Background <p>Symptomatic biliary disease frequently prompts patients to seek medical care during pregnancy. Most guidelines now recommend prompt surgical intervention regardless of trimester for complicated biliary disease during pregnancy (i.e., acute cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis). We investigated our health system’s experience with the care of this patient population in the context of current recommendations.</p> Methods <p>The electronic medical record of a large, multi-hospital health system was queried from January 2017 to December 2024 for all patients with diagnoses of pregnancy and complicated biliary disease. Patients were divided into 4 groups based on trimester at time of procedural intervention or postpartum management. Patients in the postpartum group presented with symptomatic biliary disease during their pregnancy and progressed to complicated disease within three months after delivery, necessitating procedural intervention in that period of time.</p> Results <p>The search yielded 48 patients: 7 first trimester, 22 s, 5 third, and 14 postpartum. Procedural interventions included ERCPs and laparoscopic cholecystectomies. All cholecystectomies were completed without major surgical morbidity. Most interventions occurred in the second trimester or postpartum (75%). Surgical outcomes were similar across all groups; any variability in proportions was attributable to low sample sizes. Parental-fetal outcomes, including incidence of preeclampsia, pregnancy loss, and preterm delivery, were similar across groups.</p> Conclusion <p>Our analysis confirms that procedural interventions for complicated biliary disease are safe to perform regardless of trimester. Our work also demonstrates the difficulties of studying this disease process as the prevalence is relatively low. This area of study could benefit from multi-institutional collaboration.</p> Graphical abstract <p></p>