A review of the management of gallstone disease and its complications in pregnancy

doi:10.1016/j.amjsurg.2008.01.015

The American Journal of Surgery

Volume 196, Issue 4, October 2008, Pages 599-608

https://doi.org/10.1016/j.amjsurg.2008.01.015 Get rights and content

Abstract

Background

Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women. There have been significant developments in the management of gallstone disease, but risk to the fetus has prevented their routine application in pregnant women. We reviewed the literature to find the current best evidence for the management of gallstones and its complications in pregnancy.

Data sources

MEDLINE and PubMed literature searches were performed to identify original studies.

Results and Conclusions

Six studies comparing conservative with surgical management of cholecystitis showed no significant difference in incidence of preterm delivery (3.5% vs 6.0%, P = .33) or fetal mortality (2.2% vs 1.2%, P = .57). There was no maternal or fetal mortality in 20 reports of laparoscopic cholecystectomy and 9 reports of endoscopic retrograde cholangiopancreatography, thus indicating their safety when performed with necessary precautions. Laparoscopic cholecystectomy is a safe procedure in all trimesters. In 12 reports of gallstone pancreatitis, fetal mortality was 8.0% versus 2.6% (P = .28) in conservative and surgical groups, respectively, suggesting the need for earlier surgical intervention.

Section snippets

Literature search

A computerized search was made of the PubMed and MEDLINE databases for the period from January 1966 through October 2007. The Ovid search engine (version 9; Ovid Technologies, New York, New York) was employed.

The MESH headings “cholecystitis,” “cholecystectomy,” “obstructive jaundice,” “choledocholithiasis,” “endoscopic retrograde cholangiopancreatography,” “magnetic resonance cholangiopancreatography,” and “pancreatitis” were searched. These searches were combined using the term “OR.” Then

Management of symptomatic cholelithiasis

The literature on cholelithiasis and pregnancy is broadly divided into the prelaparoscopic cholecystectomy era and the post-LC era. The 3 original reports published just before the laparoscopic era can be considered representative of practice at the time14, 15, 16 (Table 1). Two of these case studies, published from Los Angeles, held different views. In a review of 44 patients, Dixon et al¹⁴ recommended surgical treatment for patients presenting with biliary symptoms during the second trimester

Comments

The spectrum of gallstone disease ranges from biliary colic to life-threatening pancreatitis; therefore, management must be tailored to the patient according to her presentation.

The first available large study on pregnancy-related gall bladder disease was published in 1963, and in this series of 17 patients, Greene et al⁵³ noted fetal loss of 24% (4 of 17). Although a number of reports have been published since then, the dilemma still remains whether or not to treat these patients

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Cited by (148)

