Acute hemorrhage in the postoperative period can occur after many different procedures. This may occur as a result of an unrecognized trocar injury to the inferior epigastric vessels, a high cervical laceration from a dilatation and curettage, or a loose suture on a uterine artery pedicle after vaginal hysterectomy. In the recovery room, if a patient is persistently hypotensive despite fluid resuscitation, an internal hemorrhage should be suspected. One should respond by resuscitating the patient, checking blood count and coagulation studies, and ordering blood products for transfusion. If the patient does not respond, the patient may need to return to the operating room. Emergent uterine artery embolization has also shown to be a successful technique for postoperative bleeding.
DVT is a serious and potentially preventable complication of major gynecologic surgery. Patients at increased risk include those with malignancy, obesity, immobility, previous VTE, thrombophilia, smoking, estrogen-containing hormone therapy use, and increasing age. Untreated DVT can lead to a fatal pulmonary embolus.
- Diagnosis can usually be made with compression ultrasonography.
- If ultrasonography is negative but there is still a high suspicion for DVT, contrast venography is the gold standard and should be performed.
A careful history and physical is important in the diagnosis of DVT. Patients usually present complaining of unilateral leg swelling and calf or leg pain. Physical exam may reveal ipsilateral leg edema, calf tenderness, warmth, or erythema. During the exam, a cord can be palpated indicating a thrombosed vein. Homan's sign is pain with dorsiflexion of the foot. However, this sign is unreliable. A discrepancy in the calf diameter can be of some value in raising the suspicion for DVT.
Patients with DVT should be treated with anticoagulants immediately. This is done as soon as DVT is confirmed by objective testing. If there is a delay in diagnostic testing and the clinical suspicious is high, therapy should be started before such testing. Several options are available for the initial treatment of DVT according to the American College of Chest Physicians Guidelines: (1) LMWH, administered subcutaneous, without monitoring; (2) intravenous (IV) UFH, with monitoring; (3) subcutaneous UFH, with monitoring; (4) weight-based subcutaneous UFH, without monitoring; and (5) subcutaneous fondaparinux, without monitoring. For those treatments requiring monitoring, coagulation studies such as INR and partial thromboplastin time (PTT) should be measured at baseline. With UFH, the PTT should be kept 1.5–2.5 times the control value.
Anticoagulation therapy is continued for 3–6 months. Therefore, oral anticoagulants, particularly warfarin, are often started at the same time as initial treatment with the LMWH or UFH therapies above. Oral anticoagulants do not exert their full effect for 48–72 hours. Warfarin is generally started a dose of 5 mg daily, and subsequent doses are adjusted to maintain the INR value at 2.5 (range 2.0–3.0). Therefore, the LMWH or UFH therapy is continued for at least 5 days until the warfarin takes effect and the INR is ≥2.0 for 24 hours. For patients in whom bleeding is a particular risk or laboratory monitoring is problematic, LMWH can be used for long-term treatment instead of warfarin. Due to more predictable pharmacokinetics, LMWH, such as enoxaparin, can be administered subcutaneous once or twice daily without laboratory monitoring in the majority of patients. This treatment, as well as oral anticoagulation, allows initial treatment of DVT as an outpatient. Recommended long-term therapy for distal or calf vein thrombosis includes 3 months of anticoagulation. Long-term treatment for a proximal DVT is 3–6 months of anticoagulation.
Surgical treatment, such as thrombectomy, occasionally can be considered for persistent severe swelling in the extremity. An inferior vena cava filter can be placed for patients who develop DVT or pulmonary embolism that occurs despite adequate anticoagulation or in patients who have contraindications to anticoagulation therapy.
Laboratory and radiologic imaging is helpful in evaluating a patient for a pulmonary embolus (PE). With arterial blood gas, a low arterial Po2 should raise suspicion for a PE. D-dimer assays are usually elevated and have a high negative predictive value in ruling out a PE. However, recent surgery can elevate D-dimer levels and, therefore, may have little value in the workup.
Chest radiograph findings frequently show no abnormalities. However, a peripheral lung density, enlargement of the main pulmonary artery, or a small pleural effusion can be seen. Chest radiograph can rule out other diagnoses on the differential, such as pneumonia. Electrocardiogram is helpful in ruling out myocardial infarction. It can also show characteristic changes of PE, such as S1Q3T3 patterns, right bundle branch block, and T-wave inversions in leads V1 through V4.
