Considerations in Endoscopy in the Pregnant Patient

In this podcast, Eugenia Shmidt, MD, speaks about the key aspects in the performance of endoscopic procedures in patients during pregnancy, and using endoscopy to diagnose esophagitis in patients with heartburn during pregnancy. She also spoke on these topics at the American College of Gastroenterology 2022 Annual Meeting.

Eugenia Shmidt, MD, is an Assistant Professor in the Division of Gastroenterology, Hepatology, and Nutrition and a Co-Director of the Inflammatory Bowel Disease (IBD) program at the University of Minnesota. She also launched the Inflammatory Bowel Disease Preconception and Pregnancy Planning (IPREPP) Clinic, which is a dedicated IBD and pregnancy clinic (Minneapolis, MN).

TRANSCRIPTION:

Jessica Bard:

Hello everyone, and welcome to the Obstetrics and Gynecology Learning Network. I'm your moderator, Jessica Bard, joined by Dr Eugenia Shmidt, an assistant professor in the Division of Gastroenterology, Hepatology and Nutrition, and a co-director of the Inflammatory Bowel Disease Program at the University of Minnesota in Minneapolis, Minnesota. Dr Shmidt also launched the Inflammatory Bowel Disease Preconception and Pregnancy Planning Clinic, which is a dedicated IBD and pregnancy clinic. Dr. Shmidt is here to speak with us today about her session at ACG 2022 titled "Special Considerations in the Performance of Endoscopy in the Pregnant Patient." Thank you for joining us today. Can you please provide us with an overview of this session?

Dr Eugenia Shmidt:

Yeah, so research shows that gastroenterologists tend to shy away from performing procedures during pregnancy, and generally elective procedures should be reserved for the postpartum period, but in certain situations, a procedure is needed during pregnancy. And so during my session, I discuss when and how to perform GI procedures during pregnancy.

Jessica Bard:

What would you say are the key aspects in the performance of endoscopy procedures in pregnant patients?

Dr Eugenia Shmidt:

I think that you can kind of split the key aspects in a timeline fashion, so you can think about the key aspects that need to be addressed before the procedure is done, during the procedure, and then afterwards.

So before a GI procedure is done, it's very important to take a moment to think about the indication, whether or not there's an actual strong indication for the procedure in the first place. So for example, in the setting of a woman who is experiencing significant nausea and vomiting in the first trimester, most likely the reason for that is hyperemesis gravidarum. And we know that this will usually resolve by the late first trimester or second trimester. And so that's not really a strong indication that would warrant an endoscopic look.

The other thing that needs to be kept in mind before the procedure is the timing. So is it possible to perform the procedure safely in the second trimester? That's really when procedures are done in the safest fashion. And then preparation for the procedure. It's important to have a multidisciplinary collaboration with a gastroenterologist, the obstetrician or the MFM doctor, as well as the anesthesiologist.

And then the other thing to keep in mind is fetal monitoring. Depending on the gestational period, fetal monitoring should be performed. At the very minimum, that should be in the form of fetal heart rate with Doppler as well as contraction monitoring before and after the procedure.

And then once you decide on performing a GI procedure during pregnancy, there are a few things that need to be kept in mind during the procedure. So you want to make sure that the position is safe, and usually the left lateral position is favored over supine or prone. If, for example, performing a colonoscopy, you want to avoid external compression. And then again, during the procedure, fetal monitoring is a consideration, intraoperative fetal monitoring, only depending on resource availability.

And then after the procedure, think about monitoring the patient for any residual anesthetic effect. Again, perform the contraction monitoring and fetal heart monitoring after the procedure. In a lactating individual, it's important to counsel the patient that it is safe to continue to breastfeed without interruption. There's no need to pump and dump.

Jessica Bard:

Can you speak to new and relevant data or new studies that you mention in your session?

Dr Eugenia Shmidt:

I think the most recent update that many people may not be aware of is that anesthesia and sedation are considered to be safe in pregnancy. So specifically the American College of Obstetricians and Gynecologists emphasizes the fact that there's no human evidence that in utero exposure to an anesthetic or sedative drugs has any effect on the developing brain. The other thing to mention is that fetal monitoring is recommended, and in most cases, measuring a fetal heart rate and contraction monitoring before and after the procedure is sufficient. So those are data that I think most people are not aware of, and therefore likely shy away from doing GI procedures during pregnancy.

Jessica Bard:

Should endoscopy be used in the diagnosis of esophagitis in patients with heartburn during pregnancy? And can you elaborate on that?

Dr Eugenia Shmidt:

So during pregnancy, physiologic changes lead to increases in risk of reflux. So for example, progesterone leads to weakening of the lower esophageal sphincter, so that predisposes the patient to reflux. And so the mainstay of therapy during pregnancy is really symptom control with lifestyle measures and sometimes medications. Now in very rare instances, there will be a complication of severe reflux, and that would be in the form of erosive esophagitis or a stricture, but again, that is extremely rare.

If symptoms are severe and they are completely refractory to medical therapy, and especially if there's a concern for a stricture, for example, in the setting of difficulty to swallow, then it's okay to perform an upper endoscopy, preferably in the second trimester. But again, that should be done in very select cases under the care of a multidisciplinary team.

Jessica Bard:

You talked about that multidisciplinary team and the approach. Can you talk more about the importance of collaborating with an OB/Gyn in your situation?

Dr Eugenia Shmidt:

Yes. Whenever a GI procedure is considered, it's really important to reach out to the treating OB/Gyn because that is the person who knows the patient best and knows the status of the pregnancy. That's also the person who can best guide fetal monitoring during the procedure. So I cannot emphasize enough how important it is to make sure that all the key players are on board, including OB/Gyn, as well as anesthesia.

Jessica Bard:

What would you say are the overall take home messages from our conversation today, but then also from your session at ACG 2022?

Dr Eugenia Shmidt:

The main messages are that endoscopic procedures can be done in pregnancy as long as there's a strong indication. Again, that emphasis on the multidisciplinary team in order to ensure safety and no hiccups during the whole process. Anesthesia and sedation are generally safe. And then in lactating individuals, it is okay to breastfeed after receiving sedation. And as I said, no need to pump and discard the milk.

Jessica Bard:

Is there anything else that you'd like to add today that you think that we missed?

Dr Eugenia Shmidt:

I think I could just kind of circle back to what I opened with, which is that current research suggests that gastroenterologists tend to avoid procedures during pregnancy, but if there's a strong indication for it, the safest thing to do is to perform the procedure. So if you can kind of imagine a scale. So on one side of the scale is the procedure itself, and then we tend to ignore what's on the other side of the scale, which is not doing the procedure, which is allowing the disease process to advance and so forth. So those two always need to be considered.

And if there's a strong indication for a procedure, then it can and should be done, frankly, in any trimester, preferably in the second trimester. But if there's an emergent indication, that procedures can be done in the first or the third trimester, as well. And then it's just in order to ensure the safety of the procedures, you just need to make sure that all the relevant players are on board, which are OB/Gyn or MFM, as well as anesthesia.

Jessica Bard:

Thank you so much for your time today. We appreciate you being on the podcast.

For more coverage from ACG 2022, visit the OB/Gyn Learning Network on hmpgloballearningnetwork.com.