from the cystic duct. Choledochoscopy produced no maternal com‐ plications in those reports. This technique allows for the limitation or elimination of ionizing radiation through direct intraductal visualization and stone clearence confirmation. The di‐ agnostic and therapeutic capability of ERCP is increased in a manner that contributes to pa‐ tient safety and hopefully better maternal and fetal outcomes. So more studies are needed of

Endoscopic cystogastrostomy with or without endosonographic guidance for drainage of pseudocyst has been demostrated to be an acceptable alternative to radiologic or surgical drainage. For the pregnant patient who has a pancreatic pseudocyst, this technique would be ideal because it would eliminate the risk of radiation incurred by a radiologic drainage and would involve less risk to the fetus than an intraabdominal surgical procedure. There are only two cases of endoscopic cystogastrostomy procedure applied to pregnant patients. In one patient it was successful; the pseudocyst was punctured percutaneously under con‐

10 weeks after EUS probably due to recurrent cholangitis [113].

**11. Endoscopic spyscopy**

possible but unproven diagnosis and MRCP is an undesirable alternative.

this technique during pregnancy to asses the fetal outcomes [4, 114-116].

**12. Endoscopic cystogastrostomy**

So, in the case of choledocholithiasis, biliary pancreatitis, cholangitis and findings of coledo‐ chal dilatation on abdomianl US with abnormal serum liver function tests and known gall‐ stones, ERCP with / without fluoroscopy should be made.

#### **9.2. Electrocautery and hemostasis**

Using cutting and cauterizing current to lesions may occasioanlly be required during preg‐ nancy and has been safely performed without detectable adverse consequences to the devel‐ oping fetus. However, because amniotic fluid has been demonstrated to conduct electrical current [112], a number of precautions are appropriate. These include ensuring that the ex‐ ternally placed graunding pad is placed close to the interventional electrical catheter so that the uterus does not lie between them. Devices using only bipolar currents should be used to minimize this risk of 'stray' currents going through the fetus. Electrocautery is relatively safe when used for sphincterotomy and hemostasis[2,5].

Epinephrine is category C drug during pregnancy and causes a decrease in uterine blood flow. Its safety, when used as an endoscopic injectant, has not been studied, although, when given in low dose combinations for analgesia, it is safe. Its use for hemostasis should balance the benefits with the potential risks [2].

### **10. Endoscopic ultrasonography**

Endoscopic ultrasonography (EUS) is a widely accepted modality for the diagnosis of gas‐ trointestinal and pancreatobiliary diseases. EUS has been shown to reduce unnecessary in‐ terventions in patients with low or moderate probabilities for choledocholithiasis. It is a safe alternative to fluoroscopy for the evaluation of biliary disorders during pregnancy. Howev‐ er, there are only case reports on EUS for pregnant patients in the literature. The largest ser‐ ies consist of 6 cases of EUS performed for suspected choledocholithiasis in pregnant patients [102]. EUS findings revealed choledocholithiasis in two patients, biliary sludge in two patients and nonsignificant findings in two patients.

All six patients were underwent ERCP after EUS, there were no maternal complications. Fe‐ tal outcome was favorable for 5 infants but one infant outcome was unknown. In another report, EUS was performed for acute pancreatitis of unknown etiology in 3 pregnant pa‐ tients. Biliary pancreatitis without common bile duct stones found in 2 patients and pancrea‐ titis due to unspecified pancreatic anomaly was found in one pregnant patient. There were no reported maternal complications in this study with 2 healthy infants but one fetal death 10 weeks after EUS probably due to recurrent cholangitis [113].

One may argue that EUS will prolong the overall time for a procedure. However, when EUS is normal, ERCP interventions can be avoided. In addition, EUS may provide other useful information. In experienced hands, the added time for EUS can be only a few minutes. So further studies are required to assess the role of EUS in the management of pregnant pa‐ tients. However, it would seem acceptable to perform EUS when choledocholithiasis is a possible but unproven diagnosis and MRCP is an undesirable alternative.

### **11. Endoscopic spyscopy**

underwent MRCP for the indications of right upper quadrant pain, cholangitis, jaundice and pancreatitis. Fifteen of the 18 patients were also evaluated with abdominal US. Biliary dilata‐ tion was detected in 8 patients with US, but the cause of biliary dilatation could not be deter‐ mined by US in 7 patients. MRCP demonstrated the etiology in four of these patients (choledocholithiasis, Mirizzi syndrome, choledochal cysts, and intrahepatic biliary stones) and excluded obstructive pathology in the other four patients. MRCP was unremarkable in the 7 patients who had no biliary dilatation on US. Three patients underwent only MRCP; two had choledocholithiasis, and one had cholelithiasis and pancreatitis. While this study suggests that MRCP may be very helpful diagnostically for acute pancreatobiliary disease in the pregnant population, this study does not give any information about the fetal outcomes,

including the incidence of congenital amlformations after MRCP during pregnancy.

stones, ERCP with / without fluoroscopy should be made.

safe when used for sphincterotomy and hemostasis[2,5].

two patients and nonsignificant findings in two patients.

**9.2. Electrocautery and hemostasis**

338 Endoscopy

the benefits with the potential risks [2].

**10. Endoscopic ultrasonography**

So, in the case of choledocholithiasis, biliary pancreatitis, cholangitis and findings of coledo‐ chal dilatation on abdomianl US with abnormal serum liver function tests and known gall‐

Using cutting and cauterizing current to lesions may occasioanlly be required during preg‐ nancy and has been safely performed without detectable adverse consequences to the devel‐ oping fetus. However, because amniotic fluid has been demonstrated to conduct electrical current [112], a number of precautions are appropriate. These include ensuring that the ex‐ ternally placed graunding pad is placed close to the interventional electrical catheter so that the uterus does not lie between them. Devices using only bipolar currents should be used to minimize this risk of 'stray' currents going through the fetus. Electrocautery is relatively

Epinephrine is category C drug during pregnancy and causes a decrease in uterine blood flow. Its safety, when used as an endoscopic injectant, has not been studied, although, when given in low dose combinations for analgesia, it is safe. Its use for hemostasis should balance

Endoscopic ultrasonography (EUS) is a widely accepted modality for the diagnosis of gas‐ trointestinal and pancreatobiliary diseases. EUS has been shown to reduce unnecessary in‐ terventions in patients with low or moderate probabilities for choledocholithiasis. It is a safe alternative to fluoroscopy for the evaluation of biliary disorders during pregnancy. Howev‐ er, there are only case reports on EUS for pregnant patients in the literature. The largest ser‐ ies consist of 6 cases of EUS performed for suspected choledocholithiasis in pregnant patients [102]. EUS findings revealed choledocholithiasis in two patients, biliary sludge in

All six patients were underwent ERCP after EUS, there were no maternal complications. Fe‐ tal outcome was favorable for 5 infants but one infant outcome was unknown. In another

The SpyGlass system is a recently developed system for performing cholangioscopy, pan‐ creatoscopy. The main advantage over standard ERCP is that with the SpyGlass system the scope can be inserted directly into the bile duct and the pathology can be directly visualized, rather than using radiographs to visualize the bile ducts. This direct visualization allows the endoscopists to obtain a targetted biopsy, if needed, or to use electrohydraulic lithotripsy to crush stones under direct vision. This technique has been applied to 7 pregnant patients in the literature, five patients underwent choledochoscopy using spyscopy after ERCP, sphinc‐ terotomy, and balon sweeps; this procedure confirmed the removal of all choledochal stones in those patients. In one patient this technique is used to show residual 2 mm common bile duct stones after balon sweeping at ERCP, and in the remainig patient it has been used to show the sludge coming from the cystic duct. Choledochoscopy produced no maternal com‐ plications in those reports. This technique allows for the limitation or elimination of ionizing radiation through direct intraductal visualization and stone clearence confirmation. The di‐ agnostic and therapeutic capability of ERCP is increased in a manner that contributes to pa‐ tient safety and hopefully better maternal and fetal outcomes. So more studies are needed of this technique during pregnancy to asses the fetal outcomes [4, 114-116].

### **12. Endoscopic cystogastrostomy**

Endoscopic cystogastrostomy with or without endosonographic guidance for drainage of pseudocyst has been demostrated to be an acceptable alternative to radiologic or surgical drainage. For the pregnant patient who has a pancreatic pseudocyst, this technique would be ideal because it would eliminate the risk of radiation incurred by a radiologic drainage and would involve less risk to the fetus than an intraabdominal surgical procedure. There are only two cases of endoscopic cystogastrostomy procedure applied to pregnant patients. In one patient it was successful; the pseudocyst was punctured percutaneously under con‐ ventional ultrasound guidance, than it is aspirated and filled with contrast agent. Then en‐ doscopically a cystogastrostomy was created and a stent was inserted. The patient got well and gave birth to a healthy infant. In the second patient unfortunately the stent was migrat‐ ed making the procedure partially unsuccessful, but with other techniques patient again got well and gave birth to a healthy infant too. So according to these two cases endoscopic cys‐ togastrostomy is still a little bit experimental during pregnancy, it should be considered in pregnants who have symptomatic pseudocysts and cannot delay the procedure until deliv‐ ery [4,29,116-118].

[10] 10. Briggs GC, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and maternal risks, 8th edn (Lippincott, Williams & Wilkins, Philadel‐

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 341

[11] Rothman KJ, Fyler DC, Goldblatt A, Kreidberg MB. Exogenous hormones and other drug exposures of children with congenital heart disease. Am J Epidemiol 1979; 109:

[12] Ornoy A, Arnon J, Shechtman S, Moerman L, Lukashova I. Is benzodiazepine use

[13] Czeizel A. Lack of evidence of teratogenicity of benzodiazepine drugs in Hungary.

[14] Laegreid L, Olegard R, Walström J& Conradi N. Teratogenic effects of benzodiaze‐

[15] Arduini D, Rizzo G, Dell'Acqua S, Mancuso S, Romanini C. Effect of naloxone on fe‐

[16] Bland BA, Lawest EG, Duncan PW, Wanell I, Downing JW Comparison of midazo‐ lam and thiopental for rapid sequence anesthetic induction for elective cesarean sec‐

[17] Ravlo O, Carl P, Crawford ME et al. A randomized comparison between midazolam and thiopental for elective cesarean section anesthesia: II. Neonates Anesth Analg.

[18] Lazzaroni M, Bianchi Porro G. Preparation, premedication, and surveillance. Endos‐

[19] Cappell MS. Sedation and analgesia for gastrointestinal endoscopy during pregnan‐

[20] Fassoulaki A, Theodoraki K, Melemeni A. Pharmacology of sedation agents and re‐

[21] Goodlin R.C. Naloxone and its possible relationship to fetal endorphin levels and fe‐

[22] Gibbs J, Newson T, Williams J, Davidson D.C. Naloxone hazard in infant of opioid

[23] Brogden RN, Goa KL. Flumazenil. A reappraisal of its pharmacological properties and therapeutic efficacy as a benzodiazepine antagonist. Drugs1991; 42:1061-89.

