Maternal choledochal cysts in pregnancy: A systematic review of case reports and case series

Abstract

Background: Choledochal cysts (CC) are cystic dilatations of the biliary tract, usually diagnosed during childhood, with an estimated incidence in the general population of 1:100000. Complications related to CC include rupture, biliary obstruction, and cholangitis. Maternal CC in pregnancy are rarely reported, and there are no guidelines on optimal management.

Aim: To systematically review maternal CC diagnosed during pregnancy or postpartum with regard to the clinical presentation of CC, the mode of treatment and delivery, and maternal outcomes.

Methods: A literature search of cases and case series of maternal CC in pregnancy and postpartum was conducted using MEDLINE/PubMed, Web of Science, Google Scholar, and Embase. There were no restrictions on language or publication year. Databases were lastly accessed on September 1, 2022.

Results: Overall, 71 publications met the inclusion criteria, reporting 97 cases. Eighty-eight cases were diagnosed during pregnancy and nine in the puerperium. The most common symptoms were abdominal pain (81.2%) and jaundice (60.4%). Interventions for CC complications were required in 52.5% of the cases, and 34% of pregnancies were induced. Urgent cesarean section (CS) was done in 24.7%. The maternal mortality was 7.2%, while fetal mortality was inconsistently reported. Cholangitis, CC > 15 cm, and bilirubin levels > 80 mmol/L were associated with a higher likelihood of urgent CS and surgical intervention for CC. Bilirubin levels positively correlated with CC size. There was no correlation between age and cyst dimension, gestational age at cyst discovery, and CC size.

Conclusion: Although rare, maternal CC in pregnancy should be included in the evaluation of jaundice with upper abdominal pain. Symptomatology and clinical course are variable, and treatment may range from an expectative approach to emergent surgical CC treatment and urgent CS. While most cases were managed by conservative measures or drainage procedures, CC > 15 cm and progressive cholangitis carry the risk of CC rupture and septic complications, which may increase the rates of unfavorable maternal and fetal outcomes. Therefore, such cases require specific surgical and obstetric interventions.

Keywords: Cesarean section; Cholangitis; Choledochal cyst; Delivery; Pregnancy; Surgery.

Figure 1

PRISMA flow diagram.

Figure 2

Diagram showing the period (years) in which studies were published.

Figure 3

Diagram showing gestational age (weeks) of choledochal cyst diagnosing.

Figure 4

Pie chart illustrating the type and proportion of different management approaches for choledochal cyst. ERCP: Endoscopic retrograde cholangiopancreatography.

Figure 5

Pie chart illustrating the type and proportion of different management approaches for pregnancy.

Figure 6

Correlation analysis between cyst size and bilirubin levels.

Figure 7

Proposed treatment algorithm for maternal choledochal cysts in pregnancy. CC: ''choledochal cyst'', CS: ''Cesarean section''.