What is the treatment plan for a 25-year-old female at 14 weeks gestation with cholelithiasis?

From the Guidelines

The treatment plan for a 25-year-old female at 14 weeks gestation with cholelithiasis should initially focus on conservative management, with surgical intervention using laparoscopic cholecystectomy considered if symptoms are severe or complications develop, preferably during the second trimester. The first-line approach includes dietary modifications such as consuming a low-fat diet, avoiding trigger foods, and eating smaller, more frequent meals. For pain management, acetaminophen (Tylenol) is the safest option during pregnancy, typically 650-1000 mg every 6 hours as needed, not exceeding 4000 mg daily, as indicated by general medical guidelines 1. Adequate hydration should be maintained. If symptoms are severe or complications develop (such as cholecystitis, pancreatitis, or biliary obstruction), laparoscopic cholecystectomy is the standard of care regardless of trimester, but ideally in the second trimester 1. Surgery during pregnancy carries some risks but is generally safe when necessary. Expectant management until postpartum is reasonable for mild, infrequent symptoms. The patient should be monitored closely with regular prenatal visits and should seek immediate medical attention if experiencing severe abdominal pain, fever, jaundice, or persistent vomiting. This approach balances maternal symptom management with fetal safety considerations, as both untreated severe biliary disease and surgical intervention carry risks during pregnancy. In cases where endoscopic retrograde cholangiopancreatography (ERCP) is necessary for urgent indications like choledocholithiasis, it should be performed by an experienced endoscopist, ideally during the second trimester, with measures to minimize fetal radiation exposure 1. Ultrasonography is the preferred imaging modality for gallstones, and other imaging techniques like magnetic resonance cholangiopancreatography can be used when necessary to confirm the absence of a bile duct stone 1. A multidisciplinary team approach is crucial for managing complex cases, including the involvement of an advanced endoscopist, MFM physician, neonatologist, obstetrician, and anesthesiologist 1. The goal is to minimize risks to both the mother and the fetus while effectively managing the condition.

From the Research

Treatment Plan for Cholelithiasis in Pregnancy

The treatment plan for a 25-year-old female at 14 weeks gestation with cholelithiasis involves several considerations, including the severity of symptoms, the presence of complications, and the gestational age of the pregnancy.

• The management of symptomatic cholelithiasis in pregnancy is crucial to prevent complications and ensure the best possible outcomes for both the mother and the fetus 2.
• Guidelines recommend laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis in pregnancy, especially if the symptoms are severe or recurrent 2, 3.
• Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations and may not be the optimal strategy, especially if the symptoms are severe or recurrent 2.
• Ursodeoxycholic acid (UDCA) may be considered as a treatment option for symptomatic gallstone disease, particularly in patients who are unfit for surgery or have mild symptoms 4.
• The decision to perform a laparoscopic cholecystectomy during pregnancy should be made on a case-by-case basis, taking into account the severity of symptoms, the presence of complications, and the gestational age of the pregnancy 2, 5.

Considerations for Laparoscopic Cholecystectomy

• Laparoscopic cholecystectomy is generally considered safe during pregnancy, especially during the second trimester 2, 5.
• The risk of complications, such as preterm labor and fetal distress, is lower when the surgery is performed during the second trimester compared to the first or third trimester 5.
• The surgery should be performed by an experienced surgeon, and the patient should be closely monitored during and after the procedure to minimize the risk of complications 2, 5.

Alternative Treatment Options

• Ursodeoxycholic acid (UDCA) may be considered as a treatment option for symptomatic gallstone disease, particularly in patients who are unfit for surgery or have mild symptoms 4.
• Lifestyle and dietary modifications, such as a low-fat diet and increased physical activity, may also be recommended to help manage symptoms and prevent complications 3.
• Medications, such as pain relievers and anti-nausea medications, may be prescribed to help manage symptoms and improve quality of life 3.