The most common reasons for emergency department visits during the postoperative period after gynecologic procedures are pain, fever, and vaginal bleeding. A focused but thorough evaluation should be performed, including sterile speculum and bimanual examination and consultation with the gynecologist who performed the procedure is indicated. (Complications common to gynecologic and abdominal surgeries are covered in Chapter 49.)
The major complications associated with laparoscopy are thermal injury of the bowel, viscus perforation, hemorrhage, vascular injury, ureteral or bladder injuries, incisional hernia, and wound dehiscence. 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. X-rays 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, and early gynecology consultation should be obtained.
Complications of hysteroscopy include cervical and uterine perforation, postoperative bleeding, fluid overload from absorption of distention media, infection. Consultation with a gynecologist is required. Gas embolism and anesthesia reaction are intraoperative complications. Postoperative bleeding requires hemodynamic stabilization; the gynecologist may choose to insert a Foley or balloon catheter into the uterus to tamponade the bleeding. Vasopressin or misoprostol are alternative treatments. Patients with uterine perforation who present with peritoneal signs require surgical exploration. Patients with fluid overload are likely to be hyponatremic. Infection as a result of hysteroscopy is uncommon and is treated with antibiotics.
Cuff cellulitis, 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. One suggested regimen is ampicillin, 2 grams IV every 6 hours plus gentamicin, 1 milligram/kilogram IV loading dose followed by 1 milligram/kilogram 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 and pelvic pain. A CT scan or US can help 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 can occur during abdominal hysterectomy, resulting from crushing, transecting, or ligating trauma. These patients present soon after surgery with flank pain, fever, and costovertebral angle tenderness. The work-up includes a urinalysis and ...