[24] Cappell MS, Colon VJ, Sidhom O A. A study at eight medical centers of the safety and clinical efficacy of esophagogastroduedenoscopy in 83 pregnant females with follow-up of fetal outcome and with comparison to control groups. Am J Gastroen‐

during pregnancy really teratogenic? Reprod Toxicol. 1998; 12: 511-5.

pine use during pregnancy. J Pediatr. 1989; 114: 126-31.

tal behavior near term. Am J Obstet Gynecol. 1987; 156: 474-8.

phia, 2008)

Reprod. Toxicol. 1987; 1(3): 183-8.

tion. Anesth Analg. 1987; 66(11): 1165-8.

cy. Gastrointest Endosc Clin N Am 2006; 16: 1-31.

tal distress. Am J Obstet Gynecol. 1981; 139: 16-9.

versal agents. Digestion 2010; 82: 80-3.

abuser. Lancet. 1989; 2 (8655): 159-160.

1989, 68, 234-7.

copy 2005; 37 (2): 101-9.

terol 1996; 91: 348-54.

433-9.

### **Author details**

Nurten Akyurek Savas

Baskent University, Department of Gastroenterology, Istanbul Hospital, Turkey

### **References**


[10] 10. Briggs GC, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and maternal risks, 8th edn (Lippincott, Williams & Wilkins, Philadel‐ phia, 2008)

ventional ultrasound guidance, than it is aspirated and filled with contrast agent. Then en‐ doscopically a cystogastrostomy was created and a stent was inserted. The patient got well and gave birth to a healthy infant. In the second patient unfortunately the stent was migrat‐ ed making the procedure partially unsuccessful, but with other techniques patient again got well and gave birth to a healthy infant too. So according to these two cases endoscopic cys‐ togastrostomy is still a little bit experimental during pregnancy, it should be considered in pregnants who have symptomatic pseudocysts and cannot delay the procedure until deliv‐

Baskent University, Department of Gastroenterology, Istanbul Hospital, Turkey

[1] O'Mahony S. Endoscopy in pregnancy. Best Practice & Research Clinic Gastroenter‐

[2] ASGE Guideline: guidelines for endoscopy in pregnant and lactating women Gastro‐

[3] Kammerer WS. Non-obstetric surgery during pregnancy. Med Clin North Am 1979;

[4] Cappell MS. Risks versus benefits of gasrointestinal endoscopy during pregnancy.

[5] 5.Gilinsky NH, Muthunayagam N. Gastrointestinal endoscopy in pregnant and lac‐ tating women: Emerging Standard of care to guide decision-making. Obstet and Gy‐

[6] Glosten B. Anesthesia for Obstetrics. Miller RD (ed) Anesthesia Churchill Living‐

[7] Morgan GE, Mikhail SM, Murray JM. Clinical anesthesiology . McGrow-hill, New

[9] Jiraki K. Lethal effects of normeperidine. Am J Forensic Med. Pathol. 1992; 13(1):

[8] Food and Drug Administration. Federal Register 1980; 44: 37434-67

ery [4,29,116-118].

340 Endoscopy

**Author details**

**References**

Nurten Akyurek Savas

ol. 2007; 21 (5): 893-9.

63: 1157-64.

intest Endoscopy 2005; 61 (3):357-62.

necol Survey 2006;61: 791-9.

York 2000; 819-46.

42-3.

stone. New York. 2000; 2025-68.

Nat Rev Gastroenterol Hepatol 2011; 8: 610-34.


[25] Debby A, Golan A, Sadan O, Glezerman M, Shirin H. Clinical utility of esophagogas‐ troduodenoscopy in the management of recurrent and intractable vomiting in preg‐ nancy. J Reprod Med. 2008; 53: 347-51.

[40] Stiegmann GV, Goff JS, Michaletz-Onady PA, ET AL.. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N eng J Med

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 343

[41] Gimson AE, Ramage JK, Panos MZ, et al. Randomised trial of variceal banding liga‐ tion versus injection sclerotherapy for bleeding esophageal varices. Lancet 1993; 342:

[42] de la Pena J, Rivero M, Sanchez E, etal. Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial. Gastrointest

[43] Aggarwal N, Sawhney H, Vasishta K, Dhiman RK, Chawla Y. Non-cirrhotic portal

[44] Kochhar R, Kuma S, Goel RC., et al. Pregnancy and its outcome in patients with non‐

[45] Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy.

[46] Tesdal IK, Filser T, Weiss C, et al. Transjugular intrahepatic portosystemic shunts: adjunctive embolotherapy of gastroesophageal collateral vessels in the prevention of

[47] Cappell MS. Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat

[48] Brunner G, Meyer H, Athmann C. Omeprazole for peptic ulcer disease in pregnancy.

[49] Macedo G, Carvalho L, Ribeiro T. Endoscopic sclerotherapy for upper gastrointesti‐ nal bleeding due to Mallory-Weiss syndrome. Am J Gastroenterol. 1995; 90, 1364-5.

[50] Marcus MA, Vertommen JD, Van Aken H, Wouters PF. Hemodynamic effects of in‐ travenous isoproterenol versus epinephrine in the chronic maternal-fetal sheep prep‐

[51] Villar J, Merialdi M, Gülmezoğlu AM, et al. Nutritional interventions during preg‐ nancy for the prevention or treatment of maternal morbidity and preterm delivery:

[52] Wong M, Apodaca CC, Markenson MG, Yancey M. Nutrition management in a preg‐

[53] Koh ML, Lipkin EW. Nutrition support of a pregnant comatose patient via percuta‐ neous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr 1993; 17: 384-7.

[54] Shaheen NJ, Crosby MA, Grimm IS, Isaacs K. The use of percutaneous endoscopic

an overview of randomized controlled trials. J Nutr 2003; 133: 1606-25.

nant comatose patient. Nutr Clin Pract.1997; 12: 63-6.

gastrostomy in pregnancy. Gastrointest Endosc 1997; 46: 564-5.

hypertension in pregnancy. Int J Gynaecol Obstet. 2001; 72: 1-7.

cirrhotic portal hypertension. Dig Dis Sci 1999; 44:1356-61.

1992; 326: 1527-32.

Endosc 1999; 49: 417-23.

Gastroenterolgy 1996; 111: 138-46.

Digestion 1998; 59; 651-4.

variceal rebleeding. Radiology 2005; 236: 360-7.

Rev Gastroenterol Hepatol. 2010; 7: 214-29.

eration. Anesth Analg 1996; 82: 1023-6.

391-4.


[40] Stiegmann GV, Goff JS, Michaletz-Onady PA, ET AL.. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N eng J Med 1992; 326: 1527-32.

[25] Debby A, Golan A, Sadan O, Glezerman M, Shirin H. Clinical utility of esophagogas‐ troduodenoscopy in the management of recurrent and intractable vomiting in preg‐

[26] Frank B. Endoscopy in pregnancy. In: Karlstadt RG, Surawicz CM, Croitoru R., edi‐ tors. Gastrointestinal disorders during pregnancy. Arlington, VA: American College

[27] Bagis T, Gumurdulu Y, Kayaselcuk F, et al. Endoscopy in hyperemesis gravidarum

[28] Baron TH, Ramirez B, Richter JE. Gastrointestinal motility disorders during pregnan‐

[29] Bruno JM, Kroser J. Efficacy and safety of upper endoscopy procedures during preg‐

[30] Chak A, Cooper GS, Lloyd LE, et all. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest Endosc. 2001;

[31] Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.

[32] Nguyen GC, Dinani AM, Pivovarov K. Endoscopic management and outcomes of pregnant women hospitalized for nonvariceal upper GI bleeding: a nationwide anal‐

[33] Russell MA, Craigo SD. Cirrhosis and portal hypertension in pregnancy. Semin peri‐

[34] Homburg R, Bayer I, Lurie B. Bleeding esophageal varices in pregnancy. A report of

[35] Lodato F, Cappelli A, Montagnani M, et al. Transjugular intrahepatic portosystemic shunt: A case report of rescue management of unrestrainable variceal bleeding in a

[36] Starkel P, Horsmans Y, Geubel A. Endoscopic band ligation: a safe technique to con‐ trol bleeding esophageal varices in pregnancy. Gastrointest Endosc 1998; 48: 212-4. [37] Dhiman RK, Biswas R, Aggarwal N, Sawhney H, Chawla Y. Management of variceal bleeding with endoscopic variceal ligation and N-butyl-2 cyanoacrylate: report of

[38] Iwase H, Morise K, Kawase T, Horiuchi Y. Endoscopic injection sclerotherapy for esophageal varices during pregnancy. J. Clin Gastroenterol 1994; 18: 80-3.

[39] Ghidirim G, Mishin I, Dolghii A, Lupashcu A. Prophylactic endoscopic band ligation of esophageal varices during pregnancy. J Gastrointestin Liver D. 2008;17: 236-7.

and Helicobacter pyleri infection. Int J Gynacol Obstetr 2002; 79:105-9.

nancy Gastrointest Endoscopy Clin N Am 2006; 16: 33-40.

nancy. J Reprod Med. 2008; 53: 347-51.

cy. Ann Intern Med 1993;118 (5):366-75.

Ann Intern Med 2010; 152(2): 101-13.

natol 1998; 22: 156-65.

ysis. Gastrointest Endoscopy 2010; 72: 954-9.

two cases. J. Reprod Med 1988, 33: 784-6.

these cases. Gastrointest Endosc 2000; 51: 91-3.

pregnant woman. Digestive and Liver Dis 2008; 40: 387-90.

of Gastroenterology:1994. 24-9.

53:6-13.

342 Endoscopy


[55] Godil A, Chen YK. Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. JPEN J Parenter Enteral Nutr 1998; 22: 238-41.

follow up of fetal outcome and with comparison to control groups. Dig Dis Sci 1996;

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 345

[70] Huang WS, Lin PY, Wang JY, Chin CC, Hsieh CC. Urgent colectomy and cesarean section of a pregnant familial adenomatous polyposis: a case report. Int J Colorectal

[71] Ishijima N, Ojima E, Tonouchi H, Suzuki H, Fukunishi S. Delivery of a normal new‐ born after intensive medical treatment for an acute exacerbation of ulcerative colitis

[72] Minter A, Malik R, Ledbetter L, et al. Colon cancer in pregnancy. Cancer control

[73] Mirza M S, Mulla M., Hall RI, Large bowel obstruction in pregnancy: a rare entity, an

[74] Seubert DE, Puder K, Goldmeier P, Gonik B. Colonoscopic release of the incarcerated

[75] Prather CM. Pregnancy-related constipation. Curr Gastroenterol Rep 2004; 6: 402-4.

