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As the length of stay for postoperative patients decreases and
more procedures are performed on an outpatient basis, postoperative
complications previously seen among inpatients are now seen in outpatients. Emergency
physicians must therefore be familiar with complications resulting
from gynecologic procedures.
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Unanticipated hospital admission after ambulatory surgery occurs
in approximately 1% of cases overall and in >5% of
gynecologic cases, with postoperative emesis being the most common
reason for admission.1,2 The most common reasons
for ED visits during the postoperative period after gynecologic
procedures are pain, fever, and vaginal bleeding.
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A focused but thorough evaluation should be performed. Key historical questions
are listed in Table 109-1. The interval between
the surgery and the onset of symptoms is very important in determining
their cause. For example, most cases of early postoperative fevers (<24 hours) are not infectious,
and causes may include pulmonary atelectasis, hypersensitivity reactions
to antibiotics, pyogenic reactions to tissue trauma, or hematoma
formation.
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Relevant examination of all appropriate systems should be performed.
It should not be assumed that the etiology of the complaint is gynecologic, and
other potential explanations of the symptoms should be investigated.
Postoperative pain and tenderness can be difficult to assess. After
laparoscopy, patients may have pain radiating to their shoulder
for several days because of co2 bubbles
that remain after insufflation for the laparoscopic procedure. Postoperative
pain and tenderness is more concerning if associated with nausea
and vomiting and a change in bowel sounds.
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The surgical wound should be examined and a pelvic examination
performed, including both a sterile speculum and a bimanual examination. In
patients undergoing fertility treatment, the pelvic examination should
be performed with caution, or even deferred, due to the possibility
of rupturing enlarged ovarian follicles. During sterile speculum examination,
the cervix, or, if it is absent, the vaginal cuff, must be visualized.
After vaginal hysterectomy, no special precautions are needed for a
speculum examination. Evidence of bleeding, discharge, erythema,
or cuff or labial cellulitis should be noted. The presence of tenderness, masses,
and an intact cuff is recorded during bimanual examination after a
vaginal or abdominal hysterectomy. After hysteroscopy or dilatation and
curettage, cervical motion and uterine and adnexal tenderness should
be evaluated. A rectal examination should always be performed to
evaluate tenderness or masses.
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Laboratory studies should be directed toward the patient’s
complaints. A complete blood count with a manual differential count
is almost always indicated. A serum β-human chorionic
gonadotropin level should be obtained for all women with childbearing
potential. A catheterized urine specimen, along with urine, blood,
wound, and ...