The American Journal of Surgery (2008) 196, 599 608

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
a

Department of Gastrointestinal Surgery, Lancashire Teaching Hospital NHS Foundation Trust; bDepartment of
Gastrointestinal Surgery, Royal Blackburn Hospital; cDepartment of Gastrointestinal Surgery,
South Manchester University Hospital
KEYWORDS:
Cholecystectomy;
Cholecystitis;
Endoscopic retrograde
cholangiopancreatography;
Gall bladder;
Pregnancy;
Pancreatitis

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.
2008 Elsevier Inc. All rights reserved.

The most common abdominal emergencies during pregnancy are cholecystitis, acute appendicitis, and intestinal
obstruction.1,2 The incidence of gallstone-related diseases
complicating pregnancy is .05 to .8%3 6, 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 cholecystectomy within 2 weeks of index admission for gallstone
* Corresponding author. Tel.: 011-01257 245 267; fax: 011-01257
245 495.
E-mail address: ravidate@hotmail.com
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

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 radiation to the fetus during endoscopic retrograde cholangiopancreatography (ERCP), mechanical and physiologic effects
of laparoscopic cholecystectomy (LC) and the risk of anaesthesia, 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.

600

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

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 identify the original human studies and also to exclude editorials, review articles, and letters. The full text of each of the
human studies was obtained and studied. Manual crossreferencing was then carried out, based on the bibliography
of articles identified in the original searches, to ensure

Figure 1

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 headings (some overlap is inevitable because of the wide spectrum of presentation of gallstones):
1. Management of symptomatic cholelithiasis: surgical versus conservative management
2. Management of choledocholithiasis: MRCP, ERCP, intraoperative 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 chisquare 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

Summary of literature search.

601

0
1
2
5/2/2*
3/14/1
4/3/2
4/5/?
NA
NA
AC acute cholecystitis; BC biliary colic; GSP gallstone pancreatitis.
*Ten patients were postpartum.

19
18
9
0
5/1/0
NA
0
2
NA
26
44
30

7
26
21

Indication
BC/AC/GSP
Patients (n)

Hiatt et al.15
Dixon et al.14
Landers et al.16

Conservative management

Patients (n)
Patients
(total n)

Table 1

There were 6 reports of 310 patients comparing conservative with surgical management.2,11,1720(Table 2) All of
the patients were initially treated conservatively. No maternal 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 the
previous 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 management 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%) and
1 of 83 (1.2%), respectively (P .57).

Gallstone disease and pregnancy in the prelaparoscopic era

Conservative versus surgical treatment

Premature
deliveries (n)

Fetal mortality
(trimester 1/2/3)

Surgical management

Time of surgery
(trimesters 1 through 3)

Premature
deliveries (n)

Fetal mortality
(trimester 1/2/3)

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

the laparoscopic era can be considered representative of
practice at the time14 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 of pregnancy, or even before the
planned pregnancy, if symptomatic gallstones were diagnosed in young women. They also recommended a conservative approach during the first and third trimesters of
pregnancy. In contrast, continuation of medical management until delivery was recommended in a review of 26
patients by Hiatt et al15 because there was high fetal mortality in the surgical group. The investigators stated, however, that should surgery become necessary, it should be
done during the second trimester. Another study of 9 patients published at approximately the same time reported
high fetal loss (5 of 9 pregnancies).16 These articles highlight some interesting facts regarding medical practice in
that era. Five of 46 (11%) patients in these 3 studies were
found to have unsuspected pregnancy after undergoing cholecystectomy. 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.

5/1/0
3/0/0
3/0/1

Review of gallstone disease management

Investigators

R.S. Date et al.

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

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 reported a high incidence of preterm delivery (n 9), abortion (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.

0
0/0/1
0
0
0
0
1
b

Laparoscopic 3/11/0; open 0/2/1.

no data available for indication in 5 patients.
c
indications for surgery were refractory pain, deteriorating clinical status, or presentation during the second trimester.
d
twin pregnancy; death from unknown etiology.

