How are biliary diseases managed in pregnancy?

Management of Biliary Diseases in Pregnancy

The management of biliary diseases during pregnancy requires specific interventions based on disease type, with ursodeoxycholic acid being first-line therapy for cholestatic conditions and laparoscopic cholecystectomy recommended for symptomatic gallstone disease regardless of trimester. 1

Intrahepatic Cholestasis of Pregnancy (ICP)

Diagnosis and Risk Stratification

• Diagnosis based on:

  • Pruritus (often precedes laboratory abnormalities by weeks)
  • Elevated serum bile acids >10 μmol/L
  • Total bilirubin <6 mg/dL
  • Mild to moderate elevations in liver enzymes 2

• Risk stratification based on bile acid levels:

  Risk Category	Bile Acid Level	Recommended Delivery Timing
  High Risk	≥100 μmol/L	36 weeks or at diagnosis if after 36 weeks
  Moderate Risk	40-99 μmol/L	36-39 weeks gestation
  Lower Risk	<40 μmol/L	37-39 weeks gestation or at term
  2

Treatment

• Ursodeoxycholic acid (UDCA): First-line therapy

  • Dosage: 10-15 mg/kg/day in divided doses (typically 500 mg twice daily)
  • Benefits: Reduces pruritus, lowers serum bile acids and liver enzymes, decreases adverse outcomes
  • Safety: No evidence of fetal harm; can be continued during breastfeeding 1, 2, 3

• For refractory cases:

  • Rifampicin (300-600 mg daily)
  • Anion exchange resins (cholestyramine 4-8 g/day or colestipol 5-10 g/day)
    • Give at least 4 hours after UDCA to prevent interference 1

• Monitor:

  • Total serum bile acids and liver function tests every 2 weeks until 32 weeks, then weekly until delivery 2
  • Antenatal fetal surveillance (though normal testing doesn't preclude stillbirth risk) 2

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

Management During Pregnancy

• Continue UDCA during pregnancy (strong recommendation) 1
• Avoid obeticholic acid during pregnancy and lactation due to lack of safety data 1
• Fibrates may be used after first trimester if benefits outweigh risks 1
• Correct vitamin K deficiency related to cholestasis 1

For Worsening Symptoms or Liver Tests

• For pruritus:

  • Rifampicin (300-600 mg daily)
  • Anion exchange resins (cholestyramine 4-8 g/day or colestipol 5-10 g/day) 1

• For PSC with worsening cholestasis:

  • Ultrasound or MRI/MRCP to exclude obstruction or high-grade strictures
  • Consider ERCP for therapeutic interventions in second or third trimester
  • Endoscopic balloon dilation or short-term stenting for relevant strictures (>75% biliary strictures with obstructive cholestasis/bacterial cholangitis) 1

Gallstone Disease in Pregnancy

Management Approach

• Laparoscopic cholecystectomy is safe during pregnancy regardless of trimester, but ideally performed in the second trimester 1
• Conservative management has high failure rates (36%) with recurrent symptoms in 60% of patients 1, 4
• Same-admission cholecystectomy for acute biliary pancreatitis reduces early readmission odds by 85% 1

Surgical Considerations

• Use Hasson (open) technique for cannulation
• Employ reduced-pressure pneumoperitoneum (6-10 mmHg)
• Consider prophylactic tocolytics 4

Alternative Approaches

• For hemodynamically unstable patients or those at high surgical risk:
  • Percutaneous cholecystostomy tube placement
  • Percutaneous gallbladder aspiration as "bridging" therapy 1

Endoscopic Management of Biliary Disorders

ERCP During Pregnancy

• Minimize radiation exposure:

  • Use modern fluoroscopy unit with collimation and pulsed fluoroscopy
  • Employ low radiation dose protocols and low frame rates
  • Use bile aspiration technique, cholangioscopy, or EUS to reduce radiation
  • Consider stent placement for large stones with post-delivery clearance 1

• Patient positioning:

  • First trimester: Supine or prone position acceptable
  • Second/third trimesters: Left pelvic tilt or left lateral position to avoid aorta/IVC compression 1

• Safety measures:

  • Lead shielding of pelvis
  • Fetal monitoring by obstetrician
  • Thromboprophylaxis and antibiotic prophylaxis when indicated 1, 5, 6

Postpartum Care

• Stop UDCA at delivery or gradually reduce over 2-4 weeks if symptoms persist 2
• Ensure bile acids, ALT/AST, and bilirubin normalize within 3 months postpartum 2
• Investigate for underlying liver disease if liver tests remain abnormal beyond 3 months 2
• Counsel patients on:
  • High recurrence risk (up to 90%) in future pregnancies
  • Need for preconception counseling
  • Avoidance of estrogen-containing contraceptives 2

Special Considerations

• For delivery timing in ICP, follow risk-based approach based on bile acid levels 2
• Administer antenatal corticosteroids for fetal lung maturity if delivery before 37 weeks 2
• Use continuous fetal monitoring during labor due to higher stillbirth risk 2
• Consider genetic counseling for family history of ICP, severe/early-onset disease, or persistent liver abnormalities 2

The evidence strongly supports active management of biliary diseases during pregnancy, with disease-specific approaches that balance maternal and fetal outcomes while minimizing risks.