Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Risks versus benefits of gastrointestinal endoscopy during pregnancy

Subjects

Abstract

Although gastrointestinal endoscopy is generally safe, its safety must be separately analyzed during pregnancy with regard to fetal safety. Fetal risks from endoscopic medications are minimized by avoiding FDA category D drugs, minimizing endoscopic medications, and anesthesiologist attendance at endoscopy. Esophagogastroduodenoscopy seems to be relatively safe for the fetus and may be performed when strongly indicated during pregnancy. Despite limited clinical data, endoscopic banding of esophageal varices and endoscopic hemostasis of nonvariceal upper gastrointestinal bleeding seems justifiable during pregnancy. Flexible sigmoidoscopy during pregnancy also appears to be relatively safe for the fetus and may be performed when strongly indicated. Colonoscopy may be considered in pregnant patients during the second trimester if there is a strong indication. Data on colonoscopy during the other trimesters are limited. Therapeutic endoscopic retrograde cholangiopancreatography seems to be relatively safe during pregnancy and should be performed for strong indications (for example, complicated choledocholithiasis). Endoscopic safety precautions during pregnancy include the performance of endoscopy in hospital by an expert endoscopist and only when strongly indicated, deferral of endoscopy to the second trimester whenever possible, and obstetric consultation.

Key Points

  • Although gastrointestinal endoscopy is usually safe in the general population, its safety must be separately analyzed during pregnancy by clinical studies of fetal outcomes

  • A high procedural diagnostic rate and favorable fetal outcomes are reported for esophagogastroduodenoscopy during pregnancy; however, this procedure should only be performed for strong indications (for example, significant acute gastrointestinal bleeding)

  • Limited data suggest that flexible sigmoidoscopy in pregnancy seems to be relatively safe for the fetus and can be performed when there is a strong indication (for example, refractory noninfectious diarrhea)

  • Limited data suggest that colonoscopy during pregnancy should be considered during the second trimester if there is a strong indication, but data regarding this procedure in the other trimesters are insufficient

  • Therapeutic endoscopic retrograde cholangiopancreatography should be performed for strong indications (for example, complicated choledocholithiasis) in pregnancy, but the long-term consequences for children exposed to ionizing radiation in utero are unknown

  • Endoscopy safety principles during pregnancy include performance of endoscopy in hospital by an expert and only when strongly indicated, deferral of the endsoscopy to the second trimester if feasible, obstetric consultation, and avoidance of FDA category D drugs

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Arrowsmith, J. B., Gerstman, B. B., Fleischer, D. E. & Benjamin, S. B. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest. Endosc. 37, 421–427 (1991).

    Article  CAS  PubMed  Google Scholar 

  2. Seeff, L. C. et al. How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity. Gastroenterology 127, 1670–1677 (2004).

    Article  PubMed  Google Scholar 

  3. Briggs, G. C., Freeman, R. K. & Yaffe, S. J. Drugs in pregnancy and lactation: a reference guide to fetal and maternal risk, 8th edn (Lippincott, Williams & Wilkins, Philadelphia, 2008).

    Google Scholar 

  4. Cappell, M. S. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy. Gastroenterol. Clin. North Am. 32, 123–179 (2003).

    Article  PubMed  Google Scholar 

  5. Hampton, K. K. et al. Haemostatic responses and vasopressin release during colonoscopy in man. Clin. Sci. (Lond.) 81, 257–260 (1991).

    Article  CAS  Google Scholar 

  6. DiSario, J. A., Waring, J. P., Talbert, G. & Sanowski, R. A. Monitoring of blood pressure and heart rate during routine endoscopy: a prospective, randomized, controlled study. Am. J. Gastroenterol. 86, 956–960 (1991).

    CAS  PubMed  Google Scholar 

  7. Cappell, M. S. Endoscopy in pregnancy: risks versus benefits. Nat. Clin. Pract. Gastroenterol. Hepatol. 2, 376–377 (2005).

    Article  PubMed  Google Scholar 

  8. Ferguson, P. R. Selecting participants when testing new drugs: the implications of age and gender discrimination. Med. Leg. J. 70, 130–134 (2002).

    Article  PubMed  Google Scholar 

  9. Haas, D. M., Wunder, K., Wolf, J. G. & Denne, S. C. Women's health care provider's attitudes toward research in pregnancy. J. Reprod. Med. 55, 108–114 (2010).

    PubMed  Google Scholar 

  10. Answers.com What percentage of the female population is pregnant at any one time? [online], (2010).

  11. Peyron, R. et al. Early termination of pregnancy with mifepristone (RU 486) and the orally active prostaglandin misoprostol. N. Engl. J. Med. 328, 1509–1513 (1993).

    Article  CAS  PubMed  Google Scholar 

  12. Lloyd, M. E., Carr, M., McElhatton, P., Hall, G. M. & Hughes, R. A. The effects of methotrexate on pregnancy, fertility and lactation. QJM 92, 551–563 (1999).

    Article  CAS  PubMed  Google Scholar 

  13. Food and Drug Administration. Federal Register 44, 37434–37467 (1980).

  14. Vargesson, N. Thalidomide-induced limb defects: resolving a 50-year-old puzzle. Bioessays 31, 1327–1336 (2009).

    Article  CAS  PubMed  Google Scholar 

  15. Robinson, M. Review article: current perspectives on hypergastrinaemia and enterochromaffin-like-cell hyperplasia. Aliment. Pharmacol. Ther. 13 (Suppl. 5), 5–10 (1999).

    Article  PubMed  Google Scholar 

  16. Verloop, J., van Leeuwen, F. E., Helmerhorst, T. J., van Boven, H. H. & Rookus, M. A. Cancer risk in DES daughters. Cancer Causes Control 21, 999–1007 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Cappell, M. S. Sedation and analgesia for gastrointestinal endoscopy during pregnancy. Gastrointest. Endosc. Clin. N. Am. 16, 1–31 (2006).

    Article  PubMed  Google Scholar 

  18. Fairlie, F. M. et al. Intramuscular opioids for maternal pain relief in labour: a randomized controlled trial comparing pethidine with diamorphine. Br. J. Obstet. Gynaecol. 106, 1181–1187 (1999).

    Article  CAS  PubMed  Google Scholar 

  19. Heinonen, O. P., Stone, D. & Shapiro, S. Birth defects and drugs in pregnancy (John Wright, Boston, 1982).

    Google Scholar 

  20. Hodgkinson, R. & Husain, F. J. The duration of effect of maternally administered meperidine on neonatal neurobehavior. Anesthesiology 56, 51–52 (1982).

    Article  CAS  PubMed  Google Scholar 

  21. Jiraki, K. Lethal effects of normeperidine. Am. J. Forensic Med. Pathol. 13, 42–43 (1992).

    Article  CAS  PubMed  Google Scholar 

  22. Savona-Ventura, C., Sammut, M. & Sammut, C. Pethidine blood concentrations at time of birth. Int. J. Gynaecol. Obstet. 36, 103–107 (1991).

    Article  CAS  PubMed  Google Scholar 

  23. Sosa, C. G. et al. Meperidine for dystocia during the first stage of labor: a randomized controlled trial. Am. J. Obstet. Gynecol. 191, 1212–1218 (2004).

    Article  CAS  PubMed  Google Scholar 

  24. Martin, L. V. & Jurand, A. The absence of teratogenic effects of some analgesics used in anesthesia: additional evidence from a mouse model. Anaesthesia 47, 473–476 (1992).

    Article  CAS  PubMed  Google Scholar 

  25. Rayburn, W., Rathke, A., Leuschen, M. P., Chleborad, J. & Weidner, W. Fentanyl citrate analgesia during labor. Am. J. Obstet. Gynecol. 161, 202–206 (1989).

