Gallstones in pregnancy is a pathological condition with the formation of gallstones that occurred before conception, during pregnancy or after childbirth. In half of the cases, it proceeds without clinical symptoms. It can manifest itself with attacks of severe pain in the right hypochondrium, nausea, vomiting, bloating, bitterness in the mouth, heartburn, jaundice of the skin and mucous membranes. It is diagnosed on the basis of ultrasound data of the abdominal cavity, duodenal probing, biochemical blood examination. Choleretics, cholekinetics, antispasmodics, antibacterial drugs are used for treatment. If there are indications, cholecystectomy is performed.
One of the traditional risk factors for cholelithiasis (GI, cholelithiasis) is gender. Changes occurring in the biliary system during gestation are considered by most researchers in the field of modern gastroenterology, obstetrics and gynecology to be the key cause of the disease in patients of reproductive age. According to statistics, up to 6.5-8.3% of women who have not given birth suffer from cholelithiasis.
Among patients who had 2 pregnancies or more, the prevalence of gallstone pathology is almost three times higher and reaches 18.4-19.3%. Biliary sludge is first diagnosed in 15-30% of pregnant women, concretions — in 2-8% of women before childbirth and in 10% — at 4-6 weeks of the postpartum period. The frequency of cholecystectomies at gestation is 0.1-3%. The increased risk of cholelithiasis persists for 5 years after childbirth, while 0.8% of patients have their gallbladder removed.
In the development of gallstones in pregnancy, as well as outside the gestation period, a certain role is played by genetic predisposition, including hereditary and dysembriogenetic abnormalities of the development of the biliary system, irregular nutrition with the use of large amounts of sweets and animal fats, overweight, duodenal diseases that worsen the passage of bile. Specialists in the field of obstetrics have identified a number of specific factors contributing to the occurrence of gallstones in pregnancy. The main ones are:
- Increased lithogenicity of bile. Under the influence of estrogens, the concentration of which gradually increases during pregnancy, the level of cholesterol in the bile increases. Estrogens also inhibit the synthesis of henodeoxycholic acid, which contributes to the precipitation of cholesterol crystals and the formation of biliary sludge — a suspension of insoluble bile components.
- Violation of the motility of the biliary tract. Against the background of progesterone-induced relaxation of smooth muscle fibers, the contractile function of the gallbladder decreases, its emptying slows down. As a result, already from the first trimester, bile stagnation occurs in pregnant women, which is manifested by an increase in the fasting and residual volume of the organ by 30%, increases the risk of stone formation.
- Mechanical displacement of the gallbladder. Under the pressure of the uterus, the anatomical location of the organs of the upper part of the abdominal cavity changes, which are compressed to the diaphragm and partially squeezed. Pressure on the neck of the gallbladder, cystic and common ducts disrupts the evacuation of bile, provokes its stagnation and precipitation of cholesterol crystals.
- Changing the nature of nutrition. An increase in the caloric content of the diet of pregnant women, especially when eating foods rich in carbohydrates and cholesterol, is accompanied by weight gain with an increase in the volume of adipose tissue and an increase in insulin resistance. This leads to an even greater saturation of bile with cholesterol and a decrease in the total pool of bile acids, disrupts the motility of the bile secretion organs.
Previously, hypodynamia was traditionally considered one of the factors that increase the risk of gallstons during pregnancy. However, recent studies show that with an increase in physical activity, the frequency of occurrence of biliary sludge and cholesterol stones does not decrease, and metabolic parameters (lipid content, adiponectin, insulin, glucose, leptin) do not improve.
The mechanism of development of gallstones in pregnancy is associated with the action of two independent factors — an increase in the concentration of lithogenic cholesterol in bile and its stagnation. Other factors also play a role in maintaining a stable colloidal state of cystic bile — its saturation with lecithin, bile acids, etc. The imbalance of the main components of the contents of the gallbladder, characteristic of pregnant women, against the background of slowing down the emptying of the organ contributes to the nucleation of cholesterol, the deposition of microcrystals and the further growth of stones. An additional link in the pathogenesis of cholelithiasis is a compensatory increase in water reabsorption and, as a consequence, a further increase in the concentration of bile.
The systematization of clinical forms of cholelithiasis takes into account the peculiarities of the course of the disease, the severity of symptoms, the presence or absence of complications. The correct definition of the variant of cholelithiasis plays a crucial role in predicting the outcome of gestation, choosing the tactics of management of a pregnant patient and the optimal method of delivery. There are the following types of gallstones in pregnancy:
- Asymptomatic cholelithiasis. Concretions are found in the cavity of the gallbladder, but there are no clinical symptoms. The most favorable option, in which it is enough to adjust the diet for the normal course of gestation.
