Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

Table 1 General principles of endoscopic retrograde cholangiopancreatography during pregnancy

1. Counsel patient, husband, and family on risks vs benefits of ERCP for mother as well as fetus

2. Obtain written informed consent from pregnant patient (not the father)

3. Endoscopist should assess whether his/her experience and skill is adequate for dealing with anticipated biliary pathology in a pregnant patient with this medical history

4. Position patient on left side or supine, if possible, especially during advanced pregnancy

5. Preferentially perform ERCP during second trimester, if possible

6. During late third trimester, delay elective ERCP to after delivery

7. Use safety guidelines (see Table 2) to minimize fetal radiation exposure and risks

8. Consider performing EUS prior to ERCP to assess CBD diameter as well as number, size, and shape of gallstones

9. Multidisciplinary input involving a perinatologist, high-risk obstetrician, obstetric anesthesiologist, radiation safety officer, and surgeon prior to ERCP

10. Administer parenteral fluids consistent with clinical status and pregnancy requirements

11. Reverse metabolic derangements and appropriately intervene to correct abnormalities in vital signs before scheduling ERCP

12. Administer antibiotics and other drugs during ERCP that are considered relatively safe during pregnancy

13. Endoscopist should be familiar with and prepared to use full armamentarium of endoscopic techniques including needle-knife sphincterotomy, transeptal sphincterotomy, choledochoscopy, and IDUS

14. Counsel patients regarding requirements for follow-up visits, especially with stent placement

15. Avoid pancreatic endotherapy during ERCP because this entails a higher risk than biliary endotherapy

ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; CBD: Common bile duct; IDUS: Intraductal ultrasound.