Postoperative Complications and Postoperative Emergencies

Brent E. Seibel

Emergencies following gynecologic surgery may present as immediate, early, and late occurring events that require proper diagnosis and management by the gyne­cologic surgeon and/or emergency physician.

WOUND COMPLICATIONS

The most common wound complications associated with gynecologic surgery include hematoma, seroma, infection, fascial dehiscence, and hernia. Risk fac­tors include obesity, diabetes, immunosuppression, cardiovascular disease, smoking, cancer, malnutrition, previous surgery or radiation, and infection. Sur­gical factors include contamination, devitalization of tissues, the presence of foreign bodies, prolonged operating time, extensive wound dissection, and the presence of dead space in the surgical wound. Strategies for the prevention of wound complications obviously address these issues when possible and include prophylactic antibiotics when appropriate, proper surgical preparation and sterile technique, avoiding excessive dissection or devitalization of tissues, and closure of subcutaneous spaces when appropriate. A 2004 metaanalysis by Chelmow et al. (1) reviewed six studies addressing subcutaneous fat closure dur­ing c-section and found a 34% decrease in the risk of wound disruption when the subcutaneous fat thickness is >2 cm.

Hematoma and Seroma

Over 1.2 million cesarean section deliveries and nearly 600,000 hysterectomies, two of the most common obstetric and gynecologic procedures, were performed in the United States during 2005 (4). The estimated incidence of wound infections ranges from 3% to 15% for cesareans and 3% to 8% for abdominal hysterectomies. An additional 3% to 14% of cesareans are complicated by wound seroma and hematoma (5). Practicing physicians must therefore be familiar with the recognition and management of these conditions. Hematomas are collections of blood that accumulate in the subcutaneous tissues due to failure of primary hemostasis or a bleeding diathesis. Similarly, collections of serum are responsible for seromas. They both usually occur in the immediate or early postoperative period but may not present until much later with swelling, pain, drainage, and even incisional separa­tion. Seromas may not pose a serious threat to patients but the sudden release of copious amounts of serosanguinous drainage can create significant anxiety often prompting them to seek care in the emergency department. In these circumstances, the truly emergent condition of fascial dehiscence must be ruled out. Seromas and hematomas also are associated with increased risk of wound infection.

Hematoma and seroma can usually be identified by inspection, palpation, and partially opening or probing the wound.

Treatment options include secondary closure of the uninfected wound, either immediate or delayed, versus wound care and healing by secondary inten­tion. Secondary closure in this setting has been found to be successful in over 80% of patients and significantly reduces healing time over secondary intention without risks of serious complications (5-7).

Total hysterectomy by any route and vaginal repair procedures can result in postoperative hematomas above the vaginal cuff or at the site of vaginal clo­sure. These patients may present with vaginal bleeding or complaints of pain and pressure as well as anemia. Fever and leukocytosis may be observed in the presence of infection. If a mass is not observed or palpated on examination, pelvic ultrasound or computed tomography (CT) scan may help identify a pel­vic hematoma. If no systemic infection is evident, the hematoma may be allowed to gradually resolve over time. Opening the vaginal repair or vaginal cuff and evacuating the clot in the emergency department or operating room may be necessary. CT-directed drainage of a pelvic hematoma can sometimes be achieved.

Laparoscopic procedures can result in significant hematomas of the abdominal wall even though trocar incisions appear small.

Surgical Site Infections

Surgical site infections are classified by the CDC as superficial incisional (involving only the skin or subcutaneous tissue of the incision), deep incisional (involving fascia and/or muscular layers), and organ/space. They occur in 2% to 5% of patients undergoing inpatient surgery in the United States, resulting in approximately 500,000 infections each year (10). Many gynecologic procedures and all cesarean sections are classified as “clean contaminated” procedures as the genitourinary tract is entered, thus increasing the risk of wound infection. Infections usually present late in the first postoperative week with erythema and either subcutaneous pockets of exudate (if the epithelium is intact) or frank sero- sanguinous or Seropurulent drainage from an open incision. Staphylococcus aureus is common but enteric or vaginal flora is also commonly involved. Wound cultures should be obtained initially due to the increasing rate of methicillin- resistant Staphylococcus aureus (MRSA).