    Article  CAS  PubMed  Google Scholar 

  26. Regan, J., Chambers, F., Gorman, W. & MacSullivan, R. Neonatal abstinence syndrome due to prolonged administration of fentanyl in pregnancy. Br. J. Obstet. Gynaecol. 107, 570–572 (2000).

    Article  CAS  Google Scholar 

  27. Abboud, T. K., Zhu, J., Richardson, M., Peres Da Silva, E. & Donovan, M. Intravenous propofol vs thiamylal-isoflurane for caesarean section, comparative maternal and neonatal effects. Acta Anaesthesiol. Scand. 39, 205–209 (1995).

    Article  CAS  PubMed  Google Scholar 

  28. LLC PDR Network. Physician's Desk Reference 2010, 64th edn (Physicians Desk Reference Inc., Montvale, 2009).

  29. Celleno, D. et al. Neurobehavioral effects of propofol on the neonate following elective caesarean section. Br. J. Anaesth. 62, 649–654 (1989).

    Article  CAS  PubMed  Google Scholar 

  30. Lazzaroni, M. & Bianchi Porro, G. Preparation, premedication, and surveillance. Endoscopy 37, 101–109 (2005).

    Article  CAS  PubMed  Google Scholar 

  31. Baraka, A., Louis, F. & Dalleh, R. Maternal awareness and neonatal outcome after ketamine induction of anaesthesia for caesarean section. Can. J. Anaesth. 37, 641–644 (1990).

    Article  CAS  PubMed  Google Scholar 

  32. Friedman, J. M. Teratogen update: anesthetic agents. Teratology 37, 69–77 (1988).

    Article  CAS  PubMed  Google Scholar 

  33. Gilger, M. A. et al. Safety and effectiveness of ketamine as a sedative agent for pediatric GI endoscopy. Gastrointest. Endosc. 59, 659–663 (2004).

    Article  PubMed  Google Scholar 

  34. Courtens, W., Vamos, E., Hainaut, M. & Vergauwen, P. Mobius syndrome in an infant exposed in utero to benzodiazepines. J. Pediatr. 121, 833–834 (1992).

    Article  CAS  PubMed  Google Scholar 

  35. Czeizel, A. Lack of evidence of teratogenicity of benzodiazepine drugs in Hungary. Reprod. Toxicol. 88, 183–188 (1987).

    Article  Google Scholar 

  36. Jauniaux, E., Jurkovic, D., Lees, C., Campbell, S. & Gulbis, B. In-vivo study of diazepam transfer across the first trimester human placenta. Hum. Reprod. 11, 889–892 (1996).

    Article  CAS  PubMed  Google Scholar 

  37. Laegreid, L., Olegård, R., Walström, J. & Conradi, N. Teratogenic effects of benzodiazepine use during pregnancy. J. Pediatr. 114, 126–131 (1989).

    Article  CAS  PubMed  Google Scholar 

  38. Ornoy, A., Arnon, J., Shechtman, S., Moerman, L. & Lukashova, I. Is benzodiazepine use during pregnancy really teratogenic? Reprod. Toxicol. 12, 511–515 (1998).

    Article  CAS  PubMed  Google Scholar 

  39. Rothman, K. J., Fyler, D. C., Goldblatt, A. & Kreidberg, M. B. Exogenous hormones and other drug exposures of children with congenital heart disease. Am. J. Epidemiol. 109, 433–439 (1979).

    Article  CAS  PubMed  Google Scholar 

  40. Safra, M. J. & Oakly, G. P. Jr. Association between cleft lip with or without cleft palate and prenatal exposure to diazepam. Lancet 2, 478–480 (1975).

    Article  CAS  PubMed  Google Scholar 

  41. Bland, B. A., Lawes, E. G., Duncan, P. W., Wanell, I. & Downing, J. W. Comparison of midazolam and thiopental for rapid sequence anesthetic induction for elective cesarean section. Anesth. Analg. 66, 1165–1168 (1987).

    Article  CAS  PubMed  Google Scholar 

  42. Ravlo, O. et al. A randomized comparison between midazolam and thiopental for elective cesarean section anesthesia: II. Neonates. Anesth. Analg. 68, 234–237 (1989).

    Article  CAS  PubMed  Google Scholar 

  43. Tucker, A. P., Mezzatesta, J., Nadeson, R. & Goodchild, C. S. Intrathecal midazolam II: combination with intrathecal fentanyl for labor pain. Anesth. Analg. 98, 1521–1527 (2004).

    Article  CAS  PubMed  Google Scholar 

  44. Arduini, D., Rizzo, G., Dell'Acqua, S., Mancuso, S. & Romanini, C. Effect of naloxone on fetal behavior near term. Am. J. Obstet. Gynecol. 156, 474–478 (1987).

    Article  CAS  PubMed  Google Scholar 

  45. Fassoulaki, A., Theodoraki, K. & Melemeni, A. Pharmacology of sedation agents and reversal agents. Digestion 82, 80–83 (2010).

    Article  CAS  PubMed  Google Scholar 

  46. Gibbs, J., Newson, T., Williams, J. & Davidson, D. C. Naloxone hazard in infant of opioid abuser. Lancet 2, 159–160 (1989).

    Article  CAS  PubMed  Google Scholar 

  47. Goodlin, R. C. Naloxone and its possible relationship to fetal endorphin levels and fetal distress. Am. J. Obstet. Gynecol. 139, 16–19 (1981).

    Article  CAS  PubMed  Google Scholar 

  48. Welles, B., Belfrage, P. & de Château, P. Effects of naloxone on newborn infant behavior after maternal analgesia with pethidine during labor. Acta Obstet. Gynecol. Scand. 63, 617–619 (1984).

    Article  CAS  PubMed  Google Scholar 

  49. Bailey, B. Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women? Birth Defects Res. A Clin. Mol. Teratol. 67, 133–140 (2003).

    Article  CAS  PubMed  Google Scholar 

  50. Brogden, R. N. & Goa, K. L. Flumazenil. A reappraisal of its pharmacological properties and therapeutic efficacy as a benzodiazepine antagonist. Drugs 42, 1061–1089 (1991).

    Article  CAS  PubMed  Google Scholar 

  51. Cappell, M. S., Colon, V. J. & Sidhom, O. A. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison to control groups. Am. J. Gastroenterol. 91, 348–354 (1996).

    CAS  PubMed  Google Scholar 

  52. Khilnani, N. & Hussain, N. Gastrointestinal bleeding. Emerg. Med. 37, 27–32 (2005).

    Google Scholar 

  53. Debby, A., Golan, A., Sadan, O., Glezerman, M. & Shirin, H. Clinical utility of esophagogastroduodenoscopy in the management of recurrent and intractable vomiting in pregnancy. J. Reprod. Med. 53, 347–351 (2008).

    PubMed  Google Scholar 

  54. Gill, S. K., O'Brien, L., Einarson, T. R. & Koren, G. The safety of proton pump inhibitors (PPIs) in pregnancy: a meta-analysis. Am. J. Gastroenterol. 104, 1541–1545 (2009).

    Article  CAS  PubMed  Google Scholar 

  55. Frank, B. in Gastrointestinal Disorders During Pregnancy (eds Karlstadt, R. G., Surawicz, C. M. & Croitoru, R.) 24–29 (American College of Gastroenterology, Arlington, 1994).

    Google Scholar 

  56. Bagis, T. et al. Endoscopy in hyperemesis gravidarum and Helicobacter pylori infection. Int. J. Gynaecol. Obstet. 79, 105–109 (2002).

