2. Contents 1 2 3 4 5 6 The role of endoscopy in pregnant patients
Safety during pregnancy of medications 2 5
Procedural considerations in pregnancy 3 10
The role of endoscopy in lactating patients 4 13
Safety during lactation of medications 5 14
Recommendations 6 16

3. 1. THE ROLE OF ENDOSCOPY IN PREGNANT PATIENTS
GI endoscopy in pregnant patients ▶ inherently risky
FETUS : sensitive to maternal hypoxia and hypotension
hypoxia that can lead to fetal demise
Maternal oversedation → hypoventilation or hypotension
Maternal positioning → inferior vena cava compression by the gravid uterus → decreased uterine blood flow and fetal hypoxia
Other risks to the fetus
Teratogenesis (from medications given to the mother and/or ionizing radiation exposure)
premature birth
In situations where therapeutic intervention is necessary
Endoscopy : relatively safe alternative to radiologic or surgical interventions

4. 2. SAFETY DURING PREGNANCY OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
No category A drugs used for endoscopy
For endoscopic procedures, category B and category C drugs are recommended
For most procedures, the level of sedation should be anxiolysis or moderate sedation
Pregnancy-induced physiologic changes
the cardiopulmonary and GI systems
anatomic changes in the airway
such as swelling of the oropharyngeal tissues and decreased caliber of the glottic opening
▶ “Careful Monitoring”

5. 2. SAFETY DURING PREGNANCY OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Narcotic analgesics
Meperidine(Demerol)
does not appear to be teratogenic(category B)
it is preferred over morphine (category C) crosses the fetal blood-brain barrier more rapidly
Confirmed by 2 large studies
cause loss of fetal beat-to-beat cardiac variability not indicate fetal distress
Fentanyl (category C)
rapid onset of action and shorter patient recovery time than meperidine
It is not teratogenic, but is embryocidal in rats
safe in humans when given in low doses typical for endoscopy (?)
Naloxone (category B)
This rapidly acting opiate antagonist crosses the placenta
within 2 minutes of intravenous administration

6. 2. SAFETY DURING PREGNANCY OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Benzodiazepines (category D)
Diazepam should not be used for sedation in pregnant women
associated with cleft palate, neurobehavioral disorders
Midazolam has not been associated with congenital abnormalities
when sedation with meperidine alone is inadequate
Avoid in the first trimester, if possible.
Flumazenil (category C)
Little is known of the safety profile
not teratogenic in rats and mice
But, produce subtle neurobehavioral changes
Propofol (category B)
by a trained anesthesia provider
its narrow therapeutic index and the importance of close monitoring
Safety in the first trimester has not been well-studied.

7. 2. SAFETY DURING PREGNANCY OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Simethicone (category C)
category C drug because of lack of evaluation in pregnancy
it is commonly administered and probably safe
Glucagon (category B)
antispasmodic agent commonly used during ERCP
not contraindicated during pregnancy
Topical anesthetics
lidocaine (category B)
One study showed no fetal malformations in 293 infants with first trimester exposure to lidocaine
Summary of anesthetic agents
American Society of Anesthesiologists and the American College of Obstetrics and Gynecology
currently used anesthetic agents = no tetratogenic effect in humans

8. 2. SAFETY DURING PREGNANCY OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Antibiotics
Colon cleansing agents
Polyethylene glycol solutions : pregnancy category C
Sodium phosphate preparations (category C)
may cause fluid and electrolyte abnormalities and should be used with caution

9. 3. PROCEDURAL CONSIDERATIONS IN PREGNANCY
Endoscopy should be deferred to the second trimester
strong indication with a careful assessment RISK versus BENEFIT
Every endoscopic procedure → preoperative consultation with an obstetrician
regardless of the gestational age of the fetus
monitor fetal heart rate and uterine contractions
Position of Endoscopy
For all GI endoscopic procedures
the second or third trimester : SUPINE POSITION
pregnant uterus can compress the aorta or the inferior vena cava
maternal hypotension and decreased placental perfusion
“ left lateral position “