Spiral chest computed tomography (CT) is now the diagnostic procedure of choice for PE. It can frequently visualize the emboli and has high sensitivity and specificity. Pulmonary angiography is the “gold standard” test but is used less frequently given it is an invasive procedure. It is reserved in patients with a high clinical suspicion for PE despite a negative or nondiagnostic spiral CT. Another imaging modality is the ventilation-perfusion (V/Q) scan. It is not the tests of choice because the results are frequently equivocal. It is useful in diagnosis in patients who cannot receive IV contrast.
PE is a potentially fatal complication of gynecologic surgery and usually occurs suddenly as a complication of a pelvic or lower extremity DVT. Risk factors are the same as noted earlier for DVT. Symptoms usually occur abruptly and include pleuritic chest pain, dyspnea, tachypnea, and tachycardia. A large embolus may result in hypotension, shock, and even sudden death from cor pulmonale. The symptoms are not specific for PE, and the differential diagnosis includes atelectasis, pneumonia, myocardial infarction, and pneumothorax.
There is ample evidence that primary thromboprophylaxis reduces DVT and PE and that fatal PE can be prevented. Recommendations based on guidelines from the American College of Chest Physicians include prophylaxis with low-dose UFH, LMWH, or intermittent pneumatic compression (IPC) devices for the extremities. For a low-risk patient undergoing a brief procedure <30 minutes, prophylaxis is not necessary. For brief procedures and laparoscopy, in patients who have risk factors for VTE, prophylaxis may be indicated. During any major gynecologic procedure, prophylaxis is recommended with low-dose heparin twice daily; LMWH, such as enoxaparin, once daily; or IPC. This prophylaxis is started just prior to surgery and is used continuously until discharge. For patients with malignancy, who are particularly at high risk, the recommendation is to continue prophylaxis with LMWH once daily or low-dose heparin 3 times daily for 2 to 4 weeks after discharge.
Cardiopulmonary resuscitation should be instituted if necessary, and the patient should be closely monitored. Due to the risk of mortality, patients with strong clinical suspicion of PE should get immediate treatment with anticoagulation. Treatment regimens for DVT and PE are similar given they are manifestations of the same disease process and are described earlier.
According to the American College of Chest Physicians and their guidelines, in patients with acute nonmassive PE, recommendations include initial treatment with LMWH over IV UFH. In patients with massive PE, where there is concern for subcutaneous absorption, the guidelines suggest IV UFH over LMWH. For patients with a massive PE with evidence of hemodynamic compromise, thrombolytic therapy with urokinase, streptokinase, or recombinant tissue plasminogen activator is also recommended in addition to anticoagulation. Patients who are highly compromised and cannot receive thrombolytic therapy due to bleeding risks may be candidates for surgical pulmonary embolectomy.
ACOG Practice Bulletin No. 84: prevention of deep vein thrombosis and pulmonary embolism. Committee on Practice Bulletins–Gynecology, American College of Obstetricians and Gynecologist. Obstet Gynecol
2007;110(2 Pt 1):429–440.
Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest
Kearon C, Kahn SR, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest
Gastrointestinal Tract Complications
Ileus is defined as a pattern of bowel dysmotility that results in accumulation of gas and fluid in the gastrointestinal tract. During abdominal or pelvic surgery, there usually is some degree of ileus for 3–6 days postoperatively. This is due to an increase in sympathetic tone, which causes inhibition in bowel motility. Bowel manipulation during surgery causes an inflammatory reaction resulting in an ileus. Opiate pain medications also have an inhibitory effect and can prolong an ileus.
The patient usually complains of abdominal pain and may have nausea or vomiting. Clinical findings include abdominal distention with decreased or absent bowel sounds. On plain abdominal radiographs, there is generalized dilatation and gaseous distention of both the small and large bowel.
If nausea, vomiting, and abdominal distention are severe, the patient should be restricted of oral intake. A nasogastric (NG) tube should also be inserted into the stomach. IV fluids should be administered, and electrolytes should be monitored. Although an NG tube is sometimes used for treatment, routine use in all patients does not prevent ileus. Early feeding in the postoperative period does not cause ileus and shortens hospital stays. Thoracic epidural analgesia use postoperatively has shown to promote quicker return to bowel function. The use of NSAIDs and opioid receptor antagonists has not been proven to decrease ileus.
Small bowel obstruction can result as a complication of an intraperitoneal operation. This is usually due to the formation of adhesions, which can trap or kink a segment of small intestine. Other causes include herniation through a laparoscopic trocar site, internal herniation, or an inflammatory process such as an abscess. Obstruction can occur in the immediate postoperative period or several years later due to dense adhesions. This results in partial or complete bowel obstruction and can cause bowel strangulation and perforation.
