Cholecystitis during pregnancy

Cholecystitis during pregnancy is a very common pathology, especially in women who have previously had problems with their gallbladder. This is due to the fact that during pregnancy, many hormones are produced that affect all processes in the body, including digestion. This pathology is more common in those who have previously suffered from cholecystitis, pancreatitis, and dyskinesia before pregnancy. But it can also develop for the first time, when pregnancy is a trigger for a previously hidden problem.

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Causes cholecystitis in pregnancy

Cholecystitis during pregnancy most often develops in the third trimester and can cause late gestosis, as well as other complications of pregnancy and childbirth. As for the features, this pathology most often develops in older women, while it is rare during the first pregnancy.

The causes of cholecystitis during pregnancy can be varied, but the main mechanism of pathology development is hormonal changes in the body of a pregnant woman. This is due to the secretion of hormones that affect organs: for example, the hormone progesterone is able to relax the tone of smooth muscle fibers and thereby affecting the gallbladder contributes to its atony. This can be the cause of bile stagnation, which contributes to the development of pathology in the form of stone formation or infection.

Cholecystitis often develops in women who suffered from this disease before pregnancy or had predispositions to it. Often the cause of the development of such a condition during pregnancy is chronic cholecystitis. Before pregnancy, a woman may not be bothered by anything, but when pregnancy occurs, all processes in the body become aggravated, and then an exacerbation of chronic cholecystitis occurs. This also happens with concomitant cholelithiasis, when there are stones in the gallbladder and against the background of hormones secreted by the placenta, the tone of the gallbladder decreases, which leads to the activation of inflammatory processes.

There are congenital defects of the gallbladder that cause functional changes before pregnancy, and during pregnancy can cause acute cholecystitis. Such conditions include dyskinesia of the biliary tract, bends and abnormal positions of the gallbladder. This is quite common and can be asymptomatic before pregnancy, and manifest itself only during pregnancy.

Acute cholecystitis is caused by the entry of pathogenic microorganisms into the gallbladder. This is due to the fact that pregnant women often have problems with the gastrointestinal tract: the acidity of the stomach and the motor-evacuation function of the intestine decrease, and local immune forces decrease - all this contributes to the easy entry of the pathogen into the bile ducts, and then the bladder, which is accompanied by the development of an infectious process in the gallbladder.

That is, acute cholecystitis in pregnant women often occurs against the background of existing problems with the gallbladder, and pregnancy only contributes to the exacerbation of the process.

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Pathogenesis

As is known, cholecystitis most often occurs in the second half of pregnancy. These features are related to the fact that the uterus increases so much that it is at the level of the navel or in the middle between the navel and the xiphoid process - then all the organs are displaced. This also applies to the liver with the gallbladder, which is pressed or can twist, which contributes to the disruption of its normal function. In this case, bile does not enter the bile ducts, but accumulates - this contributes to bile stagnation, the formation of stones, the development of edema and inflammation. These are morphological changes associated with a change in the position of the gallbladder, but there are also other mechanisms for the development of cholecystitis.

Hormones secreted during pregnancy affect the functioning of all internal organs, including the liver. Prostaglandins, placental lactogen, oxytocin have a relaxing effect on the smooth muscle fibers of the gallbladder and sphincter, which causes atony of the bladder. Thus, its function is impaired and bile stagnation, which occurs due to anatomical features during enlargement of the uterus, increases. All these processes disrupt normal digestion, which contributes to the disruption of food evacuation and the retention of pathogenic microorganisms. These are good conditions for the penetration of the pathogen into the cavity of the gallbladder, which causes an infectious process. This is how an attack of cholecystitis occurs in a pregnant woman.

Changes in the location of the gallbladder in pregnant women can cause atypical symptoms of the disease, so it is important to take into account all the characteristics of the woman's body when carrying a child.

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Symptoms cholecystitis in pregnancy

The severity of clinical manifestations may vary – from mild dyspeptic symptoms to severe pain syndrome. This depends on the type of pathology and the conditions of clinical development.

Symptoms of cholecystitis during pregnancy have their own characteristics. This is due to the fact that the uterus increases in size and lifts the liver with the gall bladder, which contributes to atypical manifestations.

The first signs of cholecystitis during pregnancy are complaints of dyspeptic symptoms when eating fatty, fried foods. This occurs because fatty foods stimulate the secretion of bile, which is difficult due to inflammatory changes, which causes nausea and bitterness in the mouth. Also, one of the characteristic signs is heaviness in the right hypochondrium. This is the equivalent of pain syndrome. During an attack of cholecystitis, the pain can be sharp, occurs more often after errors in diet in the right hypochondrium and can radiate to the right arm or shoulder blade. This is accompanied by severe anxiety of the woman, may be accompanied by a rise in body temperature, which already indicates an inflammatory process. These are the main signs of cholecystitis. Also, with a long course of chronic cholecystitis, jaundice may appear, which has a greenish tint and is accompanied by itching of the skin. It appears due to a violation of the outflow of bile and the release of bilirubin into the blood.

