This chapter deals primarily with APGO Educational Topic Area:
TOPIC 41 GYNECOLOGICAL PROCEDURES
Students should be able to describe preoperative, perioperative, and postoperative care to optimize outcomes for gynecologic surgical patients. They should be able to outline indications, the consent process, and complications of standard inpatient and outpatient gynecologic procedures and imaging.
Clinical Case
A 34-year-old woman is referred for the evaluation of an abnormal Pap smear, which was reported as “ASCUS (atypical squamous cells of undetermined significance) with positive high-risk human papillomavirus present.” A colposcopy is performed, was satisfactory, and showed no lesions. Endocervical curettage was performed and was reported as showing a high-grade lesion.
IMAGING STUDIES
Gynecologic imaging plays an important role in the diagnostic evaluation of women for a variety of reproductive health conditions. Although the ability to image various parts and organs of the body has dramatically enhanced clinicians’ diagnostic capabilities, these methods do not replace a careful and thoughtful history and physical evaluation. However, they can add more detail, which assists in both medical and surgical management. The effective use of these modalities requires that the physician be familiar with the benefits and limitations of each method.
Ultrasonography
Ultrasonography remains the most common modality for evaluation of the female pelvis. It uses high-frequency sound reflections to identify different body tissues and structures. Short bursts of low-energy sound waves are sent into the body. When these waves encounter the interface between two tissues that transmit sound differently, some of the sound energy is reflected back toward the sound source. The returning sound waves are detected, and the distance from the sensor is deduced using the elapsed time from transmission to reception. An image is then created and displayed on a monitor. Ultrasonography is safe for pregnant and nonpregnant patients.
Most ultrasonography produces two-dimensional images. Three-dimensional studies can be used for volume calculation and to provide detail about the surfaces of particular structures. In gynecology, three-dimensional ultrasonography is especially useful in the evaluation of müllerian abnormalities (see Chapter 4). Four-dimensional ultrasonography, which shows movement, is also available and has proven helpful in evaluating such things as fetal cardiac abnormalities.
Two kinds of probes are used in gynecologic ultrasonography: transabdominal and transvaginal (Fig. 34.1). Owing to a lower frequency used, a transabdominal probe has an increased depth of penetration, which allows for the assessment of large uterine or adnexal masses. However, in obese patients, it may not allow proper imaging of pelvic structures. A transvaginal probe can be placed internally; thus, it often gives improved views of the cervix, uterus, ovaries, and tubes. Also, it has a higher frequency and shorter depth of penetration, which result in enhanced image clarity.
Uses of Ultrasonography
One of the most valuable uses of ultrasonography in gynecology is for imaging masses. The imaging technique helps distinguish between cystic and solid adnexal masses. Although magnetic resonance imaging (MRI) and computed tomography (CT) can also be used for evaluation of ovarian cysts, ultrasonography is far less costly; for this purpose, experts consider it superior to either MRI or CT. It is also possible to delineate leiomyoma (fibroid) size and number using ultrasonography.
FIGURE 34.1. Transabdominal (a) and transvaginal (B) ultrasonography.
Use of the endometrial stripe thickness for evaluation of postmenopausal bleeding has been studied extensively. Following menopause, the endometrium becomes atrophic, and its thickness decreases, remaining relatively constant without hormonal stimulation. Ultrasonographic evaluation of the endometrial stripe involves measuring the thickest portion of the endometrial echo in the sagittal plane. An endometrial stripe thickness of greater than 4 mm should be interpreted as abnormal in postmenopausal women not taking hormone therapy. These patients generally receive histologic assessment of an endometrial tissue sample to exclude endometrial carcinoma.
Saline infusion during ultrasonography (sonohysterography [SHg]) can aid in the visualization of the endometrial cavity and can often identify intrauterine polyps or submucosal leiomyomas (Fig. 34.2). In this technique, saline is infused via a transcervically inserted catheter. The saline acts as a contrast agent to delineate the endometrium and intracavity masses. The primary role of SHG is in the diagnosis of the cause of abnormal uterine bleeding (AUB). It is preferred over unenhanced ultrasonography in the evaluation of AUB because of its increased diagnostic accuracy of the endometrial cavity and greater cost effectiveness.
Computed Axial Tomography
Computed axial tomography (CAT, or CT) scanning uses computer algorithms to construct cross-sectional images based on x-ray information. With the use of oral or intravenous (IV) contrast agents, CT scanning can help evaluate pelvic masses, identify lymphadenopathy, and plan radiation therapy.
