Welcome to ASGE Endo Hangout for GI Fellows. These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Endoscopy in Pregnancy. My name is Michael DeLuttre, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit Return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now, it is my pleasure to turn over this presentation to our GI fellow moderators. Hi, everyone. My name's Hannah Systrom. I am a current third-year fellow at Dartmouth. Very excited to be here. I'm joined by Robin Jordan at Johns Hopkins and Crystal Mills at Mayo Clinic. We are the fellow moderators tonight. Very excited to have you all here. We are joined by four content experts tonight. Dr. Yakira David, who is an advanced endoscopist at the Mayo Clinic. Dr. Kush Bhugala, also advanced endoscopy at the Mayo Clinic. Dr. Shruti Mony, who is an advanced endoscopist and assistant professor of medicine at the University of Oklahoma. And Dr. Priya Samoas, who is an assistant professor and associate program director at Mount Sinai, New York. So I'll hand it over to Dr. David to kick things off. Good evening, everyone, and welcome to this evening's ASG's Annual Hangout. I want to say a sincere thank you to the ASG GI Training Committee for highlighting this as an important topic. So tonight, we're not going to talk just about pregnancy and endoscopy from the patient perspective, but also we're not going to neglect ourselves as we commonly do, but we're also going to speak about endoscopy and pregnancy from the perspective of the pregnant endoscopist. So without further ado, I'd like to introduce Dr. Priya Samoas, who will take us through her first presentation. Just for some basic housekeeping, we'll be doing the first two presentations, and then we can have a Q&A discussion after those two, and then we'll have the final two and a further Q&A discussion. Thank you. Thanks, Akira. Excited to be here today and to meet with all of you virtually. I am Priya Samoas, and I'm an assistant professor in the Division of Gastroenterology at the Icahn School of Medicine at Mount Sinai. I will be kicking off this evening's webinar. We're talking about general endoscopy and sedation in the pregnant patient. Just a few general principles of endoscopy in the pregnant patient. Always have a strong indication. So this is any procedure, really, but especially when you're doing endoscopy during pregnancy. Consult OB prior to the endoscopy and make sure that you have OB support during the case. Postpone endoscopy to the second trimester whenever possible. Use the lowest effective dose of sedatic medications and Category B drugs whenever possible, and minimize procedure time. So what are the indications for endoscopy in pregnancy? The most overwhelmingly, the most compelling indication is persistent or refractory GI bleeding that has not responded to conservative management. The next is refractory nausea and vomiting after you've sort of ruled out hyperemesis, treated medically, and still not been able to control the symptoms and they're resulting in electrolyte abnormalities and you really have to diagnose what is causing this. Dysphagia, if there is severe diarrhea with a negative medical workup, when there is a high suspicion for a colonic neoplasm, colodocal lithiasis or cholangitis, which Dr. Mone will talk more about, biliary or pancreatic duct injury, and when failure to do the procedure may harm the mother or the fetus. Contraindications are any kind of distress in the mother, so eclampsia, placental abruption, or when delivery is imminent with rupture of membranes or labor already underway. So a few things to consider. For the fetus, the fetus is exceptionally sensitive to maternal hypotension and hypoxia. Medications that you use and radiation exposure affect the fetus, and any endoscopy increases the risk of preterm birth. Another thing to consider is the physiologic changes in the pregnant patient. So we know that pregnancy brings its own share of physiologic changes, so we'll go through these system by system. So cardiovascular, there is an increase in cardiac output. So in the initial two months of pregnancy, there is an increase in resting heart rate, and then in the last trimester, there's really an increase in stroke volume because plasma volume has expanded so much. So that results in an increase in cardiac output. About 10% of the maternal blood flow is directed towards the uterus, towards the placenta and the fetus. There is a change to the respiratory system where there is increased oxygen consumption and minute ventilation, but there is also reduction in the functional residual capacity of the lungs, and that is because diaphragmatic excursion is decreased by the expanding gravid uterus. The airway changes. There is increased soft tissue in the neck. There's enlarged chest diameter, and sometimes there is laryngeal edema, making for a challenging airway. Hematology, so the blood volume increases, like I referenced earlier, by almost up to 35% in the third trimester of pregnancy, and as we all know, pregnancy is a known hypercoagulable state. The GI system, so there is upward and leftward displacement of the stomach by the gravid uterus, and there is decreased lower esophageal sphincter tone because of the effects of progesterone, as well as because of the pressure from the uterus and upward displacement of the esophagus, so both these things can result in increased aspiration risk, something to bear in mind when doing an endoscopy in a pregnant patient. So what should you do? So I divided this into pre-procedure, intra-procedure, and post-procedure just to make sure we cover everything that we should consider when scoping pregnant patients. So pre-procedure, like I mentioned before, consult OB and have them available for support. Like I said, any endoscopy can cause distress to the fetus and may precipitate delivery, so you wanna make sure you have strong obstetric support. You wanna confirm fetal heart rate with Doppler before and after sedation. Set up fetal heart rate monitoring, if available, and definitely this should be done after the age of viability, defined as 24 weeks, and consider that you may have to take additional precautions to prevent aspiration, and you may be dealing with a difficult airway. Intra-procedure, you wanna position the patient in the left lateral position with a wedge pillow under their right hip, and why is that? So this diagram sort of shows the way the gravid uterus rests on the great vessels, and when you look at it in the coronal section, you can see that when the patient is lying supine, there's almost complete compression of the aorta and the IVC, but when you move them to the left lateral position, that compression is much less. So this greatly affects hemodynamics because it changes the venous return as well as the output and the uterine blood flow. When you need to use cautery, remember that amniotic fluid, just like any other fluid, conducts current, so you wanna make sure that you're placing the grounding pad in such a way that the uterus is not between the source of current and the grounding pad. This means that the grounding pad shouldn't be placed on the side of the patient's body, but rather on the thigh below the level of the uterus. Use bipolar cautery whenever possible so that sort of straight currents do not pass through the amniotic fluid. And while it is safe to use current for something emergent like say a sphincterotomy, when you need to, anything that requires cautery that is elective and can be postponed to after the pregnancy should be. So something like a large polyp removal that requires cautery should be deferred to after pregnancy. Post-procedure, you wanna monitor uterine activity for contractions as well as fetal heart rate. You wanna make sure that the mother's provided with adequate analgesia, but avoid NSAIDs in the last trimester of pregnancy. And that is because they increase the risk of closure of the ductus arteriosus, that is the vessel in the fetus that connects the aorta and the pulmonary artery. And you wanna consider venous thromboprophylaxis if the patient is not gonna be mobile for a while because of the hypercoagulability of pregnancy. So what is the yield of procedures that we do during pregnancy? So let's start talking about endoscopy. So most of this data is old and based on retrospective studies, because as you can imagine, this is not something that people want to study or are comfortable studying. But really the largest study looked at 83 pregnant women who underwent endoscopy and used non-pregnant females as controls as well as pregnant women who didn't undergo EGD as controls. The median gestational age was about 20 weeks, so again, in the second trimester. And the diagnostic yield was pretty high, especially when acute GI bleeding for the endoscopy. So in 95% of cases, they found and treated the culprit lesion. The diagnostic yield was lower when it was another indication, but just sort of goes to show that if we do the procedure for the appropriate indication, we can change the outcome of the patient. 