<![CDATA[Background: Acute cholangitis in pregnancy is a rare but life-threatening condition, where delays in source control may accelerate maternal sepsis and compromise fetal viability. Objective: This study aimed to evaluate whether early endoscopic retrograde cholangiopancreatography (ERCP), performed with non- or low-fluoroscopy techniques, improves maternal stabilization and fetal outcomes compared with conservative or delayed intervention. Methods: A systematic evidence-based case review was conducted, combining a clinical vignette of a 28-week pregnancy complicated by severe cholangitis and sepsis with a focused literature search in PubMed, ScienceDirect, and ProQuest. Inclusion criteria followed the PICO framework, emphasizing pregnant patients with TG18-defined moderate-to-severe cholangitis, early ERCP (≤24 hours), and maternal and fetal outcomes. Critical appraisal was undertaken using the Oxford Centre for Evidence-Based Medicine methodology. Results: Findings from two eligible studies—a systematic review of over 500 ERCPs in pregnancy and a single-center cohort of 24 cases—showed consistently high technical success rates and low maternal complication rates. Post-ERCP pancreatitis emerged as the most frequent adverse event but was significantly reduced in tertiary centers with skilled operators. Fetal outcomes were generally favorable when dose-reduction strategies and shielding were applied, with preterm birth and perinatal mortality remaining uncommon. Our case illustrates the risks of clinical deterioration when source control is deferred; earlier temporizing drainage could have provided stabilization without definitive sphincterotomy until postpartum. Conclusion: Early therapeutic ERCP using radiation-sparing techniques appears safe and effective for managing severe cholangitis in pregnancy, balancing maternal survival with fetal safety.]]>