Necrotizing fasciitis represents a life-threatening soft-tissue infection pri­marily involving the superficial fascia. It is characterized by skin discoloration, skin and subcutaneous necrosis, crepitus, and sometimes hypesthesia as cuta­neous nerves become ischemic. Systemic toxicity and multiorgan involvement can occur quickly. Wong et al. reviewed 89 consecutive patients over a 5-year span with necrotizing fasciitis and reported the following: polymicrobial syner­gistic infection was the most common cause with streptococci and enterobacte- riaceae being the most common isolates. Group-A streptococcus was the most common cause of monomicrobial necrotizing fasciitis. The most common associated comorbidity was diabetes mellitus followed by advanced age. These factors and a delay in surgery of >24 hours adversely affected the outcome. Multivariate analysis showed that only a delay in surgery of >24 hours was cor­related with increased mortality. Similarly, Bilton et al. reviewed 68 cases of necrotizing fasciitis, finding that the major predictor of favorable outcome was prompt aggressive surgical debridement (11,12). When such a treatment was delayed, mortality occurred in more than one third of cases, compared with <5% with prompt aggressive surgical debridement (11,12). To summarize, when necrotizing fasciitis is suspected, prompt diagnosis, aggressive surgical debride­ment, supportive care, and broad-spectrum antibiotics appear to be the keys to avoiding overwhelming sepsis and death.

Fascial Dehiscence and Hernia

Dehiscence describes the separation of any of the layers of the abdominal wall, but the term is commonly used when partial or complete fascial disruption occurs.

Fascial dehiscence as a complication of pelvic laparotomy performed for hysterectomy and other gynecologic surgeries occurs at a rate of 0.3% to 0.7%. Dehiscence occurs more frequently in midline incisions as opposed to trans­verse incisions (13). Age, underlying medical disease, obesity, infection, and malignancy increase the risk. Dehiscence tends to occur during the first 1 to 2 weeks of postoperative period and can present with the skin layer either open or intact. The most common associated complaint is serosanguinous discharge from the wound. The patient may also describe an associated sudden tearing or popping sensation brought on by coughing, lifting, or Valsalva maneuver. The fascia must be evaluated in such situations digitally or by probing with a sterile Q-tip. Imaging studies such as ultrasound, MRI, or CT scan may reveal the dis­rupted fascia with herniated abdominal contents when the skin is intact or the examination is inconclusive. Wound dehiscence should be considered a surgical emergency as it is associated with a mortality rate of up to 10%.

Initial treatment involves protecting the wound with a large moist sterile dressing and arranging for prompt surgical debridement and fascial closure in the operating room. The patient must be medically stabilized, cultures obtained, and broad-spectrum antibiotics initiated as wound infection or sepsis is often present. If the fascia cannot be reapproximated without tension, incorporating a synthetic fascial graft into the repair may be necessary. Skin and subcutaneous layers are typically left open for wound care and healing by secondary inten­tion. Secondary closure may be an option once the wound appears adequately healthy.

Incisional hernia implies that superficial layers and peritoneum have healed but a facial defect is present. Hernias can be expected in nearly 1% of uncomplicated surgeries, in 10% when wound infection has occurred, and in 30% of patients with fascial repair after dehiscence (14). Once again, the incidence is higher with midline incisions but ventral hernias have been described in essen­tially all incisions employed in gynecologic surgery. Most incisional hernias present within the first 2 years following surgery with over 50% occurring within the first 6 months. Patients typically complain of a bulge beneath the surgical scar which may or may not be associated with discomfort and often exacerbated by straining or Valsalva maneuver.

If the contents of the hernia become entrapped in the fascial defect, incar­ceration with strangulation or obstruction can occur. Pain, peritoneal signs, and symptoms of bowel obstruction differentiate this patient from the easily reduced hernia and require stabilization and emergent surgical repair.

Minimally invasive procedures can also result in symptomatic hernias despite the relatively small incisions utilized. Reported incisional bowel hernia­tion rates after laparoscopy range from 0.02% to 0.17% and are related to larger trocar size, multiple ancillary ports, tissue extraction, and longer operative times (15-17). In spite of recommendations to close the fascia on all trocar sites 10 mm and larger, 18% of the hernias cited in the AAGL (American Academy of Gynecologic Laparoscopists) survey cited above occurred despite fascial closure. Any laparoscopic patient with unusual pain at the incision site, the presence of a bulge, nausea, and vomiting, or symptoms of bowel obstruction must be evalu­ated for port site herniation and potential infarction of herniated omentum or bowel.

