Cholecystitis during pregnancy

Cholecystitis in pregnancy is a very frequent pathology, especially in women who were previously restless with the gallbladder. This is due to the fact that during pregnancy many hormones are produced that affect all processes in the body, including digestion. More often this pathology occurs in those who before the pregnancy had cholecystitis, pancreatitis, dyskinesia. But it can also develop for the first time, when pregnancy is a trigger factor for a previously hidden problem.

[1], [2]

Causes of the cholecystitis in pregnancy

Cholecystitis in pregnancy 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 often develops in older women, whereas in the first pregnancy it is rare.

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

Cholecystitis is more likely to develop in women who before pregnancy were ill or had preconditions for this disease. Often the cause of the development of such a state when bearing a child is chronic cholecystitis. Before pregnancy, a woman can not disturb anything, but with the onset of pregnancy all the processes in the body become aggravated, and then there is an exacerbation of chronic cholecystitis. It also happens with concomitant cholelithiasis, when there are stones in the gallbladder and against the background of hormones that are released by the placenta, the tone of the gallbladder decreases, which leads to the activation of inflammatory processes.

There are congenital malformations of the gallbladder, which cause functional changes before pregnancy, and during pregnancy can cause acute cholecystitis. Such conditions include biliary dyskinesia, bends and irregular positions of the gallbladder. It occurs quite often and can have an asymptomatic course before pregnancy, but only during pregnancy.

The cause of acute cholecystitis is 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 stomach acidity and motor-evacuation function of the intestine decrease, and the local immune forces decrease - all this facilitates the easy entry of the pathogen into the biliary tract, and then the bladder, which is accompanied by the development of the infection in the gallbladder.

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

[3], [4], [5]

Pathogenesis

As you know, cholecystitis occurs more often 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 organs are displaced. This also applies to the liver with a gallbladder, which is pressed or can be twisted, which contributes to the disruption of its normal function. In this case, bile does not enter the bile ducts, but accumulates - it contributes to stagnation of bile, formation of stones, development of edema and inflammation. These are morphological changes associated with changes in the position of the gallbladder, but there are also other mechanisms for the development of cholecystitis.

Hormones that are secreted during pregnancy affect the performance 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 the atony of the bladder. So his function is disturbed and the stagnation of bile, which arises because of anatomical features when the uterus increases, intensifies. All these processes disrupt normal digestion, which contributes to the disruption of evacuation of food and the delay of pathogenic microorganisms. This is a good condition for the penetration of the pathogen into the cavity of the gallbladder, which causes an infectious process. So there is an attack of cholecystitis 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.

[6], [7]

Symptoms of the cholecystitis in pregnancy

The severity of clinical manifestations can be different - from mild diarrheal phenomena to severe pain syndrome. It depends on the type of pathology and the conditions for the development of the clinic.

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

The first signs of cholecystitis in pregnancy are complaints of dyspeptic manifestations when eating fatty, fried foods. This is due to the fact that fatty foods stimulate the secretion of bile, and this is difficult due to inflammatory changes, which causes nausea, bitterness in the oral cavity. Also one of the characteristic features is the heaviness in the right hypochondrium. This is the equivalent of the pain syndrome. During an attack of cholecystitis, pain can be severe, occurs more often after errors in the diet in the right hypochondrium and can radiate into the right arm or scapula. This is accompanied by a strong anxiety of a woman, can be accompanied by a rise in body temperature, which already indicates an inflammatory process. These are the main signs of cholecystitis. Also, with a prolonged course of chronic cholecystitis, jaundice may appear, which has a greenish tinge 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 a woman is examined, the doctor can detect all the symptoms that are characteristic of cholecystitis:

1. symptom Georgievsky-Mussi is the appearance of pain on the right when pressed in the sternum-papillary-clavicular fossa;
2. Kerr's symptom is soreness in palpation at the Kerr point;
3. a symptom of Murphy - a burst of inspiration during palpation of the left hypochondrium due to a pronounced pain syndrome;
4. a symptom of Ortner - soreness with percussion of the costal arch with the palm of the hand;
5. Symptom Obraztsova - the emergence of intense pain on the inspiration during the introduction of the arm in the right subcostal area.