CT involves slightly greater radiation exposure than a conventional single-exposure radiograph but provides significantly more information. The radiation dose of an abdominal CT is still below that thought to cause fetal harm. Nevertheless, because of CT’s increased risk of fetal effects, MRI (see below) or ultrasonography should be used for imaging instead of CT whenever possible in pregnancy.
FIGURE 34.2. Sonohysterogram showing several polyps. (From Breitkopf DM. Gynecologic imaging. In: Precis: Gynecology. 3rd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2006:17.)
Magnetic Resonance Imaging
MRI is based on the magnetic characteristics of various atoms and molecules in the body. Because of the variations in chemical composition of body tissues (especially the content of hydrogen, sodium, fluoride, and phosphorus), MRI can distinguish between types of tissues, such as blood and fat. This distinction is useful in visualizing lymph nodes, which are usually surrounded by fat; in characterizing adnexal masses; and in locating hemorrhage within organs. MRI is also useful for visualizing the endometrium, myometrium, and cystic structures in the ovaries. Emerging areas of clinical applicability include assessment of lesions in the breast and staging of cervical cancer. In pregnant patients requiring imaging beyond ultrasound, an MRI is preferred over a CT.
Breast Imaging
Mammography is an x-ray procedure used to screen for breast cancer. It is performed by passing a small amount of radiation through compressed breast tissue (Fig. 34.3). Because mammography has a high false-positive rate (10% per screening in postmenopausal women and as high as 20% per screening in obese or premenopausal women), additional testing may be required. Digital mammography allows better visualization of dense breast tissue than conventional mammography.
Ultrasonography is also used to evaluate cystic or solid breast masses and guide aspiration of cysts. MRI may also be used as an imaging technique for breast tissue and has been recommended as an adjunct in selected high-risk women.
Hysterosalpingography
Hysterosalpingography (HSg) is most often used to evaluate the patency of the fallopian tubes in women who may be infertile. This procedure is done in a radiologic suite. After a radioopaque dye is injected transcervically, fluoroscopy (live x-ray) is used to determine whether dye spills into the peritoneal cavity (Fig. 34.4). HSG can also be used to define the size and shape of the uterine cavity and to detect developmental abnormalities, such as a unicornuate, septate, and didelphic uterus (see Chapter 4). It also can demonstrate most endometrial polyps, submucous myomata, and intrauterine adhesions that are significant enough to have important reproductive consequences. It is also carried out to confirm the efficacy of transcervically placed sterilization devices (e.g., Essure).
FIGURE 34.3. Mammogram. (From Stedman’s Medical Dictionary. 27th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000.)
FIGURE 34.4. Hysterosalpingography.
PROCEDURES
Gynecologic procedures include diagnostic procedures, such as biopsy and colposcopy, as well as procedures used as treatment modalities. Some procedures, such as laparoscopy and hysteroscopy, can be performed for both diagnosis and treatment and are chosen specifically for this reason. For all invasive procedures (and some imaging studies), the informed consent process is a necessity and must precede the start of the procedure. Some form of “time out,” that includes positive identification of the patient and planned procedure, should be performed with all participating parties in the room prior to commencing the procedure.
Genital Tract Biopsy
Biopsies of the vulva, vagina, cervix, and endometrium are frequently necessary in gynecology. These procedures are usually comfortably performed in the office; they require either no anesthesia or local anesthesia.
Vulvar Biopsy
Vulvar biopsies are performed to evaluate visible lesions, persistent pruritus, burning, or pain. A circular, hollow metal instrument 3 to 5 mm in diameter, called a punch, is used to remove a small disk of tissue for evaluation (Fig. 34.5). For hemostasis, local pressure or coagulants (styptics) such as Monsel solution (ferric subsulfate) are often used. Sutures are rarely necessary. Local anesthesia is required for this type of biopsy.
Vaginal Biopsy
Vaginal biopsy is performed to assess suspicious masses and to evaluate the vagina in the presence of cervical abnormalities. Women who have had a prior hysterectomy for cervical cancer should continue to have Pap tests performed on the vaginal cuff; if a result is abnormal, a vaginal biopsy may be required. Vaginal biopsy is performed with pinch biopsy forceps. Local anesthesia is rarely required.
