Gallstones & Pregnancy

Unfortunately, there are times when women develop symptoms from gallstones during pregnancy.

These acute symptoms can range from mild to severe and may require hospitalization.

A mild attack of gallstones which resolves spontaneously is called biliary colic.  When a stone becomes lodged in the cystic duct, this causes more severe pain, which usually does not resolve.  It may be associated with an infection as well.  This is called acute cholecystitis.

Gallstones can also migrate out of the gallbladder and into this common duct and get lodged in the common duct.  This causes jaundice or yellowing of the skin.  Stones can actually pass further down and irritate the pancreas and cause pancreatitis.

So gallbladder symptoms can be mild to severe. We also know that once people start to develop symptoms from their gallstones, recurrent symptoms do tend to increase in frequency as well as in severity.

Once an attack has occurred and then resolved, there is no way to predict how severe or when another attack will occur.

Therefore, once people develop symptoms from their gallstones, surgery is recommended.  There really is no other treatment option.

However, the timing of surgery is a different story.  The easy answer is to remove the gallbladder as soon as possible after an initial attack.  If the patient is hospitalized for their symptoms, the gallbladder can be removed during that hospitalization. 

If a patient develops biliary colic, a common bile duct stone or pancreatitis, the symptoms will generally resolve and then the timing of surgery is dependent on multiple factors.  The most important factor is patient choice.  Many patients will choose to have the surgery as soon as possible or during the initial hospitalization.  However, due to multiple factors, patients may want to delay surgery. 

Patients may have important events in their lives and want to delay surgery until after that event and thus postpone surgery.

The longer surgery is delayed, the more chances increase of having another attack while waiting for surgery.  There is no predictive tool to predict when it another gallbladder attack may occur.

These principles can be applied to the pregnant patient. In the past, we would delay surgery until after the pregnancy. 

However, we now know a pregnant patient who experiences a gallbladder attack in the first trimester, has a 92% chance of having recurrent attacks, and a pregnant patient in the second trimester, has a 64% chance of having recurrent attacks.

So, a pregnant patient who does not undergo gallbladder removal, has a high probability of recurrent attacks, recurrent ER visits, and recurrent hospitalizations.  Further, while initial attacks may be mild, future attacks may be more severe and complicated.

Therefore, the current recommendation is to remove the gallbladder during the index attack in the first or second trimester.  There are NO studies showing fetal demise with laparoscopic surgery during the first and second trimesters.  Thus, it is a very safe procedure. 

If gallbladder symptoms are mild, there is no increased rate of spontaneous abortion or preterm labor comparing surgery to nonoperative management, such as waiting till after pregnancy to have your gallbladder removed.  However, there is a high spontaneous abortion rate and preterm labor late with complicated gallstone attacks.

Further, if the pregnant patient chooses NOT to remove the gallbladder during pregnancy, there is really not a great time after pregnancy.  The patient will have a newborn and will, in my experience, have difficulty finding  the time to have surgery in that year first year after pregnancy.  The patient will be dealing with a newborn and will not really have the time to have surgery and recover from the surgery without needing additional help.  That can be an issue for many.  

Also, the chances of having another attack and that year, when waiting when waiting to find the time to have surgery, is high as well.  Thus, a patient may wind up having a non-elective gallbladder removal (i.e. an emergency)  in the first year after pregnancy because symptoms are too debilitating. 

Thus, the recommendation are to remove the gallbladder in the first or second trimester during pregnancy once an attack