Chapter 105: Complications of Gynecologic Procedures

Advancements in minimally invasive gynecologic surgical techniques, such as laparoscopy and hysteroscopy, have allowed more outpatient procedures for patients. Postoperative complications among inpatients are now seen out of the hospital. The prevalence of all postoperative complications after gynecologic procedures is reported to be 9%, whereas 3.7% are considered major complications.¹ The most common reasons for ED visits during the postoperative period after gynecologic procedures are pain, fever, and vaginal bleeding.

HISTORY

Patient risk factors for postoperative complications include age >80 years, medical comorbidities, dependent functional status, and obesity or unintentional weight loss.¹ Key historical questions are listed in Table 105-1. The interval between surgery and the onset of symptoms is very important in determining the cause of symptoms. For example, most cases of early postoperative fevers (<24 hours) are not infectious but rather result from pulmonary atelectasis, hypersensitivity reactions to antibiotics, pyogenic reactions to tissue trauma, or hematoma formation. Fever occurring on postoperative days 3 to 5 may be due to a urinary tract infection. On postoperative days 4 to 6, consider venous thromboembolism, and ≥7 days after surgery, consider a surgical site infection.²

PHYSICAL EXAMINATION

Examine all appropriate body systems. Do not assume that complaint is gynecologic, and investigate other potential explanations of symptom. Postoperative pain and tenderness can be difficult to assess. After laparoscopy, patients may have shoulder or upper abdominal pain because of carbon dioxide bubbles trapped between the liver and diaphragm after insufflation for the procedure, with 50% to 70% of patients still being affected 48 hours after surgery.³ Postoperative pain and tenderness are concerning if associated with fever, nausea and vomiting, and a change in bowel sounds.

Examine the surgical wound and perform a pelvic examination, including both a sterile speculum and a bimanual examination. In patients undergoing fertility treatment, defer the pelvic examination until consulting with the gynecologist, due to the possibility of rupturing enlarged ovarian follicles. During sterile speculum examination, the cervix or vaginal cuff must be visualized. After vaginal hysterectomy, no special precautions are needed for a speculum examination. Note any evidence of bleeding, discharge, erythema, and cuff or labial cellulitis. After a vaginal or abdominal hysterectomy, record the presence of tenderness, masses, and an intact cuff. After hysteroscopy or dilatation and curettage, evaluate cervical motion, uterine, and adnexal tenderness. Perform a rectal examination to assess for tenderness, masses, or fecal impaction.

LABORATORY TESTING

Laboratory studies should be directed toward the patient's complaints. A CBC with a manual differential count is almost always indicated. Obtain a serum β-human chorionic gonadotropin level for all women with childbearing potential. A clean-catch or catheterized urine specimen along with urine, blood, wound, and cervical (if present) cultures should be obtained if the patient is febrile. A complete chemistry panel may be necessary to evaluate hepatic and renal function.

Imaging is often necessary. A chest radiograph can confirm pneumonia or inappropriate air under the diaphragm. Air or insufflated carbon dioxide should be completely absorbed by the third postoperative day. Supine and erect abdominal series help confirm bowel obstruction. Although pelvic sonogram is helpful for visualizing the pelvic structures, CT is the gold standard for diagnosing most postoperative abdominal complications, with a sensitivity and specificity of >90%.⁴ MRI may be indicated in the evaluation of septic pelvic thrombophlebitis.

LAPAROSCOPY

Gynecologic laparoscopy is used for diagnosis and treatment. Indications for laparoscopy are listed in Table 105-2. Laparoscopy is almost always an ambulatory surgical procedure and is performed under general anesthesia with endotracheal intubation.

After cesarean sections, abortion, cholecystectomy, and coronary angioplasty, tubal sterilization is the next most common operation in the United States, with a rate of 12.2 procedures per 1000 unsterilized women.^5,6,7 When not performed postpartum with cesarean sections, the procedure is almost always performed laparoscopically.⁶ Laparoscopic hysterectomy is another common procedure.

