a review of the management of gallstone disease and its

7/24/2019 A Review of the Management of Gallstone Disease and Its

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Review

A review of the management of gallstone disease and its

complications in pregnancy

R.S. Date, M.D., F.R.C.S.a,*, M. Kaushal, F.R.C.S.b, A. Ramesh, F.R.C.S.c

aDepartment of Gastrointestinal Surgery, Lancashire Teaching Hospital NHS Foundation Trust; bDepartment of

Gastrointestinal Surgery, Royal Blackburn Hospital; cDepartment of Gastrointestinal Surgery,

South Manchester University Hospital

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 cho-

lecystitis 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.

2008 Elsevier Inc. All rights reserved.

KEYWORDS:Cholecystectomy;

Cholecystitis;

Endoscopic retrograde

cholangiopancreatography;

Gall bladder;

Pregnancy;

Pancreatitis

The most common abdominal emergencies during preg-

nancy are cholecystitis, acute appendicitis, and intestinal

obstruction.1,2 The incidence of gallstone-related diseases

complicating pregnancy is .05 to .8%36, and management

of these diseases has always been a difficult diagnostic and

therapeutic challenge to surgeons.

The current literature recommends surgical rather than

conservative treatment of acute cholecystitis, within 72

hours of presentation in nonpregnant patients.7,8 The British

Society of Gastroenterology guidelines recommend chole-

cystectomy within 2 weeks of index admission for gallstone

pancreatitis.9 However, the potential risk of fetal death from

both disease and cholecystectomy make these decisions

difficult in pregnant patients.

Other perceived anxieties during pregnancy are risk of ra-

diation to the fetus during endoscopic retrograde cholangio-

pancreatography (ERCP), mechanical and physiologic effectsof laparoscopic cholecystectomy (LC) and the risk of anaes-

thesia, and the effects of magnetic fields on the fetus during

magnetic resonance cholangiopancreatography (MRCP).

Most literature on this subject is in the form of anecdotal

reports. Reviews supporting the feasibility and safety of LC

were published toward the end of the 20th century,10,11 but

they did not provide any firm guidance on the management of

gall bladder disease in general. There have been sporadic

reports of MRCP in pregnancy.12,13 There have not been any

reviews on ERCP or the management of gallstone pancreatitis.

* Corresponding author. Tel.: 011-01257 245 267; fax: 011-01257

245 495.

E-mail address:[email protected]

Manuscript received December 19, 2007; revised manuscript January

19, 2008

0002-9610/$ - see front matter 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.amjsurg.2008.01.015

The American Journal of Surgery (2008) 196, 599608
mailto:[email protected]:[email protected]:[email protected]


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Absence of reliable guidelines on this subject prompted

us to review the literature to find the current best evidence

for the comprehensive management of biliary disease in

pregnant women.

Methods

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

Medline Subject Heading pregnancy was searched. The 2

searches were then combined using the term and (Fig. 1).

Abstracts of the articles found were scrutinized to iden-

tify the original human studies and also to exclude editori-

als, review articles, and letters. The full text of each of the

human studies was obtained and studied. Manual cross-

referencing was then carried out, based on the bibliography

of articles identified in the original searches, to ensure

inclusion of all possible studies. Articles were excluded if

they were duplicate studies on the same patient group.

The literature was considered under the following head-

ings (some overlap is inevitable because of the wide spec-

trum of presentation of gallstones):

1. Management of symptomatic cholelithiasis: surgical ver-

sus conservative management

2. Management of choledocholithiasis: MRCP, ERCP, in-

traoperative cholangiogram (IOC), and common bile

duct (CBD) exploration

3. Management of acute pancreatitis (AP)

4. Surgery for gallstone disease (comparison of open versus

laparoscopic cholecystectomy, LC)

Statistical analyses

Throughout the report, n refers to the number of patients.

Statistical analyses were carried out using the SPSS software

package (version 11.5; SPSS, Chicago IL). Pearsons chi-square test was used to compare proportions in the 2 groups.

Results

Management of symptomatic cholelithiasis

The literature on cholelithiasis and pregnancy is broadly

divided into the prelaparoscopic cholecystectomy era and

Figure 1 Summary of literature search.

