In the first trimester, 32 LGEs were performed in 30 patients. All complications following LGE in the first trimester are listed in Table 1. Three adverse events occurred within 1 week of the LGE.
In one case report [ 20 ], the patient underwent sigmoidoscopy at gestational week 10 and the patient had an incomplete spontaneous abortion at The patient suffered from severe rectal bleeding due to a heterotopic, abdominal pregnancy protruding the terminal ileum.
This adverse event could possibly be attributed to the LGE, because this patient also underwent laparotomy after the LGE and suffered from severe gastrointestinal bleeding. The other two temporally related adverse events in the first trimester were both elective abortions, and were therefore classified as etiologically unrelated to the LGE [ 17 , 18 ]. In the second trimester, 39 endoscopies were performed in 35 patients.
All complications following LGE in the second trimester are listed in Table 2. Six adverse events occurred within one week of LGE. Three cases reported three fetal deaths within one week of endoscopy.
In the first case [ 51 ], the patient suffered from massive hematochezia due to multiple bleeding foci in the cecum and terminal ileum and underwent laparotomy shortly after colonoscopy. Fetal demise was evident several hours after surgery. This adverse event is possibly related to the LGE.
The second patient was diagnosed with an advanced stage of colorectal carcinoma with liver metastases and ascites during pregnancy. After colonoscopy, the patient deteriorated rapidly and seven days after endoscopy fetal death was observed by ultrasonography.
The mother died within 2 weeks after delivery [ 55 ]. This adverse event can probably be related to the LGE. After colonoscopy, radiologic studies showed no evidence of colonic perforation, but the day after colonoscopy the abdominal distension progressed further, the patient went into spontaneous labor and the physicians decided to terminate the pregnancy [ 62 ]. This adverse event could also probably be related to the LGE. Two patients diagnosed with colorectal adenocarcinoma during pregnancy underwent elective abortion within one week of LGE in gestational week 16 and 20 [ 42 , 43 ] and in one patient labor was induced with prostaglandin in gestational week 26 [ 44 ].
These three adverse events were therefore classified as unlikely related to the LGE. In the third trimester, 27 patients underwent 29 endoscopies. All complications following LGE in the third trimester are listed in Table 3. Four case reports demonstrated adverse events within one week of endoscopy.
These four cases were likely related in one, possibly related in one and unlikely related in two of the cases. The first case describes a patient who was diagnosed with ulcerative colitis upon sigmoidoscopy in the sixth week of pregnancy.
In the 28th week of pregnancy she exhibited signs of exacerbation and she underwent another sigmoidoscopy with biopsies. Following the second sigmoidoscopy, colonic perforation was suspected and an emergency caesarean section and exploratory laparotomy was performed.
No colonic perforation was seen intraoperatively [ 11 ]. A live, healthy baby of g was delivered. This adverse event was classified as likely to be related to the LGE. The second patient was 33 weeks pregnant with twins, when she underwent two subsequent colonoscopies for the treatment and decompression of acute colonic pseudo-obstruction. She was already being treated with nifedipine upon presentation for inhibition of premature contractions, and nifedipine was stopped upon hospital admission.
One day after the last colonoscopy at gestational week 34, she went into spontaneous labor and delivered healthy twins [ 85 ]. The third patient underwent sigmoidoscopy because of abdominal pain and distention in the 34th gestational week.
Upon endoscopy, the splenic flexure appeared necrotic and the patient immediately underwent laparotomy with an emergency caesarean section [ 74 ]. This adverse event is unlikely related to the LGE. The fourth patient was diagnosed with a malignancy of unknown origin, and in the metastatic workup a colonoscopy was performed in gestational week A poorly differentiated signet cell adenocarcinoma of the transverse colon was found, and after 4 days of dexamethasone administration for fetal lung maturation an elective caesarean section was performed [ 77 ].
This adverse event was unlikely related to the LGE. One case report and one case series did not report at what gestational week the LGE was performed and were therefore not categorized. One woman delivered a live baby of gram prematurely at A temporal relation was not found, and the authors do not link this adverse event to the sigmoidoscopy.
In the case series, 2 out of 5 women underwent sigmoidoscopy, and one woman delivered a live baby prematurely. It is not reported if this woman underwent LGE [ 89 ]. A sensitivity analysis was performed by elongating the time span for the temporal relation between adverse events and the LGE. Initially, all adverse events were temporally related to the LGE if they occurred within one week after the LGE, however this analysis will classify all adverse events within three weeks of the LGE as temporally related.