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

[8], [9], [10], [11]

Forms

The course of cholecystitis in pregnancy can have a different character and depends on the pathology of the gallbladder, which was previously a woman. The main types of cholecystitis in pregnancy are acute, chronic, exacerbation of chronic and calculous.

Acute cholecystitis in pregnancy, as a primary pathology is rare, because there is no predisposition to the infectious process. But in the case of the development of such a condition - the symptomatology is very pronounced and proceeds quickly. An urgent operation is necessary to prevent the development of complications and adverse effects on the fetus.

Chronic cholecystitis often occurs . Then the woman is ill during the entire gestation period. Symptoms are poorly expressed and consist in dyspeptic manifestations in the form of nausea, vomiting, 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 be an exacerbation of chronic cholecystitis, then all symptoms become aggravated, a common intoxication syndrome appears with a rise in body temperature. This state requires immediate intervention.

Another manifestation of washes is calculous cholecystitis. It is characterized by the most acute clinical symptomatology - severe pain and violation of the general condition. This is due to the fact that there are stones in the gallbladder, which for certain reasons can irritate the wall with the onset of the inflammatory process. The most pronounced clinical picture is hepatic colic - the passage of the stone along the biliary tract. This is a particularly dangerous condition not only for the mother, but also for the child, because of the severe pain syndrome.

The tactics of treatment in each case is different and depends on the severity of the clinical picture and the length of the pregnancy.

[12]

Complications and consequences

The main complications of cholecystitis in 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 can quickly occur with the development of peritonitis, peliflebite and other complications. Therefore, the suspicion of acute purulent cholecystitis requires immediate surgical intervention. Complications are also associated with possible negative effects on the fetus. The attack of cholecystitis due to severe pain syndrome can provoke premature birth, premature detachment of the placenta, distress of the fetus. Therefore, it is important to carry out anesthesia in this case with the choice of further tactics of labor management.

[13], [14]

Diagnostics of the cholecystitis in pregnancy

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

Analyzes with cholecystitis in pregnant women have characteristic signs of the inflammatory process - an increase in ESR, leukocytosis and a shift of 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 the biochemical blood test, such indicators as total bilirubin due to the indirect, as well as alkaline phosphatase, as a marker of disturbed bile outflow will be increased. As for hepatic markers, they will be normal, which makes it possible to exclude liver pathology.

Instrumental diagnostic methods are of primary importance for the diagnosis decision. The "gold standard" for diagnosing cholecystitis in pregnancy is ultrasound, because along with high informativeness, the effect on the fetus is minimal. At US in a projection of a cholic bubble it is possible to see:

• thickening and heterogeneity of the gallbladder wall, which indicates an infectious inflammation of it;
• the presence of concrements in the cavity of the gallbladder - a sign of calculous cholecystitis;
• violation of the normal location or bends - symptoms of functional disorders;

These ultrasound signs make it possible to determine the exact diagnosis and treatment tactics.

Since all diseases of the mother have a negative impact on the child, it is also necessary to carry out a diagnosis of the fetus in a comprehensive examination. One of the most accessible and informative methods is cardiotocography. This study allows you to determine the state of the child by monitoring its heart rate, movements, as well as the status of the uterus and the presence or absence of fights. This is also a reliable method of differential diagnosis of preterm labor and an attack of acute cholecystitis.

[15]

Differential diagnosis

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

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

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

When a woman is disturbed by any health problems, she worries about her child, so she immediately turns to the obstetrician-gynecologist. He, in turn, must exclude all pathologies associated with pregnancy and threatening the fetus with conditions. Symptoms of nausea, vomiting characteristic of cholecystitis, must be differentiated with late gestosis. To do this, it is important to conduct a comprehensive survey and exclude these conditions. With late gestosis, blood pressure rises, the protein in urine rises, which is not characteristic of cholecystitis.