Cervical Biopsy
Cervical biopsy is performed with biopsy forceps and, perhaps, a colposcope for visualization (see below). No anesthesia is necessary. Indications for cervical biopsy include chronic cervicitis, suspected neoplasm, and ulcer.
Endometrial Biopsy
Endometrial biopsy (EMB) is generally used to evaluate AUB, such as menorrhagia, metrorrhagia, and menometrorrhagia. EMB is accomplished with a small diameter catheter with a mild suction mechanism (Fig. 34.6). Various types are available. Anesthesia is not necessary, but many patients are more tolerant of EMB when given ibuprofen (400–800 mg) 1 hour prior to the procedure.
FIGURE 34.5. Biopsy of vulvar lesion. The punch is rotated in place to incise tissue.
FIGURE 34.6. Endometrial biopsy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2008.)
Colposcopy
Colposcopy is performed to evaluate abnormal Pap results. It facilitates detailed evaluation of the surface of the cervix, vagina, and vulva when premalignancy or malignancy is suspected based on history, physical examination, or cytology. Cervical biopsy of suspicious lesions is frequently performed during colposcopy. Chapter 47 provides more detail about colposcopy.
Cryotherapy
Cryotherapy is a technique that destroys tissue by freezing. A hollow metal probe (cryoprobe) is placed on the tissue to be treated. The probe is then filled with a refrigerant gas (nitrous oxide or carbon dioxide) that causes it to cool to an extremely low temperature (between −65° and −85°C), freezing the tissue that is in contact with the probe. Cryotherapy is most often used to treat cervical intraepithelial neoplasia (CIN) and other benign lesions such as condyloma. The formation of ice crystals within the cells of the treated tissue leads to tissue destruction and subsequent sloughing. Patients who have had cryotherapy of the cervix can expect to have a watery discharge for several weeks as the tissues slough and healing occurs. Although cryotherapy is inexpensive, well tolerated, and generally effective, it is less precise than other methods of tissue destruction, such as laser ablation and electrosurgery.Destructive therapies do not yield histologic specimens and are not used when this is a consideration.
Laser Vaporization
Highly energetic coherent light beams (light amplification by stimulated emission of radiation [laser]) may be directed onto tissues, facilitating tissue destruction or incision, depending on the specific wavelength of light used and the power density of the beam. Infrared wavelength (from a CO2 laser) is the most common type of laser used in gynecologic procedures. Yttrium-aluminum-garnet, argon, or potassiumtitanyl-phosphate lasers, all of which have different effects on tissues, are also used. Some can be used in the presence of saline or water. The type of laser is selected according to the indication or desired effect of the surgery. Although expensive, the great precision that laser offers makes it a useful tool in specific clinical settings.
Laser therapy is used to treat vaginal and vulvar lesions, such as condyloma, vaginal intraepithelial neoplasia, and vulvar intraepithelial neoplasia. Laser is also used to treat other dermatologic vulvar disorders, including molluscum contagiosum and lichen sclerosis atrophy. Prior to the development of the loop electrosurgical excision procedure ([LEEP] see below), laser ablation and conization were common treatment modalities for cervical intraepithelial neoplasia ablation and cervical conization.
Dilation and Curettage
Dilation and curettage (D&C) is a procedure in which the cervix is dilated using a series of graduated dilators, followed by curettage (scraping) of the endometrium, for both diagnostic (histologic) and therapeutic reasons. D&C is usually performed under anesthesia in the operating room. Some common indications for D&C include AUB, incomplete or missed abortion, inability to perform EMB in the office, postmenopausal bleeding, and suspected endometrial polyp(s). With the availability of newer imaging procedures, D&C is now less commonly performed. In some settings, smaller cannulae with self-contained suction devices are used in the office setting for diagnostic (EMB) or therapeutic (incomplete abortions or “menstrual extractions”) indications similar to D&C.
Hysteroscopy
Hysteroscopy is the visualization of the endometrial cavity using a narrow telescope-like device (Fig. 34.7) attached to a light source, camera, and distension medium (often normal saline). It is used to view lesions such as polyps, intrauterine adhesions (synechiae), septa, and submucous myomas. Special instruments allow directed resection of such abnormalities. Hysteroscopy is commonly performed in the outpatient setting under general anesthesia; however, it can also be performed in the office as a diagnostic procedure or in conjunction with either endometrial ablation or SHG.