600 The American Journal of Surgery, Vol 196, No 4, October 2008


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the post-LC era. The 3 original reports published just before

the laparoscopic era can be considered representative of

practice at the time1416 (Table 1). Two of these case stud-

ies, 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 of pregnancy, or even before the

planned pregnancy, if symptomatic gallstones were diag-nosed in young women. They also recommended a conser-

vative approach during the first and third trimesters of

pregnancy. In contrast, continuation of medical manage-

ment until delivery was recommended in a review of 26

patients by Hiatt et al15 because there was high fetal mor-

tality in the surgical group. The investigators stated, how-

ever, that should surgery become necessary, it should be

done during the second trimester. Another study of 9 pa-

tients published at approximately thesame time reported

high fetal loss (5 of 9 pregnancies).16 These articles high-

light some interesting facts regarding medical practice in

that era. Five of 46 (11%) patients in these 3 studies werefound to have unsuspected pregnancy after undergoing cho-

lecystectomy. Three of 7 patients presenting with biliary

symptoms during the first trimester requested therapeutic

abortion because they had been exposed to radiation during

the investigation.16 Because there were significant changes

in medical practice when these studies were performed and

reports written, the prelaparoscopic literature should be

viewed with caution. The safety of surgical intervention

during the second trimester, however, is reflected even in

the prelaparoscopic literature.

Conservative versus surgical treatment

There were 6 reports of 310 patients comparing conser-

vative with surgical management.2,11,1720(Table 2) All of

the patients were initially treated conservatively. No mater-

nal mortality was reported in either group.

In patients treated conservatively, readmission rate was

38% to 70%.19,20 Swisher et al20 reported an average of 2 to

6 relapses during pregnancy; Elamin et al17 reported an

average of 4 1.3 admissions for relapse; and Lu et al17

reported 1 to 3 additional admissions, each lasting 5 to 8

days.19

Each subsequent relapse was more severe than theprevious one.19

Eighty-three (27%) patients had to undergo surgery due

to the failure of conservative treatment (Table 2). Glasgow

et al reported an increasing trend toward surgical manage-

ment after the introduction of LC.18 In this series, 2 of 15

(13%) patients were offered surgery from 1980 through

1990, compared with 15 of 32 (47%) patients from 1991

through 1996, because conservative treatment failed.

The incidence of preterm deliveries with conservative

management was 8 of 227 (3.5%) patients compared with 5

of 83 (6.0%) patients receiving surgical treatment (P .33).

Similar figures for fetal mortality were 5 of 227 (2.2%) and1 of 83 (1.2%), respectively (P .57).

Tab

le

1

Gallstonediseaseand

pregnanc

yin

theprelaparoscopicera

Inv

estigators

Patients

(totaln)

Conservativemanagement

Surgicalmanagement

Patients(n)

Premature

deliveries(n)

Fetalmortality

(trimester1/2/3)

Patients(n)

Indication

BC/AC/GSP

Tim

eofsurgery

(tr

imesters1

through

3)

Premature

deliveries(n)

Fetalmortality

(trimester1/2/3)

Hia

ttetal.15

26

7

0

0

19

4/5/?

5/2/2*

0

5/1/0

Dix

on

etal.14

44

26

2

5/1/0

18

NA

3/14/1

1

3/0/0

Lan

dersetal.16

30

21

NA

NA

9

NA

4/3/2

2

3/0/1

AC

acutecholecystitis;BC

biliarycolic

;GSP

gallstonepancreatitis.

*Ten

patientswerepostpartum.

601R.S. Date et al. Review of gallstone disease management


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The study by Elamin et al17 stands out from the others

because of the high frequency (.33%) of acute cholecystitis

during pregnancy. This was thought to be caused by the

high prevalence of gallstones, early marriage, and repeat

pregnancies in the community. The investigators also re-

ported a high incidence of preterm delivery (n 9), abor-

tion (n 5), and fetal deaths (n 2) in their study of 49

patients.Apart from this report, there were 2 preterm deliveries

each in the surgical and conservative groups. Both preterm

deliveries in the surgical group appeared to be unrelated to

surgery. One patient had twins who were delivered in week

30 (20 weeks after LC),20 and the other patient delivered in

week 35 (25 weeks after LC).18 The only fetal death apart

from that in Elamins study was reported by Lu et al,19 and

this was not related to gallstone disease.

