choledochal cysts are congenitally malformed thin walled , dilated , intrahepatic or extrahepatic bile ducts .
these cysts offer a major challenge for diagnosis and treatment during pregnancy because of the altered physiology associated with it .
there has to be fine balance between the benefits as well as the risks associated with the treatment .
it is secondary to raised intracystic pressure because of distal stricture or stones [ 4 , 5 ] .
spontaneous rupture of the choledochal cyst during immediate post partum has rarely been reported [ 7 , 8 ] . here
we describe a young female who presented to us with choledochal cyst with cholangitis during pregnancy .
but unfortunately she presented in the immediate post partum with peritonitis secondary to spontaneous rupture of the cyst .
the rarity of this presentation in post partum poses a diagnostic dilemma in the minds of treating clinician .
this complication should be kept in mind while treating a known patient of choledochal cyst who presents to the emergency with peritonitis .
a 27-year - old primigravida presented to surgical emergency with obstructive jaundice and grade ii cholangitis at 6 months of pregnancy .
she was evaluated and was found to have a choledochal cyst on ultrasound and this was subsequently confirmed as type iv ( fig .
1 ) on magnetic resonance cholangiopancreatography ( mrcp ) . for these complaints , she underwent ercp and a biliary stent was placed so as to tide over the situation .
an endobiliary stent could be placed and she was being managed conservatively but had pain abdomen , fever and vomiting 1 week after stenting .
tachycardia ( pr : 120/min ) was present and there was generalized guarding and rigidity on abdominal examination .
a contrast - enhanced ct scan was done that revealed the rupture of the suprapancreatic part of the choledochal cyst with free fluid in the abdominal cavity ( fig .
2 ) . after optimization , this patient underwent cyst excision with roux - en - y hepaticojejunostomy .
histopathology of this excised cyst confirmed the choledochal cyst rupture without any evidence of dysplasia ( fig .
the patient did well in the postoperative period and was discharged on the 10th postoperative day .
with recent advances in medical science , choledochal cyst is diagnosed 25% of the times during adulthood and rarely during pregnancy [ 9 , 10 ] .
it is associated with multiple complications during pregnancy like cholangitis , preterm labor , abortion and even rupture .
the cumulative risk of spontaneous choledochal cyst rupture varies between 1.8% and 2.8% [ 11 - 13 ] .
rupture is more common during childhood and rare during post partum period of the pregnancy .
weakness of the dilated cyst wall with raised intracystic pressure because of stones / strictures , trauma due to multiple interventions , regurgitation of the amylase rich fluid in the bile duct and association of the anomalous pancreatobiliary junction are the commonly reported in literature [ 14 - 18 ] .
multiple ercp and stent placement secondary to cholangitis causing the cbd weakness is the most probable cause of rupture in the present case .
ercp is associated with increased risk of radiation exposure and subsequent malformations in the fetus .
many studies have proved the efficacy of ercp during pregnancy particularly when the radiation dose to the fetus is calculated .
ercp when indicated should be done with utmost care and in controlled conditions to prevent fetal damage .
. however , pregnancy along with increased pressure during childbirth puts these patients at risk for cyst rupture and fetal loss .
we tided over the complications of the cyst with minimally invasive techniques but repeated interventions for the same might have triggered the rupture .
there is no consensus on the management of the ruptured choledochal cyst due to the rarity of the condition .
friability of the cyst wall , hemodynamic instability , inflammation and edematous bowel mandate the drainage of the cbd either with a t - tube or percutaneous transhepatic drain [ 2 , 3 ] .
alternatively , single stage operation of cyst excision with bilioenteric drainage can be performed provided the intraoperative conditions are favorable .
this patient had normal bowel with minimal inflammation of the bile duct so single stage operation was contemplated .
cyst rupture should be kept as a differential diagnosis whenever a known patient harboring choledochal cyst presents with peritonitis .
pregnancy with choledochal cyst rupture puts the maternal as well as fetal life at risk .
cyst rupture should be kept as a differential diagnosis whenever a known patient harboring choledochal cyst presents with peritonitis .
pregnancy with choledochal cyst rupture puts the maternal as well as fetal life at risk .
ag , kc and lk were involved in writing , editing and approval of the manuscript .
 with the advent of newer radiological investigations , choledochal cysts are being diagnosed more often in present era . 
 these cysts are commonly diagnosed in early childhood and infancy , although some go undetected to be diagnosed in adulthood . 
 these malformations are associated with multiple complications like cholangitis , jaundice , pancreatitis , rupture or even malignancy . here 
 we describe a post partum female , who was diagnosed to have choledochal cyst during sixth month of pregnancy . 
 she presented with obstructive jaundice in cholangitis and was subjected to endoscopic retrograde cholangiopancreatography ( ercp ) with stenting . 
 this female delivered normally at term . 
 she again had jaundice with cholangitis during early post partum period . 
 endoscopic stenting could be performed . 
 she had features of peritonitis after 1 week of stenting . 
 investigations were performed and a diagnosis of spontaneous rupture of choledochal cyst was made . 
 she underwent laparotomy and lavage with complete excision of the choledochal cyst and roux - en - y hepaticojejunostomy . 
Introduction
Case Report
Discussion
Conclusion
Conflicts of Interest
Funding
Author Contributions