Vaginal Cuff Dehiscence

Unique to gynecologic surgery is the potential for postoperative vaginal cuff dehis­cence and vaginal evisceration. Although vaginal evisceration can be associated with vaginal trauma, spontaneous rupture of a large enterocele, or large uter­ine perforation with suction curettage, it should be suspected in the symptom­atic posthysterectomy patient. An extensive review of the literature by Ramirez and Klemer in 2002 (18) found that although a rare event, with only 59 patients reported, vaginal evisceration represents a surgical emergency. Of those cases reported, 37 (63%) occurred following vaginal hysterectomy, 19 (32%) after abdom­inal hysterectomy, and 3 (5%) after laparoscopic hysterectomy. Small bowel was the most common organ to eviscerate. The most common presenting symptoms among these cases of vaginal evisceration were vaginal bleeding, pelvic pain, or a protruding mass. In postmenopausal women, vaginal evisceration was associated with increased intra-abdominal pressure. In premenopausal women, however, it was most often preceded by sexual intercourse. Some suggest an increased risk of cuff dehiscence following total laparoscopic hysterectomy with the use of thermal energy for colpotomy or inadequate laparoscopic cuff closure postulated as fac­tors. One series of over 7,000 assorted hysterectomies over a 6-year span encoun­tered 10 cuff dehiscences, 6 of which included bowel evisceration. Most (80%) were complications of total laparoscopic hysterectomies with the remaining two (one in each) associated with total abdominal hysterectomy (TAH) and transvaginal hys­terectomy (TVH). The median time from surgery to dehiscence was 11 weeks. In each of these 10 cases, repair was accomplished vaginally (19).

UROLOGIC EMERGENCIES

The incidence of surgical injuries to the ureter and bladder during gynecologic procedures is dependent upon several factors including the type and route of the procedure, anatomic distortions by adhesions or diseases, skill level of the per­forming surgeon, and the lack of intraoperative recognition of the injury. Reported rates of injury to the bladder during gynecologic operations range from 0.2% to 1.8% and for ureteral injuries from 0.03% to 1.5% (20). Actual figures are uncertain as many injuries go unrecognized. Ibeanu et al. (20) described their experience with cystoscopy during 839 hysterectomies for benign disease and found a total incidence of urinary tract injury of 4.3%, with bladder and ure­teral injury rates of 2.9% and 1.8%, respectively. Cystoscopy detected 97.4% of injuries compared to only a 25.6% detection rate by visual inspection, suggesting an increased role for intraoperative cystoscopy. The most common types of ure­teral injuries were transections and kinking, which occurred 80% of the time at the level of the uterine artery and ureter junction. With potentially undetected injuries and often rapid hospital discharge after many gynecologic procedures, the diagnosis and treatment of postoperative urologic conditions often fall upon the emergency physician.

Urinary Retention

Although most postoperative patients have passed a voiding trial prior to cath­eter removal and hospital discharge, some may develop difficulty voiding and suffer urinary retention. Women who undergo incontinence procedures and dif­ficult or radical hysterectomies are at increased risk for postoperative urinary retention. These patients describe the limited ability or inability to void with pro­gressive pain and suprapubic mass. This condition can be diagnosed and easily treated by catheterization, either indwelling or intermittent self-catheterization. If presentation or diagnosis is delayed, the patient may develop an associated infection and require antibiotic treatment. Most cases of retention resolve over time but some cases persist, requiring chronic catheterization or the removal of anti-incontinence mesh.

Bladder Injuries

Incidental injuries to the bladder can occur during any type of gynecologic pro­cedure, including abdominal, vaginal, laparoscopic, hysteroscopic, or cesarean section. The incidence of bladder injuries associated with hysterectomy appears to be higher now than the 0.2% to 1% reported in the older literature, with increases observed when additional procedures for prolapse or incontinence are added and in the presence of prior surgeries. In a series of 257 hysterectomies done between 1986 and 1988, Gambone et al. (21) reported a rate of 2.3% for inad­vertent bladder injury with two thirds of those occurring in patients with prior c-section. Obvious bladder defects, bloody urine, or carbon dioxide gas in the urine collection bag during laparoscopy may lead to intraoperative recognition and repair. Injuries may also go undetected and present later with intraperito­neal urine collection or urine loss through various fistulas. Thermal intraopera­tive injury may also present days later even though the bladder appeared intact at the time of surgery.

