Our next presenter will be Dr. Jennifer Maronke. Dr. Jennifer Maronke is the Director of Endoscopy at Penn State Health Milton S. Hershey Medical Center and she will be presenting on the topic of endoscopy in pregnancy. And just again as a reminder to all, please submit your questions as they will be addressed after her presentation. Thank you. Thanks very much to the ASGE and to the course organizers for the invitation to be here with you today. This is my disclosure. This talk will discuss some pre-procedural considerations in the pregnant patient as well as specific procedural factors. We'll briefly discuss post-procedural management as well as and including lactation concerns. So endoscopy is justified when it's clear that failure to perform the procedure could expose the fetus and or the mother to harm. This is generally based on small studies which are retrospective in nature so we don't really have any good data about this. Endoscopy in a pregnant patient is inherently riskier. It's higher risk to the fetus because the fetus is more sensitive to fluctuations in blood pressure and maternal hypoxia. There's also a risk of teratogenesis from either medications or ionizing radiation and the risk of premature birth. These are the general indications for endoscopy in pregnancy. In the setting of significant or persistent GI bleeding, if there is severe or refractory nausea, vomiting, or abdominal pain, that's unexplained by other causes. If there is new onset of dysphagia or odynophagia suggesting an infectious component, these can all really impact the mother's ability to maintain hydration and nourishment and would be indications for endoscopy. Additionally, if there's a strong suspicion for colon mass or cancer, delaying the procedure until after childbirth would potentially put that mother in harm's way if there is a neoplasm because it may be diagnosed at a later stage or after it has metastasized and so it's important to pursue endoscopy in these situations. If there is the presence of severe diarrhea and the non-invasive workup to this point has been unrevealing, severe diarrhea can result in electrolyte abnormalities, dehydration, and put both the mother and the fetus at risk. And in the setting of biliary pancreatitis with a known stone, symptomatic choledocholithiasis or the presence of cholangitis. And additionally, if there's been any trauma or an injury to either the pancreatic duct or the bile duct, ERCP would be indicated. These are some of the general principles for endoscopy in pregnancy. It's important to consult with the obstetrician or the OB team pre-procedurally. So as soon as you're faced with a consult for potentially performing an endoscopy in a pregnant patient, the first step should really be, you know, get OB on board if they're not already. You want to have a strong indication, particularly in high-risk pregnancies. You want to have good justification for why this procedure could not wait. If it can wait at all, defer endoscopy to the second trimester whenever possible. And we'll get into that in a little bit. And also use the lowest effective dose of sedative medications, which we'll get into. Use category B drugs whenever possible. And be efficient in your care. Minimize procedure time. Make sure that you have your team assembled. Make sure that you have all the potential tools that you would need at the ready. Make sure that you have enough assistance in the room. This is not the kind of, you know, procedure that you want to spend more time than what's really absolutely necessary. You also want to position the patient in the left pelvic tilt or the left lateral position to avoid compression of the inferior vena cava or the aorta. In this diagram, you can see in the supine position, the fetus and the uterus are overlying the aorta and the IBC. And those can be compressed by the spine. In the lateral position, however, the fetus is pushed off over to the side, therefore minimizing any pressure on the IBC and aorta. And so you want to keep that in mind, especially in the second and third trimesters. Fetal heart monitoring will depend on the gestational age and resources available, which is, again, why it's important to consult with OB almost immediately because they'll make that determination. Typically, prior to 24 weeks gestation, you want to confirm heart rate presence by Doppler before and after sedation, and OB will do that. After 24 weeks, you want to have simultaneous electronic fetal heart and uterine contraction monitoring before and after the procedure. It's also important to remember that endoscopy is contraindicated in the setting of placental abruption. If the delivery is imminent, if there's ruptured membranes or uncontrolled eclampsia. Moving on to medication safety, there aren't any Category A medications for