It is also necessary to exclude liver damage, which allows you to make a biochemical blood test with the determination of hepatic transaminases.

Premature birth can also be accompanied by pain in the abdomen of a diffuse nature, and cardiotocography allows eliminating this condition. With cholecystitis, the normal tone of the uterus without contractions and a good heartbeat of the fetus is determined, which makes it possible to exclude premature births.

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

Treatment of the cholecystitis in pregnancy

Treatment of cholecystitis in pregnancy should be etiologically and pathogenetically justified. The method of treatment is determined in each case individually. Distinguish conservative and operative treatment. Among the conservative methods also differentiate medication, alternative remedies and homeopathic methods.

An important stage of treatment is diet 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, as the activity of the gastrointestinal tract and the secretion of bile are activated.

Diet is an important point in the treatment of cholecystitis. Food should be divided in small portions 5-6 times a day. This facilitates the release of bile at each meal and eliminates stagnation. It is necessary to exclude from the diet fatty, fried, smoked, salty foods, which irritates the liver and intensifies dyspeptic symptoms. It is necessary to include egg yolk, olive oil, and butter in small amounts in the diet, to improve the outflow of bile. But this concerns only the chronic process, with acute - this all is excluded and the diet should be sparing.

Drug treatment, as a rule, is used for chronic cholecystitis, which a woman is ill before pregnancy. The following drugs are available:

• Hofitol - a preparation of vegetable origin, which is an aqueous tincture of leaves of field artichoke. The drug has a pronounced choleretic effect, as well as a hepatoprotective effect by strengthening the membranes of hepatocytes. It is prescribed to pregnant women with late gestosis - pre-eclampsia - as a complex therapy, as well as chronic non-calculous cholecystitis. The drug is available in the form of tablets of 200 mg, take one tablet three times a day for 20 minutes before meals. Side effects that can be are allergic manifestations and dyspepsia in the form of diarrhea. It should be used with caution in the gallstones, as this can provoke hepatic colic.
• Holosas is a herbal preparation prepared from the water extract of a dogrose. It is a choleretic - it contributes to the secretion and secretion of bile from the gallbladder, which is important in connection with the atony of the bladder in pregnant women. The drug is available in the form of syrup in 300 ml vials. Take syrup on one teaspoon three times a day. Side effects are possible in the form of allergic manifestations, as well as nausea. It is necessary to be cautious with the use of the drug with concomitant diseases of the gastrointestinal tract.
• Tanatechol is a true-born choleretic that is obtained from a plant - tansy. He has a pronounced choleretic effect and promotes a change in the composition of bile. Also, the drug has a positive effect - spasmolytic - relaxes the gallbladder and ducts, which improves the outflow of bile.

Produced in the form of tablets and applied after meals, one tablet three times a day. Side effects are allergic manifestations. Do not use the drug in the presence of stones in the gallbladder, this can exacerbate the condition.

• Convaflavin is a combined herbal preparation, the main component of which is lily of the valley. In addition to pronounced choleretic action, the drug has an antispasmodic effect, which reduces the severity of the pain syndrome. The drug is available in the form of tablets of 100 mg, it is low in toxicity and is administered orally 2 tablets three times a day before meals. Side effects can be in the form of dizziness, allergic reactions and stool disorders.
• Baralgin, Drotaverin, Papaverin are preparations from the group of antispasmodics, which are prescribed in case of painful syndrome to relieve spasm of the gallbladder and bile ducts. The drugs are used in the form of tablets - taking one pill when symptoms appear.

