Is N‑butyl‑2‑cyanoacrylate glue injection for gastric varices contraindicated in pregnancy?

Cyanoacrylate Glue Injection for Gastric Varices in Pregnancy

Cyanoacrylate glue injection for gastric varices is NOT contraindicated in pregnancy and represents a viable treatment option when TIPS is not feasible or available, though data are limited and it should be performed only in centers with expertise. 1

Guideline-Based Recommendations

The 2021 AASLD guidelines explicitly address this scenario in pregnant women with portal hypertension:

• For bleeding gastric varices during pregnancy, cyanoacrylate with or without coiling are acceptable options, depending on center expertise. 1

• The guidelines acknowledge that "data on treatment of pregnant women with recurrent esophageal bleeding or bleeding from gastric varices are limited" but still include cyanoacrylate as a management option rather than listing it as contraindicated. 1

• Endoscopic procedures, including cyanoacrylate injection, should ideally be deferred until the second trimester when possible. 1

Technical Considerations for Pregnancy

When performing cyanoacrylate injection in pregnant patients, specific precautions apply:

• After 20 weeks gestation, position the patient in left lateral decubitus to prevent aortocaval compression by the gravid uterus. 1, 2

• Minimize sedation exposure, particularly in the third trimester, due to FDA warnings about potential fetal neurocognitive effects from prolonged (>3 hours) exposure to midazolam and propofol. 1

• Preoperative evaluation by a maternal-fetal medicine specialist is recommended before any endoscopic procedure. 1

Regulatory and Safety Context

A critical caveat exists regarding cyanoacrylate use in the United States:

• N-butyl-2-cyanoacrylate is NOT FDA-approved for treatment of gastric varices in the United States, though it is widely used internationally. 1

• The 2017 AASLD guidelines for non-pregnant patients state that cyanoacrylate "should be performed only in centers where the expertise is available." 1

• No specific pregnancy-related contraindications to cyanoacrylate are documented in the guidelines—the limitations relate to general availability and expertise rather than pregnancy-specific safety concerns. 1

Alternative and Preferred Approaches

The treatment hierarchy for gastric varices in pregnancy follows this algorithm:

• For GOV1 (gastroesophageal varices type 1): Endoscopic variceal ligation is preferred if technically feasible. 1

• For GOV2 or IGV1 (cardiofundal varices): TIPS is the treatment of choice for bleeding control. 1

• Cyanoacrylate serves as an alternative when TIPS is not technically feasible or immediately available. 1

Acute Bleeding Management Protocol

When gastric variceal bleeding occurs during pregnancy:

• Initiate octreotide (50 µg IV bolus, then 50 µg/hour continuous infusion for ≥5 days) immediately. 3

• Avoid terlipressin completely—it causes uterine vasoconstriction leading to placental abruption and fetal loss. 1, 3

• Administer prophylactic cephalosporins (preferred in pregnancy) for bacterial prophylaxis. 1

• Perform urgent endoscopy within 12 hours with the patient in left lateral position after 20 weeks gestation. 3, 2

Evidence Quality and Clinical Reality

The evidence supporting cyanoacrylate use in pregnancy is limited:

• No randomized trials specifically evaluate cyanoacrylate safety in pregnant women—recommendations are extrapolated from non-pregnant populations. 1

• In non-pregnant populations, cyanoacrylate achieves 87-95% primary hemostasis rates with acceptable safety profiles. 4, 5, 6

• Complications in general populations include glue embolism (rare), needle fixation, and rebleeding rates of 14-21%. 4, 6, 7

Common Pitfalls to Avoid

• Do not withhold cyanoacrylate treatment solely based on pregnancy status when it represents the best available option for life-threatening gastric variceal bleeding. 1

• Do not use terlipressin as a vasoactive agent—octreotide is the only acceptable splanchnic vasoconstrictor in pregnancy. 1, 3

• Do not perform the procedure without maternal-fetal medicine consultation and appropriate positioning after 20 weeks. 1

• Do not attempt cyanoacrylate injection without adequate institutional expertise and experience with the technique. 1

Risk-Benefit Analysis

The decision framework prioritizes maternal survival:

• Maternal mortality from uncontrolled variceal bleeding far exceeds theoretical risks of cyanoacrylate exposure to the fetus. 1

• Comprehensive management of life-threatening variceal bleeding outweighs theoretical risks of splanchnic vasoconstriction affecting placental perfusion. 1

• Pregnancy increases portal pressure due to increased blood volume (peaking at 28-32 weeks) and IVC compression, elevating bleeding risk. 2