BACKGROUND: Symptomatic choledocholithiasis during pregnancy can be treated with ERCP (endoscopic retrograde cholangiopancreatography) , but fluoroscopy may pose a risk to the fetus. Nonradiation ERCP may be a safer form of treatment, but its performance has not been optimized. OBJECTIVES: The purpose of this study was to evaluate new methods of nonradiation ERCP during pregnancy, including wire-guided cannulation techniques to achieve bile-duct access without the use of fluoroscopy, and the use of peroral choledochoscopy to confirm ductal clearance. STUDY DESIGN: A retrospective review of consecutive ERCPs performed on pregnant women. SETTING: Urban referral hospital. PATIENTS: Pregnant women with symptomatic choledocholithiasis. INTERVENTIONS: All patients underwent therapeutic ERCP without any use of fluoroscopy. Endoscopist-controlled wire-guided cannulation was performed to achieve biliary access. MAIN OUTCOME MEASUREMENTS: The rate of successful biliary cannulation and short-term outcomes. LIMITATIONS: ERCP procedures were performed by a single endoscopist. RESULTS: Successful bile-duct cannulation with sphincterotomy and the removal of biliary stones or sludge was performed without fluoroscopy in 21 pregnant women. There was one case of mild post-ERCP pancreatitis. Choledochoscopy confirmed ductal clearance in 5 cases. CONCLUSIONS: Nonradiation ERCP is a safe and effective treatment for symptomatic choledocholithiasis during pregnancy. Wire-guided biliary cannulation and choledochoscopy may enhance the performance of ERCP in this setting.