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

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

Operative treatment of cholecystitis in pregnant women is carried out only with a confirmed diagnosis of acute purulent cholecystitis or an attack of cholecystitis in cholelithiasis. Then there is a direct danger to life of the pregnant woman, because there is a foci of infection that can quickly spread to surrounding organs or pain syndrome can cause premature birth. The volume of the operation is the removal of the gallbladder, which is carried out under general anesthesia, considering the use of anesthesia that does not affect the fetus. Pregnant women do not undergo laparoscopic surgery, operative access is a medial laparotomy, for a better revision of the abdominal cavity, because the anatomy of the internal organs changes in connection with the enlarged uterus.

After removal of the gallbladder and the audit put through drainage. This operation is carried out with constant monitoring of the fetus. In case of signs of distress of the fetus - caesarean section.

Alternative treatment of cholecystitis in pregnant women

Alternative treatment of cholecystitis in pregnant women has its advantages, as medicines during pregnancy are of limited use because of the possible risk of influencing the fetus.

Many methods of alternative treatment are used, the main effect of which is a pronounced choleretic and spasmolytic effect.

• Corn stigmas are one of the most well-known drugs used in alternative medicine for the treatment of chronic cholecystitis. The fruits of the corn are dried, then poured with boiled water in a ratio of one to one and insist. Such a decoction is taken warm by half a glass three times a day.
• Dandelion - the roots of this plant blooming in yellow, not faded, you need to rinse, cut and boil for five minutes, then insist another twenty minutes and strain. You need to drink in a warm form for half a cup three times a day before meals.
• Beet juice also has a pronounced choleretic effect. Beetroot must be welded, but not to the full readiness, then clean and squeeze out the juice. This juice should be taken on a tablespoon before eating.
• The leaves of the immortelle and St. John's wort must be dried, boiled for five minutes and insisted for ten minutes, then cooled and take a quarter cup 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.

The main homeopathic remedies:

1. Cholesan is a drug that shows choleretic effect and hepatoprotective by improving metabolism in hepatocytes. The preparation is produced in granules, seven sugar granules are used for 20 minutes before meals, while they should be kept in the mouth until dissolved. Side effects were not detected with the use of this drug.
2. Bile - a homeopathic preparation that promotes the release and formation of bile, increases the motility of the gallbladder, reduces the formation of gallstones. Produced in the form of homeopathic granules. Apply five granules before meals, in the morning before breakfast for 20 minutes - 1 time per day. Adverse events were not detected. It should be used with other homeopathic remedies with a similar mechanism of action.
3. Hepel is a homeopathic remedy of a combined composition that has a pronounced antispasmodic, choleretic, antidiarrhoeal effect. It is available in the form of tablets and a solution for injection. For pregnant women, one tablet is used in the form of tablets three times a day. Can be combined with taking other medications, side effects are not revealed.
4. Choledius - a preparation of a homeopathic series complex. The drug has a pronounced anti-inflammatory effect on the gallbladder, does not affect the excretion of stones. Produced in the form of homeopathic drops. Method of application - 10 drops dissolve in half a glass of warm water, and drink a small sip once a day for forty minutes before eating. There were no side effects.

[16], [17]

Prevention

Prevention can be carried out nonspecific. It is recommended to treat chronic cholecystitis for women even before pregnancy planning, and also to monitor the course of the disease during pregnancy. Prophylaxis of complications is carried out by timely treatment and diagnosis of the disease. 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

Prognosis for chronic cholecystitis in pregnant women for the mother and fetus is favorable in case of symptomatic treatment and disease control to prevent recurrence. When acute cholecystitis requires immediate hospitalization, then surgical treatment also contributes to a favorable outcome and the possibility of prolonging the pregnancy until the end of the term.

Cholecystitis in pregnancy is a frequent pathology that requires timely diagnosis and treatment, in connection with the potential risk not only for the mother, but also for the fetus. Treatment is carried out individually, depending on the severity of clinical signs. In chronic cholecystitis, preference is given to medicinal treatment using herbal remedies, as well as alternative methods of treatment. In the case of an attack of acute cholecystitis, surgical treatment with fetal status control is necessary. With timely diagnosis and proper treatment, the prognosis of this pathology in "expectant mothers" is favorable.

[19], [20]