During normal pregnancy, the gastrointestinal (GI) tract and its appendages undergo remarkable anatomical, physiological, and functional alterations. These changes, which are discussed in detail in Chapter 4 (p. 70), can appreciably alter clinical findings normally relied on for diagnosis and treatment. Moreover, as pregnancy progresses, GI findings become more difficult to assess. The clinical examination is often obscured by a large uterus that displaces abdominal organs and can alter the location and intensity of pain and tenderness.
Several endoscopic methods can be used to evaluate the gastrointestinal (GI) tract during pregnancy without reliance on radiographic techniques. With fiberoptic endoscopic instruments, the esophagus, stomach, duodenum, and colon can be inspected (Savas, 2014; Song, 2018). The proximal jejunum also can be studied, and the ampulla of Vater cannulated to perform endoscopic retrograde cholangiopancreatography—ERCP (Fogel, 2014; Hedström, 2017). Experience in pregnancy with video capsule endoscopy for small-bowel evaluation remains limited (Bandorski, 2016). Normal pregnancy-related slowing of GI motility and thus increased transit time as well as the recorder capsule’s electromagnetic field are theoretical concerns.
Upper gastrointestinal endoscopy is used for diagnosis and management of several problems. Common bile duct exploration and drainage are used for choledocholithiasis (Chap. 58, p. 1043). Sclerotherapy and placement of percutaneous endoscopic gastrostomy (PEG) tubes also are performed endoscopically.
Colonoscopy is indispensible for viewing the entire colon and distal ileum. Except for the midtrimester, reports of colonoscopy during pregnancy are limited, but most results suggest that it should be performed if necessary (De Lima, 2015; Ludvigsson, 2017). Pregnancy indications include chronic abdominal pain, hematochezia, and diarrhea (Cappell, 2011). Bowel preparation is completed using polyethylene glycol electrolyte (GoLYTELY) or sodium sulfate (Suprep) solutions (American Society for Gastrointestinal Endoscopy, 2015). With these, most women avoid serious dehydration that may cause diminished uteroplacental perfusion. In select cases, tap water enemas may be an alternative for rectosigmoidoscopy to avoid some of these risks.
Endoscopic procedures should be performed when indicated and ideally in the second trimester (American Society for Gastrointestinal Endoscopy, 2012; Ludvigsson, 2017). A multidisciplinary approach with obstetricians, gastroenterologists, and anesthesiologists is prudent. Table 57-1 outlines preprocedural considerations in pregnancy.
Table Graphic Jump Location TABLE 57-1Preprocedural Considerations for Gastrointestinal Endoscopy During Pregnancy ||Download (.pdf) TABLE 57-1Preprocedural Considerations for Gastrointestinal Endoscopy During Pregnancy
|Plan consultation with an obstetrician, gastroenterologist, and anesthesiologist|
Place patient in left lateral decubitus position
Use lowest effective dose of sedation necessary
Give prophylactic antibiotics as indicated. Penicillin, cephalosporin, erythromycin, and clindamycin are safe options
Minimize procedure time
Obtain fetal heart tones at the discretion of the obstetrician. In general, pre- and post-procedure heart tones are adequate
For colonoscopy, favor preparation with PEG-ES or with tap water enemas depending on GI ...