How are biliary diseases managed in pregnancy?

Management of Biliary Diseases in Pregnancy

Laparoscopic cholecystectomy is the standard of care for symptomatic gallstone disease during pregnancy, regardless of trimester, though ideally performed in the second trimester. 1

Gallstone Disease Management

Surgical Management

• Laparoscopic cholecystectomy is superior to conservative management for symptomatic cholelithiasis in the first or second trimester 1
• Safety has been demonstrated across all trimesters, though the second trimester is ideal 1
• Same-admission cholecystectomy for acute biliary pancreatitis reduces 30-day readmission rates significantly (5.3% vs 33.7%) 1
• For late third trimester presentations, postponing surgery until after delivery may be reasonable if it doesn't pose immediate maternal or fetal health risks 1

Alternative Interventions

• For patients who are hemodynamically unstable, unresponsive to medical management, or high-risk for surgery:
  • Percutaneous cholecystostomy tube placement
  • Percutaneous gallbladder aspiration
  • These serve as "bridging" therapies until definitive cholecystectomy can be performed 1

Positioning During Surgery

• After first trimester, patients should be placed in left lateral or partial left lateral decubitus position to minimize inferior vena cava compression 1

ERCP Management

Radiation Safety Measures

• Multidisciplinary team approach including obstetrician, perinatologist, radiation safety officer, anesthesiologist, and experienced endoscopist 1
• Technical considerations:
  • Modern fluoroscopy unit with collimation and pulsed fluoroscopy
  • Last image hold feature and short taps of fluoroscopy
  • Avoid spot films and use of magnification
  • Position image intensifier close to patient, keeping patient away from radiation source
  • Low radiation dose protocols and low frame rates 1
• Alternative techniques to reduce radiation:
  • Bile aspiration technique
  • Cholangioscopy
  • Endoscopic ultrasound 1
• For large stones, consider stent placement and postpone lithotripsy until after delivery 1
• Avoid pelvic and gonadal shielding as radiation from newer fluoroscopy machines may penetrate lead and increase exposure 1

Patient Positioning for ERCP

• First trimester: Supine or prone position acceptable
• Second and third trimesters: Left pelvic tilt or left lateral position to avoid aorta or inferior vena cava compression 1

Specific Biliary Conditions in Pregnancy

Intrahepatic Cholestasis of Pregnancy (ICP)

• First-line treatment: Ursodeoxycholic acid (UDCA) 10-15 mg/kg/day in divided doses 2
• Delivery timing based on bile acid levels:
  • High risk (≥100 μmol/L): Deliver at 36 weeks or at diagnosis if after 36 weeks
  • Moderate risk (40-99 μmol/L): Deliver between 36-39 weeks
  • Lower risk (<40 μmol/L): Deliver at 37-39 weeks 2
• Monitor total serum bile acids and liver function tests every 2 weeks until 32 weeks, then weekly 2

Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC)

• Continue UDCA during pregnancy and breastfeeding 1
• For worsening pruritus, treatment options include:
  • Rifampicin (300-600 mg daily)
  • Anion exchange resins (cholestyramine 4-8 g/day or colestipol 5-10 g/day) given at least 4 hours after UDCA 1
• For PSC with worsening cholestasis, perform ultrasound or MRI to exclude obstruction 1
• Endoscopic balloon dilatation or short-term bile duct stenting for high-grade biliary strictures 1

Common Pitfalls and Caveats

1. Conservative management risks:

   • Recurrent biliary symptoms develop in 60% of conservatively managed pregnant patients 1
   • Higher rates of cesarean delivery in conservatively managed patients 1
   • Each symptomatic relapse adds approximately 5 additional hospital days 3

2. Radiation concerns:

   • ERCP can be safely performed during pregnancy when necessary 4
   • The radiation dose from modern fluoroscopy is considerably lower than the 50 mGy threshold of concern for fetal risk 1
   • Use radiation-minimizing techniques and limit fluoroscopy time (median reported time: 12 seconds) 4

3. Timing of interventions:

   • Don't delay necessary interventions due to pregnancy concerns
   • Second trimester is traditionally considered optimal for interventions, but evidence supports safety across all trimesters 1
   • Delaying treatment can lead to increased complications including preterm labor 3

By following these evidence-based approaches, biliary diseases in pregnancy can be managed effectively while minimizing risks to both mother and fetus.