[76] Rimensberger P, Schubiger G, Willi U. Connatal rickets following repeated adminis‐ tration of phosphate enemas in pregnancy: a case report. Eur J. Pediatr 1992; 151:

[77] Desmeules S, Bergeron MJ, Isenring P. Acute phosphate nephropathy and renal fail‐

[78] Vinod J, Bonheur J, Korelitz BI, Panagopoulos G. Choice of laxatives and colonoscop‐ ic preperation in pregnant patients from the viewpoint of obstetricians and gastroen‐

[79] Cappell MS, Fox SR, Gorrepati N. Safety and efficacy of colonoscopy during preg‐ nancy: an analysis of pregnancy outcome in 20 patients. J Reprod Med 2010; 55:

[80] Bashir RM, Montgomery EA, Gupta PK, et al. Massive gastrointestinal hemorrhage during pregnancy caused by ectopic decidua of the terminal ileum and colon. Am J

[81] Gonsoulin W, Mason B,Carpenter RJ. Colon cancer in pregnancy with elevated ma‐ ternal serum alpha-fetoprotein level at presentation. Am J Obstet Gynecol. 1990; 163:

[82] Rojansky, N. Shushan A, Livni N, et al. Pregnancy associated with colon carcinoma

[83] Van Voorhis, B, Cruikshank, D P. Colon carcinoma complicating pregnancy. A report

during pregnancy; a case report. Surg Today 1999; 29:1257-9.

unusual case. Arch. Gynecol. Obstet.2009; 279: 171-178.

terolgists. World J Gastroenterol 2007; 13 (48): 6549-6552.

overexpressing p53. Gynecol. Oncol. 1997; 64: 516–20.

of two cases. J Reprod Med. 1989; 34: 923–7.

gravid uterus. Obstet. Gynecol. 1999; 94: 792-4.

ure. N Eng J Med 2003; 349: 1006-7.

Gastroenterol 1995; 90: 1325-7.

41:2353-61.

Dis 2007; 22: 847-8.

2005; 12: 196-202.

54-6.

115-23.

1172–3.


follow up of fetal outcome and with comparison to control groups. Dig Dis Sci 1996; 41:2353-61.

[70] Huang WS, Lin PY, Wang JY, Chin CC, Hsieh CC. Urgent colectomy and cesarean section of a pregnant familial adenomatous polyposis: a case report. Int J Colorectal Dis 2007; 22: 847-8.

[55] Godil A, Chen YK. Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. JPEN J

[56] Serrano P, Velloso A, Garcia-Luna PP, et al. Enteral nutrition by percutaneous endo‐ scopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases.

[57] O'Connell MP, Wilson OF, Masson EA, Lindow SW. Pregnancy outcome in a patient

[58] Wejda BU, Soennichsen B, Huchzermeyer H et al. Successful jejunal nutrition thera‐ py in a pregnant patient with apallic syndrome. Clin Nutr 2003; 22: 209-11.

[59] Irwing PM, Howell RJ, Shidrawi RG. Percutaneous endoscopic gastrostomy with a jejunal port for severe hyperemesis gravidarum. Eur J Gastroenterol Hepatol 2004,

[60] Ceccaldi PF, Bazin A, Gomis P, et al. Persistent vegatative state with encephalitis in a pregnant woman with successful fetal outcome. BJOG. 2005 ; 112(6): 843-4.

[61] Senadhi V, Chaudhary J, Dutta S. Percutaneous endoscopic gastrostomy placement during pregnancy in the critical care setting. Endoscopy 2010; 42: E358-359.

[62] Pereira JL Velloso A, Parejo J, et al. Percutaneous endoscopic gastrostomy and gas‐ trojejunostomy. Experience and its role in domiciliary enteral nutrition. Nutr Hosp

[63] Saha S, Loranger D, Pricolo V, Degli-Esposti S. Feding jejunostomy for the treatment of severe hyperemesis gravidarum: a case series. JPEN J Parenter Enteral Nutr. 2009

[64] Belda O, Serrano P, Bozada JM, et aI. Percutaneous endoscopic gastrostomy. Reality in the intra and extra community clinical nutritional practice. Rev Clin Esp 2005; 205:

[65] Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endo‐ scopic gastrostomy (PEG) tube. A comprehensive clinical review. J Gastrointestine

[66] Siddiqui U, Proctor D.D. Flexible sigmoidoscopy and colonoscopy during pregnancy.

[67] Cappell MS, Sidhom O. Multicenter, multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up fetal outcome. Dig

[68] Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy dur‐

[69] Cappell MS, Colon VJ, Sidhom OA A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with

with chronic malnutrition. Hum Reprod 2000; 15: 2443-5.

Parenter Enteral Nutr 1998; 22: 238-41.

Clin Nutr 1998; 17: 135-9.

16: 937-9.

344 Endoscopy

1998; 13:50-56. .

33(5):529-34. .

Liver Dis 2007; 16: 407-18.

Dis Sci 1995; 40: 472-9.

Gastrointest Endoscopy Clin N Am. 2006; 16: 59-9.

ing pregnancy Gastroenterol Clin North Am 2003; 32: 123-179.

472-7.


[84] Woods, JB, Martin JN, Ingram FH, et al. Pregnancy complicated by carcinoma of the colon above the rectum. Am J Perinatol. 1992; 9: 102–10.

[102] Shelton J, Linder JD, Rivera-Alsina M. E., Tarnasky P.R. Commitment, confirmation, and clearence: new techniques for nonradiation ERCP during pregnancy. Gastroint‐

Endoscopy in Pregnant Patients http://dx.doi.org/10.5772/53242 347

[103] Gupta R, Tandan M, Lakhtakia S , et al. Safety of therapeutic ERCP in pregnancy-an

[104] Kahaleh M, Hartwell GD, Arseneau KO, et al. Safety and efficacy of ERCP in preg‐

[105] Tham TC, Vandervoort J, Wong RC, et al. Safety of ERCP in pregnancy. Am JGas‐

[106] Farca A, Aguilar ME, Rodriquez G, de la Mora G., Arango L. Biliary stents as tempo‐ rary treatment for choledocholithiasis in pregnant patients. Gastrointest. Endosc.

[107] Wagner L, Lester R, Saldana L. Exposure of the pregnant patient to diagnostic radia‐ tions: a guide to medical management. 2nd ed. Madison (WI): medical Physics Pub‐

[108] Campbell N, Sparrow K, Fortier M, Ponich T. Practical radiation safety and protec‐ tion for the endoscopist during ERCP. Gastrointest. Endosc 2002; 55: 552-7.

[109] Barthel JS, Chowdhury T, Miedema BW. Endoscopic sphincterotomy for the treat‐ ment of gallstone pancreatitis during pregnancy. Surg Endosc 1998; 12: 394-9.

[110] Shelton J, Linder JD, Rivera Alsina ME, Tarnasky PR. Commitment, confirmation, and clearence: new techniques for nonradiation ERCP during pregnancy. Gastrintest

[111] Oto A, Ernst R, Ghulmiyyah L, et al. The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreatobiliary diesase. The Br J Ra‐

[112] Einarson A, Bailey B, Inocencion G, et al. Accidental electric shock in pregnancy; a

[113] Roumieu F, Ponchon T, Audra P, Gaucherand P. Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences. Eur J Obstet Gyne‐

[114] Draganov P. The SpyGlass Direct Visualization system for cholangioscopy. Gastroen‐

[115] Uradomo L, Pandolfe F, Aragon G, Borum ML. SpyGlass cholangioscopy for man‐ agement of choledocholithiasis during pregnancy. Hepatobiliary Pancreat Dis Int

prospective cohort study. Am J Obstet Gynecol 1997; 176: 678-81.

indian experience. Indian J Gastroenterol 2005; 24: 161-3.

nancy. Gastrointest Endosc. 2004; 60: 287-292.

est. Endosc. 2008; 67: 364-368.

troenterol 2003; 98: 308-11.

1997; 46: 99-101.

lishing. 1997.

Endosc 2008; 67: 364.

diol. 2009; 82: 279-85.

col Reprod Biol 2008; 140: 141-2.

terol & Hepatol 2008; 4: 469-70.

2011; 10: 107-8.


[102] Shelton J, Linder JD, Rivera-Alsina M. E., Tarnasky P.R. Commitment, confirmation, and clearence: new techniques for nonradiation ERCP during pregnancy. Gastroint‐ est. Endosc. 2008; 67: 364-368.

[84] Woods, JB, Martin JN, Ingram FH, et al. Pregnancy complicated by carcinoma of the

[85] Chan, YM, Ngai SW, Lao T T Colon cancer in pregnancy. A case report. J Reprod

[86] Montes H, Wolf J. Cecal volvulus in pregnancy. Am J Gastroenterol. 1999; 94: 2554–6.

[87] Rausch, ME, Troiano NH, Rosen T. Use of neostigmine to relieve a suspected colonic

[88] Rozen, P., Schreiber, L. & Brazowski, E. Endometriosis, pregnancy, and colonoscopy.

[90] Kidd SA, Lancaster PA, Anderson JC, et al. A cohort study of pregnancy outcomes after amniocentesis in twin pregnancy. Pediatr Perinat Epidemiol 1997; 11: 200-13.

[92] Waterman M, Eliakim R. Capsule enteroscopy of the small intestine. Abdom Imaging

[93] Lawson M, Kern F, Jr, Everson GT. Gastrointestinal transit time in human pregnancy: prolongation in the second and third trimesters followed by postpartum normaliza‐

[94] Hogan RB, Ahmad N, Hogan RBIII, et al. Video capsule endoscopy detection of jeju‐ nal carcinoid in life threatening hemorrhage, first trimester pregnancy Gastrointest

[95] Glenn F, McSherry CK. Gallstones and pregnancy among 300 young women treated

[97] Amos JD, Schorr SJ, Norman PF, et al. Laparoscopic surgery during pregnancy. Am J

[98] Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during pregnancy. Arch Surg 1996;

[99] Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surv. 1998; 53: 566-74.

[100] Tang SJ, Mayo MJ, Rodriguez –Frias E, et al. Safety and utility of ERCP during preg‐

[101] Jamidar PA, Beck GJ, Hoffman BJ, et al. Endoscopic retrograde cholangiopancreatog‐

[96] Printen KJ, Ott RA. Cholecystectomy during pregnancy. Am Surg 1978; 44: 432-4.

[89] Entmann SS, Moise KJ. Anaphylaxis in pregnancy. South Med J.1984; 77: 402.

[91] Cragan JD. Teratogen update: metylene blue. Teratology 1999; 60: 42-8.

by cholecystectomy. Surg Gynecol Obstet 1968; 127: 1067-72.

colon above the rectum. Am J Perinatol. 1992; 9: 102–10.

pseudoobstruction in pregnancy. J Perinatol. 2007; 27, 244–6.

Med. 1999; 44: 733–6.

346 Endoscopy

Endoscopy 2003; 35: 975

2009; 34: 452-8.

Endosc 2007; 66: 205-7.

Surg 1996; 171: 435-7.

131: 546-50.

tion. Gastroenterology 1985; 89: 996-9.

nancy. Gastrointest Endosc 2009; 69: 453-61.

raphy in pregnancy. Am J Gastroenterol 1995; 90: 1263-7.


[116] Girotra M, Jani N. Role of endoscopic ultrasound / SpyScope in diagnosis and treat‐ ment of choledocholithiasis in pregnancy. World J Gastroenterol 2010; 16: 3601-2.

**Chapter 15**

**Endoscopy in Pregnancy**

Paul Mitrut, Anca Oana Docea,

http://dx.doi.org/10.5772/52550

**1. Introduction**

Cornelia - Daniela Calina and Liliana Streba

Additional information is available at the end of the chapter

women these risks have not been enough evaluated.

formed about the potential risks of sedation and analgesia.

type of annual investigation [3].