When examining a woman, the doctor can detect all the symptoms characteristic of cholecystitis:

1. Georgievsky-Mussi symptom is the appearance of pain on the right when pressing in the sterno-mamma-clavicular fossa;
2. Kerr's symptom - pain on palpation at Kerr's point;
3. Murphy's symptom - interruption of inhalation during palpation of the left hypochondrium due to severe pain syndrome;
4. Ortner's symptom - pain when percussing the costal arch with the edge of the palm;
5. Obraztsov's symptom - the appearance of intense pain on inhalation when inserting the hand into the right hypochondrium.

These are the main pathognomonic symptoms that indicate gallbladder pathology. But during pregnancy, not all of them may be expressed and not to the same extent, and there may also be other clinical signs. Therefore, it is very important to correctly establish a diagnosis and conduct differential diagnostics in pregnant women.

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Forms

The course of cholecystitis during pregnancy can have different character and depends on the pathology of the gallbladder that the woman had before. The main types of cholecystitis during pregnancy are acute, chronic, exacerbation of chronic and calculous.

Acute cholecystitis during pregnancy, as a primary pathology, is rare, since there is no predisposition to the infectious process. But in the case of the development of such a condition, the symptoms are very pronounced and progress quickly. Urgent surgery is necessary to prevent the development of complications and adverse effects on the fetus.

Chronic cholecystitis occurs more often. Then the woman is ill throughout the entire period of pregnancy. The symptoms are weakly expressed and consist of dyspeptic manifestations in the form of nausea, vomiting, a bitter taste in the mouth, heaviness in the right hypochondrium. These symptoms can accompany the entire pregnancy and do not require surgical intervention, but only conservative symptomatic therapy. But there may also be an exacerbation of chronic cholecystitis, then all the symptoms worsen, a general intoxication syndrome with an increase in body temperature appears. This condition requires immediate intervention.

Another manifestation may be calculous cholecystitis. It is characterized by the most acute clinical symptoms - severe pain and deterioration of the general condition. This is due to the fact that there are stones in the gallbladder, which, under certain circumstances, can irritate the wall with the occurrence of an inflammatory process. The most pronounced clinical picture is hepatic colic - the passage of a stone through the bile ducts. This is a particularly dangerous condition not only for the mother, but also for the child, due to the pronounced pain syndrome.

Treatment tactics are different in each case and depend on the severity of the clinical picture and the duration of pregnancy.

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Complications and consequences

The main complications of cholecystitis during pregnancy are associated with the risk of rapid spread of the infectious process to the abdominal cavity due to the state of immunosuppression of the pregnant woman. Perforation with the development of peritonitis, peliflebitis and other complications can quickly occur. Therefore, suspicion of acute purulent cholecystitis requires immediate surgical intervention. Complications are also associated with a possible negative impact on the fetus. An attack of cholecystitis due to severe pain syndrome can provoke premature labor, premature placental abruption, fetal distress. Therefore, it is important to perform pain relief in this case with the choice of further tactics for managing labor.

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Diagnostics cholecystitis in pregnancy

It is very important to correctly diagnose and begin treatment of a pregnant woman before complications arise not only from the mother's body, but also from the fetus. Therefore, in addition to anamnestic data, additional research methods must be carried out to accurately establish a diagnosis.

Tests for cholecystitis in pregnant women have characteristic signs of an inflammatory process - an increase in ESR, leukocytosis and a shift in the leukocyte formula to the left. However, these changes in laboratory parameters are not always expressed, since cholecystitis can be chronic and not accompanied by such infectious manifestations. In a biochemical blood test, such indicators as total bilirubin due to indirect bilirubin, as well as alkaline phosphatase, as a marker of bile outflow disorder, will be increased. As for liver markers, they will be normal, which allows you to exclude liver pathology.

Instrumental diagnostic methods are of primary importance for establishing a diagnosis. The "gold standard" for diagnosing cholecystitis during pregnancy is ultrasound, since along with high information content, the impact on the fetus is minimal. During ultrasound, in the projection of the gallbladder, you can see:

• thickening and heterogeneity of the gallbladder wall, which indicates infectious inflammation;
• the presence of stones in the gallbladder cavity is a sign of calculous cholecystitis;
• disruption of normal position or curvatures are symptoms of functional disorders;

These ultrasound signs make it possible to determine an accurate diagnosis and treatment tactics.

Since all mother's diseases negatively affect the child, it is necessary to conduct a comprehensive examination to diagnose the condition of the fetus. One of the most accessible and informative methods is cardiotocography. This study allows you to determine the condition of the child by monitoring its heart rate, movements, as well as the condition of the uterus and the presence or absence of contractions. This is also a reliable method for differential diagnosis of premature birth and an attack of acute cholecystitis.