Vesicoperitoneal fistula results in decreased urine output and the accumu­lation of intraperitoneal urine which can result in a peritonitis associated with pain, fever, and decreased bowel function. This can make differentiating this type of fistula from a bowel injury difficult. A CT urogram can reveal the bladder defect, but cystoscopy and retrograde evaluation of the ureters may be necessary to confirm the location of the defect. Although prolonged catheterization alone may result in spontaneous healing of small bladder injuries, surgical repair is often required.

Vesicovaginal fistulas can be seen after hysterectomies, prolapse repairs, and incontinence procedures. Vesicouterine fistulas have been reported after c-section and hysteroscopies (22,23). In both instances, patients present with continuous urine loss in spite of bladder catheterization. Differentiation from ureterovaginal fistula may be difficult and again could require CT urogram, cystoscopy, and hysteroscopy.

Ureteral Injuries

Ureteral injury is a relatively rare but well-known complication of gynecologic surgery as the path of the ureter lies in close proximity to critical anatomic structures such as the infundibulopelvic ligament, uterine artery, and anterior vagina. Ureteral ligations, angulation or kinking, and transection can occur acutely whereas strictures from scarring, devascularization, and thermal injury may appear later. As stated previously, the actual incidence of injuries associ­ated with gynecologic surgery is difficult to pinpoint as many injuries go unde­tected at the time of surgery and the risk is highly dependent on the technical difficulty of the procedure. The Collaborative Review of Sterilization (CREST) study published by Dicker (24) in 1982 reported a 0.2% ureteral injury rate for 1,851 elective hysterectomies. In comparison, Daly and Higgins (25) reported a significantly higher rate of 1.4% in 1,093 patients undergoing major gynecologic surgeries which included reoperative procedures involving the ovaries, malig­nancies, and emergency cases. Twelve injuries occurred at the pelvic brim and four others occurred elsewhere in the pelvis. Risk factors included previous s urgical procedures in the pelvis, endometriosis, ovarian neoplasm, pelvic adhesions, distorted anatomic features of the pelvis, and repair of the bladder.

Symptomatic ureteral obstruction presents with ipsilateral flank pain or tenderness due to the distention of the collection system or renal capsule and occasionally radiates to the groin or labia with lower obstructions. Fever can indicate an associated pyelonephritis. Urine output is usually normal unless bilateral injuries have occurred. If no infection is present, urinalysis may also be normal. The plasma creatinine concentration also is usually normal or only slightly elevated with a unilateral injury. Only in rare cases does unilateral obstruction lead to anuria and acute renal failure when vascular or ureteral spasm is thought to result in loss of function in the nonobstructed kidney (26). Asymptomatic obstruction can be an incidental finding months or years later during a workup for an unrelated condition, making it too late for intervention to salvage the renal function.

Bladder catheterization should be the initial step in the patient with symp­toms of obstruction in the postoperative period as urinary retention may be involved. Renal ultrasonography can usually detect hydronephrosis and hydroureter, but a false-positive rate of up to 25% can be seen when minimal criteria for obstruction are used (27). A CT urogram or an intravenous pyelo- gram (IVP) has the advantage of low false-positive rates and is more likely to identify the level of obstruction. In some instances where hydronephrosis is present but ureteral obstruction is questionable, a diuretic renogram involving the administration of furosemide prior to a radionuclide renal scan can be per­formed. However, cystourethroscopy with retrograde ureteropyelography has the advantage of both diagnosing a partial obstruction and attempting retro­grade ureteral stent placement. If successfully placed, stents are left in place for several months to be removed later. If unsuccessful with retrograde stents, per­cutaneous nephrostomy should be performed allowing an attempt at antegrade stent placement.

Surgical management of ureteral injuries depends on the type and location of the injury. Obstructing or kinking sutures should be removed and, in the case of minor injury, stents placed. Major injuries, thermal injuries, or complete transec­tions require excision of the damaged ureteral segment and definitive repair. Most distal ureteral injuries can be repaired by ureteroneocystostomy, but those near or above the pelvic brim require ureteroureterostomy (28).

Postoperative genitourinary fistulas generally present with continuous transvaginal urinary leakage developing anytime up to several weeks after sur­gery. Vaginal examination alone may yield evidence of the urethrovaginal, vesi­covaginal, or ureterovaginal fistula, but transurethral instillation of an indigo carmine-colored solution can be helpful. Direct visualization of the blue dye or staining of a vaginal tampon suggests vaginal or urethral leakage. Blue staining of the tampon after intravenous indigo carmine or orange staining after oral pyridium suggests a ureterovaginal fistula. A CT urogram, cystourethroscopy, and retrograde studies can confirm the site of injury and document renal function. Prolonged catheterization of the bladder may allow for spontaneous healing of an early, small vesicovaginal fistula as may successful stenting of ureterovaginal defects, but surgical repair is often required.