Management of choledocholithiasis

Ductal stones may pose a risk to both fetus and mother

by causing obstructive jaundice, cholangitis, or pancreatitis.

There is also the risk of exposure to ionizing radiation and

to magnetic fields during ERCP, IOC, and MRCP.

Until recently, ERCP was contraindicated in pregnancy.

It was thought that ionizing radiation would cause birth

defects or even loss of the fetus. Since the early 1990s, there

have been 9 reports on ERCP in pregnancy, all of which

showed that there is no serious harm to mother or fetus

(Table 3). The amount of radiation used during ERCP was

18 to 310 mrad,2123 which is lower than the harmful dose

of 5 to 10 rad, which is the dose at which fetal damage isknown to occur. Radiation risk is greatest during the first

trimester. Some endoscopists have reported undertaking

ERCP without fluoroscopy in pregnant women to minimize

radiation risk.24,25

The other main risk during ERCP is maternal pancreati-

tis. The cumulative incidence of pancreatitis in these studies

was 5 of 104 (4.8%).22,23,2628 All cases of pancreatitis were

mild and self-limiting. Other complications noted were

bleeding (n 2) and pre-eclampsia (n 2).

There were 4 published case reports ofMRCP in preg-

nant women for stones and cancer.12,13,29,30 No maternal or

fetal morbidity or mortality was noted in these reports. IOCwith LC was described in 8 reports.6,19,3136 IOC was used

frequently, along with cholecystectomy, until the early

1990s. However, recent literature recommends the use of

IOC only in the presence of choledocholithiasis and during

exploration of CBD.33 Morrell et al and Cosenza et al

recommended use of a shield to cover the fetus.31,34 Glas-

gow et al18 did not use IOC but described the use of

laparoscopic ultrasound (US) scan in 6 patients to exclude

retained CBD stones.18 From these reports, it is clear that

there was no maternal morbidity or mortality. However, 1

spontaneous abortion was reported.32

Six cases of laparoscopic13,18,3739 and 20 cases ofopen6,19,20,31,40 CBD exploration were described in the

Tab

le

2

Trialofconservativeversussurgicaltreatment

Inv

estigators

Patients

(totaln)

Conservat

ivemanagement

Surgicalmanagement

Patients(

n)

Premature

deliveries(n)

Fetalmortality

(trimester1/2/3)

No.of

patients

Indication

BC/AC/GSP

Timeofsurgery

(trimester1/2/3)

Premature

deliveries(n)

Fetalmortality

(trimester1/2/3)

Gla

sgow

18

47

30

0

0

17

10/6/1

3/13/1a

1

0

Elamin17

49

34

6

0/0/4

15

0/15/0

NA

3

0/0/1

Dar

adkeh2

42

26

0

0

16

13/3/0

2/10/4

0

0

Swisher2

0

72

56

0

0

16

3/4/4b

5/11/0

1

0

Sun

gler11

37

28

0

0

9

5/2/2

0/8/1

0

0

Lu19

63

53

2

0/1/0d

10

NA/NA/2c

0/8/2

0

0

Tot

al

310

227

8

5

83

31/38/9

10/50/8

5

1

aLaparoscopic

3/11/0;open

0/2/1.

bno

dataavailableforindication

in

5

patients.

cindicationsforsurgerywererefractorypain

,deteriorating

clinicalstatus,orpresentati

on

during

thesecond

trimester.

dtwin

pregnancy;death

from

unknown

etiol

ogy.



5/10

literature. There was no maternal or fetal morbidity or

mortality.