endoscopy. Typically, Category B and C are what's recommended. Sedation level should be anxiolysis or moderate sedation. So often, I think, you know, increasingly, many of us have gotten into the habit of deep sedation with endoscopy via propofol. But if we can get away with lighter sedation where there may be less fluctuations in heart rate and blood pressure, as well as oxygenation, that should be preferred. If you can, you know, in the setting of anxiolysis or even a transnasal endoscopy, if you can perform transnasal endoscopy with just topical lidocaine, that would also be safe in the setting of pregnancy. You want to use trained anesthesia for deep sedation. And also be aware that there's an increased risk of aspiration because of a variety of hormonal as well as just the size of the fetus within the abdomen and a difficult airway. There are some pregnancy-induced changes such as oropharyngeal swelling and decreased caliber of the glottic opening that may make the airway a little bit more difficult, yet another reason to keep the patient a little bit on the lighter side. It's very important to carefully monitor these patients during the procedure. This is a table of some of the commonly used medications in endoscopy. So miparidine or Demerol is a preferred narcotic, although it's not frequently used today. It is pregnancy Category B. Morphine is C and it does cross the fetal blood-brain barrier. Fentanyl is one of the more commonly used ones. It also is acceptable at a pregnancy Category C. It's short-acting and it hasn't been shown to be teratogenic, but it has been embryocytal in rats only. When given in low doses in humans, it appears to be safe. Naloxone is Category B. It should be used for respiratory depression, hypotension, or if the patient is unresponsive. Enzodiazepine are a pregnancy Category D, so we really want to use those with caution. Avoid the use of diazepam and also avoid midazolam. In the first trimester, it can be acceptable if you need to use it at other times. Little is known about the safety profile of flumazenil, but it appears to be relatively safe. And propofol is a Category B medication. It does, however, have a narrow therapeutic index, and when we're trying to avoid hypotension or hypoxia, we have to be very careful using it. You want to make sure that anesthesia is supporting you if propofol is being given, and its safety in the first trimester is unknown. Simethicone is probably safe. We don't have great data on the use of glucagon, but it is a Category B drug, as well as topical lidocaine. In terms of bowel preps, the safety of polyethylene glycol electrolyte isotonic cathartic solutions hasn't been studied. They are considered Category C and have been used throughout pregnancy without a lot of data suggesting that they are unsafe. There are sodium phosphate preps that are known to cause greater fluid shifts and electrolyte abnormalities, and so it's recommended that even though they are Category C, they should be used with caution. In our practice, if we needed to do a bowel prep on a pregnant patient, we typically err on the side of a PEG solution. Tap water enemas are also acceptable. If you can get away with just doing a flexible sigmoidoscopy, that would be another safe thing to do. In terms of procedural considerations, as I mentioned before, defer to the second trimester if possible because organogenesis has already occurred, and especially if you're using ionizing radiation, the fetus is most sensitive to that in the first trimester, in the first couple weeks of pregnancy. If your patient is in the second or third trimester, avoid the supine position. As I mentioned, you want to use the left lateral position. Place a pillow or a wedge underneath the patient's right hip to create that pelvic tilt, and you also want to consider elevating the head of the bed to help minimize the risk of aspiration. And again, continue with both patient and maternal fetal monitoring. In terms of what endoscopic procedures are safe in pregnancy, EGD has been shown to be safe and effective, and in a case control study of 83 patients, the diagnostic yield when you had one of those strong indications was actually quite high. Of those patients, there were no instances of premature labor or congenital malformations. There's very limited data on colonoscopy. Again, you want to avoid the prone or supine position late in pregnancy, and be very careful with abdominal pressure. If abdominal pressure is warranted during the procedure to advance the colonoscope, you want to apply minimally and away from the uterus. Moving on to other procedures that may be required during pregnancy, there is an increased incidence of gallstone disease. Pregnant patients are twice as likely as men to develop gallstones, and the risk increases with the number