Pregnant patients undergoing cholecystectomy: nationwide assessment of clinical characteristics and outcomes
2024, AJOG Global Reports
Gallstone disease in pregnancy is one of the most common indications for nonobstetrical surgery during pregnancy. National-level data on contemporary surgical practice and outcomes are limited.
This study aimed to assess the clinical characteristics and outcomes of patients undergoing cholecystectomy during pregnancy.
This cross-sectional study examined the Healthcare Cost and Utilization Project's 2 nationwide databases in the United States: the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample. The study population included 18,630 patients who had cholecystectomy during pregnancy from January 2016 to December 2020. The exposure was gestational age, grouped sequentially into the following 5 groups: first trimester (<14 weeks), early second trimester (14–20 weeks), late second trimester (21–27 weeks), early third trimester (28–36 weeks), and late third trimester (≥37 weeks). The main outcomes were clinical demographics, medical comorbidities, surgical information, and pregnancy characteristics and outcomes, assessed by gestational age.
Cholecystectomy was most common in the early second trimester (32.1%), followed by the first trimester (25.2%), late second trimester (23.1%), early third trimester (12.4%), and late third trimester (7.2%). Patients in the first-trimester group were more likely to be aged ≥35 years, to smoke, and to have acute cholecystitis, severe hyperemesis gravidarum including metabolic disturbance, pregestational diabetes, multifetal gestation, and sepsis/shock (P<.001). Patients in the early-third-trimester group were more likely to be obese and have gestational diabetes, Charlson Comorbidity Index of ≥1, premature rupture of membranes, and intrauterine growth restriction, whereas those in the late-third-trimester group were more likely to have gallstone pancreatitis, biliary colic, chorioamnionitis, gestational hypertension, preeclampsia, and severe maternal morbidity including sepsis (P<.001). At the cohort level, a laparoscopic approach was used in most cholecystectomy procedures (97.5%), and bile duct injury was uncommon (<0.1%). Delivery during the admission occurred in 0.3%, 0%, 0.6%, 17.8%, and 60.6% in the 5 gestational age groups, respectively (P<.001). Among the cases that had delivery in the early- and late-third-trimester groups, the delivery event preceded cholecystectomy in 61.4% and 86.2%, respectively, whereas both delivery and cholecystectomy occurred on the same day in 34.3% and 13.8%, respectively.
This nationwide analysis suggests that clinical and pregnancy characteristics and outcomes of patients undergoing cholecystectomy differ by pregnancy stage with a bimodal distribution. Although patients in the first and third trimesters have distinct medical conditions, more clinically significant pregnancy and maternal outcomes were found in both groups compared with patients in the second trimester.
Surgical emergencies in the pregnant patient
2023, Current Problems in Surgery
Surgery A survey of patients' perceptions and experiences of intervention for gallstone disease during pregnancy
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Gallstones intervention during pregnancy might be a stressful event for both mother and fetus and stress might affect outcome. The aim of this study was to identify factors that might improve the care of pregnant patients in need of intervention for gallstone disease.
By crossmatching the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Medical Birth Registry, we identified patients with gallstone intervention during pregnancy. A questionnaire covering patient experience before, during and after surgery and the Beck Depression Inventory II (BDI-II) were distributed.
In total, 275 patients subjected to cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) or both were identified, and 146 (54%) patients responded. Surgery was in median performed in pregnancy week 16 (12–20), and 62 (42%) patients had symptoms of gallstone disease before pregnancy, with 17 of these patients scheduled for surgery before pregnancy. Thirty-four (24%) patients felt that the information regarding the upcoming surgery was inadequate, with differences comparing patients with overall favorable versus overall non-favorable experiences (103 (89%) vs. 8 (27%) p < 0.001) and similar differences regarding information on disease/symptoms (95 (84%) vs. 12 (43%), p < 0.001). A majority (57%) were very worried about their expected child, and 51% thought that no measures were taken to relieve their worries. Recurring as suggested improvements was more information about the disease and the surgical procedure.
Intervention due to gallstone disease during pregnancy is a stressful event that impacts many patients negatively, both before and after surgery. Patient education might positively affect patient experience.
Guidelines on general surgical emergencies in pregnancy
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Operative vs Nonoperative Management of Acute Cholecystitis during the Different Trimesters of Pregnancy
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Risk of Complications After Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Propensity-Matched Analysis
2023, Digestive Diseases and Sciences

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ReviewA review of the management of gallstone disease and its complications in pregnancy

Abstract

Background

Data sources

Results and Conclusions

Section snippets

Literature search

Management of symptomatic cholelithiasis

Comments

Med Clin North Am

Am J Surg

Am J Surg

Am J Surg

Am J Surg

Gastrointest Endosc

Am J Gastroenterol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Am J Surg

Curr Surg

Am J Surg

Pancreatology

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Surg

Am J Obstet Gynecol

Am J Obstet Gynecol

Surgery

J Gastrointest Surg

Management of gallbladder stones during pregnancy: conservative treatment or laparoscopic cholecystectomy?

Hepatogastroenterology

The acute abdomen in the pregnant patientIs there a role for laparoscopy?

Surg Endosc

Laparoscopic cholecystectomy during pregnancy

Surg Rounds

Risk factors for gallstone-related hospitalization during pregnancy and the postpartum

Am J Gastroenterol

Cholecystectomy during pregnancy without fetal loss

Surg Gynecol Obstet

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis

Surg Endosc

Acute cholecystitis–early laparoscopic surgery versus antibiotic therapy and delayed elective cholecystectomy: ACDC-study

Trials

UK guidelines for the management of acute pancreatitis

Gut

Laparoscopy during pregnancy: a literature review

JSLS

Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy

Surg Endosc

Treatment of choledocholithiasis in pregnancy: a case report

Arch Gynecol Obstet

Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction

Surg Laparosc Endosc Percutan Tech

Acute cholecystitis in pregnancy

Obstet Gynecol

Is surgical intervention in acute cholecystitis in pregnancy justified?

J Obstet Gynaecol

Changing management of gallstone disease during pregnancy

Surg Endosc

Biliary stents as temporary treatment for choledocholithiasis in pregnant patients

Gastrointest Endosc

Endoscopic treatment of acute biliary pancreatitis in pregnancy

J Clin Gastroenterol

Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy

Surg Endosc

Safety of therapeutic ERCP in pregnancy–an Indian experience

Indian J Gastroenterol

Review
A review of the management of gallstone disease and its complications in pregnancy