In most of gastrointestinal disorders, endoscopy has a major diagnostic and therapeutic role, but though its clinical efficacy and safety have been established, it is not that well known when performing it in pregnant patients, due to the potential harm of the foetus like hypo‐

Endoscopy is generally considered to be a low risk procedure, the most frequently being performed at the patient`s request in ambulatory but also in hospitals [1]. Nevertheless, the safety and effectiveness of gastrointestinal endoscopy in particular circumstances at the pregnant woman has not been yet well studied. During the pregnancy the risks for the fetus and mother are various and the magnitude of this risk is different, according to the trimes‐ ter. Taking into consideration the difficulties in the performance of those studies to pregnant

The main concern is the fetal safety and endoscopic medication and use of sedative and an‐ algesics represent a significant risk if they are not chosen properly. It is strongly indicated the presence of an anesthesiologist and an obstetrician, in selected cases when a pregnancyrelated complication is most probable. Before the procedure, the pregnant patient should be well evaluated by the gastroenterologist, anesthesiologist and obstetrician and should be in‐

Because of the fact that there are potential risks for the fetus and for the pregnant woman, the indications of endoscopy to pregnant women limit to superior gastrointesti‐ nal hemorrhages, dysphagia, uncontrolled nausea/vomits, rectal bleeding, diarrhea, bili‐ ary lithiasis or biliary pancreatitis [2]. For that matter, endoscopy for pregnant women is considered to be a very rare procedure; in USA only 19000 pregnant women do this

> © 2013 Mitrut et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

xia, teratogenesis, trauma, placental abruption or induction of premature labor.


**Chapter 15**

## **Endoscopy in Pregnancy**

Paul Mitrut, Anca Oana Docea, Cornelia - Daniela Calina and Liliana Streba

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/52550

**1. Introduction**

[116] Girotra M, Jani N. Role of endoscopic ultrasound / SpyScope in diagnosis and treat‐ ment of choledocholithiasis in pregnancy. World J Gastroenterol 2010; 16: 3601-2.

[117] Ryan ME. Endoscopic management of a pancretaic pseudocyst during pregnancy.

[118] Gyokores T, Topa L, Marton I, Pap A. Endoscopic cystogastrostomy during pregnan‐

Gastrointest Endosc 1992; 38: 605-8.

348 Endoscopy

cy. Gastrointest Endosc 2001; 53: 516-8.

In most of gastrointestinal disorders, endoscopy has a major diagnostic and therapeutic role, but though its clinical efficacy and safety have been established, it is not that well known when performing it in pregnant patients, due to the potential harm of the foetus like hypo‐ xia, teratogenesis, trauma, placental abruption or induction of premature labor.

Endoscopy is generally considered to be a low risk procedure, the most frequently being performed at the patient`s request in ambulatory but also in hospitals [1]. Nevertheless, the safety and effectiveness of gastrointestinal endoscopy in particular circumstances at the pregnant woman has not been yet well studied. During the pregnancy the risks for the fetus and mother are various and the magnitude of this risk is different, according to the trimes‐ ter. Taking into consideration the difficulties in the performance of those studies to pregnant women these risks have not been enough evaluated.

The main concern is the fetal safety and endoscopic medication and use of sedative and an‐ algesics represent a significant risk if they are not chosen properly. It is strongly indicated the presence of an anesthesiologist and an obstetrician, in selected cases when a pregnancyrelated complication is most probable. Before the procedure, the pregnant patient should be well evaluated by the gastroenterologist, anesthesiologist and obstetrician and should be in‐ formed about the potential risks of sedation and analgesia.

Because of the fact that there are potential risks for the fetus and for the pregnant woman, the indications of endoscopy to pregnant women limit to superior gastrointesti‐ nal hemorrhages, dysphagia, uncontrolled nausea/vomits, rectal bleeding, diarrhea, bili‐ ary lithiasis or biliary pancreatitis [2]. For that matter, endoscopy for pregnant women is considered to be a very rare procedure; in USA only 19000 pregnant women do this type of annual investigation [3].

© 2013 Mitrut et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

It is being performed during the pregnancy only when there are no other ways of diagnosis or therapy less invasive, the indications for the procedure are clear and as much as possible the gastroscopy should be postponed until third trimester.

be adopted the lying down position of the pregnant woman, position that was used in a nor‐ mal way for colonoscopy. For those grounds, the endoscopist must be accustomed with en‐ doscopic procedures to pregnant women and fully evaluate anatomic and pathological

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 351

Biliary oversaturation and biliary hypomotility are as well frequently seen as physiological modifications that appear during the pregnancy. Unfortunately, this can lead to the forma‐ tion of biliary sludge and biliary calculi, which at their turn can widen biliary colics, chole‐

Airway mucosa is edematiated during the pregnancy, showing a reduction of airways. Moreover, there is a compensatory increase of ventilation on each minute in order to answer to demands of maternal and fetal oxygen. Nevertheless, pulmonary capacity is reduced as a

As well, during the pregnancy there appear hemodynamic modifications. Cardiac frequency increases from 90 to 100 beats a minute. Systolic arterial pressure can increase. Pregnant women cannot often tolerate the supine position, especially after 30 pregnancy weeks, given

Endoscopy should be performed during pregnancy only when the indication for the proce‐ dure is clear and there are no less invasive or therapeutical diagnosis ways. In order to per‐ form this operation it is necessary the patient`s informed consent. It should be taken into account that the procedure should be postponed until second trimester. The specific indica‐

tions for endoscopy during pregnancy, as ASGE recommends are the following:

**•** preferably perform endoscopy during the second trimester of pregnancy

**•** use lowest effective dose of sedative drugs and of category A or B, if available

modifications of superior and interior gastrointestinal tract.

reduced arterial pressure because of big weight of the uterus.

**•** Severe or refractory nausea and vomiting or abdominal pain

**•** Biliary pancreatitis, choledocholithiasis, or cholangitis

Also, there are a few principles (ASGE) to respect:

**3. Endoscopy indications during pregnancy**

cystitis and even pancreatitis.

result of ascension of the diaphragm.

**•** Significant or continued GI bleeding

**•** Dysphagia or odynophagia

**•** Strong suspicion of colon mass

**•** Biliary or pancreatic ductal injury

**•** have a strong indication

**•** Severe diarrhea with negative evaluation

The safety of gastrointestinal endoscopy during the pregnancy was evaluated by Cappell et al [4] who performed esophago-gastro-duodenoscopies on a lot of 83 pregnant women and concluded on the fact that the procedure is safe and does not induce birth or congenital mal‐ formations. The same authors investigated the safety of sigmoidscopy to 46 patients and es‐ tablished the safety of the procedure to the pregnant women who had small gastrointestinal bleeding and avoided to induce early labor and the appearance of congenital malformations. Nevertheless, as a result of data which are rather limited and incomplete in what concerns the safety of the procedure, fetal risk to endoscopy in the pregnancy has not been complete‐ ly excluded. In that effect, in Qureshi`s work et al. which has been approved by the Ameri‐ can Society of Endoscopic Gastrointestinal Endoscopy (ASGE, 2005) there had been distinguished the principles that the doctor must comply with when he decides to make en‐ doscopies to a pregnant woman [5].

### **2. Physiological modifications in the pregnancy and the endoscopy**

Pregnant women are susceptible to gastrointestinal reflux disease, biliary tract complica‐ tions and gastrointestinal bleeding, thus needing to be performed upper endoscopy, ERCP or colonoscopy. For example, only in the United States, upper endoscopy was necessary in over 12,000 pregnant patients per year and colonoscopy or sigmoidoscopy in more than 6000 pregnant patients per year. ERCP is also needed, as cholelithiasis has a 12% incidence in pregnant patients. Latest studies suggest that, if having good indication (upper gastroin‐ testinal bleeding, refractory nausea or vomiting), upper endoscopy is relatively safe in preg‐ nant patients.

Increase in size of pregnant uterus determines the lift of stomach along with the modifica‐ tion of intra abdominal segment of esophagus that gets into the thorax. As a result it is being reduced the tonus of the inferior esophagian sphincter and increases intragastric pressure which predisposes to gastroesophageal reflux. Even if gastric volume and acidity of gastric juice does not modify during the pregnancy, the pregnant women show a regurgitating risk through the decrease of pressure barrier of inferior eshophageal sphincter. This risk justifies the pharmacological methods of reduction of gastric secretion. 50-80% from the pregnant women show "retrosternal burning-pyrosis" which is the clinical correspondent of gastroesophageal reflux. On those grounds, the pregnant women are considered as having a full stomach [6].

During the last months of pregnancy, the pregnant uterus modifies anatomic relations be‐ tween abdominal and pelvic organs. These modifications can extend the time of perform‐ ance of the procedure, they can increase the quantity of anaesthesic medicines that are being administered and the air quantity inoculated in order to facilitate the intraluminal visualiza‐ tion. In order to diminish the compression of vena cava by the pregnant uterus there should be adopted the lying down position of the pregnant woman, position that was used in a nor‐ mal way for colonoscopy. For those grounds, the endoscopist must be accustomed with en‐ doscopic procedures to pregnant women and fully evaluate anatomic and pathological modifications of superior and interior gastrointestinal tract.

Biliary oversaturation and biliary hypomotility are as well frequently seen as physiological modifications that appear during the pregnancy. Unfortunately, this can lead to the forma‐ tion of biliary sludge and biliary calculi, which at their turn can widen biliary colics, chole‐ cystitis and even pancreatitis.

Airway mucosa is edematiated during the pregnancy, showing a reduction of airways. Moreover, there is a compensatory increase of ventilation on each minute in order to answer to demands of maternal and fetal oxygen. Nevertheless, pulmonary capacity is reduced as a result of ascension of the diaphragm.

As well, during the pregnancy there appear hemodynamic modifications. Cardiac frequency increases from 90 to 100 beats a minute. Systolic arterial pressure can increase. Pregnant women cannot often tolerate the supine position, especially after 30 pregnancy weeks, given reduced arterial pressure because of big weight of the uterus.

### **3. Endoscopy indications during pregnancy**

Endoscopy should be performed during pregnancy only when the indication for the proce‐ dure is clear and there are no less invasive or therapeutical diagnosis ways. In order to per‐ form this operation it is necessary the patient`s informed consent. It should be taken into account that the procedure should be postponed until second trimester. The specific indica‐ tions for endoscopy during pregnancy, as ASGE recommends are the following:


It is being performed during the pregnancy only when there are no other ways of diagnosis or therapy less invasive, the indications for the procedure are clear and as much as possible

The safety of gastrointestinal endoscopy during the pregnancy was evaluated by Cappell et al [4] who performed esophago-gastro-duodenoscopies on a lot of 83 pregnant women and concluded on the fact that the procedure is safe and does not induce birth or congenital mal‐ formations. The same authors investigated the safety of sigmoidscopy to 46 patients and es‐ tablished the safety of the procedure to the pregnant women who had small gastrointestinal bleeding and avoided to induce early labor and the appearance of congenital malformations. Nevertheless, as a result of data which are rather limited and incomplete in what concerns the safety of the procedure, fetal risk to endoscopy in the pregnancy has not been complete‐ ly excluded. In that effect, in Qureshi`s work et al. which has been approved by the Ameri‐ can Society of Endoscopic Gastrointestinal Endoscopy (ASGE, 2005) there had been distinguished the principles that the doctor must comply with when he decides to make en‐

**2. Physiological modifications in the pregnancy and the endoscopy**

Pregnant women are susceptible to gastrointestinal reflux disease, biliary tract complica‐ tions and gastrointestinal bleeding, thus needing to be performed upper endoscopy, ERCP or colonoscopy. For example, only in the United States, upper endoscopy was necessary in over 12,000 pregnant patients per year and colonoscopy or sigmoidoscopy in more than 6000 pregnant patients per year. ERCP is also needed, as cholelithiasis has a 12% incidence in pregnant patients. Latest studies suggest that, if having good indication (upper gastroin‐ testinal bleeding, refractory nausea or vomiting), upper endoscopy is relatively safe in preg‐

Increase in size of pregnant uterus determines the lift of stomach along with the modifica‐ tion of intra abdominal segment of esophagus that gets into the thorax. As a result it is being reduced the tonus of the inferior esophagian sphincter and increases intragastric pressure which predisposes to gastroesophageal reflux. Even if gastric volume and acidity of gastric juice does not modify during the pregnancy, the pregnant women show a regurgitating risk through the decrease of pressure barrier of inferior eshophageal sphincter. This risk justifies the pharmacological methods of reduction of gastric secretion. 50-80% from the pregnant women show "retrosternal burning-pyrosis" which is the clinical correspondent of gastroesophageal reflux. On those grounds, the pregnant women are considered as having a full

During the last months of pregnancy, the pregnant uterus modifies anatomic relations be‐ tween abdominal and pelvic organs. These modifications can extend the time of perform‐ ance of the procedure, they can increase the quantity of anaesthesic medicines that are being administered and the air quantity inoculated in order to facilitate the intraluminal visualiza‐ tion. In order to diminish the compression of vena cava by the pregnant uterus there should

the gastroscopy should be postponed until third trimester.

doscopies to a pregnant woman [5].

nant patients.

