Discussion:
Choledocholithiasis is a relatively rare complication in pregnancy, estimated at 1 in 1000 pregnancies [5]. The occurrence of acute cholangitis due to choledocholithiasis is estimated to be less than 1 in 1200 pregnancies [6].
Clinical presentation of acute cholangitis in pregnant women has no real particularities. Nevertheless, it requires management of both the mother and the fetus (obstetric ultrasound and fetal heart rate) because of sepsis’ effects. Classic symptomatic triad or “Charcot’s triad” consists on pain, fever and jaundice following each other over a period of 8 to 36 hours [5].
Biological presentation of acute cholangitis is variable. It is common to observe a hyperleukocytosis with neutrophils, blood cultures taken during fever or chills are frequently positive, disturbance of hepatic tests is the rule. This disturbance generally persists for several days after first clinical symptoms.
Medical imaging is based on abdominal ultrasound, which is the first-line examination. Two other efficient examinations allow detection of lithiasis of the main biliary tract bile duct: Biliary MRI and echo-endoscopy [4].
CT is another non-invasive method to assess biliary tree and pancreas but its accuracy is limited by its low sensitivity in the diagnosis of stones in main bile duct [7]. CT use is also limited in pregnant women due to radiation-induced teratogenesis [8].
Obstetrical examination is used to detect signs of threatened preterm birth and to check fetal vitality in order to adapt the procedure. This examination should look for gyneco-obstetric pathologies that may explain the symptomatology [9].
Fetal heart rate recording is a simple and rapid examination that allows assessment of fetal well-being and also allows detection of uterine contractions [9].
Obstetric ultrasound is an important part of obstetric assessment. It is used to search for obstetric anomalies that may explain the clinical symptomatology on one hand and to assess the fetal well-being on the other. Endovaginal ultrasound can measure the length of the cervix and assess the risk of preterm birth [9].
Medical treatment of acute cholangitis classically consists of filling with fluid and electrolyte rebalancing based on crystalloids. Colloids are contraindicated during pregnancy, only 4% or 5% albumin can be used. Intravenous antibiotic therapy targeting gram negative bacteria and anaerobes is obligatory [3]. Preceded by blood cultures, it should be empirical, then adapted to the bacteriological results. The choice of molecules must take into account the teratogenic risk for fetus.
Beta-lactams, cephalosporins, amoxicillin-clavulanic acid can be widely used in combination with an aminosid or metronidazol. These molecules are known to be mildly teratogenic. In order to correct possible hemostasis disorders, the addition of vitamin K is possible and does not present a fetal risk [10].
Surgical treatment for acute cholangitis stills possible during pregnancy. This surgery presents particularities in terms of anesthesia, approach and choice of surgical modalities. Anesthetic particularities are inherent to the risk of tracheal intubation which is often more difficult with a greater risk of hemorrhage. Good pre-oxygenation with rapid induction sequence are necessary. Drugs’ titration is essential as well as monitoring. Actually, there is no proven risk of teratogenicity due to anesthetic products [11].
As far as the approach is concerned, both laparotomy and laparoscopy are possible, and various studies comparing these two approaches in terms of prematurity rate (2.8% vs. 6.7%; p = 0.27), or death in utero (2.9% vs. 1.1%; p = 0.41), respectively for open and laparoscopic surgery groups, did not show statistically significant differences [12,13].
Although it is generally avoided in pregnancy, per-operative cholangiography is not correlated with a higher risk of preterm delivery or any other fetal complications [14].
Endoscopic sphincterotomy has been shown efficacity and safe in pregnancy for both woman and fetus [15]. It does not seem to increase pregnancy complications’ risk and seems to be a good alternative to surgical treatment [16].
Tocolysis, lung maturation with corticosteroids and transfer to a suitable maternity unit should be discussed according to gestational age [17]. Hée stated that no study has demonstrated the benefit of prophylactic tocolysis and that its use remains a matter of choice [17].