What is the recommended management approach for uncomplicated cholelithiasis (gallstones) in pregnancy?

Management of Uncomplicated Cholelithiasis in Pregnancy

Laparoscopic cholecystectomy is the recommended management for uncomplicated symptomatic cholelithiasis during pregnancy, ideally performed in the second trimester, though it can be safely performed in any trimester. 1

Initial Evaluation and Diagnosis

• Ultrasonography is the imaging modality of choice for diagnosing gallstones in pregnancy
• Right upper quadrant pain, nausea, and vomiting are common presenting symptoms
• Laboratory tests may include white blood cell count and liver enzymes, though these may be normal in uncomplicated cases

Management Algorithm

Symptomatic Uncomplicated Cholelithiasis

1. Surgical Management (Preferred Approach)

   • Laparoscopic cholecystectomy is superior to conservative management for symptomatic patients 1
   • Timing considerations:
     • Ideally performed during second trimester
     • Can be safely performed in any trimester based on current evidence 1
     • For late third trimester presentations, postponing until after delivery may be reasonable if maternal/fetal health is not at risk

2. Conservative Management (If Surgery Deferred)

   • IV hydration
   • Symptom control (pain management)
   • Dietary modifications (avoid high-fat meals)
   • Important caveat: Conservative management is associated with:
     • 60% recurrence of biliary symptoms 1
     • Increased hospitalizations 2, 3
     • Higher rates of emergency department visits 3
     • Increased likelihood of cesarean section 3

Special Considerations

• Positioning during surgery: After first trimester, patients should be placed in left lateral or partial left lateral decubitus position to minimize compression of inferior vena cava 1
• Bridging therapy options: For patients who are hemodynamically unstable or high-risk for surgery, percutaneous cholecystostomy tube placement or gallbladder aspiration can be used as temporary measures 1

Evidence Quality and Outcomes

• A study of 1,245 pregnant women with biliary pancreatitis showed significantly higher 30-day readmission rates in patients who did not undergo cholecystectomy (33.7% vs 5.3%) 1
• Multiple studies demonstrate that conservative management leads to:
  • More frequent hospitalizations (mean total days: 20.5 vs 12.4 for surgical cases) 4
  • Recurrent symptoms in 38-78% of patients 2, 5
  • More emergency department visits 3

Common Pitfalls

1. Delaying surgical intervention: The traditional conservative approach leads to higher rates of recurrent symptoms, hospitalizations, and potentially worse outcomes
2. Assuming second trimester is the only safe period: Current evidence supports safety of laparoscopic cholecystectomy in all trimesters 1
3. Failure to consider multidisciplinary care: Management should involve collaboration between obstetricians, surgeons, and gastroenterologists

By addressing symptomatic cholelithiasis with timely surgical intervention during pregnancy, providers can reduce maternal morbidity, decrease hospitalizations, and improve overall outcomes for both mother and baby.