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Differential diagnosis

Differential diagnostics of cholecystitis in pregnant women is carried out with a number of diseases: acute appendicitis, renal colic, acute pyelonephritis, as well as pregnancy disorders.

Acute appendicitis in pregnant women can often be accompanied by similar symptoms due to the rise of the appendix up to the liver. But appendicitis is accompanied by characteristic symptoms of peritoneal irritation, migration of a pain attack from the epigastric region to the right iliac region. And with cholecystitis, bladder symptoms will be expressed.

Acute right-sided pyelonephritis and renal colic can also be characterized by pain in the right side, intoxication syndrome, but a general urine analysis, which will be normal in cholecystitis, allows for differential diagnosis.

When a woman is concerned about any health problems, she worries about her child, so she immediately consults an obstetrician-gynecologist. He, in turn, must exclude all pathologies associated with pregnancy and conditions threatening the fetus. Symptoms of nausea and vomiting characteristic of cholecystitis must be differentiated from late gestosis. For this, it is important to conduct a comprehensive examination and exclude these conditions. With late gestosis, blood pressure increases, protein in the urine increases, which is not typical for cholecystitis.

It is also necessary to exclude liver damage, which can be done by performing a biochemical blood test to determine liver transaminases.

Premature labor may also be accompanied by diffuse abdominal pain, and cardiotocography helps to rule out this condition. In case of cholecystitis, normal uterine tone without contractions and good fetal heartbeat are determined, which helps to rule out premature labor.

These research methods help to establish a diagnosis and exclude other pathologies.

Treatment cholecystitis in pregnancy

Treatment of cholecystitis during pregnancy should be etiologically and pathogenetically justified. The method of treatment is determined in each case individually. Conservative and surgical treatment are distinguished. Among conservative methods, drug treatment, folk remedies and homeopathic methods are also distinguished.

An important stage of treatment is the regime and nutrition. The regime of a pregnant woman should exclude excessive loads, but at the same time it is necessary to have minimal physical activity, since the activity of the gastrointestinal tract and the secretion of bile are activated.

Diet is an important point in the treatment of cholecystitis. Meals should be fractional in small portions 5-6 times a day. This promotes the release of bile at each meal and eliminates stagnation. It is necessary to exclude fatty, fried, smoked, salty foods from the diet, which irritate the liver and increase dyspeptic symptoms. It is necessary to include egg yolk, olive oil, butter in small quantities in the diet to improve the outflow of bile. But this applies only to the chronic process, in the acute - all this is excluded and the diet should be gentle.

Drug treatment is usually used for chronic cholecystitis, which a woman suffers from before pregnancy. The following drugs are available:

• Hofitol is a herbal preparation, which is an aqueous infusion of field artichoke leaves. The preparation has a pronounced choleretic effect, as well as a hepatoprotective effect due to the strengthening of hepatocyte membranes. It is prescribed to pregnant women with late gestosis - preeclampsia - as a complex therapy, as well as with chronic non-calculous cholecystitis. The drug is available in the form of tablets of 200 mg, take one tablet three times a day 20 minutes before meals. Side effects that may be - allergic reactions and dyspepsia in the form of diarrhea. It should be used with caution in case of gallstones, as this can provoke hepatic colic.
• Holosas is a herbal preparation made from an aqueous extract of rose hips. It is a choleretic - it promotes the secretion and release of bile from the gallbladder, which is important in connection with the atony of the gallbladder in pregnant women. The drug is available in the form of a syrup in 300 ml bottles. Take one teaspoon of syrup three times a day. Side effects are possible in the form of allergic reactions, as well as nausea. It is necessary to be careful with the use of the drug in case of concomitant diseases of the gastrointestinal tract.
• Tanatsehol is a choleretic of true origin, which is obtained from the plant - tansy. It has a pronounced choleretic effect and helps change the composition of bile. The drug also has a positive effect - antispasmodic - relaxes the gallbladder and ducts, which improves the outflow of bile.

It is produced in the form of tablets and is used after meals, one tablet three times a day. Side effects - allergic reactions. The drug should not be used in the presence of gallstones, this can aggravate the condition.

• Convaflavin is a combined herbal preparation, the main component of which is lily of the valley. In addition to a pronounced choleretic effect, the drug has an antispasmodic effect, which reduces the severity of pain. The drug is available in the form of 100 mg tablets, it is low-toxic and is taken orally 2 tablets three times a day before meals. Side effects may include dizziness, allergic reactions and bowel disorders.
• Baralgin, Drotaverine, Papaverine - drugs from the group of antispasmodics, which are prescribed for pain syndrome to relieve spasm of the gallbladder and bile ducts. The drugs are used in the form of tablets - taking one tablet when symptoms appear.

