Kale KG *, Kalappa SB **, Chauhan AR ***
(* Assistant Professor, ** First Year Resident, *** Professor, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India)
Symptomatic choledocholithiasis in pregnancy, though rare, is an emergency requiring prompt treatment to prevent fatal maternal and fetal complications. Surgery, in the form of cholecystectomy with common bile duct exploration has high rate of fetal loss, hence is not preferred. Recently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been evaluated and documented as a safe and effective alternative to surgery. However, there still exist concerns about fetal radiation exposure during ERCP. We present a case of symptomatic choledocholithiasis in second trimester of pregnancy treated with therapeutic ERCP leading to a good maternal and fetal outcome.
Pregnancy is a "lithogenic" state. Marked elevation in the serum levels of estrogen and progesterone in pregnancy leads to increase in the biliary cholesterol concentration, decreased bile acid secretion and decreased gall bladder motility, thus favoring formation of gall stones. The prevalence of gall stone disease in pregnancy is estimated to be 3 - 12% and symptomatic choledocholithiasis complicates 1 in every 1000 - 1200 pregnancies. Choledocholithiasis often leads to cholangitis and/ or gallstone pancreatitis, both of which may prove fatal to the mother and the fetus, hence should be treated promptly. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is considered as the current standard of care in the treatment of choledocholithiasis in pregnancy. Although the safety of ERCP has been established by various case series till date,[2- 9] there still exist concerns about the risk of radiation exposure to the fetus.
A 22 years old female, gravida 2 presented at 24 weeks' of gestation with moderate to severe colicky pain in right hypochondrium, nausea and vomiting. On physical examination, jaundice was evident in the sclera and tenderness was present over the right hypochondrium. Uterus corresponded to 24 weeks' size without any uterine activity. Fetal heart sounds were regular on Doppler. On per vaginal examination, cervical os was closed.
Laboratory investigations showed normal hemogram, elevated total and direct bilirubin and elevated liver enzymes (total bilirubin- 2.4mg/dL, direct bilirubin- 1.36 mg/dL, AST- 88 U/L, ALT- 106 U/L, alkaline phosphatase- 212 U/L, GGT- 46 U/L). Abdominal ultrasonogram revealed multiple small gall bladder calculi, a 9 mm calculus in the distal common bile duct (CBD) and dilatation of proximal CBD with diameter of 14 mm. Obstetric ultrasound revealed single live intrauterine fetus corresponding to 23 weeks 5 days. An emergency ERCP was planned. ERCP was performed under intravenous sedation, with the patient in supine position, by an experienced endoscopic surgeon. Fetal heart was monitored pre and post operatively. Lead shielding of lower abdomen was done to minimize fetal dosing. CBD was cannulated and cholangiogram obtained which confirmed multiple stones in biliary tree including the CBD. Sphincterotomy was performed and a 9 mm CBD stone was removed using a balloon catheter followed by placement of a 10 Fr stent. No hard copy radiographs were taken during the procedure and fluoroscopy was used for as short a time as possible (2 minutes 10 seconds). There were no procedure related complications and patient had a rapid post-operative recovery with normalization of laboratory parameters.
Patient was regularly followed up in antenatal and gastroenterology OPD. Patient carried the pregnancy to term without any further complications or recurrence of symptoms and delivered a healthy female child of 3.08 kg vaginally. Apgar scores at 1 and 5 minutes were 8 and 9 respectively. No obvious congenital malformations were found. Patient was discharged along with the newborn on day 4 postpartum and was advised to follow up in gastroenterology OPD for definitive management.
Symptomatic choledocholithiasis with cholangitis and/or gallstone pancreatitis is a surgical emergency with a grave prognosis for both the mother and the fetus if not treated promptly. Traditional approach consisting of cholecystectomy with CBD exploration has high incidence of preterm labor and fetal loss; hence should be avoided.  Therapeutic ERCP with its well documented safety and efficacy for both the mother and the fetus, is currently the treatment modality of choice for symptomatic choledocholithiasis in pregnancy.[2 - 9]
The primary concern with ERCP is the fetal exposure to ionizing radiations causing intrauterine growth retardation, fetal anomalies, intrauterine fetal death and childhood cancers. The threshold conceptus dose for these fetal effects is estimated to be 100 - 200 mGy which is much larger than the average dose delivered during a routine ERCP.  The average fetal radiation exposure during ERCP in various studies ranges from 0.1 to 11 mGy [5-7] with a mean fluoroscopy time ranging from 8 seconds to 3.8 minutes. [3,5,6] According to the American College of Obstetricians and Gynecologists (ACOG), a radiation exposure of < 50 mGy is not associated with an appreciable increased rate of fetal loss or anomalies. Thus, with minimal radiation exposure, the measurement of radiation exposure for routine ERCP procedures appears unnecessary. The importance of various measures taken to minimize radiation exposure to the fetus, as was done in our case, has been stressed upon in the literature. These measures include limiting fluoroscopy time, lead shielding of abdomen, using low dose settings, avoiding hard copy radiographs and appropriate patient positioning to minimize fetal dosing.[2, 4-8]
The risk of preterm delivery after therapeutic ERCP is less, with a term pregnancy rate ranging from 89.8 % to 94.4 % in various studies.[3, 7, 9] Tang in 2009 reported that term pregnancy rate was lowest for patients who underwent an ERCP in first trimester with high preterm delivery rate of approximately 20 %. Second trimester appears to be the safest period to perform ERCP. No reported cases of intra procedure fetal distress , or procedure-related perinatal deaths, stillbirths or fetal malformations have been documented. [2,3,9] The 5 minute Apgar scores of babies born to mothers who have undergone ERCP was ≥ 8.[2,5,7] The longest follow up (6 years) by Gupta et al have found no developmental or congenital abnormalities in these children. The incidence of other procedure related complications, viz. post- ERCP pancreatitis and post- ERCP bleed was similar to that seen in non-pregnant population.
