Best practices for GI endoscopy during pregnancy

While gastrointestinal (GI) endoscopy is rarely performed during pregnancy—accounting for just 0.4% of procedures—there are times when it is urgently needed. A new review by physician-scientists from Beth Israel Deaconess Medical Center (BIDMC), published in the American Journal of Gastroenterology, offers experience-informed and, where possible, evidence-based recommendations to guide gastroenterologists in providing safe, effective care to pregnant patients when endoscopy can’t wait.

“Adverse pregnancy outcomes related to GI endoscopy appear to be extremely rare,” said senior author Tyler M. Berzin, MD, director of the Advanced Endoscopy Fellowship program at BIDMC. “In our paper, we emphasize a thoughtful, multidisciplinary approach, prioritizing maternal and fetal safety at every step.”

Berzin and colleagues provide a concise guide with pre-procedural, procedural and post-procedural recommendations.

Pre-procedural considerations

• Timing matters: While elective procedures may be postponed, urgent indications, such as GI bleeding or bile duct infection, warrant immediate intervention. Contraindications include imminent delivery and pregnancy-related complications such as eclampsia.
• Multidisciplinary planning is essential: At minimum, gastroenterologists should consult with obstetricians or maternal-fetal medicine specialists and anesthesiologists who are experienced in pregnancy care.
• Anesthesia considerations: Physiologic changes in pregnancy increase the risks associated with being sedated. Short-acting sedatives in low doses are typically safe, but pre-op planning should address increased aspiration risk and reduced tolerance for apnea.

“Both the underlying condition and any invasive procedure can pose hard-to-measure risks during pregnancy,” said the paper’s lead author Amanda H. Lim, MBBS, former advanced endoscopy fellow at BIDMC.

“Moving forward with such a procedure is always a balancing act. It requires careful judgment on the part of the medical team and honest, clear conversations that build trust between the providers, the patient, and their family.”

Procedural considerations

• Minimize procedure time and risk: Procedures should be performed by experienced teams.
• Positioning is crucial: After 20 weeks’ gestation, avoid the supine position. External abdominal pressure should be avoided. The left lateral decubitus or left pelvic tilt position is preferred for most procedures.
• Medication safety requires expert judgment:
  • Pregnancy limits the use of many common medications, making it essential that prescribing decisions are guided by a team familiar with obstetric safety.
  • Certain agents used during procedures—such as epinephrine—are typically contraindicated in pregnancy but may be used cautiously in high-risk scenarios when the benefits outweigh the risks. A skilled team will tailor these decisions to both the patient’s condition and gestational age.
  • Oral NSAIDs should be avoided after 20 weeks’ gestation due to risks like premature closure of the ductus arteriosus and neonatal complications.
  • Fluoroscopy use in ERCP: The typical fetal radiation exposure from fluoroscopy in ERCP is low, however it is important for endoscopists to be aware of all available methods to minimize this as much as possible. Shielding has not been shown to be effective and may in fact increase radiation exposure.

Post-procedural considerations

• Monitor carefully: Monitoring patients for an adequate period after the procedure is important, with early management of any post-procedural complications. An obstetrician should be available to direct fetal monitoring and any intervention for fetal indications.

“Despite the potential anxieties and uncertainties around providing endoscopic care to pregnant patients, informed gastroenterologists can confidently optimize the safety of the pregnant patient and minimize the risk of adverse pregnancy outcomes related to GI endoscopy,” said Berzin, who is also an associate professor of medicine at Harvard Medical School.

“When gastroenterologists are consulted to evaluate the need for gastrointestinal endoscopy in pregnant patients, a proactive, multidisciplinary approach—incorporating gastroenterology, obstetrics, and anesthesia teams—provides the best possible framework for ensuring a safe and successful outcome.”