What is the role of Magnetic Resonance Cholangiopancreatography (MRCP) in pregnancy?

From the Guidelines

Magnetic Resonance Cholangiopancreatography (MRCP) is generally considered safe during pregnancy when clinically necessary, as stated in the most recent guidelines from 2023 1.

Key Considerations for MRCP in Pregnancy

• MRCP should be performed when the benefits of diagnosis outweigh potential risks, particularly for conditions like biliary obstruction, choledocholithiasis, or pancreatitis that may threaten maternal and fetal health.
• No contrast agent is required for standard MRCP, eliminating concerns about gadolinium exposure to the fetus, as recommended by the American Association for the Study of Liver Diseases 1.
• If contrast is deemed necessary, gadolinium-based agents should be avoided, especially in the first trimester, as they cross the placenta and their long-term effects on fetal development remain uncertain.
• When performing MRCP during pregnancy, radiologists should optimize protocols to minimize scan time while maintaining diagnostic quality.
• The patient should be positioned comfortably, typically in the left lateral position after the first trimester to prevent inferior vena cava compression.
• While MRI uses no ionizing radiation, making it preferable to CT or other radiation-based imaging during pregnancy, healthcare providers should still follow the ALARA (As Low As Reasonably Achievable) principle.

Clinical Guidelines and Recommendations

• The European Association for the Study of the Liver (EASL) clinical practice guidelines on the management of liver diseases in pregnancy recommend imaging with ultrasound or MRCP when cholestasis worsens, to exclude obstruction by gallstones or progress of high-grade strictures 1.
• Consultation between the gastroenterologist, obstetrician, and radiologist is recommended to determine the optimal timing and protocol for MRCP during pregnancy.
• Women with primary sclerosing cholangitis (PSC) should be advised that MRCP is regarded as safe during pregnancy and can be applied for diagnostic purposes when cholestasis is worsening 1.

From the Research

MRCP in Pregnancy

• MRCP can be a valuable tool in the evaluation of pregnant patients with acute pancreaticobiliary disease, especially when ultrasound shows biliary dilatation 2.
• The use of MRCP in pregnancy can help determine the aetiology of biliary dilatation and exclude obstructive pathology, potentially saving the patient from unnecessary endoscopic retrograde cholangiopancreatography 2.
• MRI, including MRCP, is considered safe for use in pregnant patients, with no attributable harms shown in current studies 3, 4.
• However, the use of gadolinium-based contrast agents during pregnancy may be associated with a slightly higher rate of neonatal death, although this is based on limited evidence 4.
• Contrast-enhanced magnetic resonance cholangiography (CE-MRC) using hepatocyte-selective contrast agents like Gd-EOB-DTPA may provide a noninvasive functional evaluation of the hepatobiliary system, but its use in pregnancy is not well established 5.

Safety Considerations

• MRI without intravenous contrast is generally considered safe for use in pregnant patients 3, 4.
• The risks of MRI with intravenous contrast, including gadolinium-based contrast agents, must be carefully considered and discussed with patients 3, 4.
• Current guidelines recommend that MRI and contrast agents be used in pregnancy only when absolutely necessary and after careful consideration of the potential risks and benefits 6, 3, 4.