Safety and efficacy of ERCP in pregnancy

The incidence of gallstones in pregnancy is estimated at 2.5-4.2%. Cholecystectomy offers definitive therapy but its performance during pregnancy may increase the risk of the procedure. ERCP is used to defer cholecystectomy or treatment complication of pancreatic-biliary disease but data regarding its use in pregnancy is limited. Aim: To determine the safety, efficacy, and clinical outcome of ERCP for biliary complications of gall stones. 2. To determine the incidence of the biliary complications of gallstones in pregnancy. Methods: More than 71,000 deliveries occurred at Parkland Memorial Hospital between 2/93 and 7/97. ICD-9 Procedure codes for ERCP, cholecystectomy, common bile duct exploration were identified for indications of pancreatitis, cholangitis, choledocholithiasis, cholecystitis by CPT codes. 23 patients who received therapeutic ERCP were identified. Indications for ERCP included: 11 choledocholithiasis, 8 biliary pancreatitis, 3 cholangitis, and 1 acute recurrent pancreatitis. Results: The mean age was 24 (range 17-31) with 14 Hispanics, 8 African Americans and 1 Caucasian. The mean gestational age was 19 weeks (5-40 weeks). The trimester division was 10 in the 1st, 5 in the 2nd, 8 in the 3rd. Fluoroscopy technique: The uterus was lead shielded and digital fluoroscopy use was minimized. The average time was 100.3 seconds and no hard films were obtained. Sedation technique included incremental Versed and Demerol. Average Demerol (mean 117 mg, range 50-175) Versed (mean 5.3 mg, range 2.5-11). Procedure findings: CBD stones in 17, papillary stenosis in 1, hemobilia in 1, pancreas divisum in 1, gallstones in 3. Procedure Therapy: 22 patients had sphincterotomy with stone extraction in 17 patients, and clot in 1. Biliary stents were placed in 15 of 18 patients in whom delayed cholecystectomy was planned. Cholecystectomy was performed following ERCP in 5 patients while 18 patients were observed to delivery. No ERCP related complications occurred. Maternal and fetal outcomes were available in 18 patients. 16 patients had normal deliveries with fetal Apgar scores of > 8. The patient with pancreas divisum developed recurrent pancreatitis at 18 weeks and chose elective abortion. One patient experienced a spontaneous abortion 12 weeks after ERCP and 3 weeks after laparoscopic cholecystectomy. Follow-up in 8 of 15 patients with biliary stents revealed that 5/8 (62.5%) were found to have choledocholithiasis at the time of stent removal. 2 relocated and were lost to follow-up. 5 have stents in place pending delivery. Conclusions: ERCP was able to alleviate complications of gall stones without immediate complications or demise in fetal outcome. Biliary stenting and/or sphincterotomy in lieu of cholecystectomy prevented recurrence of complications. This represents the largest single center experience of therapeutic ERCP in pregnancy.