Reported overall laparoscopic complication rates range from 0.2% to 10.3%.⁸ Major laparoscopic procedures are associated with a higher rate of complications compared with minor procedures (0.6% to 18% vs 0.06% to 7.0%, respectively).⁸

Both diagnostic and therapeutic gynecologic laparoscopy are accomplished by passing a rigid endoscope through a trocar that is inserted bluntly through a small infraumbilical incision into the abdominal cavity after a Veress needle has been used to insufflate the abdomen with carbon dioxide. The pneumoperitoneum must be sufficient to displace the bowel and is maintained throughout the surgery. Additional trocars may be placed so that other accessories can be used during the surgery. The majority of complications occur during entry of these instruments.

All laparoscopic procedures entail the same potential complications (Table 105-3), but more complex surgeries carry considerably more risk.

Bowel injury is uncommon, but may not be noted at the time of surgery. Patients with greater than expected pain after laparoscopy should be considered to have a bowel injury until proven otherwise. Signs and symptoms include abdominal pain and distention, fever, nausea, vomiting, and an elevated WBC count. Plain radiographs may show an ileus or free air under the diaphragm. Complications include peritonitis, abscess, enterocutaneous fistula, and septic shock. There are three major types of bowel injury: traumatic, thermal, and vascular.

Although many significant complications of laparoscopy are recognized in the operating room under direct visualization, thermal injury can easily be missed. Patients may not develop symptoms for several days or weeks postoperatively.^9,10,11 Early gynecologic consult is critical if a thermal injury is suspected, because damage is usually more extensive than may be apparent.

Vascular injury is uncommon^9,10,11 and is usually recognized during the operation. Patients may later present with a postoperative hematoma, which requires wound exploration by the gynecologist.

The rate of urinary tract injuries is about 4%.¹² Injuries can occur from mechanical or thermal trauma. Trocar or dissection injuries to the bladder are typically recognized intraoperatively. Thermal injuries, however, may not be initially apparent and may present later as peritonitis or fistula. The diagnosis of a ureteral injury is usually delayed. Thermal injury may present up to 14 days postoperatively with abdominal or flank pain, fever, and peritonitis. An abdominopelvic CT with IV contrast shows extravasation of urine or a urinoma. Mechanical obstruction of the ureter from sutures or staples may be recognized intraoperatively by direct visualization but may also present up to 1 week postoperatively with fever and flank pain. An IV pyelogram or CT helps define the site and degree of obstruction.

Incisional hernias and dehiscence are rare complications after laparoscopy. Incisional hernias are more common when defects >10 mm are made and can develop within the first postoperative week. Patients may be asymptomatic or may note pain, mass, evisceration, or signs and symptoms of a mechanical bowel obstruction. Fever may present if the bowel is incarcerated, and peritonitis may develop after bowel perforation. Dehiscence usually involves protrusion of the omentum and, in rare cases, the small bowel. Immediate incisional repair by a gynecologist is usually sufficient; however, a laparotomy is needed for bowel incarceration or perforation.

Wound infection after laparoscopy is uncommon and rarely a serious complication. Most infections are minor skin infections that can be managed with oral antibiotics and possible drainage. Antibiotics should cover against staphylococci, including methicillin-resistant Staphylococcus aureus and streptococci. Excluding minor skin infections, pelvic infection is quite rare and includes pelvic cellulitis, abscess, and necrotizing fasciitis.

HYSTEROSCOPY

Hysteroscopy is the direct visualization of the cervical canal and endometrial cavity using a rigid or flexible fiberoptic instrument. Hysteroscopy can be done as an office procedure under IV sedation or in an operating room. Complications (Table 105-4) are uncommon and occur more frequently as a result of operative hysteroscopy than diagnostic hysteroscopy.¹³

The most common indication for hysteroscopy is abnormal vaginal bleeding. Other indications include uterine leiomyomata, intrauterine adhesions, proximal tubal obstruction, removal of intrauterine devices, müllerian anomalies, and infertility evaluation. Therapeutic applications include directed biopsies, removal of small myomata or polyps, and endometrial ablation for menorrhagia. Also, hysteroscopic sterilization is growing in popularity. The Essure^® microinsert system is currently the only method available in the United States. The device is deployed in the fallopian tube and stimulates surrounding tissue growth, resulting in fallopian tube occlusion and permanent sterilization.