of pregnancies. There are several risk factors associated with the development of gallstone disease in pregnancy, including prior pregnancies, gallbladder disease history, BMI, and prenatal physical activity, as well as others. And these are some of the pathogenic pathways. Estrogen increases cholesterol production and decreases gallbladder motility. And then additionally, progesterone leads to decreased bile acid secretion and delayed gallbladder emptying. So that's a storm of factors that increase gallstone disease and the need for ERCP. So endoscopic ultrasound and ERCP are safe in pregnancy. When it's unclear or intermediate risk for colodocalothiasis that may be symptomatic, in our guidelines, we'll sometimes either do an EUS plus minus ERCP or pursue MRCP. And I would say when we're really trying to be as least invasive as possible, if you have MR capabilities, I would recommend opting for that rather than doing a diagnostic EUS to determine if there's a common bile duct stone. Again, if you're pursuing ERCP, you should have a strong indication. Those include symptomatic colodocalothiasis, cholangitis, biliary pancreatitis with a known stone, or trauma. And in these cases, the risks of delaying the procedure have been shown to be greater than the risks of the procedure themselves. You want to use an experienced endoscopist. If your hospital does not have an ERCPist who, you know, does a lot of cases, has a decent volume, then it may be reasonable to transfer that patient to a center that does routine ERCPs at a high volume center. You also want to have a multidisciplinary team that is, so OB services on site, as well as an anesthesia team that is familiar with dealing with the pregnant patient. You want to minimize procedure duration and ionizing radiation. We'll get into that a little bit. And again, the optimal timing is, again, during the second trimester. As I mentioned, the first trimester, the fetus is more sensitive to radiation, and there's a risk for spontaneous abortion, preterm birth, and low birth weights. So what about radiation exposure during ERCP? So the highest risk for the fetus is between the second and the 15th weeks of gestation, but we have found that exposure to less than 5 rad or 50 milligray has not been associated with adverse effects, and the average radiation exposure during an ERCP is anywhere from 0.01 to less than 6 milligray. Most exposure comes from scatter, and so on the right side here is a table of a couple of techniques to reduce radiation exposure. Again, it starts with a multidisciplinary team. You want to use a modern radiation unit that will allow for collimation, and this is very important. You know, we used to be taught to shield the patient, shield the patient's uterus, even for young women of childbearing age who are undergoing ERCP. We would put a lead apron, you know, underneath them to shield them, but with the modern ERCP machines, really what that lead does is it actually accentuates and magnifies the amount of radiation that's being emitted, and so the way around this is to really use tight collimation. I don't typically take a scout film. If I'm doing a pregnant patient, I get my scope in position, and then that's my first film will be that, and then I can collimate very narrowly right around my scope to where I need to get to. Use short taps of fluoroscopy. Avoid any kind of magnification. Place the patient as far from the radiation source as possible. Use your, I would say, you know, use your normal tools for your ERCP on a pregnant patient. You want to minimize catheter exchanges. The dosimeter, you want to put that above the expected uterine location so that you can measure time and radiation dose, and then you may, if you're comfortable, you may use a bile aspiration technique or a cholangioscopy if you have EUS and you're unsure about the presence of the stone or how many stones you can use those, but overall, I would say you'll be more efficient doing what you normally do, just keeping in mind you want to minimize procedure time and minimize radiation. If you are not accustomed to routinely using cholangioscopy, this is probably not the time to pull out the cholangioscope to try to determine how many stones are there and rely rather on your fluoroscopy. Additionally, if there's a ton of stones, it may be reasonable, depending on where the patient is in her pregnancy, to cut a good sphincterotomy, get out as many stones as you can, and potentially place a stent to try to minimize procedure duration and radiation time. Patient positioning, so for the first trimester, it's okay to keep the patient in the prone position. Left lateral is recommended for the second and third trimesters, and that will also change the way that the scope sits within the duodenum when you're doing your cannulation, so