Between guidelines and reality; the complex decision-making of acute cholecystitis in pregnancy

Gallbladder disease is the primary non-obstetrical cause of hospitalization during pregnancy. The hormonal milieu changes with elevated estrogen and progesterone, reducing gallbladder contraction, promoting biliary stasis, and increasing cholesterol stone formation. This eventually causes biliary colic and acute cholecystitis. Both SAGES and ACOG consider laparoscopic cholecystectomy safe in all trimesters. We present a case series of gallbladder disease presenting during pregnancy comparing outcomes of patients who underwent Non-Operative Management (NOM) and those who received surgery.

A 10-year retrospective electronic medical records review of pregnant patients between October 2012- December 2022, with the diagnosis of gallbladder disease. Data collection included patient characteristics, clinical presentation, lab values, imaging, treatment modalities, and outcomes. Fischer's exact test was used to determine statistical significance.

A total of 228 pregnant patients presented with gallbladder disease; 8 underwent OM, with indications of failed NOM secondary to intractable pain, with no complications. Of 220 managed conservatively, 77% experienced recurrence, and most underwent elective surgery postpartum. No maternal-fetal complications occurred in either group, though NOM was associated with high recurrence and readmission rates.

Despite current guidelines recommending surgical intervention, our study reveals that non-operative management remains the predominant approach in real-world practice. While it is associated with a high rate of symptom recurrence and postpartum readmissions, fetal outcomes remain favorable in patients managed conservatively. These findings underscore the need for updated guidelines that reflect evolving clinical trends and emphasize individualized patient care.