What is the recommended management of cholelithiasis in a pregnant woman, including treatment of uncomplicated stones, acute cholecystitis, choledocholithiasis, and cholangitis?

Management of Cholelithiasis in Pregnancy

Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis during pregnancy, ideally performed in the second trimester, as conservative management leads to recurrent symptoms in 60% of patients and increases hospitalizations. 1, 2

Initial Assessment and Imaging

• Ultrasound is the diagnostic imaging modality of choice for gallstones during pregnancy due to high sensitivity and specificity without radiation exposure 1, 3
• Look for distended gallbladder, thickened gallbladder wall (>3mm), pericholecystic fluid, gallstones, and positive Murphy's sign 4
• Be aware that normal physiologic changes can be misleading: leukocytosis occurs normally in pregnancy, alkaline phosphatase increases in second/third trimesters due to placental origin, and spider angiomas/palmar erythema are normal 3

Management of Uncomplicated Biliary Colic

Initial Conservative Management

• Start with IV hydration, symptom control, and avoidance of high-fat meals 2, 3
• However, conservative management fails in 60% of cases, leading to recurrent symptoms, multiple emergency department visits, and higher rates of cesarean delivery 2, 3, 5

Definitive Surgical Management

• Laparoscopic cholecystectomy is superior to conservative management in the first or second trimester for symptomatic cholelithiasis 2
• Second trimester is optimal timing (ideally weeks 14-26) to avoid first trimester miscarriage risk and third trimester technical difficulties from uterine size 1, 2, 4
• Laparoscopic approach is safe in any trimester if symptoms are severe, with no increased risk of premature delivery, fetal loss, or maternal morbidity 2, 6
• Use Hasson cannulation technique for trocar placement and reduced-pressure pneumoperitoneum (6-10 mmHg) 6
• For biliary pain presenting late in third trimester, postponing surgery until delivery is reasonable only if it doesn't pose maternal or fetal risk 2

Management of Acute Cholecystitis

Surgery is the preferred first-line treatment for acute cholecystitis in pregnancy, not antibiotics alone. 4

• Laparoscopic cholecystectomy has significantly lower complications than open approach: maternal complications 3.5% vs 8.2%, fetal complications 3.9% vs 12.0% 4
• Begin IV hydration and pain control immediately while preparing for surgery 4
• Administer perioperative antibiotics: Amoxicillin/Clavulanate 2g/0.2g IV q8h for uncomplicated cholecystitis, or single-dose prophylaxis if early intervention within 7-10 days 4
• Conservative management with antibiotics alone carries significant risks: higher rates of spontaneous abortion, threatened abortion, and premature birth compared to cholecystectomy 4
• If patient is hemodynamically unstable or at prohibitively high surgical risk, percutaneous cholecystostomy can serve as bridging therapy, though it is inferior to cholecystectomy 4

Management of Choledocholithiasis and Cholangitis

ERCP can and should be performed during pregnancy for urgent indications including choledocholithiasis, cholangitis, and gallstone pancreatitis with retained bile duct stone. 1

Pre-ERCP Evaluation

• For suspected choledocholithiasis, obtain non-contrast magnetic resonance cholangiopancreatography (MRCP) to confirm diagnosis 1, 2
• Endoscopic ultrasound can be used if MRCP is contraindicated to confirm absence of bile duct stone and potentially avoid ERCP 1

ERCP Procedure Considerations

• Ideally perform in second trimester, but do not delay if deferring poses risk to maternal or fetal health 1
• Assemble multidisciplinary team: advanced endoscopist experienced in ERCP, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist 1, 2
• Minimize radiation exposure using: modern fluoroscopy with collimation, pulsed fluoroscopy, last image hold feature, short fluoroscopy taps, low radiation dose protocols, and low frame rates 2
• Be aware that pregnancy is an independent risk factor for post-ERCP pancreatitis (12% vs 5% in non-pregnant patients) 2
• Provide pre- and post-procedure fetal monitoring 1

Management of Cholangitis

• Cholangitis presents with Charcot's triad: right upper quadrant pain, fever, and jaundice 3
• Initial management includes IV hydration, antibiotics, and nutritional support 1
• ERCP is indicated urgently and should not be delayed regardless of trimester if patient has cholangitis 1

Management of Gallstone Pancreatitis

• Severe epigastric pain radiating to back with nausea and vomiting characterizes gallstone pancreatitis 3
• Same-admission cholecystectomy reduces odds of early readmission by 85% 2, 4
• ERCP is indicated if bile duct stone is retained after initial management 1
• Initial supportive care includes IV hydration, pain control, and bowel rest 1

Alternative/Bridging Therapies

Percutaneous cholecystostomy or gallbladder aspiration can be used as bridging therapy in specific situations: 2

• Patient is hemodynamically unstable
• Patient not responding to medical management
• Patient at high risk for surgery
• First trimester (to bridge to second trimester for definitive surgery)
• Third trimester (to bridge to postpartum period)

Key Outcomes and Pitfalls

• Patients undergoing cholecystectomy during index hospitalization have significantly lower cumulative hospitalizations compared to conservative management 4
• Studies show no significant difference in risk of premature delivery or abortion between cholecystectomy and conservative management 2
• 56% of conservatively treated patients require surgical intervention within 2 years after delivery 7
• Open cholecystectomy remains acceptable when laparoscopic equipment is unavailable, particularly in resource-limited settings 2