95% of these patients went on to deliver healthy babies. Nine of those infants were low birth weight, but EGD did not induce premature labor in any of those patients. And there was no increased risk of congenital malformations or differences in the APGAR scores of the infants that were born to those women. So what about colonoscopy? So much less studied than endoscopy. So this was the largest study that was a multi-center retrospective study looking at patients who underwent flex-sig and full colonoscopy. So there were 46 patients who had 48 flex-sigs, two had two procedures, don't ask me why, and then eight patients underwent eight colonoscopies. The indications, you can see the reasons for, so most, about 60% were done for hematochezia followed by diarrhea, abdominal pain, and then a host of other indications. The patients sort of went through these procedures equally divided between the three trimesters. Diagnostic yield was highest when the indication was rectal bleeding, but 60% of the procedures were actually diagnosed either new or reactivated IBD or some other colitis, which changed the way the patient was managed. Flexible sigmoidoscopy was not associated with induction of preterm labor or any fetal cardiac abnormalities. In the colonoscopy group, which was very small, just eight patients, six out of eight patients went on to deliver healthy infants but there was one fetal demise. So the conclusion that this study reached was that flexible sigmoidoscopy is safe, it does not induce premature labor, and should be done in patients with significant lower GI bleeding because it can change their management, but colonoscopy should really be reserved for those with life-threatening lower GI bleeding that cannot be treated with FlexSig. Okay, so let's talk a little bit about drugs that are used in pregnancy. So these are the traditional FDA drug classes that we are all sort of familiar with, and most of our drugs fall into category B or category C. So category B drugs are drugs where there is no evidence of risk in humans. That means studies in pregnant women have shown no risk despite animal studies possibly showing risk or animal studies have shown that there is no risk but there are no human studies. And category C is that risk cannot be ruled out, there is a risk in animal studies and human studies are lacking. You know, drugs that are category D and category X are almost never used, so we'll talk a little bit about which category our commonly used medications fall into. So the sedating drugs that we commonly used are the opioids. Memperidine or Demerol is really the preferred agent of sedation during pregnancy, and that is because it is the only category, it is the only opioid that is a category B. Naloxone, of course, is an opioid antagonist. All opioids have the potential to cross the placenta and cause respiratory depression in the fetus, but usually it is not very long-lasting. Propofol, which we use for the majority of our sedation is category B. Benzodiazepines are all category D with the exception of midazolam, and in general, benzos are contraindicated for sedation during pregnancy. Lidocaine, which is used sometimes as a topicalizing agent, is category B. And induction agents used for rapid sequence intubation, like rocuronium, vecuronium, and etomidate, cross the placenta, but they're rapidly metabolized by the fetus and haven't shown any harm to the fetus. So what about the other drugs that we use? So our PrEP drugs haven't really been well-studied, but polyethylene glycol PrEPs as well as sodium phosphate PrEPs have both been categorized as pregnancy class C drugs. Simethicone, which we sometimes use as a cleaning agent, is also category C, and glucagon, which we use for small bowel procedures, or ERCB, is category B. What about antibiotics? So in general, penicillin, cephalosporins, erythromycin, and clindamycin are safe to use in pregnancy. You want to avoid quinolones and tetracyclines. Don't think anyone uses streptomycin much anymore. And you want to avoid metronidazole in the first trimester because of the potential low risk of birth defects in the fetus. We'll switch gears a little bit and talk about lactation and endoscopy. So, you know, really the procedure itself carries no different risk for lactating women than for non-lactating women, with the exception of the sedating agents. So we want to talk about, you know, which agents, when we should interrupt breastfeeding, and when it is safe to continue. So more and more, I think anesthesiologists are realizing that telling patients to pump and dump is not really the standard of care, and the majority of patients can continue breastfeeding uninterrupted, but with a few exceptions. So midazolam, though it is excreted in very low quantities in breast milk, you know, the American Academy of Pediatrics does still recommend waiting four hours to feed. But again, you know, breastfeeding doesn't need to be interrupted for a prolonged period of time, just four hours, and then can be resumed. Fentanyl and propofol can both be administered without any interruption of breastfeeding. So the mother can, you know, breastfeed as quickly as like right after she's awake, after sedation, without any issues. Meparidine does hang around for longer, and is not the agent of choice in lactating women, because they do have to pump and dump after that. So use of an alternate agent, if available, is recommended. This table is from the ASGE Guideline for Endoscopy in Pregnant and Lactating Women, which is a wonderful resource, and I recommend everyone read it. But this is Antibiotic Safety in Breastfeeding. So similar to in pregnancy, penicillin, cephalosporins, erythromycin are safe to use. Tetracyclines are safe to use in breastfeeding. And then as in pregnancy, you want to avoid the quinolones and metronidazole, though the effect on the infant is not very well known. So in conclusion, when considering endoscopy during pregnancy, always have a strong indication for the procedure. So usually GI bleeding or refractory symptoms with a negative medical workup. Elective or semi-elective procedures should be postponed to the second trimester when possible. Have obstetric support before, during, and after the procedure. Proper positioning of the patient in the left lateral position minimizes hemodynamic effects. Be aware of the physiologic changes that occur during pregnancy. And consider the effect on the fetus and excretion in breast milk when you're choosing your antibiotic or anesthetic agent. That's all I have. So thank you. And I will hand over to Shruti, who will take the next part of this. All right, well, I was invited to speak on the topic of advanced endoscopy in pregnancy. And as we all know, this is a very important topic for all of us, specifically as women. And I think as a fellow, I recognize the importance of this topic, but having now experienced pregnancy myself, I have a much deeper appreciation for this and towards the gravity of this subject. So let's just delve right into it. And I have titled this as Approaching Gravity with Gravitas. I am one of the advanced endoscopists at the University of Oklahoma. I do not have any financial disclosures or conflicts of interest. A few things that we're gonna review today is just what is advanced endoscopy entailing pregnancy. There are a lot of advanced procedures that we pursue, but in pregnancy, it's very much limited and structured. And I'm gonna be focusing on ERCP in pregnancy and special considerations. And kind of like how Dr. Samois also alluded to, I'm gonna be breaking it down into pre-procedure, intra-procedure considerations, specifically looking at some technical factors, things we can do to avoid radiation and the outcomes of pregnancy. If time permits, we'll talk about a little bit about the emerging frontiers in pregnancy. I do wanna bring everyone's attention to what we have out there already. This is a very well sought out and collaborative effort by multiple gastroenterologists, OBGYNs and other physicians nationally who came up with this monograph. It was first formed in 1994 and updated in 2007. And over the last 15 years, there hasn't been any updates, although there have been a lot of changes in our literature and the pregnancy literature. And this was most recently done in 2022. So I would encourage everyone to read this. We also have guidelines of endoscopy in pregnant and lactating women, which is part of the ASGE, as well as the AGA practice update on pregnancy and related GI liver diseases. So a lot of resources for us to review. So what is the background of just advanced endoscopy in pregnancy in general, right? So advanced endoscopic procedures may occasionally be necessary during pregnancy. These include hepatobiliary procedures, such as choledocholithiasis, cholangitis, as some cases of biliary pancreatitis. Now, when you put pregnancy into the mix, you add an extra layer of complexity. And in addition to that, you not only are evaluating pregnant patients, you're also taking into consideration the fetus. So all in all, you wanna be very careful about the procedures and patients you choose, because not only do you have to follow these patients prior to pregnancy, you need to evaluate them during pregnancy and after delivery. And all in all, it is multiple things that are factors that we take into account for the pregnant