Hormonal changes during pregnancy increase the lithogenicity of bile and impair gallbladder emptying, which create a favorable environment for gallstone formation. The prevalence of gallstones in pregnancy has been reported as 3.3%-12.2%[ ¹– ³]. Acute cholecystitis is the second most common non-obstetric emergency in pregnant women. Choledocholithiasis and consequent complications such as pancreatitis and cholangitis are potentially lethal diseases for the mother and fetus. Acute pancreatitis in pregnancy has been shown to be closely related to gallstone disease[ ⁴]. Biliary pancreatitis has been found to be associated with 15% and 60% of maternal and fetal mortality rates, respectively[ ⁵].

Seven hundred and fifty ERCP procedures for choledocholithiasis and/or choledocholithiasis-induced acute cholangitis were performed on 597 patients in our Endoscopy Unit at Vakif Gureba Research and Training Hospital from 2000 to 2008. Six out of 598 ERCP patients were pregnant. One patient with biliary fistula caused by surgery for hepatic hydatid disease was also included in the study. The data regarding laboratory, ultrasonographic and endoscopic findings, and clinical course of the patients were analyzed. Magnetic resonance cholangiopancreatography (MRCP) was used for diagnosis of fistula after hydatid surgery, and for control of fistula closure after the first ERCP procedure in the patient with hepatic hydatid disease. MRCP was also used for diagnosis of choledocholithiasis in the patient with elevated bilirubin levels and a dilated common bile duct shown by ultrasonography. Patients with fever, jaundice, abdominal pain and radiological findings were diagnosed with choledocholithiasis-induced acute cholangitis.

All patients included in the study signed an informed consent for the procedures, after receiving an explanation on the risks, benefits and alternatives of ERCP and associated therapeutic procedures.

The patients were counseled by the Gynecology and Obstetrics Department before the procedure. Pre-procedural complete blood count, bilirubin, transaminase and γ-glutamyl transferase levels were noted. The fetal heart sounds were controlled before the ERCP procedure. Pethidine HCl (≤ 100 mg) and midazolam (≤ 3 mg) were used for analgesia and sedation. The patients were positioned in the left lateral position to avoid vena caval or aortic compression. After introducing the duodenoscope into the duodenum, the bile duct was cannulated with a guidewire through the papilla, and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the stones were extracted by balloon sweeping. When indicated, stents were placed.

The mean age of the patients was 28 years (range, 21-33 years). The mean gestational age of the fetus was 23 wk (range, 14-34 wk). The demographic and laboratory data of the patients are shown in Table 1. The treatment results and obstetric findings of the patients are summarized in Table 2. There were no complications related to sedoanalgesia in the mother and fetus after the procedure.

Cholangitis in pregnancy is a serious condition for the mother and fetus, and results in high mortality and morbidity. ERCP is the first-line treatment of choice for cholangitis and pancreatitis caused by choledocholithiasis. However, the use of ERCP in pregnancy is limited because of the use of radiation. In previously described ERCP procedures performed during pregnancy, abdominal shielding was used to minimize radiation exposure[ ⁷]. Fetal damage by radiation is related to the time of pregnancy and the radiation dose. Several studies have demonstrated that ERCP can be successfully and safely performed during pregnancy[ ^{2 6 8}– ¹⁰]. The role of ERCP during pregnancy for complicated biliary tract diseases is well established. However, there remains the primary concern of fetal safety in relation to exposure to ionizing radiation. The putative risks may include fetal death, intrauterine growth retardation, malformations, and childhood cancer. It has been recommended that imaging modalities without ionizing radiation be used during pregnancy[ ⁹]. Therefore, attempts for complete exclusion of radiation are of paramount importance in ERCP. The literature has shown that ERCP can be performed safely without necessitating fluoroscopic use[ ^{11 12}].

Therapeutic ERCP is used routinely in pregnancy, with strict indications in clinical practice. Although the literature related to radiation exposure in ERCP has shown that ERCP is safe and effective in the early period after the procedure, the long-term negative effects of radiation exposure of children are unknown. Late adverse effects, such as cancer, may take years to develop after delivery, therefore, it is very difficult to determine the safe dose of radiation in pregnancy for ERCP. In order to overcome this problem, ERCP without radiation in pregnancy should be the first-choice treatment modality for therapeutic ERCP procedures.

In our study group, we cannulated the bile duct with the assistance of a guidewire. Cannulation was confirmed by bile aspiration and/or visualization of the bile oozing around the guidewire after cannulation. Afterwards, bipolar biliary sphincterotomy with balloon sweeping of the biliary duct was performed. At least three times, the stone extraction balloon catheter had to be passed inside the bile duct and pulled out to achieve complete ductal clearance in patients with multiple stones. Improvements in laboratory, clinical and ultrasonographic findings were used as simple and accessible reference points for tracking the patients after ERCP. Maintenance of normal findings during follow-up of the patients after ERCP was thought to be related closely to the success of the procedure with regard to stone extraction. As wire-guided cannulation in non-radiation ERCP has the limitations of incorrect placement of the wire in the cystic duct and retained proximal stones after the procedure, choledochoscopy, real-time percutaneous ultrasonography, linear echoendoscopy, and intraductal ultrasonography are recommended for improving the performance of non-radiation ERCP[ ¹²]. Linear echoendoscopy, intraductal ultrasonography, and choledochoscopy may necessitate additional sedoanalgesia, which has a potentially jeopardizing effect on the fetus. As a result of this concern, we recommend simple monitoring of the patient with ultrasonography and biochemical and clinical parameters after the procedure. In our study, no complication was observed using these monitoring procedures.

Here, we presented six pregnant women with different etiologies, who underwent successful ERCP without the use of fluoroscopy. One case that makes our series interesting is the patient with biliary fistula after hepatic hydatid surgery. The patient was operated on because of liver hydatid disease that imitated acute abdominal findings. As a result of persistent biliary fistula after the operation, she underwent ERCP and sphincterotomy. Since the fistula lasted for an additional 2 wk after the procedure, which was documented by continuous drainage of the bile from the catheter and by MRCP, repeat ERCP with stenting was performed. In the following period, the clinical course was uneventful with closure of the fistula, and delivery occurred without any complication. The stent was removed after delivery.