Uterine perforation is rare and usually noted at surgery. Infection is very rare and most commonly occurs in patients with concurrent genital tract infections. Postoperative bleeding can be uterine or cervical in origin. Cervical lacerations are caused by forceful dilation or tears from the tenaculum. Uterine bleeding can result from resection procedures. Gas embolism is the most feared complication of using carbon dioxide gas as a distention medium for laparoscopy.¹⁴ This complication is likely to occur during or shortly after insufflation.

Complications from major abdominal procedures that lead to ED visits usually occur at least 3 days postoperatively (Table 105-5).

Hysterectomy remains one of the most common major surgical procedures in the United States, with the abdominal approach composing 60% of cases (14% laparoscopic and 26% vaginal).^2,15 A total hysterectomy is removal of the uterus and part or all of the cervix and is unrelated to removal of the ovaries. A subtotal hysterectomy involves removal of the uterus without removal of the cervix. Patients may be unsure of the type of hysterectomy that was performed.

The risk of postoperative infection after hysterectomy is 3% to 10%, with higher rates in the abdominal versus the vaginal approach.¹⁶ Risk factors for postoperative infections include obesity, diabetes, and long operative time.¹⁶

WOUND INFECTION

Most wound infections occur within the first 2 postoperative weeks; however, they can present several months after surgery. Symptoms include fever and increased pain at the incision site. Examination reveals wound tenderness, skin erythema, induration, purulent discharge from the incision, and possible dehiscence.

Empiric antibiotics should provide coverage against staphylococci, including methicillin-resistant S. aureus, and streptococci. If an incisional abscess is diagnosed, first open and drain the wound. Probe the wound with a sterile cotton swab to confirm an intact fascia. Then, irrigate the wound copiously with normal saline and pack with saline-soaked wet-to-dry dressings. If staples have been placed, they should be removed. Obtain aerobic and anaerobic cultures to tailor antibiotic therapy.

For invasive infections, consult with the operating gynecologist. Give parenteral antibiotics and, usually, admit to the hospital.

WOUND SEROMA AND HEMATOMA

Wound seromas and hematomas are characterized by drainage, rather than fever or pain, and can be visualized by bedside US. Small seromas and hematomas can be managed by observation and will usually resolve spontaneously. Large seromas can be aspirated. If there are any signs of infection, the wound should be opened and drained and then packed with wet-to-dry dressings.

VAGINAL CUFF CELLULITIS AND PELVIC ABSCESS

The vaginal cuff formed during hysterectomy is composed of the contiguous retroperitoneal space immediately above the vaginal apex and the surrounding soft tissue. Vaginal cuff cellulitis usually occurs early after surgery. Patients complain of fever; purulent vaginal discharge; and pelvic, back, or abdominal pain. Pelvic examination reveals tenderness and induration of the vaginal cuff and purulent discharge.

Vaginal cuff and pelvic abscesses and infected hematomas are rare and usually present 10 to 14 days postoperatively. Symptoms include fever, chills, tachycardia, pelvic pain, and rectal pressure. Examination findings include lower abdominal and vaginal cuff tenderness, a tender or fluctuant mass near the cuff, and bloody or purulent drainage from the cuff. US or CT can define the size and location of an abscess or hematoma.