Management of choledocholithiasis

1
3
0
1
0
0
5
3/13/1a
NA
2/10/4
5/11/0
0/8/1
0/8/2
10/50/8
47
49
42
72
37
63
310
Glasgow18
Elamin17
Daradkeh2
Swisher20
Sungler11
Lu19
Total

30
34
26
56
28
53
227

0
6
0
0
0
2
8

0
0/0/4
0
0
0
0/1/0d
5

17
15
16
16
9
10
83

10/6/1
0/15/0
13/3/0
3/4/4b
5/2/2
NA/NA/2c
31/38/9

Premature
deliveries (n)
Time of surgery
(trimester 1/2/3)
Indication
BC/AC/GSP
No. of
patients
Premature
deliveries (n)

Conservative management

Patients (n)
Patients
(total n)
Investigators

Table 2

Trial of conservative versus surgical treatment

Fetal mortality
(trimester 1/2/3)

Surgical management

Fetal mortality
(trimester 1/2/3)

602

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 is
known 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 pancreatitis. The cumulative incidence of pancreatitis in these studies
was 5 of 104 (4.8%).22,23,26 28 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 of MRCP in pregnant women for stones and cancer.12,13,29,30 No maternal or
fetal morbidity or mortality was noted in these reports. IOC
with 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 Glasgow 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 of
open6,19,20,31,40 CBD exploration were described in the

R.S. Date et al.

Table 3

Review of gallstone disease management

603

ERCP during pregnancy

Investigators
28

Patients
(n)

ERCP
(n)

ECRP timing
(trimester
1/2/3)

Indication
C/GSP/OJ/other

EBS

Jamidar
Farca21
Barthel26
Sungler11
Howden63
Tham23
Simmons25
Kahaleh22

23
10
3
5
21
15
6
17

29
11
3
5
22
15
6
17

15/8/6
3/5/2
NA
0/4/1
5/11/6
1/5/9
3/1/2
4/9/4

0/2/3/0
0/7/6/8
0/6/2/7
5/1/0/0
2/10/0/5

15#
1
3
5
17
6#
6
17

Gupta27

18

18

4/6/8

3/1/0/14

17

118

126

35/49/38

10/30/29/46

87

Total

0/1/18/4
0/2/0/8

Average
radiation
dose (mrad)

Maternal
morbidity (n)

Fetal
morbidity (n)

Fetal
mortality

1 pancreatitis
0
1 pancreatitis
0
N/A
1 pancreatitis
0
1 bleeding
1 pancreatitis
2 pre-eclampsia
1 pancreatitis
1 bleeding

1^
0
0
0
1^
0
1
2^

2
0
0
0
0
0
1
0

NA
18
NA

1^

NA

205
310
0
40

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.

literature. There was no maternal or fetal morbidity or

mortality.

Management of gallstone pancreatitis

during 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 reviewed
98 cases of AP during pregnancy and reported a further 8
new cases. In these 98 cases, maternal outcome was recorded in 81 women, of whom 30 (37%) died. This mortality rate is much higher than that associated with pancreatitis in the modern era (10%).9 A total of 12 case studies
has been published since then (including this report) reporting 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 conservatively, and 38 (33.7%) underwent surgery (Table 5). Two
patients 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 prevent recurrence. One patient underwent cholecystectomy
and CBD exploration for a presentation of gallstone pancreatitis (GSP) and obstructive jaundice.19 There was no
maternal mortality in either the surgical group or the conservatively treated group.
Morbidity in surgical group included prolonged parenteral nutrition in 1 patient because of intolerance to oral
fluids after LC19 and splenic hematoma in 1 patient, who

was treated conservatively.43 There were 6 premature deliveries in these studies, including 3 low birthweight babies. Overall fetal mortality was 8 (7.07%): 6 in the conservatively 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 4

GSP during pregnancy

Investigators
64

Corlett
Wilkinson42
Jouppila65
McKay62
Block66
Ramin67
Swisher68
Chen43
Legro69
Cosenza31
Lu19
Robertson44
Total

AP (total n)

AP during
pregnancy (n)

GSP (n)

52
8
8
20
21
43
18
8
9
9
12
4
212

43
3
8
7
11
42
18
8
9
9
12
1
171

12
1
5
6
11
28
18
5
5
9
12
1
113

604

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

Table 5

GSP: conservative versus surgical treatment

Cumulative data

Conservative

Operative

Patients (total n)
Maternal mortality (n)
Maternal morbidity (n)
Preterm labor (n)
Fetal morbidity (n)
Fetal mortality (n)

75
0
1a
18
3c
6

38
0
1b
2
0
1

.01
.28

Splenic hematoma.
b
prolonged total parenteral nutrition.
c
low birth weight.

complicated and nonresolving biliary disease during pregnancy. 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 one
fetal death unrelated to surgery.47 No maternal deaths attributable to LC.
Most investigators used the open technique for insertion of the first port. The Verres needle was used in the

Table 6

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 Cesarean section.
Open cholecystectomy versus LC. Four retrospective reports 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 compared 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 identified. The other fetal death in this series occurred 4 weeks

LC case series

Investigators

Patients (n)