    Article  CAS  PubMed  Google Scholar 

  57. Cappell, M. S. Gastric and duodenal ulcers during pregnancy. Gastroenterol. Clin. North Am. 32, 263–308 (2003).

    Article  PubMed  Google Scholar 

  58. Yucel, T., Aygin, D., Sen, S. & Yucel, O. The prevalence of Helicobacter pylori and related factors among university students in Turkey. Jpn J. Infect. Dis. 61, 179–183 (2008).

    PubMed  Google Scholar 

  59. McCall, M. L. et al. Endoscopic studies of esophagus and stomach during pregnancy. Am. J. Obstet. Gynecol. 82, 1125–1133 (1961).

    Article  Google Scholar 

  60. Castro Lde, P. Reflux esophagitis as the cause of heartburn in pregnancy. Am. J. Obstet. Gynecol. 98, 1–10 (1967).

    Article  PubMed  Google Scholar 

  61. Cappell, M. S. & Friedel, D. Abdominal pain during pregnancy. Gastroenterol. Clin. North Am. 32, 1–58 (2003).

    Article  PubMed  Google Scholar 

  62. Chak, A. et al. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest. Endosc. 53, 6–13 (2001).

    Article  CAS  PubMed  Google Scholar 

  63. Bini, E. J. et al. Systematic evaluation of complications related to endoscopy in a training setting: a prospective 30-day outcomes study. Gastrointest. Endosc. 57, 8–16 (2003).

    Article  PubMed  Google Scholar 

  64. Cappell, M. S., Colon, V. J. & Sidhom, O. A. A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups. Dig. Dis. Sci. 41, 2353–2361 (1996).

    Article  CAS  PubMed  Google Scholar 

  65. Cappell, M. S., Fox, S. R. & Gorrepati, N. Safety and efficacy of colonoscopy during pregnancy: an analysis of pregnancy outcome in 20 patients. J. Reprod. Med. 55, 115–123 (2010).

    PubMed  Google Scholar 

  66. Quan, W. L., Chia, C. K. & Yim, H. B. Safety of endoscopical procedures during pregnancy. Singapore Med. J. 47, 525–528 (2006).

    CAS  PubMed  Google Scholar 

  67. Joshi, D., James, A., Quaglia, A., Westbrook, R. H. & Heneghan, M. A. Liver disease in pregnancy. Lancet 375, 594–605 (2010).

    Article  PubMed  Google Scholar 

  68. Cappell, M. S. Hepatic disorders mildly to moderately affected by pregnancy: medical and obstetric management. Med. Clin. North Am. 92, 717–737 (2008).

    Article  PubMed  Google Scholar 

  69. López-Méndez, E. & Avila-Escobedo, L. Pregnancy and portal hypertension: a pathology view of physiologic changes. Ann. Hepatol. 5, 219–223 (2006).

    PubMed  Google Scholar 

  70. Aggarwal, N., Sawhney, H., Vasishta, K., Dhiman, R. K. & Chawla, Y. Non-cirrhotic portal hypertension in pregnancy. Int. J. Gynaecol. Obstet. 72, 1–7 (2001).

    Article  CAS  PubMed  Google Scholar 

  71. Kochhar, R. et al. Pregnancy and its outcome in patients with noncirrhotic portal hypertension. Dig. Dis. Sci. 44, 1356–1361 (1999).

    Article  CAS  PubMed  Google Scholar 

  72. Kochhar, R., Goenka, M. K. & Mehta, S. R. Endoscopic sclerotherapy during pregnancy. Am. J. Gastroenterol. 85, 1132–1135 (1990).

    CAS  PubMed  Google Scholar 

  73. Augustine, P. & Joseph, P. C. Sclerotherapy for esophageal varices and pregnancy. Gastrointest. Endosc. 35, 467–468 (1989).

    Article  CAS  PubMed  Google Scholar 

  74. Iwase, H., Morise, K., Kawase, T. & Horiuchi, Y. Endoscopic injection sclerotherapy for esophageal varices during pregnancy. J. Clin. Gastroenterol. 18, 80–83 (1994).

    Article  CAS  PubMed  Google Scholar 

  75. Nesbitt, T. H., Kay, H. H., McCoy, M. C. & Herbert, W. N. Endoscopic management of biliary disease during pregnancy. Obstet. Gynecol. 87, 806–809 (1996).

    CAS  PubMed  Google Scholar 

  76. Pötzi, R., Ferenci, P. & Gangl, A. Endoscopic sclerotherapy of esophageal varices during pregnancy—case report. Z. Gastroenterol. 29, 246–247 (1991).

    PubMed  Google Scholar 

  77. Lodato, F. et al. Transjugular intrahepatic portosystemic shunt: a case report of rescue management of unrestrainable variceal bleeding in a pregnant woman. Dig. Liver Dis. 40, 387–390 (2008).

    Article  CAS  PubMed  Google Scholar 

  78. Dhiman, R. K., Biswas, R., Aggarwal, N., Sawhney, H. & Chawla, Y. Management of variceal bleeding in pregnancy with endoscopic variceal ligation and N-butyl-2-cyanoacrylate: report of three cases. Gastrointest. Endosc. 51, 91–93 (2000).

    Article  CAS  PubMed  Google Scholar 

  79. Ghidirim, G., Mishin, I., Dolghii, A. & Lupashcu, A. Prophylactic endoscopic band ligation of esophageal varices during pregnancy. J. Gastrointest. Liver Dis. 17, 236–237 (2008).

    Google Scholar 

  80. Savage, C., Patel, J., Lepe, M. R., Lazarre, C. H. & Rees, C. R. Transjugular intrahepatic portosystemic shunt creation for recurrent gastrointestinal bleeding during pregnancy. J. Vasc. Interv. Radiol. 18, 902–904 (2007).

    Article  PubMed  Google Scholar 

  81. Starkel, P., Horsmans, Y. & Geubel, A. Endoscopic band ligation: a safe technique to control bleeding esophageal varices in pregnancy. Gastrointest. Endosc. 48, 212–214 (1998).

    Article  CAS  PubMed  Google Scholar 

  82. Zeeman, G. G. & Moise, K. J. Jr. Prophylactic banding of severe esophageal varices associated with liver cirrhosis in pregnancy. Obstet. Gynecol. 94, 842 (1999).

    CAS  PubMed  Google Scholar 

  83. Brunner, G., Meyer, H. & Athmann, C. Omeprazole for peptic ulcer disease in pregnancy. Digestion 59, 651–654 (1998).

    Article  CAS  PubMed  Google Scholar 

  84. Macedo, G., Carvalho, L. & Ribeiro, T. Endoscopic sclerotherapy for upper gastrointestinal bleeding due to Mallory-Weiss syndrome. Am. J. Gastroenterol. 90, 1364–1365 (1995).

    CAS  PubMed  Google Scholar 

  85. Grace, N. D. Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. American College of Gastroenterology Practice Parameters Committee. Am. J. Gastroenterol. 92, 1081–1091 (1997).

    CAS  PubMed  Google Scholar 

  86. Laine, L. & Cook, D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann. Intern. Med. 123, 280–287 (1995).

    Article  CAS  PubMed  Google Scholar 

  87. Cappell, M. S. Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat. Rev. Gastroenterol. Hepatol. 7, 214–229 (2010).

    Article  PubMed  Google Scholar 

  88. Laine, L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N. Engl. J. Med. 316, 1613–1617 (1987).

    Article  CAS  PubMed  Google Scholar 

  89. Laine, L. Multipolar electrocoagulation in the treatment of peptic ulcers with nonbleeding visible vessels. A prospective, controlled trial. Ann. Intern. Med. 110, 510–514 (1989).

