For these reasons, operative and endoscopic interventions are increasingly favored over conservative measures. Othman and coworkers (2012) showed that women managed conservatively had more pain, more recurrent visits to the emergency department, more hospitalizations, and a higher rate of cesarean delivery. Dhupar and associates (2010) reported more complications with conservative management of gallbladder disease compared with laparoscopic cholecystectomy in pregnancy. hese included multiple admissions, prolonged total parenteral nutrition, and unplanned labor induction for worsening gallbladder symptoms. Cholecystectomy was performed safely in all trimesters. Only one of 19 patients who underwent laparoscopic cholecystectomy had a complication, which did not require further surgery. A metaanalysis found that cholecystectomy does not increase the risk of preterm labor or of maternal or fetal mortality (Athwal, 2016). Management at Parkland Hospital has evolved to a more aggressive surgical approach, especially if there is concomitant biliary pancreatitis as subsequently discussed. During the past two decades, laparoscopic cholecystectomy has evolved as the favored surgical approach and is discussed in Chapter 46 (p. 901).
Relief from symptomatic biliary duct gallstones during pregnancy has been greatly aided by use of endoscopic retrograde cholangiopancreatography (ERCP) (Fogel, 2014; Menees, 2006). he procedure is performed if common duct obstruction is suspected or proven. Approximately 10 percent of patients with symptomatic stone disease have common duct stones (Stinton, 2012). ERCP can be modiied in many cases so that radiation exposure from luoroscopy is avoided (Sethi, 2015).
Tang and associates (2009) reported results from 68 ERCP procedures performed in 65 pregnant women at Parkland Hospital. ll but two women had gallstones, and sphincterotomy was performed in all but one woman. Common duct stones were identified in half of these 65 women, and in all but one, the stones were successfully removed. A biliary stent was placed in 22 percent of cases and removed after delivery. Complications were minimal, and post-ERCP pancreatitis developed in 16 percent. Pregnancy outcomes were not diferent than for the general obstetrical population. As a less invasive approach, 1R cholangiopancreatography (MRCP) has been reported to have utility in pregnancy in small, retrospective case series. Wu and colleagues (2014) caution against its use in pregnancy, particularly for seriously ill women. Also, MRCP is not readily available, and this may lead to delayed deinitive management.
Ascending cholangitis can complicate acute biliary obstruction. Nearly 70 percent of afected patients develop Charcot triad-jaundice, abdominal pain, and fever. The diagnosis is aided by sonography, and treatment is broad-spectrum antibiotics and biliary drainage by ERCP (Greenberger, 2015).
Acute pancreatic inlammation is triggered by factors that cause activation of pancreatic trypsinogen followed by autodigestion. It is characterized by cell-membrane disruption and proteolysis, edema, hemorrhage, and necrosis (Conwell, 2015; Fogel, 2014). Up to 10 percent of women develop necrotizing pancreatitis, which carries a mortality risk of 15 percent. This rate rises if infection develops (Cain, 2015).