Results:
1. Clinical findings:
The mean age of patients was 31.3 ± 7 years. All patients were without medical history. Two patients had multiple gestations and one patient was multiparous. The mean term of pregnancy was 19 weeks of amenorrhea. Two patients were in first trimester of pregnancy and one patient in third trimester. Duration of clinical signs was greater than 72 hours in two patients. Abdominal pain was the main complaint in all patients and was located in right hypochondrium. Fever was noted in only one patient. One patient presented nausea and vomiting. All patients were icteric at the time of diagnosis. On abdominal examination: pain on palpation of right hypochondrium was present in all patients. No abdominal mass was palpated in any case.
2. Biological findings:
The mean white blood cell count was 12100 ± 1900 elements per mm3. No patient had hyperleukocytosis. The mean hemoglobin was 12.2 ± 2 g/dL. One patient was anemic at 9.8g/dL. No patient had thrombocytopenia. The mean CRP was 26 g/L. It was elevated in two patients. Mean AST was 84 IU/L and mean ALT was 51 IU/L. Liver cytolysis was noted in all patients. Mean PAL was 233 IU/L. Cholestasis was noted in one patient. Mean total bilirubin level was 49.3 umol/L. Two patients had predominantly conjugated hyperbilirubinemia.
3. Radiological findings:
Abdominal ultrasound was performed in all patients showing a lithiasis gallbladder, non-distended and thin-walled in all cases. Two patients had a dilated main bile duct (mean diameter of main bile duct was 11.6 mm). Lithiasis in the common bile duct was observed in all three cases (Figure 1). Neither hepatic abscess nor liver or pancreas abnormalities were observed in any case.
No patient had an abdominal CT scan or biliary MRI.
4. Obstetrical findings:
All patients had a gynecological examination with obstetric ultrasound on admission, which were normal in all cases.
5. Therapeutic management:
All patients received both vitamin K supplementation and antibiotic therapy intravenously. A combination of Cefotaxime, Metronidazole and Gentamicin was used in all three patients. Average duration of antibiotic therapy was 9 ± 1.7 days. Tocolysis was indicated in only one patient in third trimester of pregnancy.
All patients underwent surgery:
The average time from admission to surgery was one day. The mean term at the time of surgery was 19 SA.
A right subcostal approach performed in all cases.
Cholecystectomy was performed in all three patients. Cholangiography was performed in two patients showing dilated bile ducts with presence of at least two stones (the number of images was limited to two in both cases, fetal protection measures with a lead gown were taken in both cases). A false biliary fistula was found in the third patient allowing direct access, extraction of stones and verification of main biliary duct with choledochoscope, avoiding cholangiography.
A choledocotomy with stone extraction was performed in two patients. Choledochorraphy with Kehr drain was performed in all three patients.
No intraoperative incidents were reported.
6. Postoperative outcomes:
Postoperative course was simple in all three patients. A postoperative cholangiography on the seventh postoperative day was carried out in both cases showing the vacuity of the bile ducts (Figure 2) (Protection of fetus with a lead gown was carried out and the number of images was equal to three). No maternal or fetal complications were noted in postoperative obstetrical ultrasound performed on the three patients. Pregnancy was carried to term for two patients. One patient was lost to follow-up.
Hospitalization’s duration was 14 days for two patients and 12 days for one patient.
Intensive care unit stay was one day for two patients and two days for one patient.