patient. In advanced endoscopic procedures specifically, you think about radiation exposure, sedation risks, procedural modification, and procedural complications. And this is a true definition of multidisciplinary care where you're involving multiple subspecialties trying to ensure you're doing the right thing for the mother and the baby. So like I alluded to before, there are multiple advanced endoscopic procedures that you may need to do during pregnancy. Some of these are endoscopic ultrasound, ERCP, single balloon endoscopy or push endoscopy, endoscopic resection or ablation, and enteral sending. But the ones that we have data on so far and the ones which are true emergencies that we think would most likely harm the patient or the fetus is an ERCP just because of its risk of radiation exposure. So that's gonna be the focus of my talk today. So what do our guidelines tell us about ERCP in pregnancy? It says that based on the AGA practice update, ERCP during pregnancy may be performed for urgent indications. These include cholangitis, symptomatic choledocholithiasis, biliary pancreatitis in some cases, and some cases of bile leaks and pancreatic duct leaks. The right time to perform a ERCP is essentially the second or third trimester, but it does state that if deferring the procedure may be detrimental to the health of the patient and fetus, you do need a collaborative team approach to convene and decide on the feasibility and safety of the procedure. Since we're focusing on ERCP and its indications, it's important to understand the pathophysiology of gallstone formation. In general, we are at a disadvantage being females because of our hormonal changes that take place on a daily basis. But during pregnancy, that is heightened to a different extent. Like you can see in this pictorial representation, estrogen is responsible for increasing cholesterol synthesis, which results in cholesterol supersaturation and eventually gallstone formation. The gallbladder motility is also reduced due to this effect and the effect of progesterone being lesser. All in all, all of these lead to gallstone formation. During pregnancy, up to 30 percent of patients develop biliary sludge. Three to 12 percent of patients develop gallstones, and one in three percent may need a cholecystectomy in their first-year postpartum. I would like to divide ERCP during pregnancy into three buckets or baskets, so to speak. What are some of the things we could do pre-procedure to consider, including understanding the indications, informed consent, alternatives to the procedure, and a collaborative effort like we talked about. Intra-procedure considerations, including things that we could do during the procedure to try to minimize the risk, including patient positioning, sedation, technical aspects, as well as radiation exposure. Finally, focusing a little bit about what is the data on the maternal and fetal outcomes in pursuing this procedure. Coming to the pre-procedure considerations, we already talked a little bit about what are the indications, but in general, you want to limit ERCP only to urgent and emergent disease states. These include cholangitis, stone formation, some cases of biliary pancreatitis or bile duct or pancreatic duct injury. You do not want to be doing an ERCP if you have a low indication or a weak indication for the procedure, especially because they're pregnant. I really take this quote very seriously. This is by Dr. Peter Cotton, where he says that ERCP is most dangerous for people who need it least. And this is something that we follow for any patient undergoing ERCP, but this is very prevalent just for pregnancy itself. We always want to get an informed consent and talk to them about the risks that the patient would undergo, as well as the fetus. We want to optimize the use of imaging. And whenever possible, if we're able to avoid radiation, so do pursue imaging techniques such as ultrasound. Those are what is preferred. MRI can be performed without contrast, obviously. And you can do a CT scan as well whenever necessary, depending on the indication and the case. What can we do during the procedure? What are some of the considerations that we need to take into account during the procedure? And like Dr. Samoa has already alluded to, in pregnancy, you want to place the patient in the left lateral position, ideally in the second trimesters when you're performing these procedures. And the main reason, like we talked about earlier, was to prevent them from having hypotension due to the uterus compressing and the major blood vessels. The third trimester as well, you want to avoid the supine position. Not going to go into the details about sedation and the medications. We already covered that. But the principles are the same. In general, you want to have an anesthesiologist, an OB-GYN, an MFM specialist monitor you and talk to you collaboratively on which patient would be safest to undergo anesthesia. Propofol versus general anesthesia is dependent on a case-by-case basis. Glucagon is safe for use in pregnancy. And the grounding pad should be placed in the upper thorax away from the fetus. Radiation in pregnancy is a very important topic. And this is a whole different topic altogether. But in general, I think this is the part that everyone's highest concern about during pregnancy. And the reason being is that radiation itself is a carcinogen. And one sievert of radiation exposure in your lifetime has a 10% increased risk of cancer. And this is linear. And this increases with more exposure. And there's no real safe cutoff for radiation exposure. And that's why we need to do whatever we can to try to prevent this and follow the ALARA criteria, which is as low as reasonably achievable. And I think Dr. David would go into the details of radiation exposure. But in general, ERCP exposure for fetal dose is anywhere between 0.1 to 0.3 milligrams. And this is considered safe. This is well below the threshold. A triagenic dose is around 50 or greater. And that's when you need to avoid it, if possible. And the worst possible scenario, when you have detrimental effects to the fetus, is when it's greater than 100. So what can we do in our ERCP unit to minimize these risks? This is a pictorial representation of what our fluoroscopy equipment includes. And you can see here, there is a C-arm. There are monitors. There are different types of fluoroscopy units. But essentially, the most common ones have the X-ray emitter coming from the bottom of the unit and the image intensifier on top. And that's why you need to do whatever you can to minimize the risk. So what are some of the things you could do? You could use a columnator, meaning you always want to focus the X-ray beams into one specific area that you're working on during the ERCP procedure. You can avoid the total fluoroscopy time. You can avoid using magnification, continue taking films in spot sequences. Try to position the patient away from radiation. Always ensure that the patient's dust emitter is above the uterus. And the most recent guidelines and recommendations actually recommend no fetal or gonadal shielding. So switching gears to what are some of the procedural things we could do to try to minimize the patient's risk of radiation. So there are a lot of data that's come out specifically from Dr. Ben Muller's group, where they're shying away from using radiation for ERCP. And where it started off was this study where they did, in a single session, used endoscopic ultrasound to assess how many stones or blockages there were in the bile duct. And during the ERCP procedure, they performed it without fluoroscopy. And this was a case series of about 10 patients, 100% technical success, and zero adverse events in the pregnant patients. This is just a pictorial representation of what an EUS-assisted ERCP during pregnancy looks like. Here is an EUS image showing a stone in the bile duct. The bile duct's being cannulated. And I'm not sure if you can appreciate it on this image, but essentially, you're aspirating bile to confirm that you're inside the bile duct. And after you perform a sphincterotomy, this particular group used a basket to retrieve the stone and confirm duct clearance. This is further followed up by a prospective randomized trial, again, using EUS-assisted ERCP without fluoroscopy versus ERCP alone for bile duct stones. So a total of about 114 patients and around 56 patients in each group. And what they found was that in the no fluoroscopy group, successful bile recannulation was achieved in over 90% of the cases. And there was no significant difference between the two groups, including the total fluoroscopy time and the procedure time. This was another study that came out in GIE, which further talks about a different technique that you could use to pursue ERCP in a pregnant patient without using radiation. And essentially, it's using cholangioscopy with ERCP to achieve stone removal. And this was a study among 40 patients, and they achieved 100% success rate for cannulation with cholangioscopy and 100% stone clearance. Only one patient had pancreatitis as a result of this. So after we've talked about the pre-procedure, intra-procedure, what are some of the