IOC

Morrell34
McKellar6
Soper70
Elerding35
Lanzafame71
Steinbrook72
Reyes-Tineo36
Abuabara73
Graham46
Geisler48
Gouldman74
Muench75
Patel32
Buser49
Rizzo76
Rollins47
Daradkeh77
Halkic78
Palanivelu79
Upadhyay33
Total

5
9
5
5
5
10
5
22
6
6
8
16
10 (2 open)
10
5
31
20
5
9
5
195

5
3
5

Time of surgery
(trimester 1/2/3)
0/3/2
2/4/3
0/5/0
1/3/1
0/3/2
3/6/1

1
17

2/16/4
2/4/0
0/4/2
1/7/0
3/11/2
3/6/1
2/4/4
2/2/1
3/19/9
4/11/5
NA
0/9/0
0/0/5
28/117/42

PTD preterm delivery.

a
Three patients were lost to follow-up.
b
two patients had choledocholithiasis.
c
includes 2 transcystic CBD explorations.
d
unrelated to gallstones.
e
voluntary termination.
f
one patient had empyema.
g
one patient failed to gain weight.

Indication
BC/AC/CC/GSP

Mean surgical
time (min)

Abdominal
pressure

0/5/0/0
NA
5/0/0/0
0/3/2/0
3/1/0/1
0/8/2/0
0/1/0/4
0/17/3//0b
3/3/0/0
NA
0/2/4/2
7/3/0/6
0/0/10/0
0/10/0/0
2/3/0/0
NA

NA
NA
51
NA
69
NA

NA
NA
12
15
15
1215

59c
NA
59
67
NA
NA
NA
61.2

1014
15
15
12
1215
NA
NA
10
13

75
45.2
NA
60.8

NA
NA
12
1015

0/5/0/0
0/8/0/0f
1/3/0/0g
21/72/21/13

PTD

Fetal
mortality
(trimester
1/2/3)

Maternal
mortality (n)

0
0
0
0
0
0
0
1d
0
0
0
0
0
1
0
2
0
0
0
0
4

0
0
0
0
0
0a
0
0
2e
0
0
0
0
0
0
1d
0
0
0
0
3

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

R.S. Date et al.

Table 7

Review of gallstone disease management

605

LC versus OC
LC

Investigators

Patients (n)

Curet40
Barone60
Cosenza31
Affleck55
Total

12
20
12
45
89

OC
EGA at
surgery (wk)
28
18.4
20.5
21 6.9

PTD

Fetal
death (n)

Conversion from
laparotomy (n)

EGA at
surgery (wk)

0
1
0
5
6

0
1
0
0
1

10
26
20 (2)
13 (2)
69

28
24.8
21
NA

PTD

Fetal
death (n)

0
0
1
1
2

0
1
1
0
2

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

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 cholecystectomies) 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 undergoing surgery with the total population. There was no difference in fetal outcome parameters between the laparoscopy
and laparotomy groups in singleton pregnancies between 4
and 20 weeks of gestation. The study suggested the following 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 increased 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 on
individual sugeries are lacking in the report by Conron. In
this study, laparoscopic surgery was performed earlier during 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 occurring after laparoscopic surgery. Four patients in the laparoscopic group in this study were at increased risk of fetal
loss from their diseases (three GSP and 1 perforated appendix). Three of these resulted in fetal death. It is difficult to
say whether the fetal deaths were caused by the disease
process 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 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 conservatively.
Risks of conservative treatment of cholecystitis include
risk to the fetus due to recurrent episodes, other complications 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 management. Although this group of patients should have been
expected to have more severe disease than those who responded to conservative management, there was no difference 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 treatment 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 hospitalization, decreased narcotic use, and quick return to a regular
diet compared with open laparotomy in pregnant women.40
Other advantages of LC include less manipulation of the
uterus and detection of other pathology that may be
present.55 It also decreases the possibility of postoperative

606
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 ERCP
is 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 experience 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 publication 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 idiopathic in origin, and hyperlipidemia has been widely reported 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 population. The subsequent management of severe AP is somewhat less controversial because maternal safety is of paramount importance, and fetal outcome becomes a secondary
concern. However, controversy exists about the treatment of
mild to moderate pancreatitis during pregnancy regarding
early elective cholecystectomy after index admission (British Society of Gastroenterology guidelines).9 When cholecystectomy 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 to
respond to conservative treatment.

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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 gallstones 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 nonpregnant patients.
The following precautions should be exercised during
LC:
1. Use open technique for insertion of the umbilical port.
2. Avoid high intraperitoneal pressures.
3. Use the left lateral position to minimize aortocaval compression.
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 controlled 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 recommendations must be based on the currently available literature, 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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