Safety of Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Systematic Review and Meta-Analysis

Introduction: Pregnant women are at increased risk for biliary lithiasis due to a decrease in gallbladder motility and breakdown of cholesterol in bile. In some cases Endoscopic Retrograde Cholangiopancreatography (ERCP) is needed to manage complications such as choledocholithiasis and gallstone pancreatitis. ERCP poses unique safety concerns to developing fetus in terms of radiation and potential procedural complications. We performed a systematic review and meta-analysis of the available literature to determine the safety of ERCP in pregnancy. Methods: A systematic search of Ovid Medline, Ovid EMBASE, Cochrane CENTRAL, Scopus, and Web of Science was performed through October 19th, 2020. Prospective, retrospective, and case series with > 5 patients were included. Standard forms were used to extract data regarding study type, procedural data, and maternal/fetal outcomes by two independent reviewers (CFV and JZ). Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I2, and meta-regression analysis was conducted. Outcomes assessed were rate of fetal and maternal complications after ERCP. Results: A total of 784 patients were included from 47 studies. The pooled overall fetal complication and maternal complication event rate was 9% and 9.5% respectively (Figure 1). The pooled rates of specific fetal complications included abortion 4.7%, preterm delivery 7.8%, and low birth weight 4%. The pooled rate of specific types of maternal complications included post ERCP pancreatitis 5.9%, acute cholecystitis 3.9%, and bleeding 4.7%. On subgroup analysis, there was no difference in outcomes when comparing ERCP with radiation use versus no radiation use, with 8.5% vs 10.2% (P = 0.58) when examining fetal complications and 10.6% vs 8.5% (P = 0.42) when examining maternal complications. On meta-regression later gestational age was associated with higher rates of fetal complications (P = 0.04) and preterm delivery (P = 0.04), however, advanced maternal age had no impact on fetal or maternal complications. Conclusion: Careful review of indications for ERCP should be utilized prior to performing ERCP in pregnant patients. The primary risk to the fetus is felt to be radiation exposure, which should be limited, but appears to have no impact on fetal outcomes in the short term. Later age of gestation at the time of the procedure may lead to increase fetal complications and preterm delivery.Figure 1.: Endoscopic appearance of GI- NET with EBL-WR.