Plain abdominal radiographs are very sensitive in the diagnosis of small bowel obstruction. They usually reveal air-fluid levels of differential height within the same loop of bowel. In patients with inconclusive radiograph films, a CT scan (with IV and oral contrast) is sensitive and specific and can give incremental information on the grade of obstruction. Signs of bowel obstruction or strangulation on CT include continuous dilation of proximal small bowel with a discrete transition zone, serrated beak sign, mesenteric fluid and ascites, and intraluminal fluid. The colon usually contains little or no gas. Enteroclysis or small bowel follow-through study with oral contrast, as well as CT enterography and magnetic resonance imaging (MRI) contrast studies, are also available as diagnostic tests.
Obstruction is characterized by abdominal pain, vomiting, abdominal distention, and obstipation. On examination, the abdomen is distended and tender with high-pitched bowel sounds. It can be difficult to differentiate from a postoperative ileus and may require diagnostic studies.
Small bowel obstruction requires immediate intervention to prevent bowel ischemia and infarction. If the patient has no signs of bowel strangulation or peritonitis, conservative treatment can be used. This includes bowel rest, IV fluid hydration, electrolyte replacement, and bowel decompression with an NG tube. Patients with leukocytosis, fever, peritonitis, metabolic acidosis, and continuous pain suggest bowel strangulation and require operative intervention. In patients who received conservation management, if there is no improvement in symptoms within 48 hours, operative intervention is recommended with either exploratory laparotomy or laparoscopy.
Constipation and a reduction in the number of bowel movements are expected in the early postoperative period given low food intake, ileus, and narcotic use. If a bowel obstruction is not suspected, stool softeners and mild laxatives can be prescribed. An enema can also be used. Fecal impaction can also be present and cause diarrhea in the postoperative patient. It is diagnosed by digital rectal examination, and treatment involves disimpaction of the firm fecal masses.
Most postoperative diarrhea is caused by antibiotic administration or oral contrast for radiographic studies. This is usually mild and self-limiting. Antibiotics can alter the bacterial flora in the gastrointestinal tract. If overgrowth with Clostridium difficile occurs, a more serious infection can occur. C difficile may be a complication after treatment with antibiotics such as clindamycin, penicillins, cephalosporins, or fluoroquinolones. If untreated, C difficile infection can progress to fulminant colitis, ileus, obstruction, perforation, and toxic megacolon; therefore, prompt diagnosis and treatment are essential.
Clinical findings include diarrhea, fever, and leukocytosis. If C difficile infection is suspected, the stool should be sent for cytotoxin assay. If the infection is strongly suspected despite negative toxin stool toxin assays, colonoscopy can be performed to detect pseudomembranous changes in the colon. Toxic megacolon is a clinical diagnosis based on dilatation of the colon >7 cm on plain films, accompanied by severe systemic toxicity.
C difficile is becoming increasingly pathogenic and contagious. Once diagnosed, the patient should be placed in isolation with infection precautions. Management includes first withdrawal of the implicated antibiotic, and then treatment with preferably oral metronidazole or vancomycin. However, oral metronidazole is preferred in order to reduce vancomycin resistance and to reduce cost. If the infection is unresponsive to antibiotics and progresses to toxic megacolon, surgical intervention with colectomy may be necessary.
Diaz JJ Jr, Bokhari F, Mowery NT, et al. Guidelines for management of small bowel obstruction. J Trauma
Hookman P, Barkin JS. Clostridium difficile
associated infection, diarrhea and colitis. World J Gastroenterol
Stewart D, Waxman K. Management of postoperative ileus. Am J Ther
Urinary Tract Complications
Postoperative urinary retention is the inability to void in the presence of a full bladder. Risk factors for development of postoperative urinary retention include prolonged duration of surgery and the use of regional anesthesia or epidural analgesia. The patient may complain of suprapubic discomfort with the inability to void. The bladder may be palpable on abdominal exam if severely distended. Retention is likely if the patient is unable to void within 8 hours after surgery or 8 hours after bladder catheter removal. The diagnosis is confirmed if a bladder ultrasound displays 500 mL of urine or if a postvoid residual is 500 mL or greater. If retention is present, complications and bladder dysfunction may result. An overdistended bladder can cause pain and an autonomic response, resulting in vomiting, hypotension, bradycardia, and cardiac dysrhythmias. Infection can also be a direct complication or an indirect complication due to an indwelling bladder catheter. Severe overdistention for prolonged periods may cause ischemia and long-term bladder dysfunction.
