Obstetric Triage Revisited: Update on Non-Obstetric Surgical Conditions in Pregnancy

Gallbladder Disease

Gallbladder-related disease is a common non-obstetric abdominal complaint. Cholelithiasis or presence of calculi/gallstones in the gallbladder or common duct occurs more frequently in pregnant women. Gallstones can present as an obstructive disease or as cholecystitis, which is an inflammation of the gallbladder secondary to gallstone obstruction of the cystic duct.

The gallbladder functions as a storage reservoir for bile produced by the liver. There is a high concentration of bile salts, pigments, and cholesterol within the bile storage pool.^[16] Following the intake of foods high in lipid content, the gallbladder contracts, ejecting the bile salts into the intestine. Within the intestinal tract, bile acid aids the absorption of lipids.

Gallstones and biliary sludge cause the most gallbladder-related pain. Sludge is considered a precursor to the formation and buildup of gallstones, which are formed from crystallization of cholesterol, calcium, or bile salts. Multiparity is considered a risk factor for gallstone development.^[17,18] However, gallstones are also noted to increase with age, and their formation may be mediated by changes in estrogen and progesterone.^[19]

Asymptomatic gallstones are seen in 3.5% to 10% of pregnancies.^[20] The incidence of gallbladder disease in pregnancy is 0.05% to 0.3%.^[13,21] Ultrasound findings of the gallbladder in pregnant women show a decrease in the emptying rate and an increase in residual volume after emptying. Eventually, this can lead to stasis and gallstone formation. An increase in gallbladder motility and the larger amounts of circulating bile salt add to more sluggish gallbladder functioning during pregnancy.

Symptoms of gallbladder disease are colicky or stabbing pain in the right upper quadrant and/or generalized epigastric pain, which can radiate to the right scapula and flank area. Colicky pain often signals a stone obstructing the common bile duct. Murphy's sign, tenderness or pain on deep palpation under the right costal margin during inspiration, may be elicited. Other symptoms include anorexia, nausea, vomiting, dyspepsia, low-grade fever, tachycardia, and fatty food intolerance. Abdominal guarding is not usually seen. Pregnant women usually present with acute epigastric pain. Laboratory testing includes assessing the WBC for elevation and elevated liver function tests, which can signal potential gallbladder and liver disease.

The imaging method of choice in diagnosing gallstones is sonography. Ultrasound is approximately 95% effective in diagnosing gallstones and has no radiation exposure.^[22,23] On ultrasound, gallstones appear as mobile echogenic structures with shadowing (Figure 1). Ultrasound findings indicative of acute cholecystitis are distention of the gallbladder, presence of pericholecystic fluid, and thickening of the gallbladder wall.

Clinical management varies, depending on gestational age and severity of symptoms. Conservative medical management is often the first consideration in the first and third trimesters, although the relapse rate for first trimester is high (Figure 2). Conservative management includes the use of intravenous fluids, correction of electrolyte imbalance, bowel rest, narcotics, antispasmodics, broad spectrum antibiotics, and a fat-restricted diet. Fetal assessment and uterine monitoring are indicated, depending on trimester. Unless symptoms are acute, surgical options are often delayed into the second trimester to avoid the risk of spontaneous abortion in first trimester. Some of this conservative approach during the first trimester is dissipating with improved outcomes from advanced surgical techniques.

Various surgical techniques are now available and include 1) endoscopic retrograde cholangiopancreatography,^[24,25] 2) open cholecystectomy, and 3) laparoscopic cholecystectomy.^[26,27] The choice of technique varies by institution, access, operator availability and skill, severity of symptoms, and gestational age. Most of these surgical procedures are used in patients with acute biliary colic, acute cholecystitis, and those with relapsing symptoms. Swisher et al.^[28] propose that elective second trimester cholecystectomy is safe and minimizes relapse time.

Endoscopic retrograde cholangiopancreatography is a procedure recently used for pregnant women with severe gallbladder symptoms and also for persons with gallstone-related pancreatic symptoms. Endoscopic retrograde cholangiopancreatography is performed by a gastroenterologist. The woman is placed on an x-ray table after sedation, and drugs are administrated to induce duodenal hypotonia (Figure 3). Contrast material is injected under fluoroscopy. In pregnant women, fetal shielding is used, and fluoroscopy time is held to a minimum. Visualization of the common bile duct is seen as well as the whole biliary tract, including the gallbladder. With endoscopic sphincterotomy, an actual incision is made through which removal of stones and the placement of stents can be performed. Small stones can be removed easily or may be pulled out with a balloon catheter or basket. Larger stones will need to be fragmented initially. For persons with gallbladder complaints undergoing endoscopic retrograde cholangiopancreatography, cholecystectomy can be delayed or may be avoided entirely. Laparoscopic cholecystectomy is another surgical option for gallstones. Graham et al.^[27] reviewed the English literature in 1998 and reported on 105 cases of laparoscopic cholecystectomy performed in pregnancy. Ninety of these cases noted gestational age at time of surgery; 12 cases (13%) were performed in the first trimester; 64 cases (71%) in the second trimester, and 14 cases (16%) in the third trimester. There were no spontaneous abortions in the women who underwent surgery during the first trimester. Graham et al. noted one case of fetal demise, 7 weeks after laparoscopic cholecystectomy, and noted that there have been anecdotal reports of stillbirths, correlating with the timing of laparoscopic surgery. They suggest using the Hasson open approach during laparoscopy to prevent inadvertent puncture of the gravid uterus and maintaining pressure between 10 and 12 mmHg. Transvaginal ultrasound for fetal assessment is ideal during laparoscopy. Compared to laparotomy, laparoscopy is associated with a shorter recovery time, less uterine manipulation, and earlier ambulation.

Cosenza et al.^[29] reviewed the surgical management of biliary gallstones in pregnancy. The most common indications were acute cholecystitis (38%), acute gallstone-related pancreatitis (28%), common bile duct stones (19%), and persistent biliary colic (16%). In this study, two women required preoperative endoscopic retrograde cholangiopancreatography and endoscopic stenting. They reported on a total of 32 cholecystectomies, 7 open common bile duct explorations, and 12 laparoscopic cholecystectomies. One spontaneous abortion was noted in the laparoscopy group. One woman in the cholecystectomy group had a preterm delivery. Monitoring for preterm labor is critical although laparoscopy has been noted to have a lower incidence of preterm labor than the incidence noted in women who undergo laparotomy.

Key Points in Triage for Gallbladder Disorders

 

• The risk of gallstones increases with number of pregnancies and with age.

• Elevated liver function tests can signal gallbladder disease.

• Ultrasound is the imaging method of choice for diagnosis.

• Surgical and gastrointestinal consultation should be readily available if a diagnosis of gallbladder disease is made.

• Surgical and interventional techniques are changing the management of disease during pregnancy.

 

J Midwifery Womens Health. 2003;48(2) © 2003  Elsevier Science, Inc.

Cite this: Obstetric Triage Revisited: Update on Non-Obstetric Surgical Conditions in Pregnancy - Medscape - Apr 01, 2003.