350 Endoscopy

stomach [6].


Also, there are a few principles (ASGE) to respect:


the pregnancy, did not succeed to report any significant complication for those pregnancies [8]. Just as well, a series of groups from 10 medical centers reported an experience of 48 flex‐ ible sigmoidoscopies and 8 colonoscopies performed during the pregnancy [9] and dit not report any negative result that could affect the fetus and that could be assigned to those en‐

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 353

From the point of view of gestation development, fetal complications are: fetal abnormali‐ ties, labor induction, preterm labor that could be determined by endoscopic procedures, having the greatest risk to appear in the first trimester of pregnancy [10]. In general, the sec‐

Even if the studies that had been performed did not seem to indicate a negative result for the fetus and which could have been assigned directly to endoscopy, the procedure itself re‐ quires a great caution from the doctors. Endoscopy, which has a diagnostic or therapeutical role must be taken into consideration only when, without its execution, the risks are higher. General rules are to postpone the procedure until labor or at least after first trimester of pregnancy. Pre-procedure training of the pregnant woman must include a special examina‐ tion from the obstetrician and his availability in care of eventual complications. There will be monitored the fetal heart beats before starting the procedure that will be revaluated as

The risk of fetal hypoxy can be reduced through minimum sedation of the pregnant woman. The procedure is not performed with the mother in position of lying down, because the pregnant uterus can compress the aorta and/inferior vena cava that causes maternal hypo‐ tension and therefore it could interfere with the placental perfusion. Therefore it is advisable left lateral position. American Society for Gastrointestinal Endoscopy has recently published the guidelines that must be fulfilled for the endoscopy to pregnant women, based on availa‐

Fetal monitoring is made through the hearts beats with the help of a monitor and it allows to the doctor to detect any fatal suffering. This difficulty can be improved through the correc‐

In 2009 ASA and American College of obstetrics and gynecology (ACOG) issued a common statement regarding the endoscopic interventions performed during pregnancy [12]. The

**•** endoscopist must obtain a pre-operative examination together with the obstetrician be‐ fore performing each endoscopic procedure. This must be achieved no matter the gesta‐

**•** when the fetus is pre-viable, Doppler detection of fetal heart beats immediately before

**•** when the fetus is viable, continuous intra-operative monitoring of fetal heart beats and

The decision to use a monitor for fetal heart beats should be individualized, according to the

the presence of a gynecology surgeon is ideal, if it appears an emergency labor.

ond trimester is considered to have the lowest risk for endoscopic interventions.

doscopic procedures.

soon as possible after the completion.

ble data and the consent of specialist doctors [11].

tion of maternal hypoxy or hypotension.

document contains the following mentions:

and after the procedure is enough.

tion age of the fetus.

availability of resources.


The decision of performing an endoscopy to a pregnant patient must be taken by a team: obstetrician – endoscopist – anaesthesist, because there must be analyzed: the implications for the fetus, for the mother, the emergency of the situation and the possibility of therapeuti‐ cal alternatives in order to solve the issue in safety conditions or postponement after labor [7]. An obstetrician must be available during the procedure if there are complications related to the pregnancy.

### **4. Fetal and maternal risks in endoscopic explorations**

#### **4.1. Endoscopic risks for the fetus**

They can be: hypoxy given to oversedation, fetal hyperperfusion given to maternal position, teratogenity given to the medicines administration, uterine trauma along with the impact on the fetus through endoscopic trauma, preterm labor through uterine compression. That is why it is advisable to avoid the performance of endoscopies in first trimester, excepting clin‐ ical emergency cases.

Among these risks, potential risk to dermine a malformation in fetal development through pills administration, early labor or giving mechanical uterine trauma seriously need evalua‐ tion when it is being analyzed an endoscopic procedure to pregnant people. Moreover, med‐ ical and ethical problems require a reticence for doctors and pregnant people in what concerns endoscopic studies and require the patient`s informed consent. Fetal normal status must be confirmed before starting the endoscopy and it must be revaluated as soon as possi‐ ble after its completion.

There is no evidence that certifies increased fetal morbidity for pregnant women that are subject to endoscopic procedures in comparison with pregnant women that had not been subject at any investigations. On the contrary, a case control study that enclosed a number of 83 superior digestive endoscopies performed to pregnant women showed that there had not been any preterm labors and any new born children of these women had not different Ap‐ gar scores to birth in comparison with those women that had not performed these kind of investigations [4].

A survey performed by 300 specialist gastroenterologists doctors, which included informa‐ tion regarding 73 digestive superior endoscopies and 13 colonoscopies performed during the pregnancy, did not succeed to report any significant complication for those pregnancies [8]. Just as well, a series of groups from 10 medical centers reported an experience of 48 flex‐ ible sigmoidoscopies and 8 colonoscopies performed during the pregnancy [9] and dit not report any negative result that could affect the fetus and that could be assigned to those en‐ doscopic procedures.

**•** minimize procedure time

aortic compression

352 Endoscopy

to the pregnancy.

ical emergency cases.

ble after its completion.

investigations [4].

**4.1. Endoscopic risks for the fetus**

endoscopic procedure

**•** position pregnant patients in left pelvic tilt or left lateral position to avoid vena cava or

**•** presence of fetal heart sounds should be confirmed before sedation is begun and after the

The decision of performing an endoscopy to a pregnant patient must be taken by a team: obstetrician – endoscopist – anaesthesist, because there must be analyzed: the implications for the fetus, for the mother, the emergency of the situation and the possibility of therapeuti‐ cal alternatives in order to solve the issue in safety conditions or postponement after labor [7]. An obstetrician must be available during the procedure if there are complications related

They can be: hypoxy given to oversedation, fetal hyperperfusion given to maternal position, teratogenity given to the medicines administration, uterine trauma along with the impact on the fetus through endoscopic trauma, preterm labor through uterine compression. That is why it is advisable to avoid the performance of endoscopies in first trimester, excepting clin‐

Among these risks, potential risk to dermine a malformation in fetal development through pills administration, early labor or giving mechanical uterine trauma seriously need evalua‐ tion when it is being analyzed an endoscopic procedure to pregnant people. Moreover, med‐ ical and ethical problems require a reticence for doctors and pregnant people in what concerns endoscopic studies and require the patient`s informed consent. Fetal normal status must be confirmed before starting the endoscopy and it must be revaluated as soon as possi‐

There is no evidence that certifies increased fetal morbidity for pregnant women that are subject to endoscopic procedures in comparison with pregnant women that had not been subject at any investigations. On the contrary, a case control study that enclosed a number of 83 superior digestive endoscopies performed to pregnant women showed that there had not been any preterm labors and any new born children of these women had not different Ap‐ gar scores to birth in comparison with those women that had not performed these kind of

A survey performed by 300 specialist gastroenterologists doctors, which included informa‐ tion regarding 73 digestive superior endoscopies and 13 colonoscopies performed during

**•** obstetric support should be available in the event of a pregnancy-related complication **•** endoscopy is contraindicated in obstetric complications such as placental abruption, im‐

minent delivery, ruptured membranes, or eclampsia.

**4. Fetal and maternal risks in endoscopic explorations**

From the point of view of gestation development, fetal complications are: fetal abnormali‐ ties, labor induction, preterm labor that could be determined by endoscopic procedures, having the greatest risk to appear in the first trimester of pregnancy [10]. In general, the sec‐ ond trimester is considered to have the lowest risk for endoscopic interventions.

Even if the studies that had been performed did not seem to indicate a negative result for the fetus and which could have been assigned directly to endoscopy, the procedure itself re‐ quires a great caution from the doctors. Endoscopy, which has a diagnostic or therapeutical role must be taken into consideration only when, without its execution, the risks are higher. General rules are to postpone the procedure until labor or at least after first trimester of pregnancy. Pre-procedure training of the pregnant woman must include a special examina‐ tion from the obstetrician and his availability in care of eventual complications. There will be monitored the fetal heart beats before starting the procedure that will be revaluated as soon as possible after the completion.

The risk of fetal hypoxy can be reduced through minimum sedation of the pregnant woman. The procedure is not performed with the mother in position of lying down, because the pregnant uterus can compress the aorta and/inferior vena cava that causes maternal hypo‐ tension and therefore it could interfere with the placental perfusion. Therefore it is advisable left lateral position. American Society for Gastrointestinal Endoscopy has recently published the guidelines that must be fulfilled for the endoscopy to pregnant women, based on availa‐ ble data and the consent of specialist doctors [11].

Fetal monitoring is made through the hearts beats with the help of a monitor and it allows to the doctor to detect any fatal suffering. This difficulty can be improved through the correc‐ tion of maternal hypoxy or hypotension.

In 2009 ASA and American College of obstetrics and gynecology (ACOG) issued a common statement regarding the endoscopic interventions performed during pregnancy [12]. The document contains the following mentions:


The decision to use a monitor for fetal heart beats should be individualized, according to the availability of resources.

### **4.2. Endoscopic risks for the pregnant woman**

Endoscopic risks for the pregnant woman can be:


Maternal hypotension appears through the compression of inferior vena cava and the reduc‐ tion of venous return. That is why there must be avoided the supine position during the procedures.

of teratogenity of medicines. It is very important that the doctor be familiar with the stages of fetal development and teratogenesis. At two weeks from the conception, embrionary cells are subject to the law "all or nothing". In this period the exposure to toxic drugs will lead either to a normal and healthy fetus or the embryo will not be viable. In the next eight weeks and until the second trimester it appears the difference of cells and organogenesis. At the moment, the exposure to teratogenic medicines will have as a result severe congenital mal‐ formations. In the second and third trimester the medicines can still generate fetal toxicity,

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 355

In order to classify their safety when using in pregnancy, drugs were divided by FDA into 5

**2.** category B - animal studies have revealed no evidence of harm to the fetus, but there are no adequate studies in pregnant women or animal studies have shown an adverse effect, but adequate studies in humans have failed to demonstrate a risk to the fetus; **3.** category C - animal studies have shown an adverse effect, and there are no adequate studies in pregnant women or no animal studies have been conducted and there are no

**4.** category D - studies in pregnant women have demonstrated a risk to the fetus (howev‐

**5.** category X - studies in both animals and humans have demonstrated evidence of fetal abnormalities; use is contraindicated in women who are or may be pregnant.

