A 35-year-old woman, gravida 2 para 1, at 20 weeks gestation comes to the office due to cholelithiasis found incidentally during a prenatal ultrasound. She has no prior history of gallstones and has no abdominal pain, jaundice, or clay-colored stool. She has no chronic medical problems, and her only medication is a daily prenatal vitamin. The patient stopped drinking alcohol after learning that she was pregnant and does not use tobacco or illicit drugs. Her mother underwent cholecystectomy for acute cholecystitis at age 40. Vital signs are within normal limits. The patient is anicteric and mucous membranes are moist and pink. Examination reveals a gravid abdomen but no tenderness. Laboratory results are as follows: Ultrasonography of the right upper quadrant reveals a 1-cm gallstone without gallbladder distension, wall thickening, or pericholecystic fluid. The intrahepatic biliary ducts and common bile duct are normal in size. Which of the following is the most appropriate intervention for this patient's gallstone?

Question

A 35-year-old woman, gravida 2 para 1, at 20 weeks gestation comes to the office due to cholelithiasis found incidentally during a prenatal ultrasound.  She has no prior history of gallstones and has no abdominal pain, jaundice, or clay-colored stool.  She has no chronic medical problems, and her only medication is a daily prenatal vitamin.  The patient stopped drinking alcohol after learning that she was pregnant and does not use tobacco or illicit drugs.  Her mother underwent cholecystectomy for acute cholecystitis at age 40.  Vital signs are within normal limits.  The patient is anicteric and mucous membranes are moist and pink.  Examination reveals a gravid abdomen but no tenderness.  Laboratory results are as follows:  Ultrasonography of the right upper quadrant reveals a 1-cm gallstone without gallbladder distension, wall thickening, or pericholecystic fluid.  The intrahepatic biliary ducts and common bile duct are normal in size.  Which of the following is the most appropriate intervention for this patient's gallstone?

Quizplus · Accepted Answer

Explanation: Pregnant women are at increased risk for gallstones due to pregnancy-related hormonal changes, which supersaturate bile with cholesterol and decrease gallbladder motility. Gallstones that form during pregnancy are rarely symptomatic and are usually discovered incidentally during prenatal ultrasound. Asymptomatic patients require no treatment as most pregnancy-related gallstones resolve spontaneously within 2 months of delivery. (Choice A) Patients who develop biliary colic while pregnant are typically treated with intravenous fluids and pain control. If symptoms cannot be controlled with supportive care, cholecystectomy is often performed during the second trimester. This asymptomatic patient does not require cholecystectomy. (Choices B and C) Although ursodeoxycholic acid can be used to dissolve gallstones, most pregnancy-related gallstones resolve spontaneously after delivery; asymptomatic individuals do not usually require medical or surgical treatment. (Choice D) Extracorporeal shock wave lithotripsy is an excellent treatment for most renal and urinary calculi but is not routinely used for gallstones. In addition, this technique is generally contraindicated during pregnancy. Educational objective: Pregnant women often develop gallstones due to pregnancy-related hormonal changes. Most patients are asymptomatic and require no treatment. Those who develop symptoms of recurrent biliary colic or acute cholecystitis typically require cholecystectomy. References: A prediction rule for risk stratification of incidentally discovered gallstones: results from a large cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/26375367) A review of the management of gallstone disease and its complications in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/18614143)

A 35-Year-Old Woman, Gravida 2 Para 1, at 20 Weeks