Procedures for nonreversible sterilization have been designed to be used in conjunction with the hysteroscope. In these procedures, metal coils (Essure) or a biocompatible silicone matrix (Adiana) are inserted into the ostium of each fallopian tube under direct visualization. Scarring of the tubal ostia then occurs. To confirm that the tubes are occluded, an HSG must be performed 3 months later.
FIGURE 34.7. Hysteroscopy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2006.)
Endometrial Ablation
Endometrial ablation is used to destroy the uterine lining. The procedure is used to treat AUB in women who do not wish to become pregnant. It is not a method of sterilization; therefore, women who undergo ablation must use some other form of birth control. Various ablation devices are available; they may use heat, electrosurgical energy, or cryotherapy. Some, but not all, of the available techniques involve direct visualization of the endometrium with a hysteroscope. Many women opt for endometrial ablation because it is a minor procedure, thus avoiding major surgery in the form of a hysterectomy. The procedure can be performed in either the surgical suite or office. In the office, a combination of nonsteroidal anti-inflammatory drugs, a local anesthetic, and an anxiolytic is used to provide pain relief. Success is not assured— hysterectomy rates associated with endometrial ablation are at least 24% within 4 years following the procedure.
Pregnancy Termination
Pregnancy termination refers to the planned interruption of pregnancy before viability and is often referred to as induced abortion. It is generally accomplished surgically through dilation of the cervix and evacuation of the uterine contents, accomplished under local anesthesia. In the first and early second trimester, removal of the products of conception uses either a suction or a sharp curette. Suction curettes are often preferred because they are less likely to cause uterine damage, such as endometrial scarring or perforation. In the second trimester, destructive grasping forceps may be used to remove the pregnancy through a dilated cervix (called dilation and evacuation).
Alternatively, in the first trimester (within 9 weeks of the first day of the last menstrual period), pregnancy can be terminated using medical rather than surgical techniques. Medical abortion may be carried out using one of the following methods:
• Mifepristone and misoprostol pills
• Mifepristone pills and vaginal misoprostol
• Methotrexate and vaginal misoprostol
• Vaginal misoprostol alone
A woman who is still pregnant after an attempted medical abortion needs to have a surgical abortion.
Cervical Conization
Conization is a surgical procedure in which a cone-shaped sample of tissue, encompassing the entire cervical transformation zone and extending up the endocervical canal, is removed from the cervix (Fig. 34.8). It may be required as the definitive diagnostic procedure in the evaluation of an abnormal Pap test when the colposcopic examination is inadequate or when colposcopic biopsy findings are inconsistent with Pap test results. Colposcopy-guided conization may also be used therapeutically in cases of CIN. Various techniques for conization are available, including cold knife (scalpel), laser excision, and electrosurgery (LEEP, also called large loop excision of the transformation zone, or LLETZ). Laser excision and LEEP are often performed in the office. Long-term complications may include cervical insufficiency and stenosis.
FIGURE 34.8. Conization of the cervix. (A) Cold-knife technique. (B) LLETZ/LEEP (large loop excision of the transformation zone/loop electrosurgical excision procedure) technique.
Minimally Invasive and Robotic Surgery
Laparoscopy (also known as minimally invasive surgery) is the visualization of the pelvis and abdominal cavity using an endoscopic telescope, which is most often placed via an incision in the periumbilical region (Fig. 34.9). The procedure may be diagnostic or therapeutic. Laparoscopic evaluation and treatment may be performed for conditions such as chronic pelvic pain, endometriosis, infertility, pelvic masses, ectopic pregnancies, and congenital abnormalities. Sterilization (bilateral tubal ligation) using techniques such as bipolar cautery, clips, or bands can be accomplished easily via laparoscopy (see Chapter 27). During the procedure, carbon dioxide is insufflated to distend the peritoneal cavity to provide visualization. Additional instruments with diameters of 5 to 15 mm may be inserted via other laparoscopic incisions. The number, length, and location of incisions depend on the instruments needed and the size of any tissue specimens that are to be removed. Transvaginal insertion of a uterine manipulator facilitates these maneuvers. Robotic devices may be used to position and manipulate the viewing and operating devices. This technology allows for three-dimensional images and finer dexterity but at a trade-off for increased setup time and equipment costs. Clear superiority for robotic techniques has only been proven for a limited number of indications.