    Article  CAS  PubMed  Google Scholar 

  90. Jensen, D. M. et al. Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots. Gastroenterology 123, 407–413 (2002).

    Article  PubMed  Google Scholar 

  91. Kahi, C. J. et al. Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis. Gastroenterology 129, 855–862 (2005).

    Article  PubMed  Google Scholar 

  92. Erdman, S., Levinsky, L., Servadio, C., Stoupel, E. & Levy, M. J. Safety precautions in the management of patients with pacemakers when electrocautery operations are performed. Surg. Gynecol. Obstet. 167, 311–314 (1988).

    CAS  PubMed  Google Scholar 

  93. Marcus, M. A., Vertommen, J. D., Van Aken, H. & Wouters, P. F. Hemodynamic effects of intravenous isoproterenol versus epinephrine in the chronic maternal-fetal sheep preparation. Anesth. Analg. 82, 1023–1026 (1996).

    CAS  PubMed  Google Scholar 

  94. O'Mahony, S. Endoscopy in pregnancy. Best Pract. Res. Clin. Gastroenterol. 21, 893–899 (2007).

    Article  PubMed  Google Scholar 

  95. Howard, P. J., Maher, L., Pryde, A., Cameron, E. W. & Heading, R. C. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 33, 1011–1015 (1992).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  96. American Pregnancy Association Statistics [online]. Accessed November 23rd 2010.

  97. Fassina, G. & Osculati, A. Achalasia and sudden death: a case report. Forensic Sci. Int. 75, 133–137 (1995).

    Article  CAS  PubMed  Google Scholar 

  98. Ohno, Y., Kawai, M., Shibata, Y. & Arli, Y. Esophageal achalasia in pregnancy. Am. J. Perinatol. 17, 53–55 (2000).

    Article  CAS  PubMed  Google Scholar 

  99. Garofalo, J. H. & Pofahl, W. E. Achalasia: a brief review of treatment options and efficacy. Curr. Surg. 59, 549–553 (2002).

    Article  PubMed  Google Scholar 

  100. Campos, G. M. et al. Endoscopic and surgical treatments for achalasia: a review and meta-analysis. Ann. Surg. 249, 45–57 (2009).

    Article  PubMed  Google Scholar 

  101. Wataganara, T., Leelakusolvong, S., Sunsaneevithayakul, P. & Vantanasiri, C. Treatment of severe achalasia during pregnancy with esophagoscopic injection of botulinum toxin A: a case report. J. Perinatol. 29, 637–639 (2009).

    Article  CAS  PubMed  Google Scholar 

  102. Aggarwal, R., Shahi, H. M. & Misra, A. Esophageal achalasia presenting during pregnancy. Indian J. Gastroenterol. 16, 72–73 (1997).

    CAS  PubMed  Google Scholar 

  103. Fiest, T. C., Foong, A. & Chokhavatia, S. Successful balloon dilatation of achalasia during pregnancy. Gastrointest. Endosc. 39, 810–812 (1993).

    Article  CAS  PubMed  Google Scholar 

  104. Pulanic, R., Kalauz, M., Opacic, M., Rustemovic, N. & Brkic, T. Successful pneumatic dilatation of achalasia in pregnancy. Dig. Liver Dis. 40, 600–601 (2008).

    Article  CAS  PubMed  Google Scholar 

  105. Product information. Botox. Allergan, 2004. As cited in Briggs, G. C., Freeman, R. K. & Yaffe, S. J. Drugs in pregnancy and lactation: a reference guide to fetal and maternal risk, 8th edn (Lippincott, Williams & Wilkins, Philadelphia, 2008).

  106. Centers for Disease Control and Prevention. Wound botulism–California, 1995. MMWR Morb. Mortal. Wkly Rep. 44, 889–892 (1995).

  107. Robin, L., Herman, D. & Redett, R. Botulism in a pregnant woman. N. Engl. J. Med. 335, 823–824 (1996).

    Article  CAS  PubMed  Google Scholar 

  108. Polo, J. M., Martin, J. & Berciano, J. Botulism and pregnancy. Lancet 348, 195 (1996).

    Article  CAS  PubMed  Google Scholar 

  109. Clemendor, A., Sall, S. & Harbilas, E. Achalasia and nutritional deficiency during pregnancy. Obstet. Gynecol. 33, 106–113 (1969).

    Article  CAS  PubMed  Google Scholar 

  110. St. Clair, E. H., DiLiberti, J. H. & O'Brien, M. L. Letter: Observations of an infant born to a mother with botulism. J. Pediatr. 87, 658 (1975).

    Article  CAS  PubMed  Google Scholar 

  111. Hamaoui, E. & Hamaoui, M. Nutritional assessment and support during pregnancy. Gastroenterol. Clin. North Am. 32, 59–121 (2003).

    Article  PubMed  Google Scholar 

  112. Zaloga, G. P. Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: assessment of outcomes. Lancet 367, 1101–1111 (2006).

    Article  PubMed  Google Scholar 

  113. Holmgren, C., Aagaard-Tillery, K. M., Silver, R. M., Porter, T. F. & Varner, M. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am. J. Obstet. Gynecol. 198, 56.e1–56.e4 (2008).

    Article  Google Scholar 

  114. Russo-Stieglitz, K. E., Levine, A. B., Wagner, B. A. & Armenti, V. T. Pregnancy outcome in patients requiring parenteral nutrition. J. Matern. Fetal Med. 8, 164–167 (1999).

    CAS  PubMed  Google Scholar 

  115. Torloni, M. R. et al. Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis. Ultrasound Obstet. Gynecol. 33, 599–608 (2009).

    Article  CAS  PubMed  Google Scholar 

  116. Shaheen, N. J., Crosby, M. A., Grimm, I. S. & Isaacs, K. The use of percutaneous endoscopic gastrostomy in pregnancy. Gastrointest. Endosc. 46, 584–585 (1997).

    Google Scholar 

  117. Godil, A. & Chen, Y. K. Percutaneous endoscopic gastrostomy for nutrition support in pregnancy associated with hyperemesis gravidarum and anorexia nervosa. JPEN J. Parenter. Enteral Nutr. 22, 238–241 (1998).

    Article  CAS  PubMed  Google Scholar 

  118. Koh, M. L. & Lipkin, E. W. Nutrition support of a pregnant comatose patient via percutaneous endoscopic gastrostomy. JPEN J. Parenter. Enteral Nutr. 17, 384–387 (1993).

    Article  CAS  PubMed  Google Scholar 

  119. Sarafov, S. et al. Two consecutive pregnancies in early and late stage of amyotrophic lateral sclerosis. Amyotroph. Lateral Scler. 10, 483–486 (2009).

    Article  PubMed  Google Scholar 

  120. Pendlebury, J., Phillips, F., Ferguson, A. & Ghosh, S. Successful pregnancy in a patient with chronic intestinal pseudo-obstruction while on ambulatory percutaneous endoscopic gastrostomy feeding. Eur. J. Gastroenterol. Hepatol. 9, 711–713 (1997).

    Article  CAS  PubMed  Google Scholar 

  121. Pereira, J. L. et al. Percutaneous endoscopic gastrostomy and gastrojejunostomy. Experience and its role in domiciliary enteral nutrition [Article in Spanish]. Nutr. Hosp. 13, 50–56 (1998).

    CAS  PubMed  Google Scholar 

  122. Serrano, P. et al. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases. Clin. Nutr. 17, 135–139 (1998).

    Article  CAS  PubMed  Google Scholar 

  123. Irving, P. M., Howell, R. J. & Shidrawi, R. G. Percutaneous endoscopic gastrostomy with a jejunal port for severe hyperemesis gravidarum. Eur. J. Gastroenterol. Hepatol. 16, 937–939 (2004).

    Article  PubMed  Google Scholar 

  124. Wejda, B. U. et al. Successful jejunal nutrition therapy in a pregnant patient with apallic syndrome. Clin. Nutr. 22, 209–211 (2003).