GASTROINTESTINAL EMERGENCIES

Postoperative nausea and vomiting related to medical or anesthetic factors typi­cally are evident in the immediate period after surgery and are usually managed prior to patient discharge. The use of general anesthesia and opioid analgesics increase the risk of ileus. When patients present with nausea and vomiting following gynecologic surgery, distinguishing ileus from bowel obstruction represents a critical, and sometimes challenging, task for the clinician.

Postoperative Ileus

A dynamic or paralytic ileus potentially occurs to some degree with any surgical procedure or intra-abdominal inflammation, but delay in return to normal func­tion beyond the typical 24 to 48 hours for uncomplicated procedures defines postoperative ileus. Factors that delay the recovery of bowel motility include the extent of bowel manipulation, length of the procedure, intraoperative bowel injury, peritonitis, intraperitoneal hemorrhage, and electrolyte imbalances such as hypokalemia, hyponatremia, and hypomagnesemia. The possibility of unrec­ognized bowel injury or inadequate repair of a recognized injury should always be entertained when return of normal bowel function is delayed. This is particu­larly important when delayed postoperative ileus develops in a patient that was recovering normally. The aforementioned CREST study reported an incidence of paralytic ileus of 2.2% with abdominal hysterectomy and 0.2% for vaginal procedures (24).

Patients typically present with abdominal discomfort, lack of flatus or bowel movements, and abdominal distention accompanied by nausea and sometimes vomiting. Differentiating ileus from bowel obstruction or an injury is crucial and can be difficult. Ileus typically is not associated with fever, leukocytosis, localized ten­derness, or peritoneal signs. Bowel sounds are absent and the distended abdomen may be tympanitic and usually nontender. Initial laboratory studies should include a complete blood count and serum electrolytes. The plain abdominal radiographs or “KUB” show multiple dilated loops of small bowel with gas visible throughout includ­ing the colon and rectum. Differential air-fluid levels are usually absent and their presence is suggestive but not always diagnostic of small bowel obstruction (SBO). CT with oral contrast can be utilized when differentiating between ileus and obstruc­tion is difficult. Megibow et al. (29) reported the overall sensitivity of CT was 94%, specificity was 96%, and accuracy was 95% for cases of obstruction. In addition, CT imaging correctly predicted the cause of obstruction in 47 of 64 cases [73%].

The treatment of postoperative ileus involves bowel rest, intravenous fluids, and electrolyte management. If vomiting or significant abdominal distention persists, the patient may benefit from nasogastric tube decompression. Limiting the use of opioids is also suggested.

Postoperative Bowel Obstruction

Although postoperative adhesions occur in over 60% of women undergoing a major gynecologic surgery, they usually do not result in significant complica­tions but are implicated as a common contributing factor in SBO. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy is approximately 0.3%. This increases to 2% or 3% among patients who undergo hysterectomy, and up to 5% if a radical hyster­ectomy is performed (30). Patients may present days or weeks after surgery, but symptoms can also occur years after the procedure. In one series of SBO attrib­uted to adhesions, 50% were related to a benign abdominal hysterectomy (31). Hernia represents the next most common cause of SBO followed by tumors, intussusception, volvulus, and Crohn’s disease. As the small bowel dilates and compromises blood flow, necrosis, strangulation, and sepsis can result.

Intermittent or crampy abdominal pain and abdominal distention with nausea, vomiting, and the absence of flatus are symptoms of bowel obstruction. Peristalsis of the obstructed bowel proximal to the obstruction can result in the characteristic high-pitched tinkling bowel sounds. Laboratory findings suggest hypovolemia and hemoconcentration as significant blood and fluid are seques­tered in the bowel resulting in the air-fluid levels seen on plain radiographs of the abdomen. Leukocytosis is particularly concerning and may indicate strangulation and necrosis.

Treatment may require surgical intervention, but the patient should be sta­bilized, metabolic abnormalities corrected, and broad-spectrum antibiotics ini­tiated when possible. Decompression by nasogastric tube, stabilization, and observation may be adequate treatment in many instances, but most series sug­gest that a majority of patients ultimately require surgery.