B vitamins are also used in combination therapy with herbal preparations. They are prescribed in injection form or in a vitamin complex.

Physiotherapy is recommended during remission, but with caution and reducing the dose to half. UHF therapy is recommended to improve bile flow, as well as blind probing with xylitol.

Surgical treatment of cholecystitis in pregnant women is performed only with a confirmed diagnosis of acute purulent cholecystitis or an attack of cholecystitis in cholelithiasis. Then there is a direct danger to the life of the pregnant woman, since there is a source of infection that can quickly spread to the surrounding organs, or the pain syndrome can cause premature birth. The scope of the operation is the removal of the gallbladder, which is performed under general anesthesia, taking into account the use of anesthesia that does not affect the fetus. Laparoscopic operations are not performed in pregnant women, the surgical approach is a midline laparotomy, for better revision of the abdominal cavity, since the anatomy of the internal organs changes due to the enlarged uterus.

After removal of the gallbladder and revision, through drainages are installed. This operation is carried out with constant monitoring of the fetus's condition. In case of signs of fetal distress - cesarean section.

Traditional treatment of cholecystitis in pregnant women

Traditional treatment of cholecystitis in pregnant women has its advantages, since medications during pregnancy have limited use due to the possible risk of affecting the fetus.

Many folk remedies are used, the main effect of which is a pronounced choleretic and antispasmodic effect.

• Corn silk is one of the most well-known remedies used in folk medicine to treat chronic cholecystitis. The fruits of corn are dried, then poured with boiled water in a one-to-one ratio and infused. This decoction is taken warm, half a glass three times a day.
• Dandelion - the roots of this yellow-flowering plant, not faded, need to be washed, chopped and boiled for five minutes, then infused for another twenty minutes and strained. Drink warm, half a glass three times a day before meals.
• Beet juice also has a pronounced choleretic effect. Beetroot should be boiled, but not until fully cooked, then peeled and juiced. This juice should be taken one tablespoon before meals.
• The leaves of immortelle and St. John's wort must be dried, boiled for five minutes and infused for ten minutes, then cooled and taken a quarter of a glass three times a day.

Homeopathic remedies are also used to treat cholecystitis in pregnant women, which is explained by their harmless effect on the child.

Main homeopathic remedies:

1. Holesan is a drug that exhibits a choleretic effect and hepatoprotective by improving metabolism in hepatocytes. The drug is available in granules, seven sugar granules are used 20 minutes before meals, and they must be kept in the mouth until completely dissolved. No side effects have been found when using this drug.
2. Zhelchevom is a homeopathic preparation that promotes the secretion and formation of bile, increases gallbladder motility, and reduces the formation of gallstones. It is produced in the form of homeopathic granules. Take five granules before meals, in the morning before breakfast 20 minutes before – once a day. No side effects have been detected. It should be used with caution with other homeopathic remedies with a similar mechanism of action.
3. Hepel is a homeopathic remedy of combined composition, which has a pronounced antispasmodic, choleretic, antidiarrheal effect. It is produced in the form of tablets and injection solution. For pregnant women, it is mainly used in the form of tablets, one tablet three times a day. It can be combined with other medications, no side effects have been identified.
4. Choledius is a complex homeopathic preparation. The preparation has a pronounced anti-inflammatory effect on the gallbladder, does not affect the removal of stones. It is produced in the form of homeopathic drops. Method of application - dissolve 10 drops in half a glass of warm water, and drink in small sips once a day forty minutes before meals. No side effects have been identified.

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Prevention

Prevention can be non-specific. It is recommended to treat chronic cholecystitis in women even before planning pregnancy, as well as to monitor the course of the disease during pregnancy. Prevention of complications is carried out by timely treatment and diagnosis of the disease. Of particular importance is the nutrition of a pregnant woman, which excludes harmful food and thus prevents not only cholecystitis, but also diseases of the gastrointestinal tract.

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Forecast

The prognosis for chronic cholecystitis in pregnant women for the mother and fetus is favorable in the case of symptomatic treatment and disease control to prevent relapses. In acute cholecystitis, immediate hospitalization is necessary, then surgical treatment also contributes to a favorable outcome and the possibility of extending pregnancy to the end of the term.

Cholecystitis during pregnancy is a common pathology that requires timely diagnosis and treatment due to the potential risk not only for the mother but also for the fetus. Treatment is individual, depending on the severity of clinical signs. In chronic cholecystitis, preference is given to drug treatment using herbal remedies, as well as traditional methods of treatment. In the case of an attack of acute cholecystitis, it is necessary to carry out surgical treatment with monitoring of the fetus's condition. With timely diagnosis and proper treatment, the prognosis of this pathology in "future mothers" is favorable.

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