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].