Management of Gallstones During Pregnancy

Epidemiology and Presentation

• Gallstone disease is the second leading cause of non-obstetric acute abdominal pain during pregnancy 1
• Ultrasonography is the imaging modality of choice for diagnosing gallstones during pregnancy 2

Natural History of Gallstones in Pregnancy

• Studies report that recurrent biliary symptoms develop in 60% of pregnant patients with gallstone disease treated conservatively, leading to a high number of hospitalizations 3
• Patients treated conservatively are more likely to undergo cesarean birth 3

Management Approach

• Initial conservative management for symptomatic gallstones includes IV hydration, symptom control, and avoidance of dietary triggers such as high-fat meals 1
• Laparoscopic cholecystectomy is considered superior to conservative management in the first or second trimester for patients with symptomatic cholelithiasis 3

Surgical Management

• Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally performed in the second trimester 3
• Same-admission cholecystectomy in pregnant patients with acute biliary pancreatitis has been found to reduce the odds of early readmission by 85% 3
• For biliary pain presenting late in the third trimester, postponing surgical intervention until delivery may be reasonable if it doesn't pose a risk to maternal or fetal health 1

Management of Complications

• For suspected choledocholithiasis, non-contrast magnetic resonance cholangiopancreatography (MRCP) can be performed safely 2
• Endoscopic retrograde cholangiopancreatography (ERCP) can be performed during pregnancy for urgent indications such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis 2
• ERCP should ideally be performed during the second trimester 2
• Pregnancy is an independent risk factor for post-ERCP pancreatitis (12% vs 5% in non-pregnant patients) 1

Special Considerations for ERCP

• A multidisciplinary team should be involved including an advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist 2
• Measures to minimize radiation exposure should be implemented, including use of modern fluoroscopy unit with collimation ability and pulsed fluoroscopy 1
• Use of last image hold feature and short taps of fluoroscopy 1
• Use of low radiation dose protocols and low frame rates 1

Alternative Management Options

• If a patient is hemodynamically unstable, not responding to medical management, or at high risk for surgery, percutaneous cholecystostomy tube placement or percutaneous gallbladder aspiration can be used as "bridging" therapy 4
• This approach can be used in the first trimester (to bridge to the second) or in the third trimester to bridge to the postpartum period 4

Outcomes

• Studies show no significant difference in the risk of premature delivery and abortion in pregnant patients undergoing cholecystectomy compared to those managed conservatively 3
• Patients who undergo cholecystectomy during the index hospitalization have a significantly lower mean number of cumulative hospitalizations 3

Management of Acute Cholecystitis in Pregnancy

Introduction to Management

• The American College of Surgeons recommends surgery as the preferred first-line treatment for acute cholecystitis in pregnant patients to avoid potential drug toxicity to the fetus, with cefotaxime and metronidazole as alternative options before surgery 5

Treatment Approach

• Surgery, preferably laparoscopic cholecystectomy, is recommended as first-line therapy to avoid complications and potential drug toxicity to the fetus, with significantly lower maternal complications (3.5% vs 8.2%) and fetal complications (3.9% vs 12.0%) compared to open cholecystectomy 6
• The second trimester is the optimal time for surgical intervention due to higher risk of miscarriage and anesthetic toxicity in the first trimester and technical difficulties related to uterine size in late third trimester 6

Risks and Considerations

• Conservative management with antibiotics carries significant risks, including higher rates of spontaneous abortion, threatened abortion, and premature birth compared to patients who underwent cholecystectomy 5
• Diagnostic challenges in pregnancy include leukocytosis being potentially misleading and Murphy's sign being difficult to evaluate in the late third trimester 5

Open Cholecystectomy for Cholecystitis in Pregnancy

Introduction to Open Cholecystectomy

• Open cholecystectomy is a viable and acceptable option for managing cholecystitis in pregnant patients when laparoscopic surgery is not available, though it carries higher maternal and fetal complication rates compared to the laparoscopic approach, as stated by the World Journal of Emergency Surgery 7

Evidence Supporting Open Cholecystectomy

• Open cholecystectomy remains a feasible option, particularly in settings of resource limitations or when laparoscopic equipment is unavailable, according to the World Society of Emergency Surgery 8
• The World Society of Emergency Surgery explicitly recognizes that open cholecystectomy is frequently performed in low-income countries and resource-limited settings, with outcomes that are acceptable when laparoscopic surgery is not accessible 8

Indications for Open Cholecystectomy

• Risk factors predicting conversion from laparoscopic to open include: age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery, as reported by the World Journal of Emergency Surgery 8
• In cases of gallbladder perforation, prompt surgical intervention (open or laparoscopic) is critical, as delayed intervention is associated with elevated morbidity and mortality rates, according to the World Journal of Emergency Surgery 8

Alternative Therapies

• Cholecystostomy is a safe and effective treatment for acute cholecystitis in critically ill patients with multiple comorbidities who are unfit for surgery, as stated by the World Journal of Emergency Surgery 8

Decision-Making Algorithm

• If laparoscopic surgery is unavailable but open surgery is feasible, the World Journal of Emergency Surgery recommends performing open cholecystectomy 8, 7
• If patient is critically ill or unfit for any surgery, consider cholecystostomy as bridging therapy, as suggested by the World Journal of Emergency Surgery 8

Management of Symptomatic Cholelithiasis in Pregnancy

Initial Assessment and Imaging

• Ultrasound is the preferred diagnostic modality for gallstones in pregnant patients because it offers high sensitivity and specificity without ionizing radiation. 9
• Non‑contrast magnetic resonance cholangiopancreatography (MRCP) should be obtained to confirm suspected choledocholithiasis before therapeutic intervention. 10
• When MRCP is contraindicated, endoscopic ultrasound can be used to rule out bile‑duct stones and may avoid the need for ERCP. 10

Timing of Definitive Surgical Management

• Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis in pregnancy, with the second trimester (approximately weeks 14–26) being the optimal window to minimize miscarriage risk and technical difficulties related to uterine size. 11

Endoscopic Retrograde Cholangiopancreatography (ERCP)

• ERCP is indicated during pregnancy for urgent indications such as choledocholithiasis, cholangitis, and gallstone pancreatitis with a retained bile‑duct stone. 11
• ERCP should ideally be performed in the second trimester, but it must not be delayed if postponement would jeopardize maternal or fetal health. [11][10]
• A multidisciplinary team—including an experienced endoscopist, maternal‑fetal medicine specialist, obstetrician, neonatologist, and anesthesiologist—should be assembled for all ERCP procedures in pregnant patients. 10
• Fetal monitoring before and after the ERCP procedure is recommended to promptly detect any adverse fetal events. 10

Management of Acute Cholangitis

• Urgent ERCP is required for pregnant patients with cholangitis, regardless of gestational age, and should not be postponed. [11][10]

Management of Gallstone Pancreatitis

• If a bile‑duct stone persists after initial supportive care for gallstone pancreatitis, ERCP is indicated to achieve ductal clearance. [11][10]
• Initial management of gallstone pancreatitis in pregnancy includes intravenous hydration, analgesia, and bowel rest. 10