Obstruction of the large intestine is rare and usually involves cecal or sig­moid volvulus. The patient may not present with the symptoms of dehydration and vomiting as seen in SBO. Careful colonoscopy may be employed to correct the condition but surgery may also be required.

Laparoscopic Bowel Injury

Bowel injury during laparoscopy may result from the insertion of the Veress nee­dle, placement of primary and secondary trocars, inadvertent thermal injury, and direct trauma during manipulation or dissection. These injuries can pose serious consequences, as up to 25% of all laparoscopic entry complications are not recognized until the postoperative period (32). Combined data show that diagnostic and minor operative laparoscopies in gynecology are associated with a 0.08% risk of bowel injury, and in major operative laparoscopy, the risk increases to 0.33%. Up to 15% of these injuries are not diagnosed during laparoscopy, and one of five cases of delayed diagnosis results in death (33).

The key to avoiding delayed diagnosis is maintaining a high degree of suspi­cion in any laparoscopy patient that displays abnormal pain, increasing pain, peritoneal signs, or a general failure to thrive. One must consider bowel perfora­tion, incarcerated hernia, bladder, or ureteral injuries in such patients and employ close observation. Symptoms from penetrating trauma or lacerations usually present in the early postoperative period. Small injuries that temporarily seal, or thermal injury followed by bowel necrosis, may not be apparent for 4 to 5 days. Ileus after laparoscopic surgery is not normal and warrants evaluation.

The initial treatment, laboratory, and imaging studies are the same as those discussed above for laparotomy cases. The presence of free air on upright abdom­inal radiographs does not indicate a ruptured viscus as 40% of patients will have >2 cm of free air imaged between the hepatic surface and the diaphragm at 24 hours postlaparoscopy (34). Failure of free air to decrease, or increasing intra­abdominal air, must be presumed to represent a ruptured viscous. In general, if a patient reports pain, fever, tachycardia, and abdominal distention, the assump­tion must be intraperitoneal injury until proven otherwise. Unnecessary delays in surgical intervention can be catastrophic.

Postoperative infections

Routine administration of perioperative prophylactic antibiotics has reduced the incidence of postoperative infections. Nonetheless, postoperative infections still constitute the most common type of postoperative complication. In a review of 10,110 hysterectomies of all types, infections were the most common compli­cation with incidences of 10.5%, 13.0%, and 9.0% in the abdominal, vaginal, and laparoscopic groups, respectively (35). The highest infection rate of 7.3% was uri­nary tract infections in the vaginal hysterectomy group, which is similar to the 7.0% rate in abdominal hysterectomies from the CREST study. As discussed earlier, wound infections among abdominal hysterectomy are also common, reaching an incidence of 3.1% in this series. Vaginal site infections occurred in 0.2%, 1.8%, and 1.4% of the abdominal, vaginal, and laparoscopic procedures, respectively.

It is important to remember that low-grade fever alone within the first 48 hours of surgery is not always indicative ofinfection but often reflects cytokine release from tissue trauma. Rates of unexplained fever range from 1.9% to 30%; this wide range reflects a lack of consistency in criteria among studies. Extensive fever workup should be reserved for high-risk patients such as those with malig­nancy, bowel injury or resection, high or prolonged fever, and increased white blood cell count.

Pelvic Cellulitis and Abscess

Patients presenting several days to a week after gynecologic surgery with persis­tent fever, pelvic pain, vaginal cuff induration, and purulent discharge should be evaluated for pelvic cellulitis and abscess. Occasionally, peritoneal signs or ileus is also present. The diagnosis is somewhat subjective, but speculum examination typically reveals a purulent discharge from an indurated and tender vaginal cuff. If pelvic examination and ultrasound or CT scan shows a pelvic fluid collection, this usually represents a cuff abscess or an infected hematoma. The cause is usually a mixed infection of endogenous vaginal bacteria including anaerobes and occasionally Gram-negative aerobic bacteria. Once the diagnosis is made, broad-spectrum antibiotics should be initiated.

If an abscess or infected hematoma is identified and antibiotics alone are ineffective, drainage is indicated. If an abscess or infected hematoma is located in proximity to the vaginal cuff, transvaginal drainage in the operating room can be accomplished. CT-guided percutaneous drainage can be attempted when the abscess cannot be reached via the vaginal cuff. Occasionally, surgical drain­age or evacuation of an abscess or hematoma must be performed via laparotomy or laparoscopy.

