This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. 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 has 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.

Endoscopy

Pregnancy

Fetal monitoring

GI bleeding

Obstetricians consultation