    Article  CAS  PubMed  Google Scholar 

  125. Ruangsin, S. & Chowchuvech, V. A randomized double-blind controlled trial comparing two forms of enema for flexible sigmoidoscopy. J. Med. Assoc. Thai. 90, 2296–2300 (2007).

    PubMed  Google Scholar 

  126. Mahadevan, U. Gastrointestinal medications in pregnancy. Best Pract. Res. Clin. Gastroenterol. 21, 849–877 (2007).

    Article  CAS  PubMed  Google Scholar 

  127. Rimensberger, P., Schubiger, G. & Willi, U. Connatal rickets following repeated administration of phosphate enemas during pregnancy: a case report. Eur. J. Pediatr. 151, 54–56 (1992).

    Article  CAS  PubMed  Google Scholar 

  128. Cappell, M. S. & Sidhom, O. A. Multicenter, multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up of fetal outcome. Dig. Dis. Sci. 40, 472–479 (1995).

    Article  CAS  PubMed  Google Scholar 

  129. Bollaert, P. E. et al. Hemorrhagic colitis with Streptococcus pyogenes preceding hemolytic uremic syndrome during early pregnancy. Nephron 52, 103–104 (1989).

    Article  CAS  PubMed  Google Scholar 

  130. Bornman, P. C., Collins, J. S., Abrahamson, M. J. & Gilinsky, N. H. Live abdominal pregnancy presenting as massive rectal bleeding. Postgrad. Med. J. 61, 759–760 (1985).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  131. Cooksey, G., Gunn, A. & Wotherspoon, W. C. Surgery for acute ulcerative colitis and toxic megacolon during pregnancy. Br. J. Surg. 72, 547 (1985).

    Article  CAS  PubMed  Google Scholar 

  132. Fraser, J. L. & Eckert, L. A. Volvulus complicating pregnancy. Can. Med. Assoc. J. 128, 1045–1048 (1983).

    CAS  PubMed  PubMed Central  Google Scholar 

  133. Friedman, S. Management of inflammatory bowel disease during pregnancy and nursing. Semin. Gastrointest. Dis. 12, 245–252 (2001).

    CAS  PubMed  Google Scholar 

  134. Moeller, D. D. Crohn's disease beginning during pregnancy. South. Med. J. 81, 1067 (1988).

    Article  CAS  PubMed  Google Scholar 

  135. Nesbitt, J. C., Moise, K. J. & Sawyers, J. L. Colorectal carcinoma in pregnancy. Arch. Surg. 120, 636–640 (1985).

    Article  CAS  PubMed  Google Scholar 

  136. Sheld, H. H. Megacolon complicating pregnancy. A case report. J. Reprod. Med. 32, 239–242 (1987).

    CAS  PubMed  Google Scholar 

  137. Tsukamoto, N., Uchino, H., Matsukuma, K. & Kamura, T. Carcinoma of the colon presenting as bilateral ovarian tumors during pregnancy. Gynecol. Oncol. 24, 386–391 (1986).

    Article  CAS  PubMed  Google Scholar 

  138. Huang, W. S., Lin, P. Y., Wang, J. Y., Chin, C. C. & Hsieh, C. C. Urgent colectomy and caesarean section of a pregnant familial adenomatous polyposis: a case report. Int. J. Colorectal Dis. 22, 847–848 (2007).

    Article  PubMed  Google Scholar 

  139. Ishijima, N., Ojima, E., Tonouchi, H., Suzuki, H. & Fukunishi, S. Delivery of a normal newborn after intensive medical treatment for an acute exacerbation of ulcerative colitis during pregnancy: a case report. Surg. Today 29, 1257–1259 (1999).

    Article  CAS  PubMed  Google Scholar 

  140. Minter, A. et al. Colon cancer in pregnancy. Cancer Control 12, 196–202 (2005).

    Article  PubMed  Google Scholar 

  141. Mirza, M. S., Mulla, M. & Hall, R. I. Large bowel obstruction in pregnancy: a rare entity, an unusual cause. Arch. Gynecol. Obstet. 279, 177–178 (2009).

    Article  PubMed  Google Scholar 

  142. Seubert, D. E., Puder, K. S., Goldmeier, P. & Gonik, B. Colonoscopic release of the incarcerated gravid uterus. Obstet. Gynecol. 94, 792–794 (1999).

    Article  CAS  PubMed  Google Scholar 

  143. Nardulli, C. et al. Use of polyethylene glycol in the treatment of puerperal constipation [Article in Spanish]. GEN 49, 224–226 (1995).

    CAS  Google Scholar 

  144. Neri, I. et al. Polyethylene glycol electrolyte solution (Isocolan) for constipation during pregnancy: an observational open-label study. J. Midwifery Womens Health 49, 355–358 (2004).

    Article  PubMed  Google Scholar 

  145. Patel, V. et al. Intestinal and renal effects of low-volume phosphate and sulfate cathartic solutions designed for cleansing the colon: pathophysiological studies in five normal subjects. Am. J. Gastroenterol. 104, 953–965 (2009).

    Article  CAS  PubMed  Google Scholar 

  146. Tan, H. L., Liew, Q. Y., Loo, S. & Hawkins, R. Severe hyperphosphataemia and associated electrolyte and metabolic derangement following the administration of sodium phosphate for bowel preparation. Anaesthesia 57, 478–483 (2002).

    Article  CAS  PubMed  Google Scholar 

  147. Vinod, J., Bonheur, J., Korelitz, B. I. & Panagopoulos, G. Choice of laxatives and colonoscopic preparation in pregnant patients from the viewpoint of obstetricians and gastroenterologists. World J. Gastroenterol. 13, 6549–6552 (2007).

    PubMed  PubMed Central  Google Scholar 

  148. Bashir, R. M. et al. Massive gastrointestinal hemorrhage during pregnancy caused by ectopic decidua of the terminal ileum and colon. Am. J. Gastroenterol. 90, 1325–1327 (1995).

    CAS  PubMed  Google Scholar 

  149. Gonsoulin, W., Mason, B. & Carpenter, R. J. Jr. Colon cancer in pregnancy with elevated maternal serum alpha-fetoprotein level at presentation. Am. J. Obstet. Gynecol. 163, 1172–1173 (1990).

    Article  CAS  PubMed  Google Scholar 

  150. Rojansky, N. et al. Pregnancy associated with colon carcinoma overexpressing p53. Gynecol. Oncol. 64, 516–520 (1997).

    Article  CAS  PubMed  Google Scholar 

  151. Van Voorhis, B. & Cruikshank, D. P. Colon carcinoma complicating pregnancy. A report of two cases. J. Reprod. Med. 34, 923–927 (1989).

    CAS  PubMed  Google Scholar 

  152. Woods, J. B. et al. Pregnancy complicated by carcinoma of the colon above the rectum. Am. J. Perinatol. 9, 102–110 (1992).

    Article  CAS  PubMed  Google Scholar 

  153. Chan, Y. M., Ngai, S. W. & Lao, T. T. Colon cancer in pregnancy. A case report. J. Reprod. Med. 44, 733–736 (1999).

    CAS  PubMed  Google Scholar 

  154. Montes, H. & Wolf, J. Cecal volvulus in pregnancy. Am. J. Gastroenterol. 94, 2554–2556 (1999).

    Article  CAS  PubMed  Google Scholar 

  155. Rausch, M. E., Troiano, N. H. & Rosen, T. Use of neostigmine to relieve a suspected colonic pseudoobstruction in pregnancy. J. Perinatol. 27, 244–246 (2007).