please be aware of this. Also, your normal X-ray view may be a little bit modified if you typically do either a supine or a prone ERCP, so be aware of that. Another important point is about bipolar electrocautery. It's safe, although the current will be conducted through amniotic fluid, so you want to position your grounding pad away from where the uterus is, and typically the right thorax in a left lateral position will be the best place. It's important to know and consent your patient on ERCP outcomes. The post-ERCP pancreatitis rate is actually quite high at 15 to 16% with an odds ratio of 2.8 compared to the general population. The reasons for this are likely multifactorial and not well-studied, but it is something that would behoove you to consent your patient for a higher risk of pancreatitis. A lot of times it doesn't make sense because the traditional teaching with rates of pancreatitis while a young woman may be at higher risk if there's a clear stone or a dilated bile duct, those would decrease the risk. But in the setting of pregnancy, there does appear to be a higher risk of pancreatitis. And now shifting to women who are breastfeeding. So those who receive midazolam infants should not be breastfed for at least four hours after maternal administration. It's recommended that after four hours, breast milk should be pumped and then discarded before reinitiating breastfeeding. In terms of opioids, fentanyl is preferred over Demerol because fentanyl does not significantly accumulate in breast milk and it may continue uninterrupted after maternal fentanyl administration. These are some of the medications that are used during endoscopy that may impact lactation. So we talked about midazolam, you want to withhold nursing for four hours and then discard. Fentanyl concentrations are too low to be significant, but it's okay to continue. Despite these both, actually all of them are excreted in breast milk, we're not really sure about the reversal agents. The paradine is concentrated in breast milk and it's also detected 24 hours post-administration, so it's recommended to avoid. Propofol achieves maximum concentrations about four to five hours later. The effects of oral consumption of propofol are not known, but it seems to be okay to continue breastfeeding. And in terms of antibiotics, penicillins and cephalosporins are okay, but it's recommended to avoid quinolones and sulfonamides. These are some additional resources. There's ASGE guidelines on this, even though they're quite old, they're still very pertinent. And the ACG also commissioned a monograph co-edited by Susie Cain, Shivangi Kothari, and Vivek Kaul that addresses a whole slew of issues in GI related to pregnancy. And there's also an ACG GI and pregnancy monograph podcast that was also enlightening. Thanks very much for your attention. Thank you. So the first question, should procedures, should we perform these procedures at facilities without OB coverage? I would really recommend you do not do that, because as I've mentioned, according to the guidelines and all of the data that we have, it's important to have a multidisciplinary team in place and having OB is critical to that. Then the next question, if you could clarify about the fetal monitoring, do you emphasize fetal monitoring irrespective of gestational age? So those, I defer those, the fetal monitoring to the OB team. And usually it is based on gestational age prior to 24 weeks. Oftentimes at eight weeks or 10 weeks, they won't even recommend fetal monitoring. But those are questions that I typically leave up to the OB team, which is another reason why a multidisciplinary team is critical. The next question is about the lead shield. Do you place a lead shield over the pregnant patient? And if you do, how do you do it? So we don't do that because it's been shown to actually increase exposure to radiation to the fetus. And so at our unit, we collimate the beam as much as possible. However, you should really check with your radiation safety team at your hospital to see what kind of C-arms or fixed floor tables you're using, because they're not all like that. And if your model is a little bit on the older side, you may need to still shield. Then the next question is about asymptomatic choledocholithiasis in a pregnant patient. When would you perform an ERCP in someone with an incidentally found choledocholithiasis? Well, I would counsel them on the symptoms of having a CBD stone, what they're at risk for, including gallstone pancreatitis and cholangitis. But I would not perform an ERCP unless they became symptomatic. The next question is about rectal NSAIDs for pancreatitis. Do you give rectal NSAIDs for pancreatitis in a pregnant patient? I generally don't, particularly in the third trimester, because NSAIDs are, I forget the pregnancy