25 April 2024
Dr. Rohit Kumar
Medical Director & Specialist General Surgeon
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Introduction:
The case is all about managing a pregnant female with gallbladder and common bile duct stones during her pregnancy. It emphasizes upon prompt decision making as well as safety and efficacy of anesthesia and surgical intervention during second and third trimester of pregnancy taking into consideration the symptoms of biliary colic. It is not always that the conservative management will work for all cases of biliary colic during pregnancy and our patient in this discussion is the live example for the same.
Patient Background:
A 25 years old female who is 28 weeks pregnant presents with acute abdominal pain more in upper abdomen with nausea and three to four episodes of Vomitings. She was being worked up in emergency where an obstetrician Dr. Pranjali first attended followed by gastroenterologist Dr. Irfan, where she gets diagnosed with a biliary colic after getting an ultrasound done. She has had deranged liver function tests where the total and direct bilirubin were high. She has had mild icterus as well. Hence she underwent MRCP where it was found that she has stones in her common bile duct which needed to be addressed on urgent basis.
Diagnosis:
She underwent a thorough work up with basic investigations including ultrasound and blood tests involving complete blood count, c reactive protein, liver and kidney function tests and serum amylase lipase. Gynecologists opinion was foremost and when MRCP showed stones in common bile duct along with gall bladder stones .Anesthetist opinion was taken as well.
Treatment:
She underwent Endoscopic retrograde cholangiopancreatography where stones were retrieved and biliary stent was placed on 20/2/2024 under the gastroenterologist Dr. Irfan and general surgeon Dr. Rohit reviewed her for an elective gall bladder surgery.
Following two weeks of ERCP patient developed severe abdominal pain along with vomiting for which she visited emergency department at International Modern Hospital and was reviewed by gastroenterologist Dr. Irfan and general surgeon Dr. Rohit Kumar and repeat blood tests were performed along with Serum amylase and lipase. She gave a history of having a constant discomfort in upper abdomen with being nauseous. Repeat ultrasound showed gallbladder stones with signs of inflammation including wall thickening hence she was admitted and after informed written consent, after obstetric clearance she underwent emergency uneventful laparoscopic Cholecystectomy for acute cholecystitis on 15/3/2024.
Post Operative Progress:
Patient was observed in hospital for one night post laparoscopic cholecystectomy where the obstetrician observed the patient along with the general surgeon. The mother and the fetus both were doing fine post surgery. Patient recovered completely from biliary colic and post operative pain management was done adequately following which patient felt comfortable and was discharged home next day.
Discussion:
Laparoscopic or key hole surgery is safe during any trimester of pregnancy. There has been no report of fetal demise during or post procedure for the same. If the patient is comfortable managing minor attacks of biliary colic without any complications including Choledocholithiasis, pancreatitis should be managed conservatively till the time of delivery. However with repeated attacks surgery is recommended by most of the doctors. Olden times gallbladder surgery was a consideration during the first and second trimester however now it has been recommended that the same can be performed during the third trimester of pregnancy safely as well.
Investigating Abdominal Pain During Pregnancy:
Obstetrician evaluates the first any abdominal pain during pregnancy. They perform routine pelvic and abdominal scans along with CTG for fetal status. Once the obstetric reason for pain is sorted out, evaluation for abdominal organs is important consideration. Common reasons are renal, appendicitis and gallbladder stones and as discussed gallbladder surgery is being recommended for recurrent abdominal pain related to gallbladder stones. Routine intraoperative fetal monitoring is recommended during any general anesthesia procedure for a pregnant female and specially a laparoscopic procedure. The penumoperitoneum created during the laparoscopic procedure changes the fetomaternal dynamics. Times have changed and so has been the development in anesthesia as well as the surgical technique. Hence laparoscopic cholecystectomy during pregnancy is safe in expert hands.
Conclusion:
Laparoscopic cholecystectomy is one of the safest procedure being performed for pregnant females along with intra operative fetal monitoring. ERCP becomes life saving procedure in situation like ours where icterus was seem along with biliary colic.