Our next speaker is Anne-Marie Joyce, who's from the Leahy Clinic in Boston, and she's going to be talking about ERCP in Pregnancy. Thank you so much. Thanks for the invite to Linda and Uzma and the ASG Committee. Okay. I have no disclosures. So I just wanted to give a little background in terms of ERCP. So I did my fourth-year fellowship at Penn many years ago, and I stayed on as an attending for a short period of time. And I got called on Friday night by the surgeon, my first case, first on calls and attending. And he said, I have a pregnant female. Just took her to the OR. I just did her cholecystectomy, and I did an IOC, and she has 10 stones in her bile duct. So she was 20 weeks pregnant, and she was in neurology attending somewhere in the city. So this was my first, yeah, I didn't sleep that night. I came in the next morning to do the case, but, you know, so this was, yeah, my first. So everything went well, and the patient did fine. But I'm going to talk about in terms of indications and timing of ERCP, anesthesia, fluoroscopy, positioning of the patient, and I'm also going to talk about a little bit on the actual pregnant physician. All right. So why do women get gallstones in pregnancy? So during pregnancy, there's a higher level of estrogen and progesterone in pregnancy, which leads to this increased gallstone formation. And in terms of the estrogen, increases the cholesterol formation, and then decreases gallbladder motility. And then progesterone leads to decreased in the bile acid secretion, which helps to typically break down this cholesterol, and so therefore leads to stones. And again, there's a delayed in gallbladder emptying. And so in terms of as the pregnancy progresses, there's a higher risk of developing these stones, and so even up to about six weeks afterwards. And it's about probably at six weeks postpartum, there can be an increased risk of about 10% of getting stones. Thankfully only about 1% to 2% are symptomatic, and even a smaller number will have actually choledocholithiasis leading to cholangitis and pancreatitis. So the indications, as we've talked about all day today in terms of what is the indication for your CP, it doesn't really change in terms of a pregnant patient. So cholangitis, pancreatitis, obstructive dondus, bile duct injury. The only thing that changes is that we really need to do some type of testing to really have the most definite, definitive confirmation of the stone. So it's not like, well, I have a high suspicion. There should be like a 100% suspicion because you're putting this patient through a risky procedure given that they are pregnant. And so ideally, you want to really confirm the presence of a stone, and that can be done through maybe a bedside ultrasound, MRCP with gadolinium is safe. If the patient is going to the operating room, maybe an intraoperative cholangiogram. And also, as the picture demonstrates, even doing an endoscopic ultrasound to confirm that there is a stone. So the contraindications to ERCP are placental abruption, imminent delivery, ruptured membranes, and eclampsia. So what are some of the effects, and why do we get worried about ERCP in pregnancy? So we'll talk about in terms of radiation. So the radiation can impact the embryological and fetal development, which is all dependent on the dose and the gestational age in terms of which trimester. Radiation exposure can lead to intrauterine fetal death, malformations. It can be carcinogenic, mutagenic. And so in terms of the standard, it's recommended that radiation exposure to less than 5 rads or 50 can be associated with no damaging effects. So maternal effects in terms of complications that occur during an ERCP can be more devastating for the mother and the fetus. There are similar rates of bleeding and infection and perforation, but those in themselves can be more devastating for the mother in terms of hypotension, infection, giving antibiotics, treating maybe a perforation that could lead to surgery. And it's controversial in terms of whether there is a higher rate of post-ERCP pancreatitis. And in one study looking at, the rate was about 16%. We know that the risk factors for post-ERCP pancreatitis include young female. Most times when we meet a female patient or any patient that's having an ERCP in the endoscopy unit, we try to hydrate them with lactated ringers. But we want to, because the mothers are fluid overloaded already, we want to limit the amount of pre-procedure IV fluids. We want to limit or eliminate the use of fluoroscopy and the patient's position, which I'm going to allude to. And then we cannot use the indomethacin that we're so used to using in preventing post-ERCP pancreatitis. So when and how to perform the ERCP on a pregnant patient. So we want to delay the intervention until absolutely indicated. So ideally, the best time would be in terms of it's going to be done during the pregnancy is during the second trimester. If we can drag our feet until after delivery, then that would be even better. But we should try to avoid doing ERCPs in the first trimester because that's in terms of the embryological development takes place. There is a higher risk of pre-term labor and delivery. And