Chapter 109

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.

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.

### History

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.

Table 109-1 Key Historical Questions to Assess Postoperative Complications

### Physical Examination

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.

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.

### Laboratory Evaluation

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 cervical (if ...

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