Admit patients for parenteral antibiotics and possible drainage by interventional radiology or colpotomy. Give broad-spectrum antibiotics, such as imipenem-cilastatin, gentamicin and clindamycin, or ciprofloxacin and metronidazole, to cover gram-negative and gram-positive bacteria and anaerobic organisms.¹⁷

DEHISCENCE AND EVISCERATION

Wound dehiscence is the failure of normal healing and the disruption of fascia and peritoneum. Evisceration occurs when omentum or bowel presents through the incision. The classic sign of impending dehiscence is the sudden outpouring of serosanguineous blood from the incision. The patient may describe a "pop" or tearing sensation. Most often, dehiscence occurs between postoperative days 5 and 8 for abdominal surgeries.¹⁸

Vaginal cuff dehiscence usually occurs 1.5 to 3.5 months after hysterectomy.¹⁹ Patients complain of postcoital bleeding, watery discharge, and pelvic pain. If bowel evisceration has occurred, patients note vaginal and pelvic pressure or a bulge.

When abdominal evisceration has occurred, cover the abdomen with moist sterile towels and support the dressing with tape to prevent further gut extrusion. The patient should be taken directly to the operating room for closure. In cases in which there is a sudden appearance of blood but no bowel, it is best to follow the same procedure because evisceration usually is imminent. Vaginal cuff dehiscence can be managed conservatively if small or partial, whereas large or complete vaginal cuff dehiscence usually requires surgical closure.

GENITOURINARY INJURY

Genitourinary injury occurs more often during the performance of abdominal hysterectomy than during any other pelvic surgery. Most bladder injuries are apparent at the time of surgery, but some ureteral injuries go unrecognized. Ureteral injury occurs less frequently than bladder injury but is generally underestimated. Operative injury to the ureter results from one of three types of trauma: crushing, transection, or ligation. Each type of injury can be either partial or complete.

Suspect ureteral injury in women who develop flank pain shortly after surgery. Fever, hematuria, and costovertebral angle tenderness may also be present. Obtain a urinalysis and abdominopelvic CT with IV contrast. Admit to the hospital for ureteral catheterization under cystoscopic guidance and possibly exploratory laparotomy. Percutaneous nephrostomy with delayed repair may also be considered. Provide parenteral antibiotics if infection is suspected.

Vesicovaginal fistulas can become evident 10 to 14 days after surgery with a watery vaginal discharge. The diagnosis can be confirmed by inserting a cotton tampon into the vagina and then instilling methylene blue or indigo carmine dye via a transurethral catheter. If the tampon stains blue, a vesicovaginal fistula is present. If no staining occurs, a ureterovaginal fistula must be ruled out by injecting 5 mL of indigo carmine dye IV. If a ureterovaginal fistula is present, the tampon should stain blue within 20 minutes.

Gynecologic consultation is necessary. Patients with a vesicovaginal fistula require prolonged urinary drainage with a Foley catheter. Although some fistulas close spontaneously, most require surgical repair.

OTHER COMPLICATIONS

Urinary tract infection is a common complication.² For detailed discussion, see chapter 91, "Urinary Tract Infections and Hematuria." Urinary retention in a healthy female after gynecologic surgery is uncommon. Urinary retention is usually a temporary result of pain or bladder atony resulting from anesthesia. However, many women experience either an inability to void or incomplete emptying of the bladder during the postoperative period, most frequently after radical hysterectomy or surgeries that involve the urethra and bladder neck (i.e., anterior repair or any modification of the retropubic urethropexy). Retention is initially relieved with insertion of a Foley catheter for 12 to 24 hours. Most patients are able to void after this period. For further discussion, see chapter 92, "Acute Urinary Retention."

Pulmonary emboli account for nearly 40% of all deaths after gynecologic surgery.² The prevalence of postoperative deep venous thromboembolism is 11% to 25%.² Fifty percent of venous thromboembolic events occur in the first 24 hours after surgery, and 75% occur in the first 3 postoperative days. There is no difference in the incidence of venous thromboembolism between abdominal, vaginal, or laparoscopic hysterectomy, but risk factors include age >60 years, cancer, and other comorbidities.²⁰ For complete discussion of diagnosis and treatment, see chapter 56, "Venous Thromboembolism."