- Uncomplicated cholecystitis. Depending on the morphological features and the nature of the changes, cholecystitis can be catarrhal and destructive (phlegmonous, gangrenous), stone-free and calculous, primary and aggravated recurrent.
- Complicated cholecystitis. Inflammation of the gallbladder can be complicated by obstruction (occlusion) of the ducts, perforation with the development of a clinic of local or diffuse peritonitis, sweating peritonitis, damage to the bile ducts and combined pancreatitis.
Domestic gastroenterologists distinguish several stages of cholelithiasis. At the I (initial, pre-stone) stage, a biliary sludge is formed from thick heterogeneous bile. Stone formation indicates the transition of the disease to stage II. Stones can be single and multiple, cholesterol, pigmented and mixed, localized inside the gallbladder, hepatic or common ducts. At this stage, gallstones in pregnancy is latent, painful with characteristic colic, dyspeptic, atypical, imitating other diseases. Stage III is characterized by a recurrent course of calculous cholecystitis, for stage IV — the occurrence of complications. In pregnant women, the disease is more often detected at stages I and II, less often at stages III.
In more than half of the patients, cholelithiasis is asymptomatic and becomes an accidental finding during ultrasound examination of the abdominal organs performed according to other indications. In 45% of cases, gallstone disease that existed before gestation worsens and manifests clinically. With latent pain—free progression of the disorder, a pregnant woman may periodically experience heaviness in the right hypochondrium, heartburn, a taste of bitterness in the mouth, note the changed nature of the stool – a tendency to constipation or relaxation, which are usually regarded by the patient as early toxicosis.
In some women, the disease manifests itself as transient jaundice with ictericity of the skin, sclera, mucous membranes, short-term darkening of urine and discoloration of feces. The most characteristic symptom of the pathology is an attack of biliary colic, which occurs in 88% of pregnant women with a manifest course. During colic, the patient feels intense pain in the epigastrium and right hypochondrium, which radiates into the right shoulder, shoulder blade, upper arm, half of the neck, interscapular space. Pain syndrome occurs more often in the evening and at night, lasts from 15 minutes to 5 hours.
The pain is usually accompanied by nausea, vomiting that does not bring relief, heartburn, bitterness in the mouth, bitter belching, bloating, a feeling of distension in the abdomen. Reflex short-term fever up to 38 ° C with chills and sticky cold sweat is possible. Provoking factors are physical exertion, stress, infectious diseases, intensive stirring of the child in late pregnancy, nutritional errors (the use of large quantities of eggs, cream, sweet pastries, fatty fried meat, carbonated drinks).
33% of women with cholelithiasis have a threat of termination of gestation. The risk of spontaneous spontaneous miscarriages or premature birth increases after gallbladder removal surgery in the 1st and 3rd trimesters. In 13% of patients, there are pronounced signs of early toxicosis with excruciating nausea, indomitable vomiting, less often — intense salivation, which are delayed until the 16th-20th and even 28-29 weeks of gestational age. 8% of patients develop gestosis. In every fourth birth, anomalies of labor activity are diagnosed.
In rare cases, gallstones in pregnancy is complicated by extragenital surgical pathology. In 0.01-0.1% of cases, a typical clinic of acute cholecystitis is formed due to the insertion of a stone into the cystic neck. In 0.03% of women, acute biliary pancreatitis may occur due to the discharge of the formed concretion along the common duct, and half of the patients had similar attacks before pregnancy. Even less often, cholangitis, hepatosis, intestinal obstruction and peritonitis are observed when combined with gallstone disease with gestation.
Diagnosis of gallstones in pregnancy is often complicated by the asymptomatic course of the disease. With characteristic complaints of a feeling of bitterness in the oral cavity, frequent heartburn, especially associated with the use of fatty and fried foods, the patient is prescribed a comprehensive examination aimed at detecting cholelithiasis. The most informative methods are:
- Ultrasound of the gallbladder. Sonography is considered the gold standard for the diagnosis of gallstone disease. Concretions have the form of hyperechoic formations of different shapes with distal acoustic shadow. The bubble walls are often thickened to 2 mm or more. The sensitivity of the echographic method reaches 95%. With the help of ultrasound, inclusions with a diameter of 2 mm are determined.
- Duodenal probing. The study is used only in complex diagnostic cases in the absence of a threat of termination of pregnancy. Probing allows you to assess the dynamics of discharge and the composition of the portion B (cystic bile). Crystals of cholesterol and calcium bilirubinate can be found in the duodenal contents. Bacteriological analysis is possible.