Because there are no well controlled studies regarding fetus safety when using pregnant pa‐

Most of the drugs used in pregnant patients sedation are category B or C. Category D drugs should be avoided and used only when the benefit outweighs the risks, while category X it is not used at all. Sedation should be moderate or anxiolisis; in case of deep sedation is need‐ ed, it should be only under the surveillance of a specialised anesthesiologist. It should be used the lowest efficacious dose of sedation or, if possible, the endoscopy should be per‐ formed without any sedation: most upper endoscopies and sigmoidoscopies can be accom‐

The most common medicines that are used for endoscopic sedation and analgesia are Meperidine, Fentanyl, benzodiazepines and Propofol. Meperidine (FDA category B) does not seem to be teratogenic. It is better than choosing Fentanyl during pregnancy. Fentan‐ yl (FDA category C) as well, can be relatively safe in small doses, but there are few available data referring to its safety. The use of some benzodiazepines (FDA category D)

The use of Diazepam is not recommended during pregnancy. The use of Diazepam dur‐ ing pregnancy had been associated with split of the hard palate to new born infants, ac‐ cording to some old studies [15] but other two meta-analyses did not succeed to confirm

tients sedation in endoscopy, no drug was classified as category A by the FDA.

**1.** category A – defined as adequate and well controlled studied in pregnant women;

especially from the neurological point of view.

adequate studies in pregnant women;

plished without sedation.

is not yet controversial.

er, the benefits of therapy may outweigh the risk);

categories:

Compression of abdominal organs by the pregnant uterus can modify the digestive lumen and therefore the duration of endoscopy can be extended, and for the vizualization it is nec‐ essary a higher amount of air breathed, the endoscope can jump-up (especially to colonos‐ copies) and it can appear an abdominal dystensia accompanied by a discomfort of the pregnant woman.

Endoscopy for pregnant women is made only in carefully selected cases. It can't be made an endoscopy in case of an imminent abortion or if there are some obstetrical problems. The procedure is better performed during day in a specialized endoscopy office. It can be admin‐ istered oxygen, but it is not compulsory.

### **5. Sedative medication used for endoscopy in pregnancy**

As well the mother and the fetus are subject to some potential risks in case of endoscopic sedation. These risks vary according to pregnancy trimester.

Sedative and analgesic agents should always be used in that smaller dose in order to mini‐ mize the potential risk of teratogenic effects. The highest risk for the fetus takes place during the first trimester when it is the most vulnerable to possible teratogenic effects.

As there are no well controlled studies regarding the safety of the fetus towards the pharma‐ cological agents that are used for sedation in the pregnant women endoscopy, no medicine has been framed by FDA in class A, without teratogenity [13].

Data for safe medicines, not teratogenic, are reduced, because the clinical studies to preg‐ nant women are very rarely performed, they are expensive and require long term monitor‐ ing [14]. This point of view led to the recommendation of sedative medicines for endoscopy during the pregnancy in very small quantities and only if it is strictly necessary.

A good cooperation between the pregnant woman and gastroenterologist should bring to the performance of a fast endoscopic procedure, simple and without sedation. But most of them are made in emergency situations and with therapeutical intentions. In these situations it is necessary the sedation, and the endoscopist should consult with obstetrician doctor and with anasthesist about the anesthesic medicines, taking into account the FDA classification of teratogenity of medicines. It is very important that the doctor be familiar with the stages of fetal development and teratogenesis. At two weeks from the conception, embrionary cells are subject to the law "all or nothing". In this period the exposure to toxic drugs will lead either to a normal and healthy fetus or the embryo will not be viable. In the next eight weeks and until the second trimester it appears the difference of cells and organogenesis. At the moment, the exposure to teratogenic medicines will have as a result severe congenital mal‐ formations. In the second and third trimester the medicines can still generate fetal toxicity, especially from the neurological point of view.

**4.2. Endoscopic risks for the pregnant woman**

Endoscopic risks for the pregnant woman can be:

**•** precipitated aspiration through abdominal dystensia

**•** uterine trauma through the anatomic modification

procedures.

354 Endoscopy

pregnant woman.

istered oxygen, but it is not compulsory.

**•** hypotension through the compression of inferior vena cava

Maternal hypotension appears through the compression of inferior vena cava and the reduc‐ tion of venous return. That is why there must be avoided the supine position during the

Compression of abdominal organs by the pregnant uterus can modify the digestive lumen and therefore the duration of endoscopy can be extended, and for the vizualization it is nec‐ essary a higher amount of air breathed, the endoscope can jump-up (especially to colonos‐ copies) and it can appear an abdominal dystensia accompanied by a discomfort of the

Endoscopy for pregnant women is made only in carefully selected cases. It can't be made an endoscopy in case of an imminent abortion or if there are some obstetrical problems. The procedure is better performed during day in a specialized endoscopy office. It can be admin‐

As well the mother and the fetus are subject to some potential risks in case of endoscopic

Sedative and analgesic agents should always be used in that smaller dose in order to mini‐ mize the potential risk of teratogenic effects. The highest risk for the fetus takes place during

As there are no well controlled studies regarding the safety of the fetus towards the pharma‐ cological agents that are used for sedation in the pregnant women endoscopy, no medicine

Data for safe medicines, not teratogenic, are reduced, because the clinical studies to preg‐ nant women are very rarely performed, they are expensive and require long term monitor‐ ing [14]. This point of view led to the recommendation of sedative medicines for endoscopy

A good cooperation between the pregnant woman and gastroenterologist should bring to the performance of a fast endoscopic procedure, simple and without sedation. But most of them are made in emergency situations and with therapeutical intentions. In these situations it is necessary the sedation, and the endoscopist should consult with obstetrician doctor and with anasthesist about the anesthesic medicines, taking into account the FDA classification

**5. Sedative medication used for endoscopy in pregnancy**

the first trimester when it is the most vulnerable to possible teratogenic effects.

during the pregnancy in very small quantities and only if it is strictly necessary.

sedation. These risks vary according to pregnancy trimester.

has been framed by FDA in class A, without teratogenity [13].

In order to classify their safety when using in pregnancy, drugs were divided by FDA into 5 categories:


Because there are no well controlled studies regarding fetus safety when using pregnant pa‐ tients sedation in endoscopy, no drug was classified as category A by the FDA.

Most of the drugs used in pregnant patients sedation are category B or C. Category D drugs should be avoided and used only when the benefit outweighs the risks, while category X it is not used at all. Sedation should be moderate or anxiolisis; in case of deep sedation is need‐ ed, it should be only under the surveillance of a specialised anesthesiologist. It should be used the lowest efficacious dose of sedation or, if possible, the endoscopy should be per‐ formed without any sedation: most upper endoscopies and sigmoidoscopies can be accom‐ plished without sedation.

The most common medicines that are used for endoscopic sedation and analgesia are Meperidine, Fentanyl, benzodiazepines and Propofol. Meperidine (FDA category B) does not seem to be teratogenic. It is better than choosing Fentanyl during pregnancy. Fentan‐ yl (FDA category C) as well, can be relatively safe in small doses, but there are few available data referring to its safety. The use of some benzodiazepines (FDA category D) is not yet controversial.

The use of Diazepam is not recommended during pregnancy. The use of Diazepam dur‐ ing pregnancy had been associated with split of the hard palate to new born infants, ac‐ cording to some old studies [15] but other two meta-analyses did not succeed to confirm these results [16]. Midazolam has not been associated with fetal malformations, but its use must be avoided in the first trimester. The safety of Propofol (FDA category B) has not yet been established, but taking into account the short duration of action, with mini‐ mum secondary effects, it could be a drug of choice when it is necessary a more pro‐ found sedation.

**5.3. Naloxone (category B)**

**5.4. Flumazenil (category C)**

**5.6. Propofol (category B)**

**5.7. Simethicone (category C)**

**5.5. Benzodiazepines (category D)**

It doesn't seem to be teratogenic. It is contraindicatedin mothers who are dependent on opi‐ ates because it may precipitate opiate-withdrawal symptoms. It is being used only in cases of respiratory depression, hypotension, or lack of response and under strict monitoring. It

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 357

It is a benzodiazepine antagonist, not very well studied, but it seems it might determine

**Diazepam** accumulates rapidly into fetal circulation after maternal administration and was associated with congenital defects in mice. As concerning the occurrence of similar anoma‐ lies in humans, opinions are divided. The data suggest that administration of diazepam in early pregnancy appears to be a risk factor, although using it during the second and third trimester could theoretically determine neurobehavioral disorders in neonates [25]. There‐

Midazolam is the most commonly used sedative for endoscopic procedures. Although it crosses the placentaandcanbedetected to the fetus, unlike diazepam, it is not concentrated in the fetal circulation and was not associated with congenital defects. However, belonging to benzodiazepines, it has the neonatal respiratory depressant potential. Therefore it should be used in small doses, with great care under the supervision of ananesthesiologist, when seda‐ tion with meperidineisin sufficient [26].A meta-analysis of studies on the risks of anesthesia for gastroscopies during pregnancy concluded that the only potential problem is a slight in‐ creased incidence of abortion in the first or second trimester of pregnancy[27]. It is not rec‐

Propofolis an increasingly used for endoscopy sedative drug, especially in the United States. It is short acting, with a much shorter recovery period than other sedative pharmacological agents[22]. However, following an arrow therapeutic index and potential respiratory de‐ pression, itis generally administered only by anesthesiologists. Gastroenterologists' medical societies have recommended that this agent should be reserved for deeper sedation and oth‐ er complicated clinical situations in a highly monitored for vital functions environment [23]. It is considered relatively safe for use during pregnancy, although few data are available re‐

It is frequently used in pregnant patients, with no reported addverse effects, but it is not ex‐

should be noted that there is a risk of resedation due to metabolising the drug.

fore, the conclusion is that diazepam should not be used during pregnancy.

neurobehavioral changes in rats if exposed to it in utero.

ommended during the first trimester of pregnancy [28].

garding its use in the first trimester of pregnancy[24].

tensively studied yet so it belongs to category C drugs.

In the first trimester endoscopic procedures must rather be achieved without sedation or by using Meperidine all alone. In the second and third trimester Meperidine remains the first choice drug, but little doses of Midazolam can be added according to needs.

If it is necessary a more profound sedation, it is recommended the examination with the an‐ aesthesist. The pregnancy in trimesters two and three represents a great challenge for endos‐ copies, taking into account the management of airways, sedation and monitoring cardiac and respiratory functions and the fluids balance. Approaching must be made by a team that includes the obstetrician, anaesthesist and the endoscopist working together in a hospital.

There are certain drugs commonly used in gastrointestinal endoscopy: meperidine, fentanyl, naloxone, benzodiazepines, pethidine, flumazenil, propofol, simethicone, glucagon, topical anesthetics, colon-cleansing agents that need to be discussed extensively, according to their category.