pregnancy and fetal outcomes and adverse effects? As we've alluded to before as well, there is not much data, and it's very hard to perform outcome-based studies on this patient population. But this was a systematic review and meta-analysis, including 27 studies and around 1,300 pregnant patients. And essentially, what they found was that ERCP is relatively safe on the fetus with no fetal or fetal congenital malformations or stillbirth. But overall, there was an increased risk of intrauterine growth restriction and preterm labor for all pregnant patients in general. The subgroup analysis further showed that in patients who had no radiation ERCP, they had lower rates of pancreatitis compared to those who had radiation. And the fetal outcomes were essentially non-superior in both groups. So overall, what this study concluded was that ERCP is safe in pregnancy. Radiation-free techniques do have some role and appear to reduce the rates of non-pregnancy-related complications, but not of fetal and pregnancy-related complications. This study further was done. This came out recently in the Digestive Disease and Sciences in 2023. And it is a propensity-matched analysis that was comparing the risk or the adverse events in the pregnant versus the non-pregnant population. And what they found was that in the pregnant population, they had a slightly higher risk of pancreatitis, of about 10%, compared to the controls, which was around 6%. But in their subgroup analysis, there was no significant difference in the pregnant versus the non-pregnant patients who have pancreatitis, whether it was related to stone formation or cholangitis. This was a readmission database study that was done in 2019, and essentially looking at how many pregnant patients came in with acute biliary pancreatitis and what affected their hospital length of stay, readmission rate, as well as outcomes. And what they found was that two out of the 10 pregnant patients with acute biliary pancreatitis were actually readmitted within 30 days. So that's around 16% of the patients. 50% of these were due to outcomes associated with acute biliary pancreatitis, so half of those patients. And pregnant patients are less likely to undergo lab cholecystectomy or ERCP. And they also found that conservative management was two times likely for early readmission within 30 days. So I would like to conclude by, you know, kind of summarizing everything we've seen so far. Although these studies are not well-validated and are retrospective in nature, can we avoid radiation altogether? That's, again, a different topic, but there are multiple studies that are emerging, and some of them include cholangioscopy-assisted ERCP for bile stones. This one came out last year in digestive endoscopy and essentially showed that without using radiation, you could still achieve successful cannulation, stone clearance with a low adverse event rate. Ductoscopy along the same lines is evolving. There are newer techniques, newer equipments, newer accessories that are coming out. And this is a seven French cholangioscope that you can see going all the way into the left intrahepatic duct. And this can be used in cases of cholangiocarcinoma or stricture, something that you can access otherwise. This is not available in the United States, but just something to keep in mind and think about. So I think I would like to conclude by saying that, in general, elective diagnostic and therapeutic advanced procedures should be avoided during pregnancy, and you only want to limit it to urgent and emergent procedures. Non-ionizing radiation imaging, such as ultrasounds, MRIs, all of those should be optimized during pregnancy, whenever possible. Indication for performing ERCP in pregnancy should be limited to urgent and emergent disease states, including choledocholithiasis, which are recurrent and symptomatic, cholangitis, and biliary pancreatitis. Always involve a multidisciplinary team, including perinatologist, radiation safety officer, an OB-GYN specialist, MFM specialist, and experienced endoscopist when reviewing all of these indications and treatments. The optimal time for these procedures is ideally during the second trimester, but if delaying the procedure can cause harm to the patient, then you should proceed with it, depending on what your multidisciplinary team decides. And if expertise is available, non-fluoroscopic ERCP techniques, like we talked about, EUS or cholangioscopy, should be considered to minimize fluoroscopy exposure. I would like to extend a special thank you to Dr. Kothari for her guidance, because she's published so much in this field, and the advanced endoscopy team at OU. Thank you. All right, thank you, Dr. Mone and Dr. Simoes for excellent presentations to start. We have a few questions in the chat. The first one came in after your presentation, Dr. Simoes. So how do you approach the risk versus benefit discussion for an acute GI bleed between endoscopy versus the radiation from a CT angiogram? Thank you, that's a good question. I think, you know, I think in general when consenting pregnant patients, it's important to sort of discuss the risks to the patient as well as potential risks to the fetus. And we have some data to show that, you know, endoscopy hasn't resulted in significant adverse outcomes to the fetus, whereas I think radiation in this case would be the greater risk, especially if there were two radiation exposures, both during a diagnostic study as well as during the actual therapeutic angiogram should it be needed. And I'm assuming, you know, if it was someone that you were scoping, you're planning to scope, it would be a fairly clinically significant GI bleed. So even to control it radiologically would require two sort of radiation exposures. And I think, you know, when you present it to the patient that way, just it's shared decision-making and, you know, kind of telling them that, you know, there's risk to you, there's risk to the fetus, and then these are the two different modalities and there's potentially, you know, double radiation exposure to the fetus if you choose to go the other route. There is of course, obviously the possibility that it is a bleed that cannot be controlled endoscopically and will require IR intervention and that would be really bad luck. But, you know, you could always... So I think presenting the options when you are taking your informed consent and sort of breaking it up into risk to the mother as well as risk to the fetus. Also discussing, you know, the timeline to achieving each of those treatment options and potential delays in care causing worsening hypotension which could also affect the fetus is also something that should influence the decision-making there. And Dr. Smith, just one follow-up, not from the chat, but just question about, you know, your experience. If you have ever thought about or have in your experience done like unsedated procedures for some of these patients like a FlexSig or a colonoscopy and if that's something that plays into your decision-making. I know you spent some time talking about some of the sedation parts. Yeah, you know, I think if Flexible Sigmoidoscopy for diagnosis say of someone you strongly suspect has new IBD and that's gonna change, you know, how you control the IBD before the baby is born and improve the health of the mother and therefore the fetus, then I think trying to approach FlexSig unsedated is probably the safest option. You know, I don't know that you can do an unsedated, completely unsedated colonoscopy or upper endoscopy. Patient tolerance probably wouldn't allow it. So I think whenever possible, minimal sedation and definitely unsedated FlexSig is something to consider if the diagnosis is gonna change the management. And there's a second question in the chat, I believe for Dr. Mone's presentation. Do you do sphincterotomy or sphincteroplasty for pregnant women and what goes into your decision-making? That's a good question. I think for pregnant women, I don't really have a set criteria, but essentially I do do a sphincterotomy because you're essentially trying to take the stones out. And it really depends on the indication. So if I feel that, you know, their vitals are tenuous and it's someone who's, it's a very quick procedure and they're not safe to undergo cautery, then I may just place a stent for cholangitis and bring them back after delivery when it's safer to do a more prolonged procedure and get the stones out. But if it's for a small stone and they're hemodynamically stable, then they should be okay getting a sphincterotomy procedure. A sphincteroplasty can also be done unless they have any contraindication for from an anticoagulation perspective. And Dr. Mone, do you think about ever when you're doing ERCP, I know you mentioned risk of post ERCP pancreatitis, do you ever think about putting in a pancreatic duct stent or like rectal endomethacin or those kinds of things, or is it different in pregnancy? Yeah, that's a very important point. I didn't cover it in my slides, but there isn't much data on rectal endomethacin used in pregnancy. And again, that's a very case dependent basis. They actually use endomethacin to decrease uterine contractions, so to prevent them