Know the Best Treatment of Gallbladder Stones during Pregnancy
What is the relation of Pregnancy & Gallbladder stone?
· Women at all ages are twice as likely as men to form cholesterol gallstones. This gender difference is seen in the fertile age of females that means it begins since puberty and continues through the childbearing years.
· Parity and length of the fertility period increase the incidence of gallstones, as well as both the frequency and number of pregnancy, which are important risk factors for gallstone formation (1).
o A study in Chile reported that the incidence of gallstones was 12.2% of multiparous women (who have more than 2 children) compared to 1.3% of nulliparous women (who is going to have a first child with current pregnancy) within the same age(2).
o Another study has reported that women under the age of 25 years with >4 pregnancies were 4 to 12 times more likely to develop cholesterol gallstones compared to nulliparous women of the same age and body weight.
· The incidence rates of biliary sludge and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum in the USA & UK(3,4).
· Most women remain asymptomatic, only 1–3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. At least 40,000 young, healthy women require postpartum cholecystectomy each year in the USA. Thus, pregnancy-associated gallbladder disease is a significant cause of a health concern in young healthy women.
· The gallbladder disease is the most common non-obstetrical cause of maternal hospitalization in the first year postpartum with 30% attacks of biliary colic in women with gallstones (5,6).
· Following acute appendicitis, acute cholecystitis is the second most common indication for non-obstetric-surgery in pregnant women.
· Moreover, biliary sludge and gallstones can spontaneously disappear after delivery (parturition) in approximately 60% of cases, mostly due to a sharp decline in estrogen levels (3).
How & Why Stone Develops in Pregnancy?
· Pregnancy itself is a risk factor for the development of gallstones in females due to hormonal changes that occur during pregnancy put women at even higher risk of gallstone formation.
o The cholesterol concentrations in gall-bladder bile increase gradually from the first to the third trimester of pregnancy that correlates with a progressive increase in the incidence of biliary sludge (a pre-cursor to gallstones) and gallstones.
· Female sex hormones play a key role in the formation of gallstones in females. The risk of developing cholesterol gallstones is markedly increased by oral contraceptive steroids and conjugated estrogens in taken during the pre-menopause period for family planning and hormone supplementation given during the post-menopause period to women.
o High levels of female sex hormone (progesterone) impair gallbladder motility function by relaxing the gallbladder smooth muscle, thus leading to gallbladder stasis. The stagnant gallbladder greatly promotes the formation of biliary sludge and gallstones in pregnant women.
What are the Symptoms of Gallbladder Stones?
· The most common clinical presentations are biliary colic, acute cholecystitis, gallstone pancreatitis, and jaundice
· Difference between true biliary colic and dyspepsia is important not only for diagnosis but also for treatment as biliary colic is cured with surgery.
How to Know That I am Having Stones during Pregnancy?
· Because biliary sludge is often diagnosed incidentally by antenatal ultrasonography done for a routine check-up.
· Real-time ultrasonography (USG) is the first choice of investigation in pregnancy as it is most sensitive to diagnose gallstones as small as 2mm. This technique is rapid and does not involve ionizing radiation so it’s safe.
· For a pregnant woman with clinically suspected to have biliary sludge and/or gallstones who have a negative result from USG, endoscopy can be indicated to collect gallbladder bile from duodenum for polarizing light microscopy test. This time endoscopy can look to evidence of gastritis or reflux disease.
What Is the Treatment of Gallbladder Stones during Pregnancy?
· For management purposes, biliary sludge and gallstones should be considered similar in almost all respects.
· In asymptomatic pregnant women with biliary sludge and gallstones, wait & watch (expectant management) is the general rule, and stone dissolving therapy (lipolysis) is not indicated.
· In a pregnant woman presenting with abdominal pain, true biliary colic should be distinguished from nonspecific abdominal discomfort. When surgery is performed for true biliary colic is usually curative.
· Supportive management is highly recommended if possible, reserving definitive treatment (surgery) after delivery. Women with uncomplicated biliary colic can be managed with intravenous hydration and narcotic pain control. Nevertheless, women who receive supportive treatment are prone to symptomatic relapses, which might increase the likelihood of premature delivery.
· In principle, stone dissolving therapy (oral lipolysis) is contraindicated in pregnancy. A major limitation of oral lipolysis, however, is the high recurrence rate of gallstones (10% per year and up to 45–50% by 5 years) (7).
· Surgery generally is reserved for pregnant women with recurrent or unrelenting biliary pain refractory to medical management or with complications related to gallstones, including obstructive jaundice, acute cholecystitis, gallstone pancreatitis, or suspected peritonitis.
· However, if a pregnant woman is under a poor health condition for surgery, percutaneous cholecystostomy with drainage should be considered. The efficacy of percutaneous cholecystostomy with drainage in the treatment of biliary sludge has not been well established (8).
When I can plan Surgery during my Pregnancy?
· Laparoscopic surgery is the preferred approach of surgery because of its relative safety during pregnancy. Elective laparoscopic cholecystectomy is relatively safe and is the first-line option,
· Surgery is recommended after the second trimester to reduce the rates of spontaneous abortion and preterm labor.
· The effect of laparoscopic surgery on a developing fetus in the first trimester is unknown and surgery is more difficult in the third trimester with uterine enlargement. The second trimester, therefore, is believed to be the optimal time for cholecystectomy.
· The risks of preterm labor or premature delivery in each trimester of pregnancy, however, are not clearly defined in the literature. If acute cholecystitis or cholangitis develops, earlier cholecystectomy should be considered.
Prevention
· Thus, asymptomatic pregnant women with biliary sludge should undergo careful follow-up and manage expectantly.
Resources:
1. Barbara L, Sama C, Morselli Labate AM, Taroni F, Rusticali AG, Festi D, Sapio C, et al. A population study on the prevalence of gallstone disease: the Sirmione Study. Hepatology 1987; 7: 913–7.
2. Neil Bajwa RB, Ambrish Ghumman, Agrawal R. M. The Gallstone Story: Pathogenesis and Epidemiology. Practical gastroenterology 2010; XXXIV
3. Maringhini A, Ciambra M, Baccelliere P, Raimondo M, Orlando A, Tine F, Grasso R, et al. Biliary sludge and gallstones in pregnancy: incidence, risk factors, and natural history. Ann Intern Med 1993; 119: 116–20
4. Bolukbas FF, Bolukbas C, Horoz M, Ince AT, Uzunkoy A, Ozturk A, Aka N, et al. Risk factors associated with gallstone and biliary sludge formation during pregnancy. J Gastroenterol Hepatol 2006; 21: 1150–3
5. Ko CW. Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol 2006; 101: 2263–8.
6. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR. Association between method of delivery and maternal rehospitalization. JAMA 2000; 283: 2411–6.
7. Lu EJ, Curet MJ, El-Sayed YY, Kirkwood KS. Medical versus surgical management of biliary tract disease in pregnancy. Am J Surg 2004; 188: 755–9.
8. Shiffman ML, Kaplan GD, Brinkman-Kaplan V, Vickers FF. Prophylaxis against gallstone formation with ursodeoxycholic acid in patients participating in a very-low-calorie diet program. Ann Intern Med 1995; 122: 899–905.