#### **5.1. Meperidine (category B)**

Of all opioidagonists that have teratogenic effects on animals, meperidine appears to be safe when being used for endoscopy in pregnant women[17; 18]. This is one of the standard drugs used for analgesia and sedation and is the preferred opiate during pregnancy. It does not cross the blood brain barriers or a pidasmorphineandis often used by obstetricians for analgesia during labor. However, using high doses close to birth time, may cause neonatal respiratory depression. Meperidine may also be responsible for transient fetal heart rate ab‐ normalities, but in the absence of other fetal changes it can not be considered an indicator of poor prognosis in this situation[19].

To obtain the minimum sedation effect during endoscopy in pregnant women it should be used the lowest dose, limited to a maximum of 75 mg meperidine during routine explora‐ tion. In case of occasional occurrence of respiratory depression or hypotension secondary to opiate use, there can be used rapid acting opiate antagonists such as naloxone (B category) [20]. It crosses the placenta shortly after administered to the mother and was not shown to be associated with teratogenicity. It is preferred compared to fentanyl and morphine.

#### **5.2. Fentanyl (category C)**

It is considered that fentanyl is a safe opiate when used in low doses if administered during pregnancy. It has a faster onset of action than meperidine and is generally indicated in preg‐ nant patients with a previous history of seizures. Although it was found as being embryoci‐ dal to rats, clinical experience in pregnant women was very similar to meperidine [21].

### **5.3. Naloxone (category B)**

these results [16]. Midazolam has not been associated with fetal malformations, but its use must be avoided in the first trimester. The safety of Propofol (FDA category B) has not yet been established, but taking into account the short duration of action, with mini‐ mum secondary effects, it could be a drug of choice when it is necessary a more pro‐

In the first trimester endoscopic procedures must rather be achieved without sedation or by using Meperidine all alone. In the second and third trimester Meperidine remains the first

If it is necessary a more profound sedation, it is recommended the examination with the an‐ aesthesist. The pregnancy in trimesters two and three represents a great challenge for endos‐ copies, taking into account the management of airways, sedation and monitoring cardiac and respiratory functions and the fluids balance. Approaching must be made by a team that includes the obstetrician, anaesthesist and the endoscopist working together in a hospital.

There are certain drugs commonly used in gastrointestinal endoscopy: meperidine, fentanyl, naloxone, benzodiazepines, pethidine, flumazenil, propofol, simethicone, glucagon, topical anesthetics, colon-cleansing agents that need to be discussed extensively, according to their

Of all opioidagonists that have teratogenic effects on animals, meperidine appears to be safe when being used for endoscopy in pregnant women[17; 18]. This is one of the standard drugs used for analgesia and sedation and is the preferred opiate during pregnancy. It does not cross the blood brain barriers or a pidasmorphineandis often used by obstetricians for analgesia during labor. However, using high doses close to birth time, may cause neonatal respiratory depression. Meperidine may also be responsible for transient fetal heart rate ab‐ normalities, but in the absence of other fetal changes it can not be considered an indicator of

To obtain the minimum sedation effect during endoscopy in pregnant women it should be used the lowest dose, limited to a maximum of 75 mg meperidine during routine explora‐ tion. In case of occasional occurrence of respiratory depression or hypotension secondary to opiate use, there can be used rapid acting opiate antagonists such as naloxone (B category) [20]. It crosses the placenta shortly after administered to the mother and was not shown to

It is considered that fentanyl is a safe opiate when used in low doses if administered during pregnancy. It has a faster onset of action than meperidine and is generally indicated in preg‐ nant patients with a previous history of seizures. Although it was found as being embryoci‐ dal to rats, clinical experience in pregnant women was very similar to meperidine [21].

be associated with teratogenicity. It is preferred compared to fentanyl and morphine.

choice drug, but little doses of Midazolam can be added according to needs.

found sedation.

356 Endoscopy

category.

**5.1. Meperidine (category B)**

poor prognosis in this situation[19].

**5.2. Fentanyl (category C)**

It doesn't seem to be teratogenic. It is contraindicatedin mothers who are dependent on opi‐ ates because it may precipitate opiate-withdrawal symptoms. It is being used only in cases of respiratory depression, hypotension, or lack of response and under strict monitoring. It should be noted that there is a risk of resedation due to metabolising the drug.

### **5.4. Flumazenil (category C)**

It is a benzodiazepine antagonist, not very well studied, but it seems it might determine neurobehavioral changes in rats if exposed to it in utero.

#### **5.5. Benzodiazepines (category D)**

**Diazepam** accumulates rapidly into fetal circulation after maternal administration and was associated with congenital defects in mice. As concerning the occurrence of similar anoma‐ lies in humans, opinions are divided. The data suggest that administration of diazepam in early pregnancy appears to be a risk factor, although using it during the second and third trimester could theoretically determine neurobehavioral disorders in neonates [25]. There‐ fore, the conclusion is that diazepam should not be used during pregnancy.

Midazolam is the most commonly used sedative for endoscopic procedures. Although it crosses the placentaandcanbedetected to the fetus, unlike diazepam, it is not concentrated in the fetal circulation and was not associated with congenital defects. However, belonging to benzodiazepines, it has the neonatal respiratory depressant potential. Therefore it should be used in small doses, with great care under the supervision of ananesthesiologist, when seda‐ tion with meperidineisin sufficient [26].A meta-analysis of studies on the risks of anesthesia for gastroscopies during pregnancy concluded that the only potential problem is a slight in‐ creased incidence of abortion in the first or second trimester of pregnancy[27]. It is not rec‐ ommended during the first trimester of pregnancy [28].

#### **5.6. Propofol (category B)**

Propofolis an increasingly used for endoscopy sedative drug, especially in the United States. It is short acting, with a much shorter recovery period than other sedative pharmacological agents[22]. However, following an arrow therapeutic index and potential respiratory de‐ pression, itis generally administered only by anesthesiologists. Gastroenterologists' medical societies have recommended that this agent should be reserved for deeper sedation and oth‐ er complicated clinical situations in a highly monitored for vital functions environment [23]. It is considered relatively safe for use during pregnancy, although few data are available re‐ garding its use in the first trimester of pregnancy[24].

#### **5.7. Simethicone (category C)**

It is frequently used in pregnant patients, with no reported addverse effects, but it is not ex‐ tensively studied yet so it belongs to category C drugs.

### **5.8. Glucagon (category B)**

It is a safe to use antispasmodic, especially in ERCP.

#### **5.9. Topical anesthetics (category B)**

Lidocaine is used to provide pharingeal anesthesia and it was reported as being safe to use even in the first trimester of pregnancy.

habits. Sigmoidoscopy is not causing congenital abnormalities and isn't inducing labor, all

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 359

**Colonoscopy** safety during pregnancy is not yet properly studied, thus guidelines are not available. It is recommended only for life-threatening situations. Maneuvers like placing the patient in the prone position or exerting external abdominal compression should be avoid‐

There can be used endoscopic videocapsules which offer theoretical advantages of gastroin‐ testinal mucosa inspection. They do not need sedation of the patient or mechanical pressure on the abdomen, but safety of their use during pregnancy is unknown. Originally designed to view the small intestine, a change in the original design is now available to inspect the esophagus. It remains to be seen if technical adjustments of this technology will allow future

Virtual colonoscopy by MRI is safer during pregnancy than using classic CT. Although still classified as "experimental", virtual technologies are increasingly used as a screening tool for colorectal neoplasia. However, its safety has not been studied in pregnancy al‐ though there are some reports showing the usefulness and lack of teratogenicity from ab‐ dominal MRI with gadolinium as contrast agent in different clinical situations during

Performing endoscopies in pregnant patients has not only to be done by a physician experi‐ enced in general gastroenterology and endoscopic procedures but also highly experienced in performing such procedures in pregnant women. It is not recommended for these endos‐ copies to be performed by a beginner, as they carry the unique issue of fetal safety. Endo‐ scopic interventions in pregnancy must be performed quickly and with caution. The endoscopist should always be prepared to discontinue the action at any time for safety rea‐ sons. An anesthesiologist and an obstetrician must be part of the working team, especially

A number of studies concluded that esophagogastroduodenoscopy and sigmoidoscopy are not contraindicated during pregnancy. If for instance significant upper gastrointestinal bleeding is suspected, emergency esophagogastroduodenoscopy should be performed. Sig‐ moidoscopy is to be considered when the pregnant patient is stabilized, and only if strong

**9. Nonendoscopic imaging modalities of the digestive tract during**

studies performed so far reporting delivery of healthy new borns at term.

ed, especially in the third trimester of pregnancy.

**pregnancy**

use for the colonas well.

pregnancy [30; 31; 32].

**10. Conclusions**

ready for emergencies.

indications for this procedure exist.

#### **5.10. Colon cleansing-agents**

Most of them are category C, due to lack of studies during pregnancy, and this is the case for PEG solutions (polyethylene glycol) and sodium phosphate solutions which can cause fluid disturbance. It is considered that for flexible sigmoidoscopy tap water enemas are sufficient.

#### **6. Endoscopy and variceal bleeding in pregnancy**

Variceal gastrointestinal bleedings during pregnancy are true emergencies. A delay in their treatment could lead to serious complications and even death of the mother and fetus. Ther‐ apeutic endoscopic procedures (sclerotherapy) are recommended as first line treatment. Ef‐ fectiveness and relative safety of these approaches during pregnancy is documented in the literature [29]. Octreotide is used to treat variceal bleeding but its safety in pregnancy has not been established.Non-variceal gastrointestinal bleeding were successfully treated with endoscopic therapy during pregnancy using an epinephrine injection plus either placement of hemostatic clips or thermo-coagulation.

#### **7. Endoscopic Retrograde Cholangiopancreatography (ERCP)**

It is strongly recommended to be performed by very well trained endoscopists and is indi‐ cated in pregnant patients with pancreatitis, cholangitis, choledocholithiasis (complicated with jaundice, impacted or not). If possible, ERCP should be postponed from the first tri‐ mester to the second in order to minimize irradiation's potential teratogenic effect. There should be used a lead shielding for the patient's abdomen, a guidewire as opposed to injec‐ tion of contrast and minimal use of fluoroscopy and spot radiographs.

### **8. Lower endoscopy**

It is indicated in important lower intestinal bleeding, severe unexplained diarrhea and colon neoplasm suspicion. Colorectal cancer screening or change in bowel habits are indications that may be postponed for the postpartum period.

Most of the studies specify **sigmoidoscopy** as a safely procedure during pregnancy (in sta‐ ble pregnant patients, having strong indication: sigmoid or rectal mass, severe diarrhea – prolonged and not responding to specific treatment, lower intestinal hemorrhage). It should be postponed until after birth for patients complaining abdominal pain or change in bowel habits. Sigmoidoscopy is not causing congenital abnormalities and isn't inducing labor, all studies performed so far reporting delivery of healthy new borns at term.

**Colonoscopy** safety during pregnancy is not yet properly studied, thus guidelines are not available. It is recommended only for life-threatening situations. Maneuvers like placing the patient in the prone position or exerting external abdominal compression should be avoid‐ ed, especially in the third trimester of pregnancy.