from going into labor. And there are some studies that show that endomethacin can actually affect the fetus and cause growth retardation and all of those teratogenic effects. So given, although when we're doing it during ERCP, the dose is extremely, extremely small, there isn't much data to support its use. And because of what's out there right now with its risks, we actually prefer to avoid using it. We could consider giving lactated ringers as fluids and consider placing a pancreatic duct stent, just again, depending on their risks. The studies do show that the pancreatitis risk is higher, but I think we have to take everything that we read about with a grain of salt because their risk may be higher because of multiple reasons associated with what we're doing in the procedure. So I would not use reclindomethasin in a pregnant patient and I would consider using alternative methods to prevent pancreatitis. Thank you so much. I think we'll move on next to Dr. Khushbu Gala. Good evening, everyone. My name is Khushbu Gala. I'm an advanced endoscopy fellow at Mayo Clinic in Rochester. And my topic for today is ergonomics for the pregnant endoscopist. Before I start, I would like to thank the ASGE for the opportunity to discuss this very important topic that is often overlooked. Our learning objectives for today will include a discussion on musculoskeletal changes and issues in pregnancy, understanding ergonomics in endoscopy with a focus on the pregnant endoscopist, and discussing some common issues in pregnancy. So there's a growing number of female GI providers, close to 20% from a study in 2021. And recent data show that almost a third of GI fellows currently are women. The average age of most GI fellows is in their early 30s. And so we land into this modern day conundrum where training and early career often clash with prime time for pregnancy. This makes the issue of ergonomics during endoscopy even more important, as most of us have not yet perfected endoscopy or ergonomic practices in our early years. There's ample data looking at outcomes of pregnancy in physicians. A survey of 850 surgeons from 2021 showed that an alarming 42% of surgeons had experienced pregnancy loss, and especially had a higher risk of pregnancy complications if they were operating for more than 12 hours. In another survey, higher rates of infertility evaluation and treatment were seen in female physicians, along with higher rates of pregnancy loss and preterm birth. And unfortunately, even in 2025, due to systemic and societal failure, pregnancy leads to professional losses among female physicians, as was shown in this survey from 2023. To make a case for prioritizing ergonomics, let me first show you data on the physical toll of endoscopy. So the majority of GI providers spend more than 40% of their time performing endoscopy. And so obviously this is a very key part of most of our practices. A systematic review and meta-analysis from 2024 shows that there's an increased risk of multiple musculoskeletal complaints with endoscopy, including carpal tunnel syndrome, tenosynovitis, thumb, neck, and back pain. And this is not just a problem for older providers. There is a study from 2019, which shows that 20% of GI fellows have had endoscopy-related pain or injuries. Endoscopy results in musculoskeletal issues due to microtrauma, and this occurs from repetitive motions, prolonged awkward postures, and sustained high pinch forces. So what are the musculoskeletal changes and issues that occur in pregnancy? Pregnancy leads to a significant change in the center of gravity, causes weakening of the abdominal muscles, causes hyperlordosis and increased pelvic tilt. causes hyperlordosis and increased pelvic tilt. And all of these factors contribute to increased back strain. In addition, laxity of ligaments, weight gain, water retention and soft tissue edema, and loss of the medial foot arch all result in joint strain during pregnancy. And so major musculoskeletal issues in pregnancy are low back pain, pelvic girdle pain, knee and foot pain, carpal tunnel syndrome, and Beaker-Wayne's tenosynovitis. You may recall that all of these are also issues that are faced by endoscopists. And so especially having pre-existing injuries, these can be worsened during pregnancy. There is high quality data that show that shift work, long hours, prolonged standing and physical workload all increase adverse outcomes in pregnancy, including rates of preterm delivery, low birth rate, preeclampsia and miscarriage. A study that looked at more than 800,000 pregnant women showed that standing for more than two and a half hours per day increased the risk of preterm delivery and low birth weight. There's another study from 2019 that shows that working more than 55 hours a week results in poor pregnancy outcomes. And another study that shows that working more than 32 hours a week along with a high physical workload again leads to poor outcome. I chose to highlight these three studies because all of them are things that are common among GI physicians, especially those who are in training and those with endoscopy heavy practices. And so clearly there's a very real problem here. So let's move on to ergonomics and endoscopy. Ergonomics is the interaction of the endoscopist with the endoscope and the endoscopy unit. Ideally, the principle is that we should be designing the job to fit the individual instead of the other way around. Although we see every day in our endoscopy practices with the scopes that we use and the rooms that we work in, that this is not the case. And so in this situation, the goal of optimizing ergonomics is to minimize endoscopy-related injuries, optimize well-being, and maximize system performance. There are six fundamentals of endoscopy ergonomics and we'll go through all of them except for endoscope handling, which I will forego today in the interest of time. So starting with room setup, the first thing is getting the endoscopy tower in line with the orifice that needs to be intubated and then spend some time adjusting your monitor to an optimal position. I'm hoping that most of your endoscopy units have adjustable monitors. So ideally, your monitor should be about 20 centimeter lower than the height of the endoscopist and with the center slightly lower than the eye level. The ideal distance between the monitor and endoscopist has not been well-defined. It depends on the size of the monitor as well as the definition, but can be anywhere between 52 to 182 centimeters. Adjusting the height of the bed is also very important to decrease forward flexion or shoulder abduction. Ideally, it's supposed to be 10 centimeter below elbow height but this may have to be adjusted based on the pregnant abdomen as well. And then something very simple but that is often overlooked is that floor pedals for cotrie and water should be easily accessible. Some special considerations in pregnancy. So the first is use of a cushioned floor mat. This decreases foot and back strain and can be very helpful in pregnancy, especially for long days of scoping. In the latter stages of pregnancy, resting the abdomen on the bed can also help relieve some back stress. And lastly, there's a point to be made about seated endoscopy, which may be more comfortable, especially in the latter stages of pregnancy. Seated endoscopy is something that we are not very familiar with in the United States, but it is practiced more commonly in Asia. And there's one study from Japan that showed similar sacral incubation rates in endoscopists performing colonoscopy seated or standing, although there was a slight increase in procedure time. Moving on to ergonomic stance. So an ergonomic or athletic stance is very important for even weight distribution and avoiding excessive strain on any one joint. It includes a neutral neck and back position, even weight distribution between legs, avoiding knee hyperextension, having your shoulders back and chest out and feet hip-width apart. Moving on to personal accessories. So if anyone on the call is a runner or a hiker, they will know that personal accessories can be very helpful for prevention of injuries, and it is the same in endoscopy. Using cushioned shoes or insoles can help significantly with relieving foot strain. Compression stockings have evidence from randomized trials, which support improvement in pedal edema and circulation. And so these are helpful tools, especially in the latter stages of pregnancy. Graduated compression stockings are those that are tightest at the ankles and then gradually less tight. And these are the ones that are generally recommended. Finally, lead aprons should be two-piece to decrease back strain. And of course, there are special considerations for using of lead aprons and radiation in pregnancy, which we will hear about in the next lecture. Then coming to ergonomic timeouts and microbreaks. So these are useful tools to remind yourself and your team about optimal ergonomic positioning. Similarly, taking breaks, both during cases as well as in between cases, can help relieve hand and body strain. In pregnancy, it's more important than ever to take a break after standing for two hours or more to be able to combat some of the