How should gallstones diagnosed during pregnancy be managed?

Management of Gallstones During Pregnancy

Gallstones diagnosed during pregnancy may resolve spontaneously after delivery, but laparoscopic cholecystectomy is the standard of care for symptomatic cases regardless of trimester, ideally performed in the second trimester. 1

Epidemiology and Presentation

• Gallstone disease is the second leading cause (after acute appendicitis) of non-obstetric acute abdominal pain during pregnancy 1
• Ultrasonography is the imaging modality of choice for diagnosing gallstones during pregnancy 1

Natural History of Gallstones in Pregnancy

• Some gallstones diagnosed during pregnancy may resolve spontaneously after delivery 2
• Studies report that recurrent biliary symptoms develop in 60% of pregnant patients with gallstone disease treated conservatively, leading to a high number of hospitalizations 1
• Patients treated conservatively are more likely to undergo cesarean birth 1

Management Approach

• For asymptomatic gallstones: observation is appropriate 2
• For symptomatic gallstones:
  • Initial conservative management includes IV hydration, symptom control, and avoidance of dietary triggers such as high-fat meals 1
  • Laparoscopic cholecystectomy is considered superior to conservative management in the first or second trimester for patients with symptomatic cholelithiasis 1

Surgical Management

• Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally performed in the second trimester 1, 3
• Same-admission cholecystectomy in pregnant patients with acute biliary pancreatitis has been found to reduce the odds of early readmission by 85% 1
• For biliary pain presenting late in the third trimester, postponing surgical intervention until delivery may be reasonable if it doesn't pose a risk to maternal or fetal health 1

Management of Complications

• For suspected choledocholithiasis, non-contrast magnetic resonance cholangiopancreatography (MRCP) can be performed safely 1
• Endoscopic retrograde cholangiopancreatography (ERCP) can be performed during pregnancy for urgent indications such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis 1
• ERCP should ideally be performed during the second trimester 1
• Pregnancy is an independent risk factor for post-ERCP pancreatitis (12% vs 5% in non-pregnant patients) 1

Special Considerations for ERCP

• A multidisciplinary team should be involved including an advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist 1
• Measures to minimize radiation exposure should be implemented, including:
  • Use of modern fluoroscopy unit with collimation ability and pulsed fluoroscopy 1
  • Use of last image hold feature and short taps of fluoroscopy 1
  • Use of low radiation dose protocols and low frame rates 1

Alternative Management Options

• If a patient is hemodynamically unstable, not responding to medical management, or at high risk for surgery, percutaneous cholecystostomy tube placement or percutaneous gallbladder aspiration can be used as "bridging" therapy 1
• This approach can be used in the first trimester (to bridge to the second) or in the third trimester to bridge to the postpartum period 1

Outcomes

• Studies show no significant difference in the risk of premature delivery and abortion in pregnant patients undergoing cholecystectomy compared to those managed conservatively 1
• Patients who undergo cholecystectomy during the index hospitalization have a significantly lower mean number of cumulative hospitalizations 1