Management of gallstone pancreatitisduring pregnancy

AP in pregnancy has attracted attention since the early

part of the 20th century, suggesting a specific association

between the 2 conditions.41

In 1973, Wilkinson42

reviewed98 cases of AP during pregnancy and reported a further 8

new cases. In these 98 cases, maternal outcome was re-

corded in 81 women, of whom 30 (37%) died. This mor-

tality rate is much higher than that associated with pancre-

atitis in the modern era (10%).9 A total of 12 case studies

has been published since then (including this report) report-

ing a total of 212 patients. Forty-one patients had AP during

the postpartum period. Of the remaining 171 patients, 113

had confirmed gallstone-induced AP (Table 4). For the

purpose of this review, we analyzed this group of 113 cases.

Seventy five (66.3%) patients were managed conserva-

tively, and 38 (33.7%) underwent surgery (Table 5). Twopatients underwent drainage of pancreatic abscess, and the

remainder underwent cholecystectomy. The indication for

cholecystectomy was failure to respond to conservative

management or recurrent disease in 21 (55.2%) patients,

and 15 (39.5%) patients underwent planned surgery to pre-

vent recurrence. One patient underwent cholecystectomy

and CBD exploration for a presentation of gallstone pan-

creatitis (GSP) and obstructive jaundice.19 There was no

maternal mortality in either the surgical group or the con-

servatively treated group.

Morbidity in surgical group included prolonged paren-

teral nutrition in 1 patient because of intolerance to oralfluids after LC19 and splenic hematoma in 1 patient, who

was treated conservatively.43 There were 6 premature de-

liveries in these studies, including 3 low birthweight ba-

bies. Overall fetal mortality was 8 (7.07%): 6 in the con-

servatively managed group and 2 in the surgical group (P

.28). Two patients lost fetuses: 1 after LC and the other after

drainage of pancreatic abscess.44

Surgery for gallstone disease

LC.In the early days, pregnancy was considered to be an

absolute contraindication for LC. Subsequently, many case

reports were published testifying to the feasibility and safety

of the procedure during pregnancy. These reports were

reviewed independently by Ghumman et al, Nezhat et al,

and Sungler et al, in the late 1990s.10,11,45 The investigators

concluded that LC was a safe and effective option for

Table 3 ERCP during pregnancy

Investigators

Patients

(n)

ERCP

(n)

ECRP timing

(trimester

1/2/3)

Indication

C/GSP/OJ/other EBS

Maternal

morbidity (n)

Fetal

morbidity (n)

Fetal

mortality

Average

radiation

dose (mrad)

Jamidar28 23 29 15/8/6 0/1/18/4 15# 1 pancreatitis 1^ 2 NAFarca21 10 11 3/5/2 0/2/0/8 1 0 0 0 18

Barthel26

3 3 NA 3 1 pancreatitis 0 0 NASungler11 5 5 0/4/1 0/2/3/0 5 0 0 0Howden63 21 22 5/11/6 0/7/6/8 17 N/A 1^ 0 205Tham23 15 15 1/5/9 0/6/2/7 6# 1 pancreatitis 0 0 310Simmons25 6 6 3/1/2 5/1/0/0 6 0 1 1 0Kahaleh22 17 17 4/9/4 2/10/0/5 17 1 bleeding

1 pancreatitis

2 pre-eclampsia

2^ 0 40

Gupta27 18 18 4/6/8 3/1/0/14 17 1 pancreatitis

1 bleeding

1^ 0 NA

Total 118 126 35/49/38 10/30/29/46 87 6 3

C cholangitis; EBS endoscopic biliary sphincterotomy; OJ obstructive jaundice.

#Biliary stent inserted in 1 patient.

^preterm delivery.

one infant death, 1 abortion, and 2 additional elective abortions.

Table 4 GSP during pregnancy

Investigators AP (total n)AP duringpregnancy (n) GSP (n)

Corlett64 52 43 12Wilkinson42 8 3 1Jouppila65 8 8 5McKay62 20 7 6Block66 21 11 11Ramin67 43 42 28Swisher68 18 18 18Chen43 8 8 5Legro69 9 9 5Cosenza31 9 9 9Lu19 12 12 12Robertson44 4 1 1

Total 212 171 113



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complicated and nonresolving biliary disease during preg-

nancy. In our review, case studies reporting 5 LCs in

pregnancy were excluded to minimize publication bias.