stress. And lastly, moving on to physical fitness. Physical fitness is very important for endoscopists in general and should be kept up during pregnancy. It is safe in most situations. And then general guidelines from obstetric societies recommend 30 to 60 minutes of exercise, perform three to four times per week in a temperature-controlled environment. Exercises in pregnancy should generally be limited to moderate intensity exercises. And I will note that even beyond the physical benefits, there are several benefits of physical activity during pregnancy, including decreased prenatal depression, anxiety, and stress, and improved quality of life. Some other ergonomic considerations in pregnancy in your office includes the use of office chairs with adequate back support, and then trying to limit the work week to 40 hours or least possible. And lastly, avoiding rotating shifts or overnight shifts to maintain sleep hygiene. Let's talk about some common complaints in pregnancy and how we can best mitigate them while working in the endoscopy unit. And so looking at symptoms by trimesters, in the first trimester, the predominant symptoms are nausea, vomiting, and fatigue. The first two can be particularly exacerbated in a room full of smells, such as what we are prone to working in. The second trimester is generally one where most women feel best. However, sometimes girt can be a concern. And in the third trimester, there are multiple factors that can be challenging while performing procedures, which includes frequent urination, lower extremity edema, overheating, carpal tunnel, and back pain. And so let's look at some tips and tricks for managing these symptoms. In the first trimester for nausea, using essential oils on your mask can help cover any odors and help with combating nausea. Using motion sickness bands can be very handy. And then keeping some snacks and snacks at hand like crackers can help prevent nausea. For both the first and the third trimester, trying to minimize call and if possible, discussing or reducing your procedural practices by one or two cases can be very helpful to accommodate for breaks. Now, the second trimester, just like Dr. Samois said, the second trimester is a great time to perform procedures on pregnant women. And it is also a good time to be an endoscopist performing these procedures. It's a good opportunity to make up for missed call weekends and for scheduling longer cases. In the third trimester, the major complaints of edema can be managed by using compression stockings like we discussed before. And don't be afraid of putting your feet up between cases. Overheating is a common symptom especially during the end of pregnancy. And so keeping your endoscopy room temperature on the cooler side can definitely help. For carpal tunnel syndrome, using wrist splints and stretching can be very important. And lastly, for back pain, stretching and yoga are very useful. And you also get maternity support belts of different levels of support that can actually also be prescribed. And so summarizing today's talk, there's a very real impact of endoscopy on physical health. And there is a very real impact of physical and mental stress on pregnancy. It can be very daunting to advocate for yourself, especially when you are a trainee or you're new in your practice. But remember to speak up when you need something because no one is going to speak up for you. And if you have any questions, please feel free to reach out to us. Remember that room setup of endoscopy is key along with being mindful of your own posture and performing ergonomic timeouts. Judicious use of personal accessories can be very helpful. And lastly, don't underestimate the importance of physical fitness in your practice. in your endoscopy and pregnancy journey. Thank you all, and happy to take questions after Dr. David's talk. Thank you, Dr. Gallo, for that great overview of endoscopy and pregnancy considerations for all of us. Now, I want to move on to an area that has often been a source of controversy and concern for a lot of female endoscopists for those going into advanced endoscopy. All right, at the end of this talk, I just want to go over a couple of relevant radiation definitions so that we can really appreciate the different risks that are associated or not associated with advanced endoscopy and being a pregnant endoscopist. I'll talk a little bit about the dose limits to monitor your exposure and different strategies for reducing exposure. So, as we were talking about recently, about 33.6% of GI fellows are female, but only 12.8% of advanced endoscopy fellows are female. And part of the reason for that is that there are a lot of perceived risks of radiation exposure, and that has shown itself to be a major deterrent for a lot of female fellows from pursuing advanced endoscopy. Now, the risks that people are concerned about are perceived and the fact is that we don't really get much training in radiation safety at all, either for ourselves or for the patient as a whole. So, what's the current National GI Society guidance for radiation safety in pregnant endoscopists? In the US, none of our societies actually have any formal guidance on radiation safety for pregnant endoscopists. We do a really good job about outlining how we should approach radiation exposure for our patients, but we've somehow not addressed that in ourselves as advanced endoscopists. Now, loosely, if we look at national regulations beyond GI, if you look at the recommendations from the CDC as well as the US Nuclear Regulatory Commission, they generally recommend following the ALARA principle, which is that occupational radiation doses should be as low as reasonably achievable, which is very vague and very open. If you look at our European colleagues, they don't have a guideline that specifically addresses pregnant endoscopists, but they have a guideline that overall addresses radiation safety within the endoscopy unit, and they have a paragraph that addresses pregnant endoscopists that says keep exposures below the permissible dose. What does that mean at all? What's considered a safe or permissible radiation dose? Before we go into that, I just wanted to talk a little bit about all of these different units that are used when we talk about radiation. So you would have heard about the unit called the gray, and that's the unit that we often see at the end of our endoscopy reports or at the end of our fluoroscopy report, and it says how many grays of radiation were used, and this is really a unit of how much ionizing radiation is absorbed by any object, regardless to what it is. Now, the sievert is a measurement of the amount of absorbed radiation, which is adjusted for a particular organ and the sensitivity of that organ to injury from radiation. The RAN is also another unit that measures the exact same thing as a sievert, but the conversion rate for that is one sievert is equivalent to 100 RAN. Now, another term that's often used when talking about radiation safety and occupational exposure is dose equivalent and total effective dose equivalent. Now, dose equivalent is a measure of the absorbed dose increase multiplied by a quality factor that's assigned to each particular organ, which is a reflection of how sensitive that organ is to damage from radiation exposure. Your total effective dose equivalent is the sum of the dose equivalent for external exposures as well as the calculated internal exposure as well, which is, again, based on the sensitivity of different organs to radiation exposure. When we look at what the limits are for different parts of the body, it's recommended that your total body exposure dose per year should be about 5,000, should be less than 5,000 millirems for the entire year. If we look at the embryo fetus of what we call a declared radiation worker, it's recommended that the exposure be less than 500 millirems per year, and these are just some of the other exposures, looking at the exposure to the skin and extremities and the eyes, what the recommended exposures are per year. Now, while these are the national regulations, your specific institution may have different cutoffs for appropriate dose exposures. More into detail about the fetal dose limits, as I mentioned, it's recommended that the exposure be less than 500 millirems for the entire gestational period, but in addition to that, it's recommended that this not be like a bolus dose exposure, but the dose over the entire course of the pregnancy should be relatively uniform, and it's recommended that per month, the exposure should not exceed more than 50 millirems when accounting for pregnancy being roughly 10 months if you divide it into four-week blocks. Now, if we look at the International Commission on Radiological Protection, they are actually a lot more conservative compared to the US regulations, and they recommend that over the entire pregnancy, the exposure should not exceed 100 millirems. What are the fetal risks of radiation exposure? So the dominant risks are usually at times when nobody else knows that you're pregnant and you may not be ready to declare your pregnancy as yet. Often some of these risks happen even before you know that you're pregnant. So within