The safety of endoscopic band ligation of esophageal varices during pregnancy versus endoscopic sclerotheraphy in patients with cirrhotic portal hypertension

Abstract

Introduction: Pregnancy is unusual in women with portal hypertension (PH), and no clear guidelines for the management of esophageal varices (EV) during pregnancy and their major complication- variceal bleeding have not been yet established. The purpose of this study was to compare the efficacy of endoscopic band ligation (EBL) in treating of the EV during pregnancy, versus endoscopic sclerotheraphy(ES). Materials and Methods: The subjects of the present study were four cases of pregnant women (mean age-30.3± 1.4) with posthepatitis (HCV, HBV) liver cirrhosis and high-risk of EV (F3, RCS+++). Severity of liver disease was classified: A/B/C-2/1/1, the mean(s.d.) score on admission was 6,7/10/12(9,3). EBL has been carried out with MBL-6 or MBL-\0{Wilson-Cook\ Winston-Salem, NC, USA) in three cases. EBL was performed at 27,6 ± 4,2 weeks gestation. In one case it was perfomed ES. Results: Characteristics of EBL were: total sessions-3, mean (s.d.) rubber band consumption-4.3(0.8). The complete EV eradication (FO, RCS-) was obtained in this patients with zero episodes of EV bleeding. The patients underwent delivery thorugh cesarean section in two cases (n=2) and per vias naturalis in one case (n=l), with an elective-assisted second stage. There was 1 maternal death in the postpartum period due to fulminant hepatic failure. In case of endoscopic sclerotheraphy, the complete EV eradication was not obtained. The patient underwent delivery by cesarean section at 37 weeks of gestation because of deep fetal grow restriction(FGR) in baby and high-risk EV(F2) in mother. Conclusions: Treatment of EV during pregnancy is a rare and serious clinical dilemma especially in endemic zone. Initial experience and sporadic cases described in special medical literature, had demonstrated that EBL appear to be a useful treatment in pregnant women with EV without fetal complications. In the same time ES, according to conflicting data in literature, is not very safe during pregnancy. This may cause deep necrosis of esophageal wall with its rupture or stenosis in mother and FGR or fetal malformations in baby. With this approach, firstly we can think that FGR in our case may be a complication of ES. EBL represents a major alternative to ES, because no chemicals are used during the procedure and the risk for baby decreases. Secondly, in case of EBL was obtained a complete EV eradication.