In the first trimester, this approach yielded no extra temporally related adverse events. In the second trimester, one additional temporally related adverse event was detected. In this case, the mother was diagnosed with advanced colorectal carcinoma during pregnancy and died together with the fetus two weeks after hospital admission around gestational week 23 [ 45 ]. This adverse event was unlikely to be related to the LGE. Finally, in the third trimester another seven temporally related adverse events were detected.
Six premature deliveries were unlikely related to the LGE, as they were all elective caesarean sections [ 76 , 78 - 80 , 87 ] or induced labor [ 66 ]. The seventh patient suffered from ulcerative colitis and underwent LGE for assessment of disease activity in gestational week Endoscopy showed the colon to be severely inflamed and two weeks later the patient delivered a premature baby of grams [ 64 ].
This adverse event is classified as probably related to the LGE. The objective of this systematic review was to assess the risk of LGE in all trimesters of pregnancy. Three retrospective cohort studies investigated the safety of LGE during pregnancy. Of these, two studies describe the same study population, and report no difference in birth outcomes and adverse events between the study and the control group. None of the reported fetal and maternal adverse events showed a temporal or an etiological relation with the LGE [ 8 , 10 ].
Although these studies report no adverse events related to LGE, it remains unclear in which trimester the LGE was performed. The third study [ 3 ], on which the recent endoscopy guidelines [ 9 ] seem to be based, focuses exclusively on colonoscopies during pregnancy. The authors conclude that colonoscopies during pregnancy are probably safe to perform, but limit their conclusion to the second trimester because of insufficient data in the first and third trimester.
Prior to this study in , the authors identified 17 case reports on colonoscopy during pregnancy and add these data to their own conclusion that there is still insufficient evidence to claim safety of colonoscopy in each trimester [ 3 ]. In total six 6.
Out of these 79 case reports 42 case reports described 51 colonoscopies in 49 patients during pregnancy, distributed equally across the trimesters 21, 16 and 14 colonoscopies in trimester 1, 2 and 3, respectively.
Three temporally and etiologically related adverse events occurred in these 49 patients 6. Although the evidence level of these case reports is low, these data suggest colonoscopy during pregnancy is probably safe to perform.
This finding is in agreement with the primary conclusion of the included studies. However, the data from our included case reports in fact suggests colonoscopy to be of similar low risk in each trimester. In addition, we identified 37 case reports, describing 49 sigmoidoscopies in 43 patients. In this subset of patients, also three temporally and etiologically related adverse events occurred in these 43 patients 7. Furthermore, in our view, postponing LGE during pregnancy or even until after pregnancy might hamper the patient and the pregnancy more than the LGE itself.
A diagnostic delay will inevitably induce an unwanted therapeutic delay, and therefore the risks of LGE during pregnancy must be weighed against the expected benefits. Consequently, elective endoscopies e. Safety research during pregnancy is always a challenging field, as prospective studies are rarely, and experimental studies are almost never performed. Therefore, we rely on retrospective studies and case series to support our conclusions and guidelines. Although the evidence in this systematic review is anecdotal and more controlled studies are needed, this review appears to be the most extensive overview of available studies on this subject.
The major limitation of this exhaustive systematic review is the lacking of a solid control group for the summarized case reports. Furthermore, the majority of case reports describe severely ill patients in whom the true effect of LGE during pregnancy is hard to untangle. In addition, none of the case reports primarily aimed to describe the effect of LGE during pregnancy, rendering these effects subject to our interpretation.
Type of bowel preparation and sedation are not mentioned in the majority of included case reports, and their effects cannot be taken into consideration.
Also, mild and more subtle adverse events due to LGE could have been easily missed. We therefore focused on serious adverse events like spontaneous abortion, stillbirth and premature delivery. In conclusion, we underline that LGE should only be performed during pregnancy when strongly indicated and is probably of low risk. Postponing LGE during pregnancy to the second trimester or puerperium however, is unnecessary and in most cases unwanted because of the therapeutic delay which might hamper the pregnancy outcomes more than the LGE itself.
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A preliminary version of this paper was presented orally at the Annual Convention of the American Gastroenterology Association on May 15, , in San Diego, California 1. Reprints and Permissions. Cappell, M. A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups.
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Search SpringerLink Search. Abstract To analyze the risks versus benefits of flexible sigmoidoscopy and colonoscopy to the pregnant female and fetus, we conducted a multiyear, retrospective study at 10 hospitals of 46 patients undergoing 48 sigmoidoscopies and 8 patients undergoing 8 colonoscopies during pregnancy.
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