CHOLECYSTITIS IN PREGNANCY der levels. Ultimately, with increased cost con- sciousncss, decreased drug monitoring and fewer doses mean lower overall costs related to cephalo- sporin use. Pipcracillin, an extended spectrum penicillin, has broad coverage against all organisms commonly bound in the biliary tract, excellent biliary excre- tion, and negligible nephrotoxicity. It has also been shown to be efficacious in patients with acute cho- lecystitis, zz,z’ The overall cure rate for acute cho- lecystitis in patients treated with piperacillin, am- picillin and tobramycin, or cefopcrazonc was 92% with no difference in any of the three groups, zz Hence, when considering antibiotic therapy in pa- tients with acute cholecystitis, the standard of a penicillin and an aminoglycosidc remains an effec- tive regimen. However, when considering more current issues such as cost containment, alterna- tives including extended spectrum penicillins or third generation cephalosporins cannot be ignored. In managing acute cholecystitis in pregnancy, many physicians advocate initial non-operative management in an effort to prevent surgical inter- vention prior to completion of the pregnancy. The pregnancy outcomes are highly dependent on the trimester during which the biliary symptoms occur. One study evaluated 26 pregnant patients with acute cholecystitis in all three trimesters. Only 2 of the 7 patients who presented in the first trimester had pregnancies which went to term, whereas all patients who presented in the third trimester com- pleted a successful pregnancy, z4 Twenty of the pa- tients did not require operation before resolution of the pregnancy. Non-operative therapy has classi- cally been the primary goal for pregnant women with acute cholecystitis. Having said that, there is evidence to suggest a high rate of recurrence of biliary pain in pregnancy complicated by cholelithiasis and cholecystitis. In a recent retrospective review of 44 women with bil- iary colic or cholecystitis, experience with conser- vative, non-operative therapy was not favorable. Twenty-six of the 44 patients were managed con- servatively and 58% of those had recurrent symp- toms. Twenty-seven percent of these women were rehospitalized two or more times during their preg- nancy. The average hospital stay for these women was 14 days as opposed to 6 days for the group with surgical intervention, zs CASEY AND COX Surgical Management The implication is that cholecystcctomy should bc considered early in the management of these women. With regard to non-obstetric surgical therapy, several comments can be made. During pregnancy appendicitis is the most common indi- cation for non-obstetric surgery followed by adnex- al masses and cholecystectomy, z6 Cholecystectomy is performed at a rate of 1-6/10,000 pregnancies, z7 In a review of approximately 50,000 pregnancies, the preterm delivery rate within 2 weeks of any surgery was significantly higher in the third trimes- ter than in the second trimester (25.7% vs. 8.2%). Also, there was a trend toward prcterm delivery for those procedures performed emergently vs. those that were planned. Finally, in this study, tocolytic agents were not found to be beneficial, z7 Based on the current literature, the following overall recommendations can be made with regard to management of pregnant women with acute cho- lecystitis. First, prepregnancy cholecystectomy is advised in those women with a history of choleli- thiasis. Second, biliary colic or acute cholccystitis occurring during the first trimester of pregnancy should initially be treated medically. If possible, elective surgery should be scheduled for the sec- ond trimester. Biliary symptoms occurring in the second trimester should ideally be treated surgi- cally. Finally, symptoms of biliary colic or evidence of acute cholecystitis in the third trimester should be treated medically, when possible. Postpartum surgical therapy should then be pursued, zs In con- clusion, due to high recurrence rates of biliary symptoms in pregnant women with acute cholecys- titis, surgery should be considered early in manage- ment as opposed to postponing definitive therapy. Once the decision for surgical intervention has bccn made, the question is which approach should be used. The options include endoscopic retro- grade cholangiopancreatography (ERCP) with sphincterotomy and stone removal, laparoscopic cholecystectomy, or open cholecystectomy. Prior to any of the above procedures, however, appropriate antibiotics should be instituted. With respect to E RCP with sphinctcrotomy and stone removal, conventional wisdom is that due to potential radiation-induced damage to the fetus, fluoroscopic procedures should be avoided. Several studies in the second and third trimesters, how- INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 307