    Article  CAS  PubMed  Google Scholar 

  156. Rozen, P., Schreiber, L. & Brazowski, E. Endometriosis, pregnancy, and colonoscopy. Endoscopy 35, 975 (2003).

    Article  CAS  PubMed  Google Scholar 

  157. Cappell, M. S. Endoscopy in pregnancy: risks versus benefits. Nat. Clin. Pract. Gastroenterol. Hepatol. 2, 376–377 (2005).

    Article  PubMed  Google Scholar 

  158. Gilinsky, N. H. & Muthunayagam, N. Gastrointestinal endoscopy in pregnant and lactating women: emerging standard of care to guide decision-making. Obstet. Gynecol. Surv. 61, 791–799 (2006).

    Article  PubMed  Google Scholar 

  159. Liao, Z., Gao, R., Xu, C. & Li, Z. S. Indications and detection, completion, and retention rates of small-bowel capsule endoscopy: a systematic review. Gastrointest. Endosc. 71, 280–286 (2010).

    Article  PubMed  Google Scholar 

  160. Lawson, M., Kern, F. Jr & Everson, G. T. Gastrointestinal transit time in human pregnancy: prolongation in the second and third trimesters followed by postpartum normalization. Gastroenterology 89, 996–999 (1985).

    Article  CAS  PubMed  Google Scholar 

  161. Storch, I. & Barkin, J. S. Contraindications to capsule endoscopy: do any still exist? Gastrointest. Endosc. Clin. N. Am. 16, 329–336 (2006).

    Article  PubMed  Google Scholar 

  162. Waterman, M. & Eliakim, R. Capsule endoscopy of the small intestine. Abdom. Imaging 34, 452–458 (2009).

    Article  PubMed  Google Scholar 

  163. Brent, R. L. The effect of embryonic and fetal exposure to x-ray, microwaves, and ultrasound: counseling the pregnant and nonpregnant patient about these risks. Semin. Oncol. 16, 347–368 (1989).

    CAS  PubMed  Google Scholar 

  164. Lowe, S. A. Diagnostic radiography in pregnancy: risks and reality. Aust. NZ J. Obstet. Gynaecol. 44, 191–196 (2004).

    Article  Google Scholar 

  165. Kammerer, W. S. Nonobstetric surgery during pregnancy. Med. Clin. North Am. 63, 1157–1164 (1979).

    Article  CAS  PubMed  Google Scholar 

  166. Tamir, I. L., Bongard, F. S. & Klein, S. R. Acute appendicitis in the pregnant patient. Am. J. Surg. 160, 571–575 (1990).

    Article  CAS  PubMed  Google Scholar 

  167. Wax, J. R., Pinete, M. G., Cartin, A., Winn, S. S. & Blackstone, J. Cavernous transformation of the portal vein complicating pregnancy. Obstet. Gynecol. 108, 782–784 (2006).

    Article  PubMed  Google Scholar 

  168. Hogan, R. B. et al. Video capsule endoscopy detection of jejunal carcinoid in life-threatening hemorrhage, first trimester pregnancy. Gastrointest. Endosc. 66, 205–207 (2007).

    Article  PubMed  Google Scholar 

  169. Van Bodegraven, A. A. et al. Gallbladder contents and fasting gallbladder volumes during and after pregnancy. Scand. J. Gastroenterol. 33, 993–997 (1998).

    Article  CAS  PubMed  Google Scholar 

  170. Valdivieso, V., Covarrubias, C., Siegel, F. & Cruz, F. Pregnancy and cholelithiasis: pathogenesis and natural course of gallstones diagnosed in early puerperium. Hepatology 17, 1–4 (1993).

    CAS  PubMed  Google Scholar 

  171. Ko, C. W., Beresford, S. A., Schulte, S. J., Matsumoto, A. M. & Lee, S. P. Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy. Hepatology 41, 359–365 (2005).

    Article  PubMed  Google Scholar 

  172. Al-Hashem, H., Muralidharan, V., Cohen, H. & Jamidar, P. A. Biliary disease in pregnancy with an emphasis on the role of ERCP. J. Clin. Gastroenterol. 43, 58–62 (2009).

    Article  PubMed  Google Scholar 

  173. Ramin, K. D. & Ramsey, P. S. Disease of the gallbladder and pancreas in pregnancy. Obstet. Gynecol. Clin. North Am. 28, 571–580 (2001).

    Article  CAS  PubMed  Google Scholar 

  174. Vitale, G. C. Endoscopic retrograde cholangiopancreatography (ERCP) and the surgeon. Interventional endoscopy in the management of complex hepatobiliary and pancreatic disease. Surg. Endosc. 12, 387–389 (1998).

    Article  CAS  PubMed  Google Scholar 

  175. McKellar, D. P., Anderson, C. T., Boynton, C. J. & Peoples, J. B. Cholecystectomy during pregnancy without fetal loss. Surg. Gynecol. Obstet. 174, 465–468 (1992).

    CAS  PubMed  Google Scholar 

  176. Tham, T. C. et al. Safety of ERCP during pregnancy. Am. J. Gastroenterol. 98, 308–311 (2003).

    Article  CAS  PubMed  Google Scholar 

  177. Baron, T. H. & Schueler, B. A. Pregnancy and radiation exposure during therapeutic ERCP: time to put the baby to bed? Gastrointest. Endosc. 69, 832–834 (2009).

    Article  PubMed  Google Scholar 

  178. Samara, E. T. et al. Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial? Gastrointest. Endosc. 69, 824–831 (2009).

    Article  PubMed  Google Scholar 

  179. Tang, S. J. et al. Safety and utility of ERCP during pregnancy. Gastrointest. Endosc. 69, 453–461 (2009).

    Article  PubMed  Google Scholar 

  180. Shelton, J., Linder, J. D., Rivera-Alsina, M. E. & Tarnasky, P. R. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest. Endosc. 67, 364–368 (2008).

    Article  PubMed  Google Scholar 

  181. Jamidar, P. A. et al. Endoscopic retrograde cholangiopancreatography in pregnancy. Am. J. Gastroenterol. 90, 1263–1267 (1995).

    CAS  PubMed  Google Scholar 

  182. Gupta, R. et al. Safety of therapeutic ERCP in pregnancy–an Indian experience. Indian J. Gastroenterol. 24, 161–163 (2005).

    PubMed  Google Scholar 

  183. Kahaleh, M. et al. Safety and efficacy of ERCP in pregnancy. Gastrointest. Endosc. 60, 287–292 (2004).

    Article  PubMed  Google Scholar 

  184. Sharma, S. S. & Maharshi, S. Two stage endoscopic approach for management of choledocholithiasis during pregnancy. J. Gastrointest. Liver Dis. 17, 183–185 (2008).

    Google Scholar 

  185. Farca, A., Aguilar, M. E., Rodriguez, G., de la Mora, G. & Arango, L. Biliary stents as temporary treatment for choledocholithiasis in pregnant patients. Gastrointest. Endosc. 46, 99–101 (1997).

    CAS  PubMed  Google Scholar 

  186. Daas, A. Y., Agha, A., Pinkas, H., Mamel, J. & Brady, P. G. ERCP in pregnancy: is it safe? Gastroenterol. Hepatol. (NY) 5, 851–855 (2009).

    Google Scholar 

  187. Bani Hani, M. N. et al. Safety of endoscopic retrograde cholangiopancreatography during pregnancy. ANZ J. Surg. 79, 23–26 (2009).

    Article  PubMed  Google Scholar 

  188. Chong, V. H. & Jalihal, A. Endoscopic management of biliary disorders during pregnancy. Hepatobiliary Pancreat. Dis. Int. 9, 180–185 (2010).

    PubMed  Google Scholar 

  189. Al-Akeely, M. H. Management of complicated gallstone disease during pregnancy. Saudi J. Gastroenterol. 9, 135–138 (2003).