After laparoscopy, the most common complaints include incisional pain and shoulder pain due to referred pain of diaphragmatic irritation from the gas used to provide visualization. Rare but serious complications include damage to major blood vessels, the bowel, and other intra-abdominal or retroperitoneal structures. However, when compared with laparotomy, laparoscopy has several advantages, including avoidance of long hospital stays, smaller incisions, quicker recovery, and decreased pain.
FIGURE 34.9. Laparoscopy. (Figure adapted from the American College of Obstetricians and Gynecologists, © 2008.)
Hysterectomy
Hysterectomy, removal of the uterus, is still one of the most commonly performed surgical procedures. In the United States, more than 500,000 hysterectomies are completed annually. The indications for hysterectomy are numerous; they include AUB that has not responded to conservative management, pelvic pain, postpartum hemorrhage, symptomatic leiomyomas, symptomatic uterine prolapse, cervical or uterine cancer, and severe anemia from uterine hemorrhage.
Patients are often confused by inaccurate terms used to describe types of hysterectomy. To many patients, a “complete” hysterectomy means removal of the uterus, fallopian tubes, and ovaries, and a “partial” hysterectomy means removal of the uterus but not the tubes and ovaries. However, the correct term for the removal of both tubes and both ovaries is a bilateral salpingo-oophorectomy, and this procedure is generally not part of a hysterectomy. Thus, it is important to determine exactly what procedure a patient may have had. Equally important is what a patient is expecting when a surgical procedure is planned. A total hysterectomy is the removal of the entire uterus, whereas a supracervical (or subtotal) hysterectomy removes the uterine corpus while leaving the cervix. The uterus may be removed by several different routes.
Abdominal Hysterectomy
Abdominal hysterectomy is performed via a laparotomy incision. The laparotomy incision can be either transverse, usually pfannenstiel, or vertical. The decision to perform a laparotomy involves many factors—the skill of the surgeon, the size of the uterus, concern for extensive pathology (e.g., endometriosis or cancer), the need to perform adjunct surgery during the surgery (e.g., lymph node dissection, appendectomy, and omentectomy), and previous intra-abdominal scarring or surgeries.
Vaginal Hysterectomy
Vaginal hysterectomy is preferred if there is adequate uterine mobility (descent of the cervix and uterus toward the introitus), the bony pelvis is of an appropriate configuration, the uterus is not too large, and there is no suspected adnexal pathology. In general, vaginal hysterectomy is performed for benign disease. The advantage of vaginal surgery is less pain than with abdominal surgery, quicker return of normal bowel function, and a shorter hospital stay. If indicated, a unilateral or bilateral salpingo-oophorectomy can be performed in conjunction with a vaginal hysterectomy.
Laparoscopic-Assisted Vaginal Hysterectomy
Laparoscopic-assisted vaginal hysterectomy (LAVH), with or without a bilateral salpingo-oophorectomy, is often performed for patients who desire minimally invasive surgery and may not have adequate descensus of their uterus to undergo a vaginal hysterectomy. LAVH can be accomplished by performing most or all of the procedure laparoscopically; then the uterus is removed through the vagina. The vaginal cuff can then be sutured transvaginally or laparoscopically.
Total Laparoscopic Hysterectomy
It is possible to perform a hysterectomy totally via the laparoscopic approach. This is usually accomplished with the assistance of a morcellator, which divides the uterus into multiple smaller specimens that can be removed through the ports. Even large uteri can be safely removed through small incisions. This approach is reserved for benign indications only because a histological evaluation is not practical after morcellation.
UROGYNECOLOGY PROCEDURES
Many gynecologists perform urogynecology procedures in the office and operating room. These procedures include the Q-tip test, urodynamic tests, cystoscopy, transvaginal tape (sling), and the Burch procedure. A description of these procedures can be found in Chapter 30.
PREOPERATIVE, INTRAOPERATIVE, AND POSTOPERATIVE CONSIDERATIONS
Preoperative Considerations
Any surgical procedure carries risks. Naturally, more invasive procedures carry higher risks. Before patients sign preoperative surgical consent forms, they should be counseled on the risks of infection, hemorrhage, and damage to surrounding structures (bowel, bladder, blood vessels, and other anatomic structures). Many hospitals require that patients also sign a consent form for a blood transfusion in case of an emergency. Some patients refuse to sign such consents for blood transfusion for personal or religious reasons, and this should be clearly documented in the chart. A discussion with the patient regarding the safety of the blood used for transfusion should address the risk of acquiring human immunodeficiency virus, hepatitis B and C viruses, and other bloodborne pathogens.
