Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

Table 2 Maximizing radiation safety of endoscopic retrograde cholangiopancreatography during pregnancy

1. Highly qualified and experienced ERCP endoscopist

2. Limited (solely observational) role of inexperienced gastroenterology fellow during ERCP

3. Informed consent to include discussion of radiation teratogenicity

4. Consult perinatologist

5. Consult radiation safety officer and medical physicist, if available, to minimize fetal radiation exposure

6. Endoscopist performing ERCP should become familiar with fluoroscopy equipment, especially with options to minimize radiation exposure

7. Formal consultation of anesthesiologist before ERCP

8. Anesthesiologist to attend during entire ERCP, even if nurse-anesthetist is present

9. Consider using an obstetric anesthesiologist rather than a general anesthesiologist for ERCP

10. Avoid ERCP for weak indications

11. Avoid solely diagnostic ERCP

12. Strongly consider MRCP as an alternative for diagnostic ERCP in low yield indications

13. Obtain informed, written consent that includes discussion of risks of fetal radiation

14. Perform ERCP at a hospital endoscopy unit rather than an ambulatory center in order to better manage procedural complications

15. Perform ERCP at a tertiary hospital rather than a community hospital where highly specialized consultants are likely to be present

16. Perform ERCP as expeditiously as possible to minimize radiation exposure and anesthesia medications

17. Employ modern and highly collimated radiation unit with the smallest possible field

18. Position patient as far as possible from radiation source consistent with reasonable images

19. If possible, employ “low-dose” radiation protocol in terms of kvp, field size, and frame rate

20. Place lead shield underneath patient between likely fetal area and radiation tube

21. Place dosimeters on patient above expected uterine location and record fluoroscopy time and total radiation dosage

22. Minimize procedure time, procure all anticipated endoscopy equipment within endoscopy room before beginning the procedure

23. Employ static images as opposed to continuous fluoroscopy to reduce radiation exposure

24. Use digital image acquisition technology if possible, instead of film-screen radiography

25. Position patient to permit anterior-posterior beam projection

26. Avoid image magnification

27. Employ last image-hold or fluoroscopy loop recording feature when possible rather than additional fluoroscopy

28. Consider radiation-free ERCP in conjunction with other techniques such as temporary stenting and, if needed, needle-knife and transpapillary sphincterotomy

29. Document ductal clearance without radiation using IDUS or choledochoscopy

30. X-ray image receptor should be placed as close as possible to the patient

31. Adjust patient position between choices of supine, prone, or lateral to minimize fetal radiation exposure

ERCP: Endoscopic retrograde cholangiopancreatography; kVp: Peak kilovoltage; IDUS: Intraductal ultrasound.