- Blood testing. With cholelithiasis, the level of bound bilirubin often increases. With the localization of stones in the common bile duct, the presence of fever and jaundice, the activity of alkaline phosphatase, AlT, AsT, GGT may increase, and other liver tests may change. The cholesterol content in the blood plasma often increases. In a general blood test, leukocytosis and an increase in ESR are possible.
Differential diagnosis of GI is carried out with acute appendicitis, pancreatitis, gastroduodenitis, pyelonephritis, renal colic in urolithiasis and glomerulonephritis, perforation of gastric or duodenal ulcers, ectopic pregnancy. If necessary, in addition to an obstetrician-gynecologist and gastroenterologist, the patient is examined by a surgeon, urologist, hepatologist.
The choice of medical tactics for cholelithiasis depends on the clinical form of the disease, the leading symptoms and the presence of complications. With an asymptomatic variant of the disease, pregnant women are prescribed dynamic monitoring and exclusion of factors that provoke colic (abundant food, fried and fatty foods, shaking ride.). In the postpartum period, such women may be shown a cholecystectomy, since gallstone disorder often manifests during the first year after childbirth.
In order to reduce the stagnation of bile and prevent the formation of biliary sludge at the initial stage of the gastrointestinal tract, a pregnant woman is recommended frequent fractional nutrition, drinking highly mineralized mineral waters, taking herbal choleretics — broths of immortelle, corn stigmas, peppermint, dill seeds or pharmaceuticals based on them. Drug therapy of latent subclinical variants of cholelithiasis includes the following groups of drugs:
- Choleretics. Choleretic drugs that stimulate bile formation in the liver are indicated when hyperkinetic dysfunction of the gallbladder is detected. This disorder is more often observed in the first trimester of pregnancy. The appointment of combined products containing digestive enzymes also allows to normalize the functions of the gastrointestinal tract.
- Cholekinetics. Medicines of this group have a mild antispasmodic effect, facilitate the discharge of cystic bile. The safest cholekinetic drugs for the fetus and pregnant woman are myotropic antispasmodics, flavone aglycones, hypertonic magnesia solution, sweeteners (xylitol, sorbitol, mannitol).
- Antibiotics. In cholelithiasis, antibacterial agents are used only to a limited extent (only with reliable confirmation of the infectious process). In the 1st trimester, it is possible to prescribe drugs from the penicillin group, in 2-3 trimesters, cephalosporins are more often administered. When choosing a specific antibiotic, the sensitivity of the microflora should be taken into account.
To stop biliary colic, antispasmodics are usually used. Analgesics are widely used abroad to relieve pain, but domestic specialists refrain from prescribing drugs that can lubricate the clinical picture with unclear abdominal pain. In the absence of the effect of drug therapy within 5 hours, a pregnant woman with hepatic colic must be urgently hospitalized in a surgical hospital.
Surgical methods of treatment are indicated in the presence of complications. Conservative wait-and-see tactics with constant aspiration of the contents of the duodenum and stomach, the use of enveloping agents, choleretic drugs, adsorbents, antispasmodics, massive detoxification and antibacterial therapy is permissible only in acute catarrhal cholecystitis. If the drug treatment carried out for 4 days is ineffective, cholecystectomy is performed at any gestational period. In urgent order, the operation is performed in the diagnosis of destructive forms of inflammation.
Planned removal of the bladder is carried out with a manifest course of the gastrointestinal tract 3-4 weeks after an attack of colic due to the high probability of its recurrence. The intervention is usually performed by laparoscopic or open method in the second trimester, since this period is the safest for such surgical intervention. Extracorporeal shockwave lithotripsy is not used during pregnancy, which is associated with a high frequency of recurrence of cholelithiasis. Pregnant women with GI recommend natural childbirth with a shortened period of exile. Caesarean section is performed in the presence of obstetric indications.
Prognosis and prevention
With uncomplicated forms of cholelithiasis, the prognosis for pregnant women and children is favorable. Adequate conservative therapy, the use of modern techniques of surgical treatment and anesthesia with the removal of the gallbladder in the 2nd trimester (when indications are detected) allowed to minimize the likelihood of extragenital, obstetric and perinatal complications. In 60-80% of cases, the biliary sludge that occurs in a pregnant woman regresses independently after childbirth.
Spontaneous resorption of concretions formed during gestation is observed only in 20-30% of patients. For preventive purposes, women who are planning a pregnancy and suffer from GI are recommended to undergo a course of medication or surgical treatment in advance. At the stage of pregnancy, you should strictly follow a diet, give up long breaks between meals, reduce the consumption of sweets, fatty and fried, follow medical recommendations.