Twenty reports were identified that included a total of

197 patients (Table 6). Two patients requested termination

of pregnancy at the time of surgery,46

and there was onefetal death unrelated to surgery.47 No maternal deaths at-

tributable to LC.

Most investigators used the open technique for inser-

tion of the first port. The Verres needle was used in the

left upper quadrant by Upadhyay et al and by Geisler et

al in 10 and 6 patients, respectively.33,48 Buser49 reported

perforation of the uterus during the third trimester, which

was caused by manipulation of a blunt 10-mm canula

while attempting to insert a telescope. LC was completed,

and the patient subsequently underwent uneventful Ce-

sarean section.

Open cholecystectomy versus LC. Four retrospective re-

ports comparing open cholecystectomy (OC) versus LC

were identified (Table 7). These studies did not show any

significant difference in maternal and fetal outcome. There

were 6 of 89 (6.74%) preterm deliveries in the LC group

compared with 2 of 69 (2.90%) in the open-surgery group

(P .27). One fetal death occurred in the LC group com-

pared with 2 in the open-surgery group (P .41). The fetal

death reported by Cosenza et al occurred on postsurgical

day 6. This woman underwent LC converted to OC for

gallstone-induced pancreatitis in the 14th week of gestation.In a report by Barone et al, a 27-year-old woman died from

postsurgical hemorrhage after undergoing LC in the 20th

week of gestation. The source of bleeding was not identi-

fied. The other fetal death in this series occurred 4 weeks

Table 5 GSP: conservative versus surgical treatment

Cumulative data Conservative Operative P

Patients (total n) 75 38Maternal mortality (n) 0 0Maternal morbidity (n) 1a 1b

Preterm labor (n) 18 2 .01

Fetal morbidity (n) 3

c

0Fetal mortality (n) 6 1 .28

aSplenic hematoma.bprolonged total parenteral nutrition.clow birth weight.

Table 6 LC case series

Investigators Patients (n) IOC

Time of surgery

(trimester 1/2/3)

Indication

BC/AC/CC/GSP

Mean surgical

time (min)

Abdominal

pressure PTD

Fetal

mortality

(trimester

1/2/3)

Maternal

mortality (n)

Morrell34 5 5 0/3/2 0/5/0/0 NA NA 0 0 0McKellar6 9 3 2/4/3 NA NA NA 0 0 0Soper70 5 0/5/0 5/0/0/0 51 12 0 0 0Elerding35 5 5 1/3/1 0/3/2/0 NA 15 0 0 0Lanzafame71 5 0/3/2 3/1/0/1 69 15 0 0 0Steinbrook72 10 3/6/1 0/8/2/0 NA 1215 0 0a 0Reyes-Tineo36 5 1 0/1/0/4 0 0 0Abuabara73 22 2/16/4 0/17/3//0b 59c 1014 1d 0 0Graham46 6 2/4/0 3/3/0/0 15 0 2e 0Geisler48 6 0/4/2 NA NA 15 0 0 0Gouldman74 8 1/7/0 0/2/4/2 59 12 0 0 0Muench75 16 3/11/2 7/3/0/6 67 1215 0 0 0Patel32 10 (2 open) 2 3/6/1 0/0/10/0 NA NA 0 0 0Buser49 10 2/4/4 0/10/0/0 NA NA 1 0 0

Rizzo76 5 2/2/1 2/3/0/0 NA 10 0 0 0Rollins47 31 3/19/9 NA 61.2 13 2 1d 0Daradkeh77 20 4/11/5 0 0 0Halkic78 5 NA 0/5/0/0 75 NA 0 0 0Palanivelu79 9 0/9/0 0/8/0/0f 45.2 NA 0 0 0Upadhyay33 5 1 0/0/5 1/3/0/0g NA 12 0 0 0Total 195 17 28/117/42 21/72/21/13 60.8 1015 4 3 0

PTD preterm delivery.aThree patients were lost to follow-up.btwo patients had choledocholithiasis.cincludes 2 transcystic CBD explorations.dunrelated to gallstones.evoluntary termination.fone patient had empyema.gone patient failed to gain weight.



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after surgery after the mother underwent OC in the 16th

week of gestation.

