A 32-year-old primigravid woman at 36 weeks gestation comes to the office for consultation regarding abnormal test results. The tests were part of an evaluation for an episode of burning epigastric pain that radiated to the chest and has since resolved without treatment. The patient has fatigue and malaise but attributes these symptoms to pregnancy. She has no chronic medical conditions and has had no surgeries. The patient takes a prenatal vitamin daily and acetaminophen as needed for lower back pain. She does not use tobacco, alcohol, or illicit drugs. The patient's father died of alcoholic cirrhosis, and her mother underwent a cholecystectomy for gallstone cholecystitis.
Blood pressure is 120/70 mm Hg and pulse is 82/min. Examination reveals a nontender gravid uterus appropriate for gestational age and 1+ bilateral pedal edema. The remainder of the physical examination is unremarkable.
Laboratory results are as follows:
Abdominal ultrasound shows normal liver echogenicity, a liver span of 12 cm, a normal-sized spleen, a gallbladder with multiple stones, and a common bile duct size of 4 mm. There is no pericholecystic fluid.
Which of the following is the best next step in management of this patient?

Question

A 32-year-old primigravid woman at 36 weeks gestation comes to the office for consultation regarding abnormal test results.  The tests were part of an evaluation for an episode of burning epigastric pain that radiated to the chest and has since resolved without treatment.  The patient has fatigue and malaise but attributes these symptoms to pregnancy.  She has no chronic medical conditions and has had no surgeries.  The patient takes a prenatal vitamin daily and acetaminophen as needed for lower back pain.  She does not use tobacco, alcohol, or illicit drugs.  The patient's father died of alcoholic cirrhosis, and her mother underwent a cholecystectomy for gallstone cholecystitis.
Blood pressure is 120/70 mm Hg and pulse is 82/min.  Examination reveals a nontender gravid uterus appropriate for gestational age and 1+ bilateral pedal edema.  The remainder of the physical examination is unremarkable.
Laboratory results are as follows:
 Abdominal ultrasound shows normal liver echogenicity, a liver span of 12 cm, a normal-sized spleen, a gallbladder with multiple stones, and a common bile duct size of 4 mm.  There is no pericholecystic fluid.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98a1_a273_853d_a9765214c048_MD0002_00 Maternal physiologic changes in pregnancy begin at 4 weeks gestation, and by the third trimester, significant laboratory abnormalities are expected. Common findings include mild anemia (due to expansion of plasma volume), mild leukocytosis (due to increased neutrophil demargination), and elevated acute phase reactants (due to stimulation of liver synthetic function by estrogen and progesterone). In addition, alkaline phosphatase is formed by the placenta and is often moderately elevated during late pregnancy. By contrast, transaminases and bilirubin levels are not altered in normal pregnancy, so abnormalities in these markers should raise suspicion for hepatobiliary disease. Similarly, hormonal changes during pregnancy decrease gallbladder contractility and increase biliary cholesterol concentration, promoting gallstone formation. However, indigestion, bloating, and belching are not considered typical symptoms and are unlikely to be caused by cholelithiasis. Symptomatic cholelithiasis typically presents with biliary colic (pain in the right upper quadrant) or cholecystitis (prolonged pain, fever, nausea), neither of which is apparent in this patient. This patient's laboratory values are within the expected ranges for pregnancy; her heartburn was likely nonbiliary; and her cholelithiasis does not require further intervention at this time. (Choice B) Hepatobiliary cholescintigraphy (hepatobiliary iminodiacetic acid scan) is useful for evaluating the patency of the cystic and common bile ducts when ultrasound is inconclusive. It is safe in pregnancy but provides little benefit in patients with visualized stones on ultrasound in whom acute cholecystitis is not suspected. (Choice C) Ursodeoxycholic acid is used to decrease maternal symptoms and fetal risk in patients with intrahepatic cholestasis of pregnancy, which presents with elevated transaminases and generalized pruritus that is most intense on the palms and soles. Its use in dissolving gallstones in pregnant patients has not been studied and is not typically recommended. (Choice D) Early delivery may be indicated in cases of acute fatty liver of pregnancy (eg, vomiting, increased transaminases), HELLP syndrome (eg, hemolysis, low platelets), or preeclampsia (eg, hypertension, proteinuria). This patient does not have evidence of these complications. (Choice E) Indications for cholecystectomy include recurrent biliary colic and cholecystitis. Pregnant patients with an isolated episode of biliary colic often respond well to supportive care (eg, pain control, low-fat diet). Educational objective: Physiologic changes during pregnancy can lead to laboratory values that fall outside of normal reference ranges. Moderate elevations in alkaline phosphatase and asymptomatic cholelithiasis are common and do not require intervention. In addition, patients with a single episode of uncomplicated biliary colic typically require only supportive care. __________ References: Pregnancy and laboratory studies: a reference table for clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/19935037) Outcomes of gallstone disease during pregnancy: a population-based data linkage study. (http://www.ncbi.nlm.nih.gov/pubmed/28881393)

A 32-Year-Old Primigravid Woman at 36 Weeks Gestation Comes to the Office