then in the third trimester where there is an increased risk of pre-term delivery and you know, in terms of the mother is getting close to delivery and so it can lead to, as I said, pre-term delivery. It's very important to have a long discussion with the patient, the patient's family. ERCP ideally should be performed in a high volume center and in a center with obstetrics. So the position. So in terms of if there is not kind of a huge belly, then you can do, you know, in early pregnancy you can do it in the prone position. But in terms of most likely you're going to be doing this in the left lateral position or kind of a left pelvic tilt. And the idea is that the uterus can cause some compression on the aorta and IVC. And then that can lead to, you know, blood pressure changes and stuff like that. So it's important and this is just kind of demonstrating a pillow underneath. And so you want to basically try to get the mother in the most comfortable position but kind of a little bit of a left tilt. And this also may also help with radiation exposure. So radiation shielding. So in a standalone unit, not the CR, but a standalone unit as was alluded to today, the radiation comes from the bottom of the table up. And so typically we put a lead shield, which is usually in our hospital is a skirt. We would put one of the floral lead skirts on top of the table. And then we would also sometimes place another one on top of the mother's abdomen. In terms of that helps with the direct radiation, but there's also, you know, basic radiation scatter, you know, from the mother as well. But with the CR, the radiation comes from the top. And so at that point you have to make sure to put the lead on top. In terms of fetal monitoring, typically documenting of fetal heart tones prior to sedation and then immediately upon completion. In terms of also continuous monitoring can be considered and that's definitely suggested in terms of the trimester. And then in the third trimester, these typically should be performed in the operating room and have obstetrics on call. So antibiotics. So we have to get concerned in terms of what medications can we give these patients. So in terms of antibiotics, we typically give fluoroquinolones if we're going to give antibiotics and they usually are typical ERCPs, but we have to avoid them in this patient population. So penicillin, cephalosporins, erythromycin, clindamycin are safe. Glucagon for the motility within the small bowel is safe. Contrast agents are considered Category D. They may cross the placenta to cause hypothyroidism. Again we're going to limit the amount of fluoro or not use fluoro. We usually dilute the contrast so hopefully this won't be a major issue. Indomethacin is technically a Category C, but it can result in early delivery. So anesthesia. So I think it's important to have an anesthesiologist that's familiar with dealing with pregnant females. We have to be very careful in terms of maternal hypotension, hypoxia, which can lead to fetal distress. These patients can receive modern anesthesia care like propofol or they can receive general anesthesia. In terms of propofol is safe and paradine is safe. Small doses of midazolam is safe and small doses of fentanyl during just the procedure is safe. But in this day and age most patients will be given sedation by an anesthesia provider and therefore receive propofol with or without general anesthesia. So the grounding pad, another thought is to put the grounding pad on the patient's right shoulder so that the amniotic fluid actually can be a good conductor of electric current so you don't want to put it close to the abdomen. So fluoroscopy, we talked about this earlier today, but the idea is to limit or to avoid the amount of fluoro that's used. We talked about just in terms of if you are going to use fluoro to do very short taps. Do not take any like spot films or hard copy films. Utilize the last image hold. Avoid magnification. Use a low dose rate pulse fluoroscopy. Limit the beam so that you're using the smallest field possible. And in some situations there are some recommendations to put a dosimeter over on top of the abdomen to monitor how much fluororadiation is being exposed. So I definitely think it's important to work with your radiation safety officer to come up with some technique in terms of using fluoroscopy in these patients. So non-radiation techniques. So this is the ideal. But if you don't really have that much experience doing ERCP and the non-radiation techniques takes you much longer than a standard ERCP, you're exposing the mother and the fetus to longer anesthesia, more complications potentially with hypotension, more complications in terms of post ERCP pancreatitis. So yes, it sounds wonderful to do, you know, to avoid radiation. But you basically have to figure out what you are capable of doing. So one thing would be to consider doing an endoscopic ultrasound prior to the procedure. And this is confirming the presence of stones and it's also counting the number of stones. And so that way you know that you can do these balloon sweeps. You can avoid like an occlusion cholangiogram, which obviously use a lot of contrast. Another technique