Septic Pelvic Thrombophlebitis

Septic pelvic thrombophlebitis should be considered in the postoperative female patient with continued fever in spite of adequate broad-spectrum antibiotic therapy. Iliofemoral vein involvement may be accompanied by radiating pain toward the leg while ovarian vein thrombus contributes to unilateral pelvic or low back pain. Pulmonary embolus can occur from the pelvic thrombus. Fortunately, pulmonary embolus is a rare occurrence after gynecologic proce­dures. Pulmonary embolus is more common after vaginal delivery and cesarean section with reported incidences of 1:9,000 and 1:800, respectively (36). In the past, the diagnosis was implied when the patient responded to heparin therapy, but CT scan or MRI will confirm the diagnosis.

In many cases, simply continuing or changing antibiotic coverage will result in patient improvement as was shown by Brown et al. (36) where women given heparin in addition to antimicrobial therapy for septic pelvic throm­bophlebitis did not have better outcomes than did those for whom antimicrobial therapy alone was continued. The other option is to add therapeutic heparin to the broad-spectrum antibiotic regimen until the patient is afebrile and clinically well for 48 hours, after which the anticoagulant can be discontinued.

OTHER GYNECOLOGIC POSTOPERATIVE EMERGENCIES

Serious complications can be seen after relatively minor gynecologic procedures such as uterine dilatation and evacuation, operative hysteroscopy, and uterine artery embolization (UAE). Since these are outpatient procedures, the patient may present first to the emergency room seeking care.

Uterine Perforation

Cervical dilatation and curettage, uterine evacuation, and hysteroscopy all can result in uterine perforation, which can be associated with bleeding, infection, and bladder or bowel injury. Endometritis, pelvic inflammatory disease or abscess, and sepsis require broad-spectrum antibiotic treatment and stabilization. Opera­tive hysteroscopy and global endometrial ablation techniques add the potential of thermal energy injuries to the bowel. Patients presenting with atypical pain, fever, or peritoneal symptoms should be aggressively evaluated and managed.

Uterine Artery Embolization

UAE is becoming a common minimally invasive alternative to myomectomy and hysterectomy in the treatment of symptomatic uterine leiomyomata. Performed by the interventional radiologist, this procedure can be associated with rare but serious conditions including pain, infection, fibroid expulsion, catheter site hema­toma, and sequelae from inadvertent embolization of other structures. Ischemia from inadvertent embolization can affect the bowel, bladder, nerve, muscle, and skin as well as ovarian function. Postembolization syndrome commonly occurs following UAE and consists of low-grade fever, malaise, nausea, and leukocytosis. Pain is the most common cause for hospital readmission (37).

Hysterectomy may be necessary after UAE as was reported in a 2003 multi­center prospective trial following 555 patients. By 3 months, eight women (1.5%) underwent complication-related hysterectomy [39]. Indications for hysterecto­mies were infections [2], postembolization pain [4], vaginal bleeding [1], and pro­lapsed leiomyoma [1] (38). Ischemic uterine rupture, sepsis, and even death have been reported following UAE (39).

Retained Foreign Objects

In an attempt to identify risk factors for retained foreign bodies, authors from a 2003 study reviewed 10 hospitals over 15 years and found 54 patients with a total of 61 retained foreign objects. Over two thirds were sponges and 31% were instruments. Statistically significant risk factors for the retention of a foreign body were emergency surgery, unplanned change in the operation, and increased body mass index (40).

In the event of an incorrect count, plain radiographs of the entire abdomen and pelvis must be performed and reviewed before the patient leaves the operat­ing room. This does not benefit the situations, however, when sponge, needle, and instrument counts are reported to be correct and the object remains in the patient undetected.

Retained foreign objects are ideally managed by prompt removal but occasionally remain asymptomatic until they are discovered during unrelated radiologic studies or present with symptoms much later. Removal of retained laparotomy pads or sponges can be difficult due to extensive adhesions. Retained instruments must be removed as they may cause pain and risk perforation injury. Small needles arguably pose little risk and may not require removal, but larger ones may result in injury.

SUMMARY

As with all surgical procedures, gynecologic surgeries entail the risk of postop­erative complications. Obstetricians, gynecologists, and emergency department physicians who are cognizant of the spectrum of possible complications, and appropriate management strategies, can improve outcomes for women experiencing these complications.

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