© Springer International Publishing Switzerland 2015
Omer Engin (ed.)Colon Polyps and the Prevention of Colorectal Cancer10.1007/978-3-319-17993-3_77. Lower Gastrointestinal Tract Endoscopy in Pregnant Women
(1)
Surgery Department, Bozyaka Training and Research Hospital, Izmir, Turkey
Even though endoscopic procedures are considered as low-risk procedures that can usually be performed without hospitalization, they can be more complicated in pregnant patients [1, 2]. The physiological and anatomical changes in pregnancy and maternal and fetal risk factors create some disadvantages during endoscopic procedures of lower gastrointestinal tract (LGIT) in particular. Controlled trials are not possible due to medicolegal factors and patients’ refusal. In addition to the theoretical knowledge, the information obtained from the studies which usually include retrospective case series with small sample size has been stayed at suggestion level [2]. The experience regarding the used medications only consists of animal experiments [3].
Maternal Risk Factors
Aspiration
Hypotension
Hypoxia
Bowel trauma
Uterine trauma
Delay in diagnosis and treatment
In the late phases of pregnancy, the growing uterus pushes the abdominopelvic organs and changes the intra-abdominal anatomy. This condition raises some difficulties for the endoscopist: procedure period may prolong and the dose of sedative medication and insufflated CO2 amount needed may increase to evaluate colon lumen better. All of these difficulties affect negatively the comfort of the patient during the procedure and also may increase the injury risk to mother or fetus [1, 4].
Pregnant women have more regurgitation risk due to increased intra-abdominal pressure and decreased gastroesophageal sphincter pressure. The sedation administered to patient during LGIT endoscopy and the increased intra-abdominal pressure due to CO2 insufflation increases the aspiration risk of the patient [1].
There is physiological restriction in the airways in pregnancy due to edematous airway mucosa. Furthermore, pulmonary capacity decreases due to diaphragm elevation. This condition is compensated with increased breath rate [1].
Even though very rarely used in LGIT endoscopy, supine position may cause maternal hypotension in pregnancy by blocking venous return due to the pressure of the growing uterus on vena cava inferior. This condition becomes especially apparent after 30th week. Left lateral position is recommended during the procedure [3].
Fetal Risk Factors
Hypoxia
Hypotension
Teratogenesis
Uterine trauma
Premature delivery
Abortus
Fetus is extremely sensitive to maternal hypoxia and hypotension. Since uterine arteries cannot provide sufficient autoregulation when the systemic artery pressure is decreased, uterine blood flow decreases due to maternal hypotension and compensatory vasoconstriction. Fetal bradycardia which may be seen in this situation may present itself even before hypotension becomes clinically visible [4].
During colonoscopy, sometimes extra-abdominal compression may be necessary and this maneuver may cause fetal distress due to the pressure on uterus.
Endoscopic Procedure
Endoscopist should asses the present risk factors, clinical condition of the patient, and the urgency of the planned procedure, and if possible, delays the procedure after delivery or at least to second trimester. Procedures should be avoided during the first trimester in which the organogenesis occurs and the third trimester in which there is a risk of premature delivery [3, 7]. The physician should also make the decision considering the risk of delay in diagnosis and treatment along with risks of the procedure.
The procedure should not be performed for elective reasons such as family history of cancer or change in bowel habits. The American Society for Gastrointestinal Endoscopy (ASGE) recommended LGIT endoscopy indication in pregnant women [3].
LGIT Endoscopy Indications Recommended by ASGE
Severe and persistent gastrointestinal bleeding
Strong suspicion for malignancy
Unexplained severe diarrhea
Severe and persistent abdominal pain
Some authors recommended two more indications in addition to these criteria [2]:
For decompression in colonic pseudo obstruction
Other therapeutic procedures that can be performed instead of colon surgery
Endoscopist should question the patient’s history, comorbidities, and obstetric condition following the procedure decision. There should be multidisciplinary assessment before the procedure by the endoscopist, anesthesiologist, obstetrician, and primatologist, if needed. The risks of the procedure should be identified, and the risks regarding the mother and fetus should be explained to patient, and informed consent should be obtained. The gestational development of the fetus should be determined by obstetric examination and possible contraindications should be assessed [1, 4].
Endoscopy Contraindications in Pregnancy [3, 4]
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