class of them, but it's not recommended, especially in the third trimester. So that may be another reason contributing to the higher rates of post-USP pancreatitis is that they're not generally given. This next question is about cholecystectomy, maybe a perspective from a GI. When would you give your input for a cholecystectomy in a pregnant patient if not acutely inflamed? So it really, I think that if they had symptomatic choledocholithiasis or cholangitis that we effectively treated with an ERCP, I would recommend close monitoring of that patient throughout the course of their pregnancy. And if they were to develop further symptoms of acute cholecystitis, then it may be unavoidable. However, with a good sphincterotomy, they may be able to get away with waiting until after delivery. Then the next question is about twins or triplets, multiple pregnancies. Is your advice the same? It is, but you really want to make sure you have a strong indication, because those are inherently higher risk procedures. The lateral, the left lateral position, the pelvic tilt is going to be even more critical because there's more volume and weight in there. The aspiration risk is going to be higher. Everything is really amplified and the risks are really amplified. And in that setting, absolutely having early involvement with the maternal fetal medicine team is going to be critical. And then the final question, which might be a lecture on its own, it's about the pregnant endoscopist. Oh, yeah, yeah. A recommendation from a general GI perspective, any sort of precautions that they would need when performing general GI procedures, and then from, in terms of like time off, and then from the interventional perspective, radiation safety and things of that sort. Yeah, I think that this is a whole other talk. And I toyed with adding a couple of slides to it at the end of my talk to discuss the pregnant endoscopist, but it really, you know, there's a lot of things to touch on. I think that for, you know, general endoscopy, I think it's important to focus on ergonomics. You want to have, you know, sturdy shoes. Your posture needs to be good. You need to stay well hydrated, frequent breaks, micro breaks, all of the things that we recommend for, you know, all of us for wellness, we should really be even more cognizant of the pregnant patient. You were, the patient, excuse me, the pregnant endoscopist, your ergonomics are going to change. Your center of gravity is going to change as you progress through your pregnancy. And so it's very important to be aware of all of that. I would also, you know, consult with your OB about, you know, how you're doing, how the baby's doing, and if it's okay to continue the physical strain of scoping through your pregnancy, because for some women, it's going to be okay. Some pregnancies are going to be okay. And then some pregnancies, it's going to get to the point where you're really putting yourself and your baby at risk. And so having, you know, close follow-up with your OB about these specific issues is very important. I think for the interventional endoscopist who's pregnant, it's often an individual decision. I don't think that there's data that say, you know, a pregnant endoscopist should not be exposed to, you know, to ERCP or do ERCP, because, you know, we're protected. We have, you know, well-fitting lead. You get a fetal, if you choose to be, if you're able to have the choice and you choose to be exposed to ionizing radiation through your pregnancy, you will have a fetal dosimeter that you wear underneath your lead, which is monitored not quarterly, but monthly. And, you know, I have gone through that, and my fetal dosimeter luckily was zero throughout my entire pregnancy, but I also had a lot of support at work. And so while I did routine cases, cases that I knew were going to require a lot of fluoroscopy, chronic pancreatitis cases, things like that, I had colleagues that would support me and do those cases to try to minimize my exposure and my baby's exposure. Other endoscopists prefer to avoid that part of their practice as much as possible. And I would say in the lifetime of, you know, your job as an endoscopist, it's really a small amount of time that you're out of the ERCP room. It really is an individualized decision. But if you do choose to, if you are scoping, you should at least protect yourself and your baby with well-fitted lead. The other thing is that at some point, you know, I had to switch from a two-piece to a one-piece because you really can't have that weight hanging off your belly, and sometimes even had to wear more. So you really need to stay in, you know, kind of a strong physical condition to be able to do that. Thank you, Dr. Moran. Sure.

endoscopy

pregnancy

GI bleeding

sedative doses

ERCP

medication considerations