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

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

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”

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

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.

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

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

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 “

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

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

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 ??

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

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

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

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