The most appropriate management is laparoscopic cholecystectomy prior to hospital discharge. This patient has uncomplicated gallstone pancreatitis in her second trimester. This is very likely her second symptomatic episode of gallstone disease, and cholecystectomy should be performed. Her risk of recurrent pancreatitis over the next 90 days is about 20%. Laparoscopic cholecystectomy can be safely performed during pregnancy, particularly in the second trimester.

Bile acid dissolution therapy for gallstones has not gained widespread acceptance because most patients, such as this one, are candidates for laparoscopic cholecystectomy and few are candidates for bile acid dissolution therapy. Bile acid dissolution therapy is expensive, requires long-term multiple daily dosing, necessitates repeated ultrasonography, and has a potential long-term risk for cancer in the remaining gallbladder. Finally, most nonsurgical therapies for gallstones are contraindicated in pregnant patients. The safety of bile acid therapy in pregnant women is largely unknown.

In a study of pregnant women who had complications related to gallstones during pregnancy, recurrent biliary symptoms, repeated visits to the emergency department, and recurrent hospitalizations were significantly more common in patients who received conservative treatment as compared with women who underwent laparoscopic cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP). Waiting until after delivery is not the best option for this patient.

ERCP with sphincterotomy could be used, but it should be performed only if this patient had contraindications to cholecystectomy or if there was high clinical suspicion of a persistent common bile duct stone. Neither of these conditions is present in this patient.

Extracorporeal shock-wave lithotripsy (ESWL) is reserved for patients with symptomatic gallstones who are poor candidates for surgery and in those patients with bile duct stones that are refractory to removal at ERCP owing to large size. After ESWL, the gallbladder remains in place and stones recur in about 50% of patients. This patient does not have an indication for ESWL.