GuidelineASGE Guideline: guidelines for endoscopy in pregnant and lactating women
Introduction
The safety and the efficacy of GI endoscopy in pregnant patients is not well studied. Studies involving humans tend to be small and retrospective. Much of the drug safety data is based on animal studies. Invasive procedures are justified when it is clear that by not doing so could expose the fetus and/or the mother to harm. Informed consent should include risks to the fetus as well as the mother.
The fetus is particularly sensitive to maternal hypoxia and hypotension, either of which may cause fetal hypoxia that can lead to fetal demise.1 Maternal oversedation, with resulting hypoventilation or hypotension, or maternal positioning that might lead to inferior vena caval compression by the gravid uterus can lead to decreased uterine blood flow and fetal hypoxia. Other potential risks to the fetus include teratogenesis (both from medication given to the mother and radiation exposure from fluoroscopy) and premature birth.
In situations where therapeutic intervention is necessary, endoscopy offers a relatively safe alternative to radiologic or surgical intervention.1, 2, 3, 4 The main indications for endoscopy in pregnancy are outlined in Table 1. General principles that apply to endoscopy in pregnancy are shown in Table 2.
Section snippets
Safety of commonly used medications for endoscopy during pregnancy
The U.S. Food and Drug Administration lists 5 categories of drugs with regard to safety during pregnancy (Table 3). There are no category A drugs used for endoscopy. For use during endoscopic procedures, category B and, when necessary, category C drugs are recommended. Category D drugs may be used when the benefits clearly outweigh the risks. These categories are of limited value for determining the safety of one-time use; therefore, consultation with an obstetrician regarding medication should
Procedures
For all endoscopy procedures, it is suggested that the patient who is in the second or third trimester not lie on her back while waiting for the procedure or afterward in recovery. This is because the pregnant uterus can compress the aorta and/or the inferior vena cava (IVC), causing maternal hypotension and decreased placental perfusion. By placing a wedge or pillow under the right hip, a “pelvic tilt” is created to prevent this. The patient also may sit up if she so prefers, because this will
Indications and contraindications
Diagnostic and therapeutic endoscopy in lactating women do not vary in terms of indication, preprocedural preparation, procedural monitoring, radiation exposure, and endoscopic equipment. Caution needs to be exercised in the use of certain medications, because these drugs may be transferred to the infant through breast milk. In these instances, where there is a concern regarding the transfer to the infant, the woman should be advised to pump her breast milk and discard it, with the timing
Summary
For the following points: (A), Prospective controlled trials. (B), observational studies. (C), Expert opinion.
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Endoscopy during pregnancy should only be done when there is a strong indication and should be postponed to the second trimester whenever possible. (C)
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The close involvement of obstetrical staff is recommended. (C)
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The degree of maternal and fetal monitoring needs to be individualized. (C)
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For procedural sedation during pregnancy, meperidine alone is preferred, followed by small doses of
Acknowledgment
The American Society for Gastrointestinal Endoscopy thanks the American College of Obstetrics and Gynecology Committee on Obstetric Practice and Stanley Zinberg, MD, MS, FACOG, Deputy Executive Vice President and Vice President, Practice Activities, for their input and review of this guideline.
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