the first four weeks of pregnancy, the most, the highest risk is loss of pregnancy. And that occurs at radiation doses in excess of 100 to 200 millisieverts. Now, if we consider that the average ERCP exposure results in 0.002 millisieverts per ERCP, if you are appropriately shielded, that would require you doing about 50,000 to 100,000 ERCPs to reach that level of exposure. The next stage of pregnancy, which is the last, the 48-week stage, exposures of 200 to 500 millisieverts can result in growth retardation. Again, that would require you doing a lot more ERCPs than we likely will ever achieve, which is 100,000 to 250,000. Fetal malformations can also happen at this particular gestational period, if you have exposures of greater than 250 to 500 millisieverts. Between eight to 15 weeks, this is a time where the fetus is most sensitive to radiation injury. And the threshold at which injury can occur is the lowest at this time. And exposures of greater than 60 millisieverts to 500 can result in developmental delay. But again, the amount of ERCPs that you would have to perform are pretty high, which is in the range of 30,000 to 250,000. At less than 15 weeks, microcephaly is also another concern, but you require really high doses of radiation exposure for that to happen. So greater than 20,000 millisieverts and decreases in IQ can happen beyond this time. Radiation exposures of more than 100 millisieverts. So overall, the times that the gestational period at which it's most critical to ensure that you are appropriately shielded and minimize your radiation exposure generally are within the first trimester. And again, this is a time where you might not be ready to declare to anyone else that you're pregnant. So we're hopefully gonna give you some strategies to help reduce your exposure and your risk. How do we go about doing this? There are a couple of principles that we need to follow to reduce fetal radiation exposure. The first is instituting appropriate monitoring, shielding, as I was alluding to just now, having the right equipment to ensure that there's proper shielding, and then there's specific practices of the way that you perform endoscopy, similar to what you would do for a pregnant patient that are also applicable to reducing your risk and your fetuses' risk for radiation exposure. So each institution that you work at should have a radiation safety department. And it's helpful if you declare your pregnancy in writing to the radiation safety department, and each institution should have a protocol in place for that already. Now, declaration to the radiation safety department is optional, but the benefits of doing that by declaring you achieve declared pregnant radiation worker status. And what that means is that this mandates your institution to provide monthly reports on radiation exposure to your entire body risk, as well as fetal risk. And it also allows for the adjustment of responsibilities as needed to prevent exceeding the recommendation doses. Additionally, they are a phenomenal resource for providing you with guidance and literature on how to best protect yourself from radiation exposure. So it's really useful to declare to them. They should be mandated to keep this confidential if you're not ready for your supervisor or other staff members to know of your pregnancy. The first step in radiation dose monitoring is that you should be wearing two decimeters. The fist is externally at the level of the collar above the lead apron, and this gives a measure of your entire whole body dose exposure. And then the second should be worn under your lead at the level of the umbilicus, and this gives a measure of the fetal exposure. This likely still overestimates the fetal exposure because it does not account for attenuation from passage of radiation through the additional tissues in your body. In terms of shielding, we all should be wearing lead when we're doing procedures. During pregnancy, it's even more important that you are wearing appropriate lead. Now, not all lead is made equally. It's recommended that you use a two-piece wrap-around lead apron. The whole piece is easy to put on, but it often doesn't provide protection at the array. And then also, because of the weight of the lead, dividing it into two pieces helps redistribute that weight, both of your shoulders and your hips, as opposed to all of it weighing on your hips, on your shoulders, sorry. Now, lead comes in different thicknesses, and different thicknesses result in different levels of protection. It's recommended that in pregnancy, you should wear a lead that has a thickness of 0.5 millimeters in size, because that reduces the risk of the dose, it reduces the dose by 90% compared to what would be on the outside of lead. Now, most skirts that we wear for two-piece lead are actually 0.25 millimeters in thickness. So to achieve the 0.5 millimeter thickness, you actually have to have it wrap around you entirely and overlap in the front, ensure that the protection is actually 0.5 millimeters in thickness. Now, as your abdomen expands, the front of the lead skirt may not overlap completely. And to help reduce the exposure, you can also add a maternity apron, which is this basically like a half apron that has 0.5 millimeter thickness, and it's just in the front. And it has like a Velcro band that attaches it around, and it doesn't add too much weight to your overall lead apron outfit. Now, when you speak with a lot of women who have been in this radiation field, a lot of them talk about double leading, or wearing two sets of lead skirts. And to be honest, for my first pregnancy, I also did that because I didn't know any better, and I was scared. So there's no additional benefit to wearing two sets of lead to achieve a thickness of one millimeter in size, but it has been found that wearing two sets of lead does increase your risk of musculoskeletal injuries. So it's generally not recommended that you do so. Now, beyond the lead that you wear for personal protective equipment, your equipment should also have some shielding. So your typical fluoroscopy bed, a lot of fluoroscopy beds do not have lead skates around the edge, around the base of it. And it's really important that these beds are using 0.5 millimeter thick lead drapes, because again, this reduces exposure by 90%, and then further, when you wear your lead, that further reduces the exposure from radiation. Alternatives to using lead skates include these mobile plastic lead shields, which can also be used for shielding between the radiation source and the USC endoscopist. Additionally, it matters what kind of radiation source you have. So there are over-the-couch radiation units, which are like in this picture, deliver the radiation from above the couch, and then the image is captured below. The problem with these is that more radiation bounces off of the couch and the patient, and exposes the endoscopist, the increased head and neck exposure from radiation. It's generally recommended that under-the-couch units result in less radiation bouncing off and hitting the endoscopist, as most of it is reflected onwards and away from the endoscopist. And additionally, if you have lead skates around the bed, then all of that adds to reduction in the dose. A lot of us use mobile C-arms. It's overall found that the dose is 30% less with stationary units compared to mobile C-arm units. Now, after you've had appropriate monitoring and you have appropriate shielding, there are certain procedural practices, similar to what Dr. Mooney was discussing, that help reduce the amount of radiation that you're exposed to. The first thing is to really try to reduce your exposure time, and it procedures to the shortest duration possible. Not only the procedure, but the amount of time that you spend on the fluoroscopy pedal. There's often no need to have continuous writing of the fluoroscopy. A lot of things we can do by just getting still images and then conducting our maneuvers. For instance, balloon sweeps for stones. There's no need to watch that continuously on the fluoroscopy. Now, it also depends on who controls the radiation. So in some units, the endoscopist controls the radiation flow, exclusively, whereas there are other units where the fluoroscopy is controlled by a radiology tech. And one interesting study looked at a particular endoscopy unit, and it was found that when endoscopists controlled the fluoroscopy pedal, the radiation exposure was 26% less than when it was controlled by the radiology tech. So as far as possible, try to control your own fluoroscopy, because this will certainly reduce your exposure. Now, fluoroscopy is delivered in either continuous films or just pulse films. And it's found that pulsed films give you similar image quality, but significantly reduces your risk of exposure. Another factor that you can adjust on your CM or your fluoroscopy unit is the image rate. Now, every time you hit the fluoroscopy pedal, it takes a series of images per second. And you can adjust how many per second. And if you use 7.5 images per second, that's associated with a 70 to 80% radiation dose reduction compared to if you use 15 images per second. And overall, the quality of the images is not