Laparoscopic surgery was compared with open surgery

in pregnancy in 3 other studies. LC and OC formed the part

of respective cohort, but they were not discussed separately

in these articles.A large population study based on the Swedish Health

Registry evaluated laparoscopic cases (including cholecys-

tectomies) from 2 million deliveries in Sweden during a

2-decade time frame (1973 to 1993).50 They compared 5

fetal outcome parameters in pregnant patients undergoing

laparotomy (n 2,491) with those in pregnant patients

undergoing laparoscopy (n 2,233). They also compared

the same outcome parameters in pregnant women undergo-

ing surgery with the total population. There was no differ-

ence in fetal outcome parameters between the laparoscopy

and laparotomy groups in singleton pregnancies between 4

and 20 weeks of gestation. The study suggested the follow-ing increased risks, relative to the total population, for

infants in both the laparoscopy and laparotomy groups:

weight 2,500 g, delivery at 37 weeks, and having in-

creased incidence of growth restriction. It is not clear

whether this increased risk is related to the disease process

itself or to the surgery. The results of this large study are

limited by the absence of disease-specific subgroup

analysis.

Two further case studies were reported by Amos et al

(n 7 vs 5) and Conron et al (n 2 vs 9) comparing

laparoscopic surgery (cholecystectomy, appendectomy, and

diagnostic laparoscopy) with open surgery.51,52 Data onindividual sugeries are lacking in the report by Conron. In

this study, laparoscopic surgery was performed earlier dur-

ing pregnancy compared with open surgery (12 weeks vs 29

weeks,P .001). There was 1 miscarriage 7 days after LC.

The investigators concluded that laparoscopic surgery does

not show higher fetal loss compared with open surgery.

Contrary to this, Amos et al51 reported 4 fetal deaths oc-

curring after laparoscopic surgery. Four patients in the lapa-

roscopic group in this study were at increased risk of fetal

loss from their diseases (three GSP and 1 perforated appen-

dix). Three of these resulted in fetal death. It is difficult to

say whether the fetal deaths were caused by the diseaseprocess or the surgery.

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 gallbladder 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 conservatively.

Risks of conservative treatment of cholecystitis include

risk to the fetus due to recurrent episodes, other complica-

tions of gallstones, and risk of malnutrition caused by lack

of oral intake. In contrast, surgical treatment carries risk to

the fetus from surgery and anaesthesia and risks specific to

laparoscopic surgery. In our review, it was evident that 27%

of the patients failed to respond to conservative manage-

ment. Although this group of patients should have been

expected to have more severe disease than those who re-

sponded to conservative management, there was no differ-

ence in morbidity and mortality in the 2 groups.

Surgical intervention, if necessary, is best deferred until

the second trimester when fetal risk is at its lowest.54 The

historic reasons for carrying out a surgery at this time

include the fact that organogenesis is complete and the

uterus is not big enough to obliterate the surgical view.

However, equally good results have been noted during other

trimesters as well.

5559

On the basis of 4 retrospective studies comparing LC

with OC, it is difficult to recommend any particular treat-

ment because these studies did not specifically look at the

physiologic effects of pneumoperitoneum or CO2- induced

acidosis on the fetus during LC or the effects of uterine

manipulation during OC.31,40,55,60

LC in pregnant women provides all of the advantages of

laparoscopic surgerysuch as significantly reduced hospital-

ization, decreased narcotic use, and quick return to a regular

dietcompared with open laparotomy in pregnant women.40

Other advantages of LC include less manipulation of the

uterus and detection of other pathology that may bepresent.55 It also decreases the possibility of postoperative

Table 7 LC versus OC

Investigators

LC OC

Patients (n)

EGA at

surgery (wk) PTD

Fetal

death (n)

Conversion from

laparotomy (n)

EGA at

surgery (wk) PTD

Fetal

death (n)

Curet40 12 28 0 0 10 28 0 0

Barone60

20 18.4 1 1 26 24.8 0 1Cosenza31 12 20.5 0 0 20 (2) 21 1 1Affleck55 45 21 6.9 5 0 13 (2) NA 1 0Total 89 6 1 69 2 2

EGA estimated gestational age; NA not available; PTD preterm delivery.