10. 3. PROCEDURAL CONSIDERATIONS IN PREGNANCY
Upper endoscopy (EGD)
as in nonpregnant patients
Case series and case-control studies
EGD is safe and effective in pregnancy
In a case-control study of 83 EGDs performed during pregnancy
EGD did not induce premature labor
no congenital malformations were reported
Colonoscopy
limiting the ability to detect uncommon adverse outcomes
very small numbers (lack of study)
Should NOT be placed supine or prone
If external abdominal pressure is required
apply mild force and direct it away from the uterus

11. 3. PROCEDURAL CONSIDERATIONS IN PREGNANCY
ERCP
Only therapeutic intervention
Biliary pancreatitis, symptomatic choledocholithiasis, or cholangitis
lead to fetal loss if not treated properly
Several studies
confirmed the safety of ERCP in pregnancy
one study demonstrated an increased risk of pancreatitis
A major concern : fetal radiation exposure
True radiation exposure to the fetus
patient body size, fetal gestational age, and exposure techniques
External shielding
with LEAD placed under the pelvis and lower abdomen
But, Majority
as a result of radiation scatter within the pregnant patient
the most effective method to reduce radiation-associated risk
to limit fluoroscopy time and overall radiation exposure

12. 3. PROCEDURAL CONSIDERATIONS IN PREGNANCY
by collimating the beam to the area of interest
by using brief “snapshots” of fluoroscopy
to confirm cannula position and common bile duct stones
with a low-dose-rate setting
adjusting the patient’s position to minimize fetal radiation exposure
without fluoroscopy by using a wire-guided cannulation technique
A 2-stage approach
Electrocautery
Amniotic fluid can conduct electrical current to the fetus
Bipolar electrocautery
Relatively safe – BUT, polyp removal involving electrocautery ??

13. 4. THE ROLE OF ENDOSCOPY IN LACTATING PATIENTS
Diagnostic and therapeutic GI endoscopy in lactating women
≒ Those of the pregnant women
indications/contraindications, preprocedure preparation, procedural monitoring, radiation exposure, and endoscopic equipment
Certain medications
transferred to the infant through breast milk
In situations where there is a concern regarding medication or metabolite transfer to the infant
pump her breast milk and discard

14. 5. SAFETY DURING LACTATION OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Midazolam
excreted in breast milk
WITHHOLD nursing of the infant for at least 4 hours following administration of midazolam
Fentanyl
but the concentrations are too low
to be pharmacologically significant
fall to undetectable levels by 10 hours
Meperidine
concentrated in breast milk
detected up to 24 hours after administration
may have neurobehavioral effects
use an alternative such as fentanyl whenever possible

15. 5. SAFETY DURING LACTATION OF MEDICATIONS COMMONLY USED FOR ENDOSCOPY
Propofol
excreted in breast milk
with maximum concentrations at 4 to 5 hours
A study of 5 lactating women undergoing induction for general anesthesia
a total of 180 to 200 mg of propofol
0.015% of the maternal dose exposure of nursing infants within 24 hours
The effects of small oral doses of propofol on the infant are unknown
So, no interruption of breastfeeding is recommended
Reversal agents
The safety of naloxone and flumazenil : unknown
Naloxone is not orally bioavailable
Antibiotics

16. 6. RECOMMENDATIONS Pregnancy Lactation
only strong indication, to the second trimester, lateral decubitus position
close involvement of obstetrical staff
Meperidine + small doses of midazolam
Therapeutic ERCP is generally safe in pregnancy
minimize radiation exposure to the fetus
Electrocautery : bipolar electrocautery
Antibiotic choice
many antibiotics can be safely
BUT!! quinolones, streptomycin, tetracyclines
Lactation
maternal fentanyl administration : OK
at least 4 hours after maternal midazolam administration
maternal propofol administration
antibiotic choice
Avoid : quinolones and sulfonamides
Penicillins, cephalosporins, tetracyclines, and erythromycin : OK