any more, it's not inferior. And it also doesn't result in any adverse patient outcomes. There's certain characteristics of the way that you capture your images as well that can help reduce your radiation exposure. And those include image collimation, as Dr. Mone had mentioned. But that basically means that instead of taking this big, wide picture when you're doing fluoroscopy, you can narrow the field of exposure to just focus on where you're working. And that helps reduce the amount of radiation that's utilized, as well as gives you a better image quality as well. You can also minimize the amount of magnification you use, because that increases radiation exposure. Using the highest voltage on your CRM as well helps improve the quality of your image while using less radiation. And using last image hold instead of spot images helps reduce your radiation exposure as well. What that means is that when we take fluoroscopy images, whatever was the last image that was on the screen, we can ask the radiation tech to save that image and that will go into your fluoroscopy catalog of images, as opposed to taking still x-rays, because that in itself requires a higher dose of radiation and is equivalent to three seconds of fluoroscopy. In summary, the highest fetal risk is between eight to 15 weeks, but it still requires a lot more radiation exposure than you would typically use if you are appropriately shielded. It's important to contact the radiation safety office early so that they can institute appropriate monitoring and adjust your work responsibilities if necessary to help reduce your risk of exposure. It's important to implement appropriate monitoring, again, to help you guide your practice moving forward during your pregnancy. As far as possible, we can try to follow the ALARA principle, which is the as low as reasonably achievable dose of radiation exposure. And that's achieved by using under-the-couch stationary x-ray sources, using appropriate equipment and personal shielding, using deliberate procedure modifications, all of which reduce your risk of exposure from fluoroscopy. And ultimately, it's important to note that with all of these steps, fluoroscopy can be performed safely for the duration of your pregnancy. Thank you. And now we'll be happy to take any questions about endoscopy in pregnancy from both a general GI and advanced endoscopy and radiation perspective. Thank you, Dr. David and Dr. Ghala for a thorough and insightful presentations. We have one question here for Dr. Ghala. Any specific brand of cushioned shoes that you recommend? And I guess you can extend that to both the pregnant and non-pregnant endoscopists. Yeah, that's a good question. I will start by saying that, you know, obviously there's a huge variety of brands out there in the market. Things that you should be looking for is good arch support. So what's important when you're standing all day is having good arch support, whether that means you're going to have a insole inserted into your shoe or whether you're gonna have a shoe that has a big cushion. And then a couple other things. One is, you know, looking for shoes that have a wider toe box. That also helps keep your feet comfortable. And then in cases of pregnancy, especially during the latter stages, you will find that maybe your shoe size goes up a little bit or at least you get a lot of swelling in your feet. And so sizing your shoes up can be helpful or at least trying to buy shoes maybe at the end of the day when your feet are at the most swollen can be a good tip to finding the right size. As to a particular brand, I'm not sure if I'm allowed to say that or not, but the one that I use is Hoka, which I find is a good brand, but there are several others that people use and they found helpful. And this is maybe for any of our content experts, but if you have been pregnant or have had kids, did you do any of these kind of accessories or think about things like belly belts or things like that kind of later in pregnancy? On the advice of my OB, I actually used a support belt for my second pregnancy and compression stockings. And I didn't use them for my first pregnancy because I was sort of skeptical and I did find them to be pretty helpful. So I would say, definitely consider using them. And then endoscopy centers started using cushion mats for everyone, like just providing them. So they were available, again, something I didn't have for my first pregnancy, but I had for my second pregnancy. And I did find that maybe the fatigue was a little bit, you know, less at the end of the day with using that. Yeah, I agree. I think I was probably like anyone else, very cautious in my first pregnancy because it's your very first time. So I did use a lot of accessories as well. And I found them helpful for my second pregnancy. I think I wasn't as cautious as my first one, but I think regardless in general, everything that we learned about today for ergonomics is a true problem. And it's something that I think even outside of pregnancy, we should continue to follow. So if it's anything that I took while I was pregnant was the fact that even outside of pregnancy, you could develop all of these complications and microtrauma and you need to just find a way to incorporate it in your daily life. Thank you. And I would add that the compression stockings or compression socks, I also endorse them for face trimester. Sometimes during face trimester, as you have increases in your plasma volume, your blood pressure tends to drop. You tend to have pooling in your legs as well, which can make you light headed during endoscopy. So having, wearing compression socks also helps really well in the face trimester, early face trimester, early second trimester as well as in the phase that we would expect it to. Great, thank you. And Dr. David, maybe this is more for you, but just thinking about how you mentioned, trying to limit your own radiation exposure as an advanced endoscopist, having been pregnant and had kids, did you change your practices at all in terms of your workload or like caseload? And how did you kind of navigate that at work? Well, I'm the only advanced endoscopist at bi-institution, so I didn't make any changes to the volume of cases at all. I was very mindful of how much fluoroscopy that I used for cases. So one of the things I didn't mention that is also really important to take note of is that as much as possible, utilize all the available non-invasive imaging that you have of your patient before to plan your procedures so you don't really need to rely as heavily on your cholangiogram, for instance, for determining the steps in your procedure. So I was just very mindful of that. Traditionally at my institution, the radiology tech controls the fluoroscopy, but as I was pregnant, I took over that responsibility exclusively so that I could directly control how much fluoroscopy was utilized. And Dr. David, on that note, you mentioned a significant number of endoscopists lacked formal radiation safety training. From your experience and the work you've done, is there anything kind of at institutional or societal level that we should be doing to increase this awareness? I think the time is ripe for us to actually have an AHV guideline on radiation practices as a whole in the endoscopy suite, and within that, build in a specific segment that focuses on pregnant endoscopists. So I think that's the first step of it. I have to say, I'm really appreciative of the ASG GI training committee for even considering this as a topic, because I think it allows us to reach fellows who are in the formative stages of their career and can continue these practices throughout and train those who are falling behind us. And so I think those are the main steps that we need to start taking. So I want to thank all of you for being part of this really important and wonderful discussion. I really learned a lot from everyone. Thank you to our fellow moderators as well for keeping this as an engaging discussion. And I'd like to hand this over, hand it back over to Michael, who has some announcements coming up on further ASG Hangout sessions. Thank you to our GI fellow moderators and to our content experts for tonight's amazing presentation. Before we close out, I want to let the attendees know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of ASGE events. The next end of Hangout session, Approach to Your First Job, will take place on Thursday, June 19th. It'll take place from seven o'clock to 8.30 p.m. Central Time. And again, registration is open. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we offer interactive sessions that fit your educational needs. As a reminder, ASGE trainee membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to sign up. In closing, thank you again to our presenters for this excellent webinar and thank you to our attendees for making this session interactive. We hope this information has been useful to you and with that, I will conclude this presentation. Have a wonderful night.

endoscopy in pregnancy

GI fellows

Michael DeLuttre

Hannah Systrom

Robin Jordan

Crystal Mills

Yakira David

Kush Bhugala

Shruti Mony

Priya Samoas

radiation safety

ergonomics for endoscopists