Septic pelvic thrombophlebitis complicates 0.1% to 0.5% of gynecologic procedures, more commonly after cesarean delivery than hysterectomy.²¹ The two forms of septic pelvic thrombophlebitis, ovarian vein thrombosis and deep septic pelvic thrombophlebitis, often occur together. Signs include abdominal pain and fever. The diagnosis may be aided by CT and MRI, but a negative study does not exclude disease.^21,22 Treatment is heparin and parenteral antibiotics. Long-term anticoagulation is not needed unless septic pulmonary emboli develop.

High-grade squamous intraepithelial lesions of the cervix are treated by loop electrocautery, laser ablation, or cold-knife conization. The most common complication of conization procedures is bleeding, which can be rapid and severe. Delayed hemorrhage may occur 7 to 14 days postoperatively.

Visualization of the cervix is the key to controlling bleeding. Application of Monsel solution (a commercially available ferrous subsulfate solution) is a reasonable first step if it is readily available. Monsel solution should be available from the hospital pharmacy. Direct pressure for 5 minutes with a large cotton-tipped swab may also be effective. Alternatively, cauterization with silver nitrate may be attempted. If these maneuvers are unsuccessful, consult the gynecologist for suturing or cauterization of the bleeding arteriole. The vagina can be packed with gauze if the bleeding is severe while waiting for definitive therapy. Often the patient must be taken to the operating room for repair because adequate visualization is difficult in the ED.

There are three major methods for termination of pregnancy: instrumental evacuation by vaginal route, stimulation of uterine contraction, and major surgical procedures. Overall, less than 1% of women have complications.²³ Complications can be categorized by time after procedure: immediate, delayed, or late (Table 105-6).

Due to the approval of mifepristone in 2000, medical abortions now account for 23% to 37% of all nonhospital abortions.^24,25 Mifepristone is usually followed by misoprostol, a regimen with a 92% efficacy rate.²⁶ Common side effects include nausea, vomiting, diarrhea, headaches, dizziness, and fatigue. Methotrexate, in combination with misoprostol, is an alternative therapy.

Uterine perforation occurs in approximately 0.1 to 3 per 1000 abortion procedures.²⁷ Most perforations are noted at the time of surgery; however, small perforations may go unnoticed. Patients can present with pain and/or bleeding and, possibly, signs of shock.

If a cervical laceration is noted, treatment includes pressure, followed by application of Monsel solution or use of silver nitrate sticks. Suturing may be necessary if there is no resolution of bleeding.

Incomplete abortion and retained products of conception occur in 0.5% of medical abortions and 0.29% to 1.96% of all abortions.²⁵ Women present with abdominal pain, bleeding, and possibly fever. On physical examination, the cervical os is usually open, and the uterus is boggy, enlarged, and tender. A pelvic US is the diagnostic test of choice and can identify a thickened endometrium and retained echogenic contents. Treatment consists of dilatation and curettage or medical management with misoprostol. If coexistent endometritis is present, treatment with broad-spectrum antibiotics is required for at least 10 to 14 days.

Postabortal endometritis not associated with retained products of conception presents with a closed cervical os and a firm yet tender uterus. Uncomplicated endometritis is treated with antibiotics.

Women who are Rh negative require Rh0 (D) immunoglobulin, 300 micrograms IM, after spontaneous or induced abortion. If it is not prescribed within 72 hours, the overall risk of sensitization in the second pregnancy is approximately 3%.

Obtain gynecologic consultation for all patients with complications after induced abortion.

Serious complications from intrauterine devices are rare, occurring in less than 1% of patients, and include pelvic inflammatory disease, ectopic pregnancy, and uterine perforation.²⁸ The only possible indication for removal of an intrauterine device in the ED is infection (salpingitis, endometritis, pyosalpinx, or pelvic peritonitis). The risk of pelvic inflammatory disease in intrauterine device users is more related to preexisting sexually transmitted infections rather than the intrauterine device itself.^29,30 Patients may present to the ED for intrauterine device removal for other reasons, such as irregular menses or pain; however, patients should be referred to their gynecologist for removal.

