The use of percutaneous endoscopic gastrostomy in pregnancy

Safety of Percutaneous Endoscopic Gastrostomy Placement in Pregnancy: A Case Report and Literature Review

Gastrostomy tube placement in pregnancy is historically contraindicated due to risk of injury to the developing fetus and exposure to anesthetic agents. However, in cases where oral nutritional access is severely jeopardized, percutaneous endoscopic gastrostomy (PEG) tube placement can be a life-saving measure. In this case report and literature review, we present a case of successful PEG placement in a pregnant woman, followed by a discussion of the existing literature regarding PEG placement during pregnancy.

An overview of percutaneous endoscopic gastrostomy tube placement in the intensive care unit

Critically ill patients are at increased risk for malnutrition as they often have underlying acute and chronic illness, stress related catabolism, decreased appetite, trauma and ongoing inflammation. Malnutrition is recognized as a leading cause of adverse outcomes, higher mortality, and increased hospital costs. Percutaneous endoscopic gastrostomy (PEG) tubes provide a safe and effective route to provide supplemental enteral nutrition to these patients. PEG placement has essentially replaced surgical gastrostomy as the modality of choice for longer term feeding in patients. This is a highly prevalent procedure with 160,000 to 200,000 PEG procedures performed each year in the United States. The purpose of this review is to provide an overview of current knowledge and practice standards with regards to placement of PEG tube in the Intensive Care Unit (ICU). When a patient is considered for a PEG tube, it is important to evaluate the treatment alternatives and identify the best option for each patient. In this review, we provide the advantages and disadvantages of various feeding modalities and devices. We review the indications and contraindications for PEG tube placement as well as the risks of this procedure. We then describe in detail the per-oral pull, per-oral push, and direct percutaneous techniques for PEG tube placement. Additionally, we review the feasibility of having interventional pulmonologists place PEG tubes in the ICU.

Gastrointestinal endoscopy in pregnancy

Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.

Use of Gastrostomy Tube to Prevent Maternal PKU Syndrome

Maternal Phenylketonuria Syndrome (MPKU) can occur in infants born to mothers with PKU with poor metabolic control during pregnancy. Elevated phenylalanine (phe) acts as a teratogen to the developing fetus with consequences including intellectual disability, microcephaly, facial dysmorphism, growth retardation, and congenital heart disease. MPKU can be prevented if metabolic control is achieved by 8-10 weeks gestation. If control is not achieved, there is a significant risk for MPKU. Therefore, in women with poor metabolic control at time of pregnancy, establishing metabolic control quickly is important.Clinically, establishing metabolic control in women with PKU can present challenges. Social issues, psychological issues, and insufficient education about PKU play an important role in a patient's inability to reinstitute this challenging diet. Maintaining phe levels within a range to allow for infant growth, while preventing toxicity, is challenging, particularly for those women who no longer follow the PKU diet. Gastrostomy tube placement is an option to deliver medical formula to women who are unable to restart diet due to severe nausea or palatability issues.Here we discuss two pregnancies in which a gastrostomy tube was placed to achieve metabolic control after other measures failed to reduce phe concentrations into the recommended range. For these two pregnancies, placement of the gastrostomy tube led to improvement in phe levels with normal infant outcomes including normal growth, head circumference, and heart structure.

Feeding tube placement: errors and complications

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

[Safety of gastrointestinal endoscopy during pregnancy]

There are only few data of gastrointestinal endoscopy in pregnant patients. Only 0.4% of all procedures are carried out during pregnancy. Case reports and some small retrospective studies are available. Because of physiological changes in pregnancy there might be special risks of endoscopy. There might be complaints which can be physiologic during pregnancy, but can be signs of gastrointestinal disorders, too. Therefore, indications for endoscopy are not always clear and easy. Safety of the procedures is also not well studied. Besides the risks of endoscopy, medication given to the mother, electrocoagulation and radiation exposure from fluoroscopy during endoscopic retrograde cholangiopancreatography might be harmful to the fetus. Endoscopy should only be done when indication is unquestionable and strong. Only FDA "A" and "B" category medication is allowed. Gastroscopy is necessary for bleeding and for patients with pyrosis going together with alarm signs. Nausea, vomiting, abdominal pain and fecal occult blood test positivity are not indications for endoscopy, only for gastroenterogical consultation. Sigmoidoscopy is recommended for indication of lower gastrointestinal bleeding and sigmoid or rectal mass. Only therapeutic endoscopic retrograde cholangiopancreatography should be performed. Obstructive jaundice and biliary pancreatitis need immediate endoscopic intervention. The fetus must be shielded from radiation exposure.

[Techniques and complications in post-interventional and long-term enteral nutrition]

Enteral nutrition in patients is a well established procedure. Percutaneous endoscopic gastrostomy has been widely used to maintain long-term enteral nutrition and has become the method of choice. Under careful observation of indication, contraindication and technique the risk of complication of PEG is reduced drastically. The enteral nutrition via PEG is a step of the multimodal treatment in critically ill patients.

Gastrointestinal endoscopy in pregnant and lactating women: emerging standard of care to guide decision-making

Endoscopic procedures generally are considered to be low-risk modalities, being performed on an on-demand basis in many ambulatory endoscopy centers and hospitals. However, the safety and efficacy of gastrointestinal endoscopy in pregnancy has not been well studied. In pregnancy, the risks to the fetus and mother are numerous and the magnitude of this risk will differ depending on trimester, the disease process being addressed, the underlying health and status of the maternofetal unit, and the nature of the endoscopic intervention being contemplated. Given the difficulties in performing prospective studies in the pregnant patient, these risks have not been well-quantified. Decision-making in practice is at times highly individualized. The obstetrician and endoscopist may therefore need to rely on prudent practice based on personal experience in conjunction with recognized underlying basic principles and consensus guidelines, rather than hard scientific data, to guide decision-making and advising patients. The purpose of this review is to make those caring for pregnant patients aware of the clinical considerations necessary to ensure a successful outcome and to provide guidance with respect to what is now considered to be the standard of care when managing pregnant and lactating patients in whom an endoscopic procedure is being contemplated.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases

We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.