Anitha Mathew
The most common reasons for emergency department (ED) visits during the postoperative period following gynecologic procedures are pain, fever, and vaginal bleeding.
A focused but thorough evaluation should be performed, including a sterile speculum and bimanual examination.
Consultation with the gynecologist who performed the procedure is typically indicated. (Complications common to gynecologic and general surgery are discussed in Chapter 51.)
COMPLICATIONS OF ENDOSCOPIC PROCEDURES
LAPAROSCOPY
Major complications associated with laparoscopy are listed in Table 67-1.
Patients with thermal injury may not develop symptoms for several days to weeks postoperatively and typically present with bilateral lower abdominal pain, fever, elevated white blood cell count, and peritonitis.
Radiographs can show an ileus or free air under the diaphragm.
Patients with greater than expected pain after laparoscopy have a bowel injury until proven otherwise; early gynecology consultation should be obtained.
TABLE 67-1 major complications associated with laparoscopy
Thermal injury of the bowel
Perforation of viscus
Hemorrhage
Vascular injury
Ureteral or bladder injuries
Incisional hernia
Wound dehiscence
HYSTEROSCOPY
Complications of hysteroscopy include cervical and uterine perforation, postoperative bleeding, fluid overload from absorption of distention media, and infection.
Consultation with a gynecologist is required.
Postoperative bleeding is the most likely cause of hospital revisit. After hemodynamic stabilization, the gynecologist may insert a Foley or balloon catheter into the uterus to tamponade the bleeding; vaso-pressin or misoprostol are alternative treatments.
Patients with uterine perforation can present with peritoneal signs and require surgical exploration.
Fluid overload is rare, but affected patients are likely to be hyponatremic.
Infection as a result of hysteroscopy is uncommon; treat with antibiotics.
COMPLICATIONS RELATED TO MAJOR ABDOMINAL SURGERY
VAGINAL CUFF CELLULITIS
Cuffcellulitis, a common complication after hysterectomy, is an infection of the contiguous retroperitoneal space immediately above the vaginal apex and the surrounding soft tissue.
Patients typically present between postoperative days 3 and 5 with fever, abdominal pain, pelvic pain, back pain, and abnormal vaginal discharge.
Cuff tenderness and induration are prominent during the bimanual examination, and a vaginal cuff abscess may be palpable.
Treat with broad-spectrum antibiotics, such as ampi-cillin, 2 grams IV every 6 hours, plus gentamicin, 1 milligram/kg IV every 8 hours, plus clindamycin, 900 milligrams IV every 6 hours.
Admit for continuation of antibiotics and possible abscess drainage.
POSTOPERATIVE OVARIAN ABSCESS
Patients with ovarian abscesses typically present shortly after hospital discharge with fever and abdominal or pelvic pain.
A CT scan can help to identify and localize the abscess.
A sudden increase in pain can signal possible abscess rupture, which requires emergent laparotomy.
Patients with ovarian abscesses should be admitted for IV antibiotics and possible drainage.
URETERAL INJURY
Ureteral injury can occur during abdominal hysterectomy, resulting from crushing, transecting, or ligating trauma.
Patients present soon after surgery with flank pain, fever, and costovertebral angle tenderness.
Workup includes a urinalysis and either a CT scan with IV contrast or an IVP to evaluate for obstruction.
Patients should be admitted for ureteral catheteriza-tion and possible repair.
OTHER COMPLICATIONS OF GYNECOLOGIC SURGERY
VESICOVAGINAL FISTULA
Patients typically present 10 to 14 days following abdominal hysterectomy with watery vaginal discharge and should receive prompt gynecologic consultation.
Patients are treated with Foley catheter drainage after the diagnosis is confirmed.
POSTCONIZATION BLEEDING
The most common complication associated with loop electrocautery, laser ablation, and cold-knife coniza-tion of the cervix is bleeding, which can be rapid and excessive.
Delayed hemorrhage can occur 1 to 2 weeks postop-eratively.
Directly visualize the bleeding site, then apply Monsel solution, hold direct pressure for 5 minutes with a large cotton swab, or cauterize with silver nitrate.
If unsuccessful, the bleeding site may be better visualized and treated in the OR.
SEPTIC PELVIC THROMBOPHLEBITIS
Patients with ovarian vein thrombosis present within a week after delivery or surgery with fever, tachycardia, GI distress, and unilateral abdominal pain.
Patients with deep septic pelvic thrombophlebitis present a few days after delivery or surgery with spiking fevers that are unresponsive to antibiotics; these patients may also have abdominal pain.
Ultrasound, CT, and MRI are frequently non-diagnostic, making this a diagnosis of exclusion.
Patients are admitted for anticoagulation (heparin or enoxaparin) and IV antibiotics, such as ampi-cillin/sulbactam 3 grams IV every 6 hours, pip-eracillin/tazobactam 4.5 grams IV every 8 hours, or ticarcillin/clavulanate 3.1 grams IV every 4 hours. Monotherapy with a carbapenem, such as imipenem 500 milligrams every 6 hours, may be used for patients with beta-lactam intolerance.
INDUCED ABORTION
Complications associated with induced abortion include uterine perforation, cervical lacerations, retained products of conception, and postabortal endometritis (Table 67-2).
TABLE 67-2 Complications Associated with Induced Abortion
Patients with retained products of conception usually present with excessive bleeding and abdominal pain.
Pelvic examination reveals an enlarged and tender uterus with an open cervical os.
A pelvic ultrasound should be obtained to confirm the diagnosis.
Treatment is dilatation and curettage.
Endometritis can occur with or without retained products of conception and is treated with antibiotics, as previously discussed under Vaginal Cuff Cellulitis.
Women who are Rh negative require Rh0 immu-noglobulin, 300 micrograms IM.
ASSISTED REPRODUCTIVE TECHNOLOGY
Complications related to ultrasound-guided aspiration of oocytes include ovarian hyperstimulation syndrome, pelvic infection, intraperitoneal bleeding, and adnexal torsion.
Ovarian hyperstimulation syndrome can be a life-threatening complication of assisted reproduction.
Patients with mild cases present with abdominal dis-tention, ovarian enlargement, and weight gain.
In severe cases, patients have rapid weight gain, tense ascites from third spacing of fluid into the abdomen, pleural effusions, hemodynamic instability, oliguria, electrolyte abnormalities, and increased coagulability.
Bimanual pelvic examination is contraindicated to avoid rupturing the ovaries.
Initiate intravenous volume replacement, obtain CBC, electrolytes, liver function tests and coagulation studies, and consult gynecology for admission.
POSTEMBOLIZATION SYNDROME
Postembolization syndrome consists of postproce-dure pelvic pain, nausea, vomiting, and fever lasting 2 to 10 days due to myometrial and fibroid ischemia after fibroid embolization.
Evaluate patients for other causes of fever, and provide pain control.
Patients with inadequate pain control or those with infection may require admission.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 109, “Complications of Gynecologic Procedures,” by Michael A. Silverman.