Standard treatment for retention is immediate bladder drainage with sterile catheterization. Although intermittent in-out catheters are an alternative, most patients have an indwelling bladder catheter placed while in the hospital. The catheter is placed for approximately 24 hours, and then a void trial is performed. With incontinence procedures, such as suburethral slings, there may be retention due to overcorrection of the bladder neck requiring outpatient treatment with a catheter for several days.
In the immediate postoperative period, patients are at risk for urinary tract infection (UTI). They are at risk of UTI due to urinary retention that follows surgery and anesthesia, as well as due to instrumentation or catheterization during surgery. Catheter-associated UTI is one of the most common nosocomial infections.
Cystitis and UTI can cause increased frequency of urination, urgency, and dysuria. White blood cells, leukocyte esterase, and nitrites can be seen on urine analysis. When fever is present, pyelonephritis should be considered. If untreated, pyelonephritis can progress to urosepsis.
In patients suspected of having a UTI, a urine specimen should be sent for culture. Appropriate antibiotic therapy should be instituted and adjusted based on culture and sensitivity results. In patients with urinary retention, a bladder catheter is recommended. However, in patients without urinary retention, removal of the bladder catheter at the earliest possible time is important in treating and preventing UTIs.
Lower Urinary Tract Fistula
A lower urinary tract fistula is a rare complication of gynecologic surgery and obstetric trauma. These fistulas include vesicovaginal and ureterovaginal fistulas. Risk factors for fistula include malignancy, radiation therapy, intraoperative injury to bladder or the ureter, and obstructed labor. Most lower urinary tract fistulas in the Unites States occur after hysterectomies.
A lower urinary tract fistula can present perioperatively as gross hematuria or urinoma noted after surgery. In the postoperative period, patients with fistulas usually present 1 to 3 weeks after surgery complaining of urinary incontinence or persistent vaginal discharge. A speculum exam may reveal a fluid collection in the vagina and scarring at the apex. If a vesicovaginal fistula cannot be seen, a “tampon test” can be performed in the clinic. This test is performed by instilling methylene blue transurethrally into the bladder after placing vaginal sponges or a tampon in the vagina. The patient is then asked to walk around and perform the Valsalva maneuver. Intravenous indigo carmine or oral phenazopyridine can be given to exclude an ureterovaginal fistula. A voiding cystourethrogram can also be performed to diagnose and evaluate the size and location of a vesicovaginal fistula.
Cystoscopy is indicated in all cases to evaluate the size, location, and number of fistulas and the condition of the tissue. Radiologic imaging such an IVP or cystoscopic retrograde urogram is recommended to exclude a ureterovaginal fistula or hydronephrosis.
If a vesicovaginal fistula is diagnosed early, conservative management can be attempted. Although the timing, fistula size, and success rate remain unclear, limited data suggest that fistulas less than 1 cm in size diagnosed within 3 weeks of surgery can close spontaneously after bladder drainage. In 1 study, 39% of fistulas closed with bladder drainage if diagnosed within 3 weeks of surgery, while only 3% closed if diagnosed greater than 6 weeks after surgery. The duration of bladder drainage remains unclear, but some authors recommend 4 weeks of continuous drainage.
Ureteral fistulas are usually treated with ureteral stents for 6 to 8 weeks. An IVP is performed after 4 to 6 weeks to evaluate if the fistula has healed. If the fistula has healed, the stent is removed and IVP is performed at 3, 6, 12, and 24 months to rule out stricture formation. If the fistula has not healed, the stent is left in place for 8 weeks and the IVP repeated. If the fistula is not healed in 8 weeks, surgical repair is recommended.
The timing of vesicovaginal fistulas is controversial. Ideally, the fistula should be repaired within 72 hours of injury, before inflammation and induration take place. Some surgeons recommend waiting 3 to 6 months until the fistula has matured. Other surgeons have successfully closed fistulas earlier, after the initial inflammation has subsided. Timing of surgical repair should be individualized and based on cystoscopic evidence of healing, including the fistula site and adjacent tissue being pliable, noninflamed, epithelialized, and free of granulation tissue and necrosis. Vesicovaginal fistulas can be repaired vaginally or abdominally, but the surgical technique is beyond the scope of this chapter.
Baldini G, Bagry H, Aprikian A, et al. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology
Bazi T. Spontaneous closure of vesicovaginal fistulas after bladder drainage alone: a review of the evidence. Int Urogynecol J Pelvic Floor Dysfunct
Karram MM. Lower urinary tract fistulas. In Walters MD, Karram MM, eds. Urogynecology and Reconstructive Surgery. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2007.