### **9. Nonendoscopic imaging modalities of the digestive tract during pregnancy**

There can be used endoscopic videocapsules which offer theoretical advantages of gastroin‐ testinal mucosa inspection. They do not need sedation of the patient or mechanical pressure on the abdomen, but safety of their use during pregnancy is unknown. Originally designed to view the small intestine, a change in the original design is now available to inspect the esophagus. It remains to be seen if technical adjustments of this technology will allow future use for the colonas well.

Virtual colonoscopy by MRI is safer during pregnancy than using classic CT. Although still classified as "experimental", virtual technologies are increasingly used as a screening tool for colorectal neoplasia. However, its safety has not been studied in pregnancy al‐ though there are some reports showing the usefulness and lack of teratogenicity from ab‐ dominal MRI with gadolinium as contrast agent in different clinical situations during pregnancy [30; 31; 32].

### **10. Conclusions**

**5.8. Glucagon (category B)**

358 Endoscopy

**5.10. Colon cleansing-agents**

**5.9. Topical anesthetics (category B)**

even in the first trimester of pregnancy.

It is a safe to use antispasmodic, especially in ERCP.

**6. Endoscopy and variceal bleeding in pregnancy**

of hemostatic clips or thermo-coagulation.

that may be postponed for the postpartum period.

**8. Lower endoscopy**

**7. Endoscopic Retrograde Cholangiopancreatography (ERCP)**

tion of contrast and minimal use of fluoroscopy and spot radiographs.

Lidocaine is used to provide pharingeal anesthesia and it was reported as being safe to use

Most of them are category C, due to lack of studies during pregnancy, and this is the case for PEG solutions (polyethylene glycol) and sodium phosphate solutions which can cause fluid disturbance. It is considered that for flexible sigmoidoscopy tap water enemas are sufficient.

Variceal gastrointestinal bleedings during pregnancy are true emergencies. A delay in their treatment could lead to serious complications and even death of the mother and fetus. Ther‐ apeutic endoscopic procedures (sclerotherapy) are recommended as first line treatment. Ef‐ fectiveness and relative safety of these approaches during pregnancy is documented in the literature [29]. Octreotide is used to treat variceal bleeding but its safety in pregnancy has not been established.Non-variceal gastrointestinal bleeding were successfully treated with endoscopic therapy during pregnancy using an epinephrine injection plus either placement

It is strongly recommended to be performed by very well trained endoscopists and is indi‐ cated in pregnant patients with pancreatitis, cholangitis, choledocholithiasis (complicated with jaundice, impacted or not). If possible, ERCP should be postponed from the first tri‐ mester to the second in order to minimize irradiation's potential teratogenic effect. There should be used a lead shielding for the patient's abdomen, a guidewire as opposed to injec‐

It is indicated in important lower intestinal bleeding, severe unexplained diarrhea and colon neoplasm suspicion. Colorectal cancer screening or change in bowel habits are indications

Most of the studies specify **sigmoidoscopy** as a safely procedure during pregnancy (in sta‐ ble pregnant patients, having strong indication: sigmoid or rectal mass, severe diarrhea – prolonged and not responding to specific treatment, lower intestinal hemorrhage). It should be postponed until after birth for patients complaining abdominal pain or change in bowel Performing endoscopies in pregnant patients has not only to be done by a physician experi‐ enced in general gastroenterology and endoscopic procedures but also highly experienced in performing such procedures in pregnant women. It is not recommended for these endos‐ copies to be performed by a beginner, as they carry the unique issue of fetal safety. Endo‐ scopic interventions in pregnancy must be performed quickly and with caution. The endoscopist should always be prepared to discontinue the action at any time for safety rea‐ sons. An anesthesiologist and an obstetrician must be part of the working team, especially ready for emergencies.

A number of studies concluded that esophagogastroduodenoscopy and sigmoidoscopy are not contraindicated during pregnancy. If for instance significant upper gastrointestinal bleeding is suspected, emergency esophagogastroduodenoscopy should be performed. Sig‐ moidoscopy is to be considered when the pregnant patient is stabilized, and only if strong indications for this procedure exist.

Even if no definitive data exist at the present time, ERCP should be performed when the possibility for a sphincterotomy exists. It should only be attempted by highly trained per‐ sonnel, in a center with extensive experience and the resources to resolve all possible issues that may incur.

[8] Frank B. Endoscopy in pregnancy. In: Karlstadt RG, Surawicz CM, Croitoru R, eds. Gastrointestinal Disorders During Pregnancy. American College of Gastroenterolo‐

Endoscopy in Pregnancy http://dx.doi.org/10.5772/52550 361

[9] Cappell MS, Colon VJ, SidhomOA . A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups. Dig Dis Sci 1996;

[10] Gupta R, Tandan M, Lakhtakia S, Santosh D, Rao GV, Reddy DN. Safety of therapeu‐ tic ERCP in pregnancy-an Indian experience. Indian J Gastroenterol 2005; 24: 161-163.

[11] American Society for Gastrointestinal Endoscopy. Guidelines for Endoscopy in Preg‐ nant and Lactating Women. Gastrointestinal Endoscopy. Vol. 61, No. 3: 2005.

[12] American Society of Anesthesiologists (ASA) and the American College of Obstetri‐ cians and Gynecologists (ACOG) Statement on non obstetric surgery during preg‐

[13] Meadows M. Pregnancy and the drug dilemma. FDA Consumer Magazine, May–

[14] Powrie RO. Principles for drug prescribing in pregnancy. Editors: Rosene-Montella K., Keely E., Barbour LA., Lee RV. Medical care of the pregnant patient. 2nd ed. Phil‐

[15] Safra MJ., Okley GP., Association between cleft lip with or without cleft palate and

[16] Dolovich LR., Addis A., Vaillancourt JM., et al. Benzodiazepine use in pregnancy and major malformations or oral cleft: metaanalysis of cohort and case-control studies.

[17] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 7th ed. Philadelphia: Lippincott Williams & Wil‐

[18] Briggs GG, Wan SR. Drug therapy during labor and delivery, part 1. Am J Health

[19] Cunningham FG, Grant NF, Leveno KJ, et al. Analgesia and sedation. In: Cunning‐ ham FG, Grant NF, Leveno KJ, et al, eds. William's Obstetrics, 21st Ed. New York:

[20] Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy dur‐

[21] Martin LV, Jurand A. The absence of teratogenic effects of some analgesics used in anesthesia: additional evidence from the mouse model. Anesthesia 1992. 47: 473-6.

[22] Lazear SE, Course 1055: Moderate sedation/analgesia. CME resources. P. 44.

June 2001. Available at: www.fda.gov/fdac/features/2001/301\_preg.html.

prenatal exposure to Diazepam. Lancet 1975; 2: 478-80.

ing pregnancy. GastroenterolClin N Am 2003. 32: 123–179.

gy, 1994: 24–29

4: 2353-2361.

nancy 10/2009.

adelphia: ACP press. 2008.

BMJ 1998; 317: 839-43.

Syst Pharm 2006; 63: 1038–1047.

McGraw-Hill, 2001: 537–563.

kins, 2005.

### **Author details**

Paul Mitrut1 , Anca Oana Docea2 , Cornelia - Daniela Calina2 and Liliana Streba1\*

\*Address all correspondence to: lilianastreba@gmail.com

1 Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Romania

2 Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Romania

### **References**


[8] Frank B. Endoscopy in pregnancy. In: Karlstadt RG, Surawicz CM, Croitoru R, eds. Gastrointestinal Disorders During Pregnancy. American College of Gastroenterolo‐ gy, 1994: 24–29

Even if no definitive data exist at the present time, ERCP should be performed when the possibility for a sphincterotomy exists. It should only be attempted by highly trained per‐ sonnel, in a center with extensive experience and the resources to resolve all possible issues

, Cornelia - Daniela Calina2

1 Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Romania

2 Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Romania

[1] Mitruţ P., Mitrut Anca Oana, Streba Liliana, Calina Daniela, Salplahta D. Sedation re‐ lated to gastrointestinal endoscopy. In: Pascu O. (ed.) Gastrointestinal Endoscopy. In‐

[2] O'MahonyS. Endoscopy in pregnancy. Best Pract Res ClinGastroenterol. 2007; 21:

[3] Cappell MS. The fetal safety and clinical efficacy of gastrointestinal endoscopy dur‐

[4] Cappell MS, Colon VJ, SidhomOA . A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow up of fetal outcome with comparison control groups. A m J Gastroenterol

[5] Qureshi WA, Rajan E, Adler DG, Davila RE, Hirota WK, Jacobson BC, Leighton JA, Zuckerman MJ, Hambrick RD, Fanelli RD, Baron T , Faigel DO. American Society for Gastrointestinal Endoscopy. ASGE Guideline: Guidelines for endoscopy in pregnant

[7] Gilinsky NH, Muthunayagam N. Gastrointestinal endoscopy in pregnant and lactat‐ ing women: emerging standard of care to guide decision-making. Obstetrical & Gy‐

ing pregnancy. GastroenterolClin North A m 2003; 32: 123-179.

and lactating women. Gastrointest Endosc 2005; 6: 357-362.

[6] Acalovschi I, Anestezie clinică, Ed. Clusium Cluj Napoca, 2001.

necological Survey 2006; 61:791-799.

and Liliana Streba1\*

that may incur.

360 Endoscopy

**Author details**

, Anca Oana Docea2

\*Address all correspondence to: lilianastreba@gmail.com

Paul Mitrut1

**References**

Tech, 2011; 3: 23-44.

1996; 9: 348-354.

893-899.


[23] Augustyn D, Brill JV, Faigel D, et al. National Affairs: Three Gastroenterology Spe‐ cialty Groups Issue Joint Statement on Sedation in Endoscopy. March 8, 2004. Availa‐ ble at: www.acg.gi.org/members/nataffairs/trisociety.asp.

**Chapter 16**

**Modern Upper Urinary Tract Endoscopy**

Upper urinary tract endoscopy has come a long way from the first endoscopic examination performed in 1912 by Young and McKay. They used a 9.5 F rigid cystoscope in a patient with a very dilated ureter [1]. Current semi-rigid and flexible instruments are purposely de‐ signed to allow diagnostic and effective therapeutic interventions with minimal associated morbidity. The timeline of this evolution is perfectly described elsewhere [2].This chapter summarises the instrumentation available to the modern urologist, the basic principles be‐

This section will describe the endoscopes in modern use and the ancillary equipment we use for therapeutic indications. While some units still use a rigid ureteroscope these have been

The semi-rigid ureteroscope is the workhorse of endoscopic ureteric surgery. It was devel‐ oped from the larger rigid ureteroscope primarily because of concerns about the inability of the rigid scope to access the upper ureter without causing significant damage to the urothe‐ lium. The "flexibility" and reduced size are primarily due to the introduction of fibre-optics.

and reproduction in any medium, provided the original work is properly cited.

© 2013 Naidu et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

hind their use and the major clinical outcomes now expected from their use.

replaced in many units by semi-rigid and flexible ureteroscopes.

Maheshi Samaraweera and John G. Calleary

Additional information is available at the end of the chapter

Puru Naidu, Jessica Packer,

http://dx.doi.org/10.5772/52750

**1. Introduction**

**2. Technology**

**2.1. Endoscopes**

*2.1.1. Semi-rigid*

