Endoscopic management of biliary disorders during pregnancy

Biliary interventions during pregnancy are associated with risks to both the pregnancy and developing fetus. In this report we summarize our experience with endoscopic interventions including endoscopic ultrasound (EUS) in the management of biliary disorders during pregnancy.

Endoscopic retrograde cholangiopancreatographies (ERCPs) performed between May 2003 through January 2010 (n=607) were identified from our database, and cases of interventions during pregnancy were reviewed. All procedures were done using conscious sedation and lead shielding.

Nine ERCPs (1.5%) were performed in 8 pregnant patients. Their median gestational period was 22 weeks (range, <2-36 weeks). Two, 5 and 2 patients were in their first, second and third trimester, respectively. Indications for ERCP included obstructive jaundice (6 patients) cholangitis (2), and acute pancreatitis/obstructive jaundice (1). Two patients underwent EUS before ERCP. Fluoroscopy was used in 5 ERCPs (median 12 seconds; range 2-20 seconds), and the overall time for a ERCP ranged from 5 to 25 minutes. During ERCP endoscopic sphincterotomy was performed in 5 patients, stenting in 6, and balloon clearance in 3. One procedure caused complication in induction of labor. During pregnancy, there were 4 non-procedure related complications including acute cholecystitis (1), HELLP syndrome resulting in spontaneous abortion (1) and stent migrations (2). Five pregnancies had uncomplicated term deliveries, whereas 2 required urgent caesarian sections (one for fetal distress and 1 for cholangitis secondary to stent migration). One patient was well in her second trimester during follow-up. Seven babies were well at birth with median APGAR scores of 9, and 10 at 5 and 10 minutes, respectively. One baby died of sudden death syndrome at age of 40 days.

ERCP is a safe procedure for pregnant women. It can be conducted for biliary stenting and subsequent clearance after deliveries. EUS has a complementary role. Different strategies can be applied according to the conditions or expertise of endoscopists.