If referral is impractical, grasp the string of the intrauterine device with a Kelly clamp or long forceps and pull with steady, gentle force until the intrauterine device emerges from the uterus. Do not jerk the string because it may detach from the intrauterine device, making removal more difficult. If the string cannot be visualized, a lost intrauterine device may be located with ultrasonography. If the intrauterine device is extrauterine or fractured, surgical removal will be necessary.

Endometrial ablation is used to treat abnormal uterine bleeding. Although there are numerous technologies, they share similar postoperative complications, including pregnancy after ablation, pain-related obstructed menses, and infection. Pregnancy incidence after endometrial ablation is 0.7%.³¹ There is a much greater risk of complications during these pregnancies, including preterm birth, intrauterine scarring, and postpartum hemorrhage. Also, the ectopic rate is 6.5%, almost three times the baseline risk. Persistent endometrium is common after ablation, as are uterine contracture and scarring. This results in obstructed egress of menses, causing cyclic cramping and pain. The incidence of infectious complications ranges from 1% to 2%, including endometritis, myometritis, pelvic inflammatory disease, and pelvic abscess.³¹ Patients present with fever, uterine and/or adnexal tenderness, and vaginal discharge usually within 3 days of surgery.

Surgery using transvaginal mesh can be used to treat pelvic organ prolapse. Associated complications include bladder perforation, mesh erosion and vaginal exposure, chronic pelvic pain, dyspareunia, infection, and fistula formation.³² This has prompted the U.S. Food and Drug Administration to release several public notifications on the safety and effectiveness of transvaginal mesh for treatment of prolapse.

Transvaginal US-guided aspiration of oocytes is used during in vitro fertilization. Complications related to US-guided retrieval and preparation for retrieval of oocytes are rare and include ovarian hyperstimulation syndrome, pelvic infection, intraperitoneal bleeding, and adnexal torsion. Occasionally, complications develop hours to weeks after the procedure and require prompt surgical intervention.

Ovarian hyperstimulation syndrome occurs in 1 in 10 women going through in vitro fertilization. Rarely, it can be a life-threatening complication. Symptoms of mild disease include abdominal distention, ovarian enlargement, and weight gain. Patients with severe disease have rapid weight gain, tense ascites due to third spacing of fluid into the abdominal cavity, pleural effusions, tachypnea, orthostatic hypotension due to hypovolemia, tachycardia, progressive oliguria, and electrolyte abnormalities. Increased coagulability and decreased renal perfusion are also noted. The moderate-to-severe form is seen in 1% to 2% of patients undergoing assisted reproduction.

Bimanual pelvic examination is contraindicated due to extremely fragile ovaries that are at high risk of rupture or hemorrhage. Defer examination until after discussion with the gynecologist. Laboratory evaluation includes a CBC, chemistry panel, coagulation studies, and blood for type and cross-match. An ECG to evaluate hyperkalemia should also be obtained.

Treatment in the ED consists of IV volume repletion. Consult the gynecologist for admission. Patients with suspected adnexal torsion should undergo evaluation with Doppler US.

Uterine artery embolization is a safe, effective approach for treating symptomatic uterine fibroids that may help patients avoid myomectomy and hysterectomy. It is an outpatient procedure performed by interventional radiologists in collaboration with the gynecologist. Compared to hysterectomy, uterine artery embolization is less expensive, results in a move favorable short-term quality of life, and has a significantly lower rate of major complications.³³

Postembolization syndrome is characterized by abdominal pain, fever, and leukocytosis after embolization and occurs in 2.8% of patients.³³ It is likely caused by an inflammatory response to myometrial and fibroid ischemia and necrotic tissue. Symptoms begin 1 to 2 days after the procedure and can last up to 7 days. In the ED, control pain and consider other possible causes for symptoms, particularly infection such as endometritis. Evaluation may include a CBC and a CT scan. Vaginal discharge and fibroid expulsion may be seen on pelvic exam. Approximately 1% of patients require hysterectomy due to infection. Some patients may require admission for pain control and IV antibiotics.

Acknowledgment: The author gratefully acknowledges the contributions of Michael A. Silverman, contributing author of this chapter in the previous edition.