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deep vein thrombosis because improved early mobility can

be promoted in such patients.

Bile duct stones pose diagnostic as well as therapeutic

dilemmas during pregnancy. Diagnostic modalities, such as

ERCP and MRCP, are not without risk. The data showed

that ERCP in pregnancy is reasonably safe if the radiation

dose is kept to a minimum. The incidence of maternal

pancreatitis and other complications occurring after ERCPis low. The literature also suggested that the procedure

should only be performed by an experienced endoscopist,

and the fetus should be shielded at all times.

Even though there is paucity of data on the safety of

MRCP, an inference can be extrapolated from the experi-

ence of MRI during pregnancy. The American College of

Radiologists guidelines recommend cautious use of MRI

during pregnancy when the benefits outweigh the risks.61

With the advent of ERCP and MRCP, the need for IOC

is minimal, although specialized units use it routinely for

demonstrating the anatomy of the biliary tree. There have

been no reports investigating the safety of IOC during

pregnancy. In the absence of clear evidence, potential risks

should be discussed with the patient. Laparoscopic US scan

appears to be an attractive alternative to IOC to detect

retained CBD stones, but experience of this technique is

limited to specialized units.18

There have been few reported cases of CBD exploration

during pregnancy. There was no significant morbidity or

mortality during such, although there could have been pub-

lication bias in reporting. It appears from the available

literature that the management of CBD stones in pregnancy

is similar to that in the nonpregnant population.Pancreatitis during pregnancy was thought to be idio-

pathic in origin, and hyperlipidemia has been widely re-

ported as a cause of AP.41 However, the advent of the US

scanning has confirmed that the majority of cases are caused

by gallstones.62

The initial management of AP during pregnancy during

pregnancy is similar to management in the general popula-

tion. The subsequent management of severe AP is some-

what less controversial because maternal safety is of para-

mount importance, and fetal outcome becomes a secondary

concern. However, controversy exists about the treatment of

mild to moderate pancreatitis during pregnancy regardingearly elective cholecystectomy after index admission (Brit-

ish Society of Gastroenterology guidelines).9 When chole-

cystectomy is deferred until after delivery, nearly 60% of

patients develop recurrence during the same pregnancy,

which significantly increases morbidity, frequency, and

length of hospitalization.20 There is also an increased risk of

fetal loss, although this is not statistically significant. GSP

also increases the risk of prematurity and babies born with

low birth weight.

To summarize:

1. A quarter of pregnant patients with cholecystitis fail torespond to conservative treatment.

2. The results of conservative and surgical management of

cholecystitis are similar in terms of maternal and fetal

morbidity and mortality.

3. Although there is no difference between laparoscopic

cholecystectomy and OC, LC might be the preferred

option because of its inherent advantages.

4. LC appears to be a safe procedure during all trimesters

but is best carried out during the second trimester.5. It may be advisable for women with symptomatic gall-

stones to undergo cholecystectomy before planning

pregnancy.

6. Although generally considered safe, there are no clear

guidelines for the use of MRCP during pregnancy.

7. ERCP is a safe intervention in patients with symptomatic

choledocholithiasis if necessary precautions are taken.

8. LC should be offered to the patients with mild to

moderate GSP according to guidelines for nonpreg-

nant patients.

The following precautions should be exercised duringLC:

1. Use open technique for insertion of the umbilical port.

2. Avoid high intraperitoneal pressures.

3. Use the left lateral position to minimize aortocaval com-

pression.

4. Avoid rapid changes in the position of the patient.

5. Take care to use electrocautery cautiously and away

from uterus.

It must be realized that there are no randomised con-

trolled trials to support the recommendations in this review.

It is unlikely that such trials could be performed in the near

future because of the ethical issues involved. It is also

difficult to accumulate a sufficient number of cases from a

single institution. Under the circumstances, the recommen-

dations must be based on the currently available litera-

ture, and their limitations should be appreciated. It is

worth noting that overall morbidity and mortality is minimal

in the published literature; however, this may be due to

publication bias. We recommend the development of a

central database at the regional or national level to improve

the reporting of cases and to avoid publication bias.

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a review of the management of gallstone disease and its

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