    PubMed  Google Scholar 

  190. Güitrón-Cantú, A., Adalid-Martínez, R., Gutiérrez-Bermúdez, J. A. & Aguirre-Díaz, A. Endoscopic management of choledocholithiasis during pregnancy [Article in Spanish]. Rev. Gastroenterol. Mex. 68, 11–15 (2003).

    PubMed  Google Scholar 

  191. Akcakaya, A., Ozkan, O. V., Okan, I., Kocaman, O. & Sahin, M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J. Gastroenterol. 15, 3649–3652 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  192. Simmons, D. C., Tarnasky, P. R., Rivera-Alsina, M. E., Lopez, J. F. & Edman, C. D. Endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy without the use of sedation. Am. J. Obstet. Gynecol. 190, 1467–1469 (2004).

    Article  CAS  PubMed  Google Scholar 

  193. Tarnasky, P. R., Simmons, D. C., Schwartz, A. G., Macurak, R. B. & Edman, C. D. Safe delivery of bile duct stones during pregnancy. Am. J. Gastroenterol. 98, 2100–2101 (2003).

    Article  PubMed  Google Scholar 

  194. Shah, O. J., Robanni, I., Khan, F., Zargar, S. A. & Javid, G. Management of biliary ascariasis in pregnancy. World J. Surg. 29, 1294–1298 (2005).

    Article  PubMed  Google Scholar 

  195. Vandervoort, J. et al. Is ERCP during pregnancy safe? [abstract]. Gastrointest. Endosc. 43, 400 (1996).

    Google Scholar 

  196. Baillie, J., Cairns, S. R., Putnam, W. S. & Cotton, P. B. Endoscopic management of choledocholithiasis during pregnancy. Surg. Gynecol. Obstet. 171, 1–4 (1990).

    CAS  PubMed  Google Scholar 

  197. Sungler, P. et al. Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy. Surg. Endosc. 14, 267–271 (2000).

    Article  CAS  PubMed  Google Scholar 

  198. Savas, M. C., Kadayifci, A. & Koruk, M. Re: Tham et al.–Safety of ERCP during pregnancy. Am. J. Gastroenterol. 98, 2331–2332 (2003).

    PubMed  Google Scholar 

  199. Barthel, J. S., Chowdhury, T. & Miedema, B. W. Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy. Surg. Endosc. 12, 394–399 (1998).

    Article  CAS  PubMed  Google Scholar 

  200. Baillie, J. ERCP during pregnancy. Am. J. Gastroenterol. 98, 237–238 (2003).

    Article  PubMed  Google Scholar 

  201. Uomo, G., Manes, G., Picciotto, F. P. & Rabitti, P. G. Endoscopic treatment of acute biliary pancreatitis in pregnancy. J. Clin. Gastroenterol. 18, 250–252 (1994).

    Article  CAS  PubMed  Google Scholar 

  202. Llach, J., Bordas, J. M., Ginès, A., Mondelo, F. & Terés, J. Endoscopic sphincterotomy in pregnancy. Endoscopy 29, 52–53 (1997).

    Article  CAS  PubMed  Google Scholar 

  203. Sbeih, F., Boghdadly, S. E., Palkar, V. & Nayak, P. Endoscopic retrograde cholangiopancreatography (ERCP) for symptomatic choledocholithiasis during pregnancy. Ann. Saudi Med. 17, 233–234 (1997).

    Article  CAS  PubMed  Google Scholar 

  204. Berger, Z. Endoscopic papillotomy without fluoroscopy in pregnancy. Endoscopy 30, 313 (1998).

    Article  CAS  PubMed  Google Scholar 

  205. al Karawi, M. & Mohamed, S. A. Therapeutic endoscopic retrograde cholangiopancreatography with ultra-short fluoroscopy: report of two cases. Endoscopy 29, S31 (1997).

    Article  CAS  PubMed  Google Scholar 

  206. Hernandez, A. et al. Acute pancreatitis and pregnancy: a 10-year single center experience. J. Gastrointest. Surg. 11, 1623–1627 (2007).

    Article  PubMed  Google Scholar 

  207. Soo, Y., Kim, M. D., Dominic, K. H. & Wong, M. D. ERCP in the management of pancreaticobiliary disease during pregnancy [abstract]. Gastrointest. Endosc. 43, 385 (1996).

    Article  Google Scholar 

  208. Friedman, R. L. & Friedman, I. H. Acute cholecystitis with calculous biliary duct obstruction in the gravid patient. Management by ERCP, papillotomy, stone extraction, and laparoscopic cholecystectomy. Surg. Endosc. 9, 910–913 (1995).

    CAS  PubMed  Google Scholar 

  209. Eichenberg, B. J. et al. Laparoscopic cholecystectomy in the third trimester of pregnancy. Am. Surg. 62, 874–877 (1996).

    CAS  PubMed  Google Scholar 

  210. Axelrad, A. M., Fleischer, D. E., Strack, L. L., Benjamin, S. B. & al-Kawas, F. H. Performance of ERCP for symptomatic choledocholithiasis during pregnancy: techniques to increase safety and improve patient management. Am. J. Gastroenterol. 89, 109–112 (1994).

    CAS  PubMed  Google Scholar 

  211. Bagci, S., Tuzun, A., Erdil, A., Gulsen, M. & Dagalp, K. Treatment of choledocholithiasis in pregnancy: a case report. Arch. Gynecol. Obstet. 267, 239–241 (2003).

    PubMed  Google Scholar 

  212. Iyilikci, L., Akarsu, M., Kocaayan, E. & Topalak, O. Sedation for endoscopic retrograde cholangiopancreatography (ERCP) in a pregnant patient. J. Anesth. 21, 69–71 (2007).

    Article  PubMed  Google Scholar 

  213. Lu, E. J., Curet, M. J., El-Sayed, Y. Y. & Kirkwood, K. S. Medical versus surgical management of biliary tract disease in pregnancy. Am. J. Surg. 188, 755–759 (2004).

    Article  PubMed  Google Scholar 

  214. Freistuhler, M., Braess, A. & Petrides, A. S. Ultrasound-guided endoscopic sphincterotomy in a pregnant woman with severe acute biliary pancreatitis. Z. Gastroenterol. 37, 27–30 (1999).

    CAS  PubMed  Google Scholar 

  215. Pasquale, L. et al. Endoscopic management of symptomatic choledocholithiasis in pregnancy without the use of radiations. Eur. Rev. Med. Pharmacol. Sci. 11, 343–346 (2007).

    CAS  PubMed  Google Scholar 

  216. Goldschmiedt, M., Wolf, L. & Shires, T. Treatment of symptomatic choledocholithiasis during pregnancy. Gastrointest. Endosc. 39, 812–814 (1993).

    Article  CAS  PubMed  Google Scholar 

  217. Binmoeller, K. F. & Katon, R. M. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointest. Endosc. 36, 607–609 (1990).

    Article  CAS  PubMed  Google Scholar 

  218. Parada, A. A. et al. Endoscopic papillotomy under ultra-sonographic control. Int. Surg. 76, 75–76 (1991).

    CAS  PubMed  Google Scholar 

  219. Duseja, A. et al. Safety and efficacy of ERCP in pregnancy. Gastrointest. Endosc. 61, 352–353 (2005).

    Article  PubMed  Google Scholar 

  220. Zágoni, T. & Tulassay, Z. Endoscopic sphincterotomy without fluoroscopic control in pregnancy. Am. J. Gastroenterol. 90, 1028 (1995).

    PubMed  Google Scholar 

  221. Rahmin, M. G., Hitscherich, R. & Jacobson, I. M. ERCP for symptomatic choledocholithiasis in pregnancy. Am. J. Gastroenterol. 89, 1601–1602 (1994).

