From the Guidelines
Antibiotics are not indicated in a pregnant patient with a common bile duct (CBD) stone but no signs of infection. The management of CBD stones during pregnancy primarily involves supportive care and consideration of endoscopic retrograde cholangiopancreatography (ERCP) for stone removal, as recommended by the American Society for Gastrointestinal Endoscopy guidelines 1. If the patient develops signs of infection, such as fever, elevated white blood cell count, or clinical features of cholangitis, then antibiotics would be warranted.
In cases where antibiotics are necessary, safe options during pregnancy include ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, or ampicillin-sulbactam 3g IV every 6 hours. The rationale for withholding antibiotics in non-infected cases is that antibiotics target bacterial infections, not the mechanical obstruction caused by stones. Unnecessary antibiotic use can lead to antimicrobial resistance, alteration of maternal microbiome, and potential adverse effects on the developing fetus.
Key considerations in the management of pregnant patients with CBD stones include:
- Minimizing fetal radiation exposure during ERCP, with total fetal radiation exposure influenced by gestational age, body size, and fetal exposure 1
- Avoiding compression of the aorta or inferior vena cava by placing the patient in the left pelvic tilt or left lateral position during ERCP in the second and third trimesters 1
- Administering thromboprophylaxis and antibiotic prophylaxis when indicated, such as in cases of infection or high-risk procedures 1
- Regular monitoring for signs of infection, as pregnancy increases the risk of complications from biliary disease, and prompt intervention with antibiotics would be necessary if infection develops.
From the Research
Antibiotics in Pregnant Patients with CBD Stones
- There is no direct evidence in the provided studies to suggest that antibiotics are indicated in a pregnant patient with a common bile duct (CBD) stone but no signs of infection 2, 3, 4, 5, 6.
- The management of CBD stones typically involves procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic CBD exploration, with the goal of removing the stone and relieving any obstruction 2, 3, 5.
- Antibiotics may be considered in certain situations, such as in patients with suspected or confirmed infection, including cholangitis, but this is not explicitly stated in the provided studies as a recommendation for pregnant patients with CBD stones and no signs of infection.
- The European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention, but do not specifically address the use of antibiotics in pregnant patients 5.
- In general, the management of CBD stones in pregnant patients should be individualized and based on the specific clinical situation, taking into account the risks and benefits of different treatment options, including the potential need for antibiotics in certain cases.