What are the symptoms of gallstones in pregnant women?

Symptoms of Gallstones in Pregnancy

Symptomatic biliary colic is the most common presentation of gallstones in pregnancy, though patients may also develop acute cholecystitis, pancreatitis, or cholangitis. 1

Primary Clinical Presentations

Biliary Colic

• Right upper quadrant or epigastric pain that is typically episodic and colicky in nature 1
• Pain may radiate to the back or right shoulder 2
• Often triggered by high-fat meals 2
• Represents the most frequent symptomatic manifestation in pregnant patients 1

Acute Cholecystitis

• Persistent right upper quadrant pain (unlike the episodic nature of biliary colic) 2
• Fever and signs of systemic inflammation 2
• Murphy's sign may be difficult to evaluate in late third trimester due to uterine size 2
• Leukocytosis can be misleading as it occurs physiologically in pregnancy 2

Gallstone Pancreatitis

• Severe epigastric pain radiating to the back 1
• Nausea and vomiting 1
• Elevated pancreatic enzymes 1
• Occurs less frequently but carries higher fetal mortality risk (8.0% with conservative management) 3

Cholangitis

• Right upper quadrant pain with fever and jaundice (Charcot's triad) 1
• Represents a more severe complication requiring urgent intervention 1
• May present with obstructive jaundice and scleral icterus 4

Diagnostic Considerations

Imaging

• Ultrasound is the diagnostic imaging modality of choice for detecting gallstones during pregnancy 1, 2
• High sensitivity and specificity without radiation exposure 5
• Can detect both gallstones and biliary sludge 5

Laboratory Findings

• Elevated serum ALT and bile acids may accompany symptoms 1
• Normal bilirubin, prothrombin time, and gamma-glutamyltransferase should be expected in uncomplicated biliary colic 1
• Any elevation in these parameters warrants further evaluation 1

Clinical Context and Risk Factors

Epidemiology

• Gallstone-related disease complicates 0.5% to 0.8% of pregnancies 1, 5
• Gallstones may occur in up to 10% of pregnancies overall 1
• Strongest risk factors include high prepregnancy BMI and elevated serum leptin levels 1

Pathophysiology

• Hormonal changes during pregnancy cause decreased gallbladder motility and lithogenic bile 1, 6
• Progesterone therapy (used for uterine bleeding) can exacerbate risk by further reducing gallbladder motility 4
• Biliary sludge develops in up to 30% of pregnancies and represents a precursor to gallstones 7

Natural History and Recurrence

Symptom Recurrence

• 60% of pregnant patients with gallstone disease treated conservatively develop recurrent biliary symptoms, leading to multiple hospitalizations 2
• Patients managed conservatively are more likely to require cesarean delivery 2
• Some biliary sludge and gallstones dissolve spontaneously postpartum (20-30%), but many persist requiring intervention 7, 8

Important Clinical Pitfalls

Diagnostic Challenges

• Normal physiologic changes in pregnancy can mimic chronic liver disease, including spider angiomas and palmar erythema 1
• Alkaline phosphatase increases normally in second and third trimesters due to placental origin 1
• Leukocytosis occurs physiologically in pregnancy, making it unreliable for diagnosing acute cholecystitis 2

Timing Considerations

• Symptoms typically manifest when gallstone disease becomes complicated rather than from asymptomatic stones 1
• Late third trimester presentations may warrant delaying intervention until delivery if maternal-fetal health is not compromised 2