    CAS  PubMed  Google Scholar 

  222. Martins, L., Rodrigues, R. & Meirinho, M. Acute pancreatitis and pregnancy [Article in Portugese]. Acta Med. Port. 10, 715–719 (1997).

    CAS  PubMed  Google Scholar 

  223. Freeman, M. L. et al. Complications of endoscopic biliary sphincterotomy. N. Engl. J. Med. 335, 909–918 (1996).

    Article  CAS  PubMed  Google Scholar 

  224. Bremme, K. A. Haemostatic changes in pregnancy. Best Pract. Res. Clin. Haematol. 16, 153–168 (2003).

    Article  PubMed  Google Scholar 

  225. Cappell, M. S. The safety and efficacy of gastrointestinal endoscopy during pregnancy. Gastroenterol. Clin. North Am. 27, 37–71 (1998).

    Article  CAS  PubMed  Google Scholar 

  226. Basso, L., McCollum, P. T., Darling, M. R., Tocchi, A. & Tanner, W. A. A study of cholelithiasis during pregnancy and its relationship with age, parity, menarche, breast-feeding, dysmenorrhea, oral contraception and maternal history of cholelithiasis. Surg. Gynecol. Obstet. 175, 41–46 (1992).

    CAS  PubMed  Google Scholar 

  227. Aszodi, A., Ponsky, J. L., Kiwi, R. & Parulekar, S. G. Choledochal cyst in a pregnant adult. Am. J. Gastroenterol. 85, 1048–1049 (1990).

    CAS  PubMed  Google Scholar 

  228. Oto, A. et al. The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreatobiliary disease. Br. J. Radiol. 82, 279–285 (2009).

    Article  CAS  PubMed  Google Scholar 

  229. Roumieu, F., Ponchon, T., Audra, P. & Gaucherand, P. Acute pancreatitis in pregnancy: place of the different explorations (magnetic resonance cholangiopancreatography, endoscopic ultrasonography) and their therapeutic consequences. Eur. J. Obstet. Gynecol. Reprod. Biol. 140, 141–142 (2008).

    Article  CAS  PubMed  Google Scholar 

  230. Chong, V. H. EUS complements ERCP during pregnancy. Gastrointest. Endosc. 70, 1285–1286 (2009).

    Article  PubMed  Google Scholar 

  231. Gyokeres, T., Topas, L., Marton, I. & Pap, A. Endoscopic cystogastrostomy during pregnancy. Gastrointest. Endosc. 53, 516–518 (2001).

    Article  CAS  PubMed  Google Scholar 

  232. Ryan, M. E. Endoscopic management of a pancreatic pseudocyst during pregnancy. Gastrointest. Endosc. 38, 605–608 (1992).

    Article  CAS  PubMed  Google Scholar 

  233. Girotra, M. & Jani, N. Role of endoscopic ultrasound/SpyScope in diagnosis and treatment of choledocholithiasis in pregnancy. World J. Gastroenterol. 16, 3601–3602 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  234. Esposito, T. J. Trauma during pregnancy. Emerg. Med. Clin. North Am. 12, 167–199 (1994).

    CAS  PubMed  Google Scholar 

  235. Winstead, N. S. & Wilcox, C. M. Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis. Aliment. Pharmacol. Ther. 26, 1371–1377 (2007).

    Article  CAS  PubMed  Google Scholar 

  236. Boyce, R. A. Enteral nutrition in hyperemesis gravidarum: a new development. J. Am. Diet. Assoc. 92, 733–736 (1992).

    CAS  PubMed  Google Scholar 

  237. Gulley, R. M., Vander Pleog, N. & Gulley, J. M. Treatment of hyperemesis gravidarum with nasogastric feeding. Nutr. Clin. Pract. 8, 33–35 (1993).

    Article  CAS  PubMed  Google Scholar 

  238. Hsu, J. J., Clark-Glena, R., Nelson, D. K. & Kim, C. H. Nasogastric enteral feeding in the management of hyperemesis gravidarum. Obstet. Gynecol. 88, 343–346 (1996).

    Article  CAS  PubMed  Google Scholar 

  239. Saha, S., Loranger, D., Pricolo, D. & Degli-Esposti, S. Feeding jejunostomy for the treatment of severe hyperemesis gravidarum: a case series. JPEN J. Parenter. Enteral Nutr. 33, 529–534 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  240. Trovik, J., Haram, K., Berstad, A. & Flaatten, H. Nasogastric tube feeding in hyperemesis gravidarum: an alternative to parenteral nutrition [Article in Norwegian]. Tidsskr. Nor. Laegeforen. 116, 2442–2444 (1996).

    CAS  PubMed  Google Scholar 

  241. Vaisman, N., Kaidar, R., Levin, I. & Lessing, J. B. Nasojejunal feeding in hyperemesis gravidarum—a preliminary study. Clin. Nutr. 23, 53–57 (2004).

    Article  CAS  PubMed  Google Scholar 

  242. Jaffe, P., Liberman, M. M., McFadyen, I. & Valman, H. B. Letter: Incidence of congenital limb-reduction deformities. Lancet 1, 526–527 (1975).

    Article  CAS  PubMed  Google Scholar 

  243. Bruno, J. M. & Kroser, J. Efficacy and safety of upper endoscopy procedures during pregnancy. Gastrointest. Endosc. Clin. N. Am. 16, 33–40 (2006).

    Article  PubMed  Google Scholar 

  244. Katz, J. A. Endoscopy in the pregnant patient with inflammatory bowel disease. Gastrointest. Endosc. Clin. N. Am. 12, 635–646 (2002).

    Article  PubMed  Google Scholar 

  245. Siddiqui, U. & Proctor, D. D. Flexible sigmoidoscopy and colonoscopy during pregnancy. Gastrointest. Endosc. Clin. N. Am. 16, 59–69 (2006).

    Article  PubMed  Google Scholar 

  246. Strand, E. Gastrointestinal endoscopy in pregnant and lactating women: emerging standard of care to guide decision-making. Obstet. Gynecol. Surv. 62, 253 (2007).

    Article  PubMed  Google Scholar 

  247. Qureshi, W. A. et al. ASGE Guideline: Guidelines for endoscopy in pregnant and lactating women. Gastrointest. Endosc. 61, 357–362 (2005).

    Article  PubMed  Google Scholar 

  248. Rodriguez, S. A. et al. Ultrathin endoscopes. Gastrointest. Endosc. 71, 893–898 (2010).

    Article  PubMed  Google Scholar 

  249. Swain, P. At a watershed? Technical developments in wireless capsule endoscopy. J. Dig. Dis. 11, 259–265 (2010).

    Article  PubMed  Google Scholar 

  250. Ciuti, G. et al. Robotic versus manual control in magnetic steering of an endoscopic capsule. Endoscopy 42, 148–152 (2010).

    Article  CAS  PubMed  Google Scholar 

  251. Tortora, G. et al. Propeller-based wireless device for active capsular endoscopy in the gastric district. Minim. Invasive Ther. Allied Technol. 18, 280–290 (2009).

    Article  PubMed  Google Scholar 

  252. Niv, Y. Capsule endoscopy: no longer limited to the small bowel. Isr. Med. Assoc. J. 12, 178–180 (2010).

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Ethics declarations

Competing interests

The author declares no competing financial interests.

Supplementary information

Supplementary Tables

Safety of anesthetic medications commonly used in gastrointestinal procedures (DOC 406 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cappell, M. Risks versus benefits of gastrointestinal endoscopy during pregnancy. Nat Rev Gastroenterol Hepatol 8, 610–634 (2011). https://doi.org/10.1038/nrgastro.2011.162

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2011.162

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing