2024 FSA Podium and Poster Abstracts

P031: DO THE BENEFITS OUTWEIGH THE RISKS? MANAGEMENT OF EMERGENT LAPAROSCOPIC CHOLECYSTECTOMY IN PREGNANCY
Valentina Rojas Ortiz; Jonathan Nieves; Tyler Chonis; Shayla McMahon; Nicholas Nedeff; Omar Chahine; HCA Florida Kendall Hospital

40-year-old female G1P0 at 27.2 weeks of pregnancy with a history of hypothyroidism and former smoker who came due to acute right upper abdominal pain, 10/10, associated with nausea and vomiting. Denied vaginal bleeding and amniotic fluid leakage, + fetal movements. Patient was diagnosed with acute cholecystitis demonstrated by US and physical exam. 

The patient was recommended to have surgical treatment as not undergoing cholecystectomy has been demonstrated to have a higher risk of adverse outcomes in pregnancy such as preterm delivery, longer hospital stay, and being readmitted to the hospital. Also, recurring biliary colic symptoms in pregnant women can be more severe than the initial episodes, and the risk of ascending cholangitis can be devastating in pregnancy. Patient was also explained about potential complications due to surgery such as preterm labor, miscarriage, fetal demise, and aspiration, and how insufflation precludes the use of an intraoperative FHR monitor. 

The initial plan was general anesthesia with rapid sequence intubation, FHR monitor for most of the case plus standard ASA monitors for the mother. Patient had an adequate airway. No eventful events during intubation, intraoperative, and emergence. But 20 minutes in PACU, a nurse called about patient saturating 89% breathing room air and chest tightness. And oxygen saturation with supplemental oxygen of 8L with a mask was 93%. HR was 110 with blood pressure of 97/59. Upon auscultation, patient presented bilateral crackles with no wheezing. Incentive spirometry was recommended to the patient to persistent use every 10 mins. At this time, we thought of three possible diagnosis which are aspiration, basal atelectasis, or pulmonary embolism. 

We decided to do an ABG for A-a gradient to rule out possible PE. We decided not to do a chest X-ray now to avoid radiation unless it was absolutely necessary. We continue watching the patient very closely for 3 more hours in PACU. 

On post-op day two patient was complicated with ileus, and continued with constant dry cough and chest tightness. Although requiring 2L in NC. Hospitalist decided to take an x-ray, which showed reticular densities diffusely throughout the lungs bilaterally which can be seen with congestion or infection. Patient started a course of antibiotics with cefepime and vancomycin. 

Finally, pregnancy can be complicated with different surgical emergencies that may potentially compromise the mother as well as the fetus. Laparoscopic cholecystectomy is acceptable at all stages of pregnancy. Appropriate early intervention is essential to decrease morbidity and mortality. Medical decisions and determining whether the benefits outweigh the risks can be challenging during pregnancy as two individuals, the mother and fetus are involved.