Preoperative testing, which could include blood work, urinalysis, other laboratory tests (e.g., glucose, creatinine, hemoglobin, and coagulation parameters), pregnancy testing, electrocardiogram, and imaging studies (e.g., CT and MRI), should be individualized based on the patient’s age (especially in pediatric patients), concurrent medical problems, route of anesthesia, and surgical procedure planned.
Minor procedures are now more commonly performed in the office setting for patient convenience, avoidance of general anesthesia, and improved reimbursement. In addition, not all patients are surgical candidates, and nonsurgical therapeutic options should always be considered. Patients may have such significant medical problems (e.g., poorly controlled diabetes, heart disease, and pulmonary disease) that they might not safely tolerate anesthesia or surgery.
Intraoperative Considerations
Several intraoperative and perioperative issues should be considered. Prophylactic antibiotics are indicated for some gynecologic surgeries and should be administered within 1 hour of skin incision. Often, a Foley catheter is inserted prior to surgery to prevent the bladder from becoming distended during the procedure. A preoperative pelvic examination of the anesthetized patient can prove useful.
Postoperative Considerations
Postoperatively, a nurse and a member of the anesthesia team assess the patient in the postanesthesia care unit. The patient is either discharged to home or admitted to the hospital, depending on the type of procedure performed and the condition of the patient. An operative note must be documented in the chart immediately postoperatively, outlining the preoperative diagnosis, postoperative diagnosis, procedure, surgeon(s), type of anesthesia, amount and type of IV fluid administered, any other fluids given (transfusions or other products), urine output (if indicated), findings, pathology specimens sent, complications, and a statement of patient’s condition upon completion of the procedure. This note should generally document steps made to ensure patient safety such as a preoperative “time out”; deep vein thrombosis (DVT) prophylaxis, as indicated; and sponge and instrument counts at the end of the case. Postoperative orders for inpatient stays should include a notation of the procedure performed, the name of the attending physician and service, frequency of vital signs, parameters for calling the physician, diet, activity, IV fluids, pain medications, resumption of any home medications (e.g., antihypertensives, diabetic drugs, and antidepressants), antiemetic medications, DVT prophylaxis, Foley catheter, incentive spirometer, and any necessary laboratory studies.
During a postoperative hospitalization, the patient should be seen at least daily. Careful assessment and monitoring of pain, bladder and bowel function, nausea and vomiting, and vital signs are routine. Early ambulation can reduce the risk of thromboembolism. The most common surgical complications are fever, urinary tract infection (UTI), surgical site drainage and bleeding, minor separation of skin incisions, hemorrhage, pneumonia, ileus, and minor surgical site infection(s). Less common postoperative complications include skin and subcutaneous wound separation, fascial dehiscence or evisceration, bowel perforation, urinary tract injury, severe hemorrhage requiring reoperation, DVT, pulmonary embolism (PE), abscess, sepsis, fistulas, and anesthetic reactions.
Postoperative Complications
Fever is defined as two oral temperatures of ≥38°C at 4-hour intervals. Primary sources of fever include the respiratory and urinary tracts, the incision(s), thrombophlebitis, and any medications or transfusions.Atelectasis occurs when patients do not take large inspiratory breaths due to abdominal discomfort. Use of an incentive spirometer can minimize the risk of atelectasis and pneumonia. Use of an indwelling urinary catheter should be minimized, because placement for more than 24 hours increases the risk of UTI (cystitis or pyelonephritis). Ambulatory status affects breathing (hypoventilation when supine) and possible thrombosis (DVT or PE). The wound should be assessed for any signs of infection. If there are no easily visible incisions as with vaginal surgery, a pelvic examination and/or imaging of the pelvis may be needed. If the fever resolves after withdrawal of a medication, then a presumptive diagnosis of drug reaction can be made. If the patient has received blood products, the possibility of a reaction to antigens in the transfusion should be investigated as a cause of the fever. Antibiotics should be ordered only when infection is suspected.
Clinical Follow-Up
Based on this patient’s discrepancy between the relatively benign Pap findings and those of the endocervical curettage, further evaluation is required. Because the main area of concern is the endocervical canal, the patient is scheduled for a deep, narrow cold-knife conization.
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