Safety of endoscopy during pregnancy in women with portal hypertension

Introduction

Pregnant women with portal hypertension (PHT) require a second trimester variceal surveillance oesophagogastroduodenoscopy (OGD). There remains variation in practice and concerns regarding sedation use during pregnancy. The aim of this study was to review the safety of endoscopy during pregnancy in women with PHT.

Methods

Data on pregnancies in women with PHT from 2005 – 2022 in a single centre were collected retrospectively.

Results

There were 114 pregnancies including 105 with cirrhosis and 9 with non-cirrhotic PHT. 70 patients did not have a surveillance OGD of which 10 were due to early pregnancy loss/termination, 9 patients declined and the remainder was unrecorded. 44 patients received surveillance OGD at mean gestation of 22 weeks. The MELD score was significantly higher in the OGD group compared to the non-OGD group (9 versus 8, p = 0.01). The pregnancy related outcomes including live birth rate, complications during pregnancy, preterm births, miscarriage rate and congenital malformations were not significantly different between the 2 cohorts. However, there were 4 stillbirths in the OGD group (p = 0.03). Within the OGD group, 14 had no sedation, 23 received sedation, 1 was under general anaesthesia and data was incomplete for 6. The 2 stillbirths in women who had OGD with sedation were deemed unrelated to the procedure as 1 was in a patient with severe liver disease who had a catastrophic parametrial haemorrhage at 33 weeks whilst the other patient was admitted for hepatic encephalopathy prior to the OGD and the stillbirth occurred >2 weeks after the OGD. There was 1 miscarriage in a patient 1 week after the OGD with 5mg midazolam and 50mcg fentanyl. Post procedure fetal monitoring was satisfactory. The rate of preterm births and complications during pregnancy were higher in the sedation group compared to the non-sedation group (p = 0.01 and p = 0.04 respectively). None of the patients experienced procedure related complications, required an admission <1 week of the OGD and the preterm births all occurred >2 months after the procedure.

Conclusions

Patients with more severe liver disease or complex comorbidities may be more likely to undergo surveillance endoscopy. No procedural related complications were detected in our cohort and endoscopy should be considered safe in pregnancy.