Bacterial contamination of the operative site is a common occurrence in major gynecologic surgery. Hysterectomies are classified as “clean contaminated” cases due to the entrance into the genital tract and contamination with endogenous vaginal flora. Although antibiotic prophylaxis decreases the risk of postoperative infection, it still remains one of the most common postoperative complications. The diagnosis of a postoperative infection is generally made when there is pain and tenderness in the area contiguous with the infection and an oral temperature of ≥38°C on 2 separate occasions at least 6 hours apart or of >38.5°C at any time.
Antibiotic prophylaxis is usually only indicated for hysterectomy and urogynecology procedures. Cefazolin (1 g) is the most commonly used agent and is given within 30 minutes of the start of the procedure. A second dose of intraoperative antibiotic may be given if the duration of the surgery approaches 3 hours or in cases with increased blood loss (>1500 mL). Doxycycline is also used before and after surgical abortion. For procedures such as laparoscopy or exploratory laparotomy that do not directly enter the genital tract, antibiotic prophylaxis is not indicated.
An abscess should be considered in the postoperative patient with fever and no other source or in a patient who has failed initial antibiotic treatment. The patient usually presents with fever and abdominal pain. Clinical findings may include a mass palpated on pelvic examination. Pelvic hematomas that become infected can also present in a similar manner.
If an abscess is suspected, imaging should be performed with ultrasound or a CT scan with contrast. If confirmed, treatment involves parenteral antibiotics. Some regimens include gentamicin and clindamycin; ampicillin, gentamicin, and metronidazole; imipenem/cilastatin; and levofloxacin and metronidazole. Parenteral antibiotics are continued until the patient has been afebrile for 24 to 48 hours, and then patients are switched to oral antibiotics. Many abscesses, especially large ones, require drainage for adequate treatment. Percutaneous drainage of the fluid collection is often possible with insertion of a large-caliber “pigtail” catheter under ultrasound or CT guidance. An infected cuff hematoma or abscess can sometimes be managed by reopening the cuff. If the abscess does not respond to the above treatment, the patient may need a laparotomy with opening of the abscess, irrigation, and drain placement.
A wound infection is usually localized to the skin and fatty tissue above the fascia. The diagnosis of a postoperative wound infection is usually made several days after surgery, on postoperative day 4 or 5.
With wound infections or cellulitis, skin erythema (redness and warmth), subcutaneous induration, and fever are usually present. If there is incisional drainage present, there may be an abscess or fluid collection beneath the incision.
Cellulitis alone is usually treated with a single agent that is effective against streptococci, staphylococci, and most gram-negative organisms, such as a cephalosporin. If there is a fluid collection presenting with purulent drainage from the wound, it should be opened to allow drainage and debridement if necrotic tissue is present. The wound should be gently probed to check for fascial integrity. If the fascia is intact, the wound should be packed with moist gauze dressings 2 or 3 times daily.
Wound Dehiscence & Evisceration
Wound dehiscence is a postoperative wound separation that involves all layers of the abdominal wall. Risk factors include age, malnutrition, diabetes, smoking, malignancy, chronic steroid use, and obesity. Wound infection also predisposes the wound to disruption. Evisceration includes disruption of these layers with protrusion of intestines through the incision. The hallmark of this complication is profuse serosanguinous discharge from the abdominal incision. This is a surgical emergency that requires immediate closure in the operating room.
- Diagnosis is based on physical findings of a rapidly progressing infection.
- Radiologic tests, such as CT, MRI, or plain films, will display gas in the subcutaneous tissue.
- Surgical exploration will confirm the diagnosis, which reveals necrotic subcutaneous tissue and fasciae.
Necrotizing fasciitis is a rare and often fatal infection that is characterized by extensive necrosis of the fascia and adjacent subcutaneous tissue. Predisposing factors include advanced age, obesity, hypertension, arteriosclerosis, diabetes, malnutrition, renal failure, immunosuppression, and trauma. The bacteria that cause these infections include group A Streptococcus and other anaerobes such as Clostridium perfringens.
The clinical triad includes sepsis, inordinate pain, and unilateral edema. On physical examination, patients may appear septic with a fever and leukocytosis. The skin around the incision site is usually cool, gray, and boggy, and may reveal crepitus. Usually, the wound will display a marked degree of subcutaneous edema and varying degrees of cutaneous discoloration. There also may be a sensory deficit over the area of infection.
The most important treatment includes early and aggressive surgical debridement of the infection. This includes removal of all the necrotic tissue that is not bleeding and discolored. Healing is usually by secondary intention, with skin grafts often being necessary. Therefore, a gynecologic oncologist or plastic surgeon is usually involved. Treatment also includes broad-spectrum antibiotics, including a penicillin. Hyperbaric oxygen treatment