What is the management of cholecystitis in a pregnant woman at 37 weeks gestation?

Management of Cholecystitis at 37 Weeks Pregnancy

Laparoscopic cholecystectomy is the recommended treatment for cholecystitis at 37 weeks pregnancy when symptoms are severe and recurrent, with delivery planning coordinated between surgical and obstetric teams. 1, 2

Diagnostic Considerations

• Ultrasound is the preferred imaging modality for diagnosing gallstones during pregnancy
• Murphy's sign may be difficult to evaluate in the late third trimester 1
• MRI/MRCP (without contrast) is preferred for suspected bile duct stones 2

Management Algorithm

Initial Management

1. Conservative management as first-line approach:

   • IV hydration
   • Pain control
   • Correction of electrolyte abnormalities
   • NPO status initially
   • Antibiotics for infectious cholecystitis

2. Assessment of severity:

   • Evaluate for signs of complications (pancreatitis, cholangitis)
   • Monitor maternal vital signs and fetal well-being
   • Assess response to conservative management

Surgical Management Decision

For cholecystitis at 37 weeks, consider the following factors:

• If symptoms are severe, recurrent, or not responding to conservative management:

  • Proceed with laparoscopic cholecystectomy, as it has been shown to have better outcomes than non-operative management 1, 2
  • Laparoscopic approach is preferred over open cholecystectomy (lower maternal complications: 3.5% vs 8.2%) 1

• If symptoms are mild and well-controlled:

  • Consider delaying cholecystectomy until after delivery
  • Be aware that conservative management has a 60% recurrence rate of biliary symptoms 2

Special Considerations for Surgery at 37 Weeks

• Use proper port placement techniques accounting for the enlarged uterus 3
• Maintain pneumoperitoneum pressure at 12 mmHg or lower 4
• Consider left lateral positioning to minimize uterine compression of vena cava
• Continuous fetal monitoring during the procedure when possible

Delivery Planning

• If cholecystectomy is performed, coordinate with obstetric team for potential delivery needs
• At 37 weeks, if cholecystitis is severe and not responding to treatment, consider:
  • Combined management with cholecystectomy and planned delivery
  • Early delivery (37-39 weeks) may be reasonable in this context 1

Complications and Pitfalls to Avoid

• Maternal risks:

  • Increased risk of preterm labor if surgery is delayed and symptoms worsen
  • Higher risk of emergency department visits and hospitalizations with conservative management 2

• Surgical considerations:

  • Avoid excessive manipulation of the uterus during surgery
  • Be prepared for subtotal cholecystectomy if anatomic identification is difficult 1
  • Consider ERCP with sphincterotomy if there is evidence of bile duct obstruction 5

• Post-procedure monitoring:

  • Monitor for signs of preterm labor
  • Continue fetal monitoring after the procedure
  • Ensure adequate pain control to minimize stress response

Multidisciplinary Approach

Management should involve coordination among:

• Surgeons
• Obstetricians
• Anesthesiologists
• Gastroenterologists (if ERCP is needed)

This coordinated care is essential for optimizing outcomes for both mother and fetus, especially at this advanced gestational age.