would be to do your EOS and do the ERCP and then consider even doing an EOS afterwards under the same anesthesia to make sure that you have completely cleaned out the stones or also even using it for confirmed placement of the stent. You could also, which is a little bit, you know, kind of cumbersome would be to use a bedside ultrasound to check in terms of placement of the stent. But that might be a little bit more challenging to really see is it in the cystic duct versus the common bowel duct. But you could consider, you know, the pre-procedure, post-procedure endoscopic ultrasound. In terms of a way to avoid, you know, radiation in terms of with a native papilla is to basically cannulate with a sphincter tome. You would put in, so we have typical like 10cc syringes of contrast. So only put 5cc of contrast in and then have your nurse or tech actually aspirate bile. I typically do this a lot with all of my ERCPs. It's just the way that I was trained. So basically cannulating, getting into the bowel duct and then aspirating bile. And then that way you can confirm that you're in the bowel duct. And again, another way to avoid radiation. If patient has had a previous sphincterotomy you could consider putting up cholangioscopy. And that would help in terms of again avoiding radiation. You could use cholangioscopy to confirm clearance of the stones. If you have a very sick patient, and as Uzma alluded to, you know, you could put a stent in and kind of get out of dodge, you know. So just basically, you know, get into the bowel duct, may or may not do a sphincterotomy, and then just put the stent in and then kind of reevaluate after the mother has delivered. So in terms of there have been a total of eight studies that looked at high volume centers using no fluoro for these ERCPs, and it was safe and successful. But it is important that, you know, this is at a high volume center where you feel confident in doing, you know, ERCPs. And this is just kind of alluding to some of those studies. This was again Tang study, which is probably one of the larger studies dealing with pregnancies, which was 68 ERCPs in about 65 patients. As I mentioned earlier, the post-ERCP pancreatitis was about 16%. About 90% of those patients had a full-term pregnancy. Of the patients that underwent an ERCP in their first trimester, only 73% of those mothers had a full-term pregnancy. So there was a higher risk of preterm delivery and a higher risk of low birth weight. And there were similar findings in smaller studies. There have been no reports of congenital abnormalities, but the limited long-term follow-up. And then so moving on to for the physician or the staff that's in the room, the nurses, the techs. So when I started, I was about five or six years into my training, and I was pregnant. And so I figured out, what am I going to do? And my career was just starting. I mean, there was no way I was going to be quitting ERCP for nine months. And so I went to the radiation safety officer and basically had a conversation. And so in terms of there are certain recommendations in terms of what we should be exposed to if we're pregnant. I wore a skirt that had the crossover lead. And I sometimes would wear, as I got bigger, it didn't fit. So I would sometimes wear kind of the one piece, and then I would put a lead curtain outside. I wore a monthly fetal monitor underneath the lead on my waist. And then basically, as I got further along in the pregnancy, I was doing my last ERCPs a couple of days before I delivered. But it was one of the fellows, she's now an attending, said it was the first time that I ever saw you sit during an ERCP. So I would not suggest to go that far into the pregnancy, but it is something to think about. The lead does get heavy, but it is very safe. I felt very safe. When I did deliver, I did check my child's fingers and toes. I will tell you. And made sure that everything was intact because of this. I went on to have a second child and they're 10 and 12 and perfectly fine. So ERCP in summary should be performed with a highly experienced endoscopist with a modern fluoroscopy unit, just because that helps to be able to calibrate the appropriate amount of radiation if you're going to use radiation. If the ERCP needs to be done during the pregnancy, the second trimester is probably the safest. But if you can drag your feet in terms of waiting until there's delivery, that would be the best approach. And it's important to get everybody involved, that everybody's on the same page. The patient, the patient's family, obstetrics, anesthesia. And in terms of, if you can, if you feel confident enough to use certain techniques to avoid fluoroscopy, but again, don't bite on more that you can chew. And in terms of, it's important to basically decrease the amount of procedure time as well as really minimize the fluoroscopy. I think that case that I did on that woman was my first on-call case. I think my radiation was 23 seconds that I used for the 10 stones. So and that's it. So thank you very much.

ERCP in pregnant patients

endoscopic retrograde cholangiopancreatography

gallstones in pregnancy

indications for ERCP

radiation risks in ERCP during pregnancy