CHOLECYSTITIS IN PREGNANCY ever, have reported successful pregnancy outcomes following E RCP with biliary stone removal, zS,z9 Additionally, Hoffman and Cunningham3 re- ported four pregnant women who underwent E RCP during the first trimester. In this report, ra- diation exposure after appropriate abdominal shielding was calculated and found to be well be- low levels at which damage to the fetus can occur. " Ultimately, then, ERCP with sphincterotomy and stone removal and possible stcnting of the gallblad- der appears to be a safe procedure in pregnant women with uncomplicated cholelithiasis. 31 In cases of acute cholecystitis or complicated cholelithiasis, depending on gestational age at di- agnosis, the surgical management may differ. Lap- aroscopic cholecystectomy in pregnancy was first reported in 1991. 3z The laparoscopic approach theoretically avoids potential postoperative compli- cations such as thrombophlebotic and embolic events in the pregnant, hypcrcoagulablc state. This report described a pregnancy in the early second trimester with the uterus at the pelvic brim. The patient was discharged on postoperative day with an eventual successful pregnancy outcome)z Lap- aroscopic cholecystectomy has been performed successfully in non-pregnant patients with acute cholecystitis, common duct stones, previous surgi- cal history, obesity, coagulopathy, and dilated bowel. 33 Also, gynecologic laparoscopics are fre- quently performed during pregnancy.e Therefore, a laparoscopic cholecystectomy is a reasonable con- sideration in pregnant women. Despite longer sur- gery times, reduced morbidity and mortality along with decreased cost of hospitalization justifies its use in experienced hands. Pregnancy should not be considered an absolute contraindication to the lap- aroscopic approach in these patients. There is no consensus, however, at what gesta- tional age/uterine size laparoscopy would be con- traindicated. Clear contraindications such as sepsis, cholangitis, common duct stones, and portal hyper- tension would still apply. "’,4 If it is the opinion of the experienced surgeon that he or she cannot safely place the trocar into the peritoneal cavity or perform an open laparoscopy, the traditional lapa- rotomy approach should be the treatment of choice. As stated previously, tocolytic therapy has been shown to be of no benefit in these patients, z6 308 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY CASEY AND COX CONCLUSION Biliary tract disease in pregnancy is a relatively un- common occurrence. Because of the heterogeneous nature of the disease, progression to acute chole- cystitis can be difficult to recognize. Once diag- nosed, the initial management plan should be con- servative and include institution of antibiotic therapy. Then, depending on the gestational age at diagnosis, the management plan may differ. Surgi- cal intervention, when indicated, should not be de- layed and a planned intervention during the second trimester appears to offer a better outcome than surgery performed under emergent conditions, e6 REFERENCES 1. Birnholz JC: Population survey: Ultrasound cholecys- tography. Gastrointest Radio 7:165, 1982. 2. Glenn F, McSherry CK: Gallstones and pregnancy among 300 young women treated with cholecystectomy. Surg Gynecol Obstct 127:1067-1072, 1968. 3. Crichlow RW, Seltzer MH, Sannetha PJ: Cholecystitis in adolescents. Digest Dis 17:68-72, 1972. 4. Scragg RKR, McMichael AJ, Seamark RF: Oral contra- ceptives, pregnancy and endogenous oestrogen in gall- stone disease: A case control study. Br Med J 288:1795- 1799, 1984. 5. Buiumsohn A, Albu E, Gerst PH, Subbarao MJ: Chole- lithiasis and teenage mothers. J Adol Health Care 11: 339-342, 1990. 6. Barbara L, Samra C, Labate AMM, Taroni F, Rusticali AG, Festi D, et al.: A population study on the preva- lence of gallstone disease. The Sirmione Study. Hepa- tology 7:913-917, 1987. 7. Swisher SG, Schmit PJ, Hunt KK, Hiyama DT, Ben- nion RS, Swisher EM, Thompson JE: Biliary disease during pregnancy. Am J Surg 168:576-579, 1994. 8. Stauffer RA, Adams A, Wygal J, Lavery JP: Gallbladder disease in pregnancy. Am J Obstet Gynccol 144:661- 665, 1982. 9. Chcsson RR, Gallup DG, Gibbs RL, Jones BE, Thomas B: Ultrasonographic diagnosis of asyptomatic cholelithi- asis in pregnancy. J Reprod Med 30:920-922, 1985. 10. Basso L, McCollum PT, Darling MR, Tecchi A, Tanner WA: A study of cholelithiasis during pregnancy and its relationship with age, parity, menarche, breast-feeding, dysmenorrhea, oral contraception, and a maternal his- tory of cholelithiasis. Surg Gynecol Obstet 175:41-46, 1992. 11. Grundy SM, Kalscr SC: Highlights of the meeting on prevention of gallstones. Hepatology 7:946-951, 1987. 12. Valdivieso V, Covarrubias C, Siegel F, Cruz F: Preg- nancy and cholelithiasis: Pathogencsis and natural course of gallstones diagnosed in early puerperium. Hepatology 17:1-4, 1993.