In an effort to eliminate radiation exposure, few authors have tried various modifications of therapeutic ERCP. Akcakaya et al and Sharma et al implemented cannulation of CBD using a guidewire and confirmed its position by aspiration of bile (fluoroscopy was not used). This was followed by sphincterotomy and balloon sweeping of the duct with/without stent placement. This approach however has various disadvantages: Firstly, there is risk of inadvertently cannulating the cystic duct. Secondly, complete stone clearance is not achieved due to lack of visualization of biliary tree which may lead to recurrence. To overcome these disadvantages, Shelton et al have recommended the use of real-time percutaneous ultrasonography, intraductal ultrasonography, linear echoendoscopy and choledochoscopy during the performance of non-radiation ERCP. However, greater degree of experience is required with these novel techniques of non- radiation ERCP before they can be routinely employed.
Therapeutic ERCP appears safe and effective in the management of symptomatic choledocholithiasis in pregnancy. Second trimester appears to be the safest period for performance of the procedure with high term delivery rates and good fetal outcome. All measures to reduce fetal radiation exposure should be undertaken. Newer techniques of non radiation ERCP should be evaluated further for possible use in future.
- de Bari O, Wang TY, Liu M, Paik CN, Portincasa P, Wang DQ. Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment. Ann Hepatol. 2014 Nov-Dec; 13(6):728-45.
- Daas AY, Agha A, Pinkas H, Mamel J, Brady PG. ERCP in pregnancy: is it safe? Gastroenterol Hepatol (N Y) 2009; 5(12): 851-5.
- Gupta R, Tandan M, Lakhtakia S, Santosh D, Rao GV, Reddy DN. Safety of therapeutic ERCP in pregnancy - an Indian experience. Indian J Gastroenterol 2005; 24(4): 161-3.
- Al-Hashem H, Muralidharan V, Cohen H, Jamidar PA. Biliary disease in pregnancy with an emphasis on the role of ERCP. J Clin Gastroenterol. 2009; 43(1):58-62.
- Tham TC, Vandervoort J, Wong RC, Montes H, Roston AD, et al. Safety of ERCP during pregnancy. Am J Gastroenterol. 2003; 98(2):308-11.
- Kahaleh M, Hartwell GD, Arseneau KO, Pajewski TN, Mullick T, et al. Safety and efficacy of ERCP in pregnancy. Gastrointest Endosc. 2004; 60(2):287-92.
- Fine S, Beirne J, Delgi-Esposti S, Habr F. Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy. World J Gastrointest Endosc 2014; 6(8): 352-8.
- Smith I, Gaidhane M, Goode A, Kahaleh M. Safety of endoscopic retrograde cholangiopancreatography in pregnancy: Fluoroscopy time and fetal exposure, does it matter? World J Gastrointest Endosc 2013; 5(4): 148-153.
- Tang SJ, Mayo MJ, Rodriguez-Frias E, Armstrong L, Tang L, Sreenarasimhaiah J, Lara LF, Rockey DC. Safety and utility of ERCP during pregnancy. Gastrointest Endosc 2009; 69(3 Pt 1): 453-61.
- ACOG Committee on Obstetric Practice. ACOG Committee Opinion. Number 299, September 2004. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104: 647-651.
- Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009; 15(29): 3649-3652.
- Sharma SS, Maharshi S. Two stage endoscopic approach for management of choledocholithiasis during pregnancy. J Gastrointestin Liver Dis 2008; 17(2): 183-5.
- Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008; 67(2): 364-8.
Kale KG, Kalappa SB, Chauhan AR. Endoscopic Retrograde Cholangiopancreatography In Pregnancy. JPGO 2015. Volume 3 No. 5. Available from: http://www.jpgo.org/2016/05/endoscopic-retrograde.html