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Marcie Feinman is director of the surgical intensive care unit at Sinai Hospital.
Marcie Feinman is director of the surgical intensive care unit at Sinai Hospital. (Sinai Hospital)

Hormonal changes during pregnancy can make expectant mothers more prone to developing gallstones. While gallstones won't hurt the fetus or complicate pregnancy, in some cases they may cause pain and discomfort for the mom, said Dr. Marcie Feinman, director of the surgical intensive care unit at Sinai Hospital. Sometimes the gall bladder has to be removed, she said.

What are gallstones and why are pregnant women at high risk for getting them?

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The gallbladder stores bile, which is fluid made by the liver to help with digestion. Gallstones occur when the balance of the components of bile are out of proportion. In the United States, cholesterol stones are the most common. If bile contains too much cholesterol, crystals will form which will coalesce into stones over time. Risk factors for stone formation include obesity and being female. Pregnant women are at increased risk of developing gallstones due to hormonal changes, especially the increase in estrogen levels. Hormone replacement with estrogen after menopause carries similar risks.

What are some of the symptoms of gallstones in pregnant women?

The majority of women with gallstones show no symptoms and will only know they have gallstones if they are found during a radiologic study for another cause. Of the people who have symptoms, cramping under the right rib cage, often after eating a big meal, is the most common. When gallstones cause pain, called biliary colic, there is no danger to mom or baby. However, the pain is often associated with nausea and vomiting, in which case there can be issues with mom getting adequate nutrition. If the gallstones cause infection in the gallbladder (cholecystitis) or block the flow of bile from the liver to the intestines through the bile duct,fever and chills can be present. Some people present with pain in their right shoulder or back, or complain of heartburn as well.

If symptoms of gallstones exist, an ultrasound is obtained to confirm whether they are present. This test is non-invasive and does not involve radiation, so it is safe for pregnant women. It is very accurate for gallstones. It can also determine if the gallstones are stuck in the bile duct and if the gallbladder is infected. Blood may also be taken to look for signs of infection or blocked bile duct. Additional tests can include MRIs based on the initial findings.

How do you treat gallstones in pregnant women? Do they need to be removed?

If the gallstones are not symptomatic, no treatment is required. If they cause pain and nausea, medications for these symptoms are prescribed to see if they help. If the pain is severe or associated with a prolonged inability to eat, the gallbladder may need to be removed. Similarly, if there is evidence of infection from the gallstones, antibiotics are given and ultimately the gallbladder is removed.

When gallstones travel outside of the gallbladder, they can get stuck in the bile duct, causing bile to back up and get infected. In this situation, a procedure called an endoscopic retrograde cholangiopancreatography may be needed. This involves putting a camera through the mouth into the intestines and removing the stone that is causing the blockage. Once the bile is free-flowing again, the entire gallbladder is surgically removed during a separate procedure.

If surgery is necessary, the gallbladder containing all the stones is taken out. The gallbladder is not an essential organ, and if it is removed the body learns to compensate. There are several options based on the timing of the pregnancy. Minimally invasive surgery is always preferred to decrease the chance of wound infections and allow for faster recovery. In the first and second trimester, laparoscopy is feasible. This approach is minimally invasive and consists of making several small incisions to remove the gallbladder. The abdomen is inflated with air (carbon dioxide) in order to have room to work. The air is removed at the completion of the operation. In the third trimester (or earlier with multiples), there may not be enough space to operate laparoscopically. In this situation, a larger incision under the rib cage may be necessary.

What are the health complications that can come as a result of the gallstones?

Inability to eat due to nausea and vomiting from gallstones can lead to low birth weight babies. Additionally, infections in the gallbladder and the bile ducts can lead to preterm labor. If gallstones travel out of the gallbladder down into the bile ducts, they can cause pancreatitis, or inflammation of the pancreas. The pancreas makes digestive enzymes that your body uses to break down and process food. The pancreas also makes insulin, the hormone that regulates sugar (glucose) in the blood.. Severe pancreatitis can lead to significant illness in mom with poor outcomes for the baby.

Can the gallstones hurt the baby or make delivery more complicated?

Gallstones themselves will not interfere with the health of the baby or complicate delivery. There is no increased incidence of delivery by Cesarean section due to gallstones.

Are the chances of developing gallstones shortly after delivery also common?

Symptomatic gallstones are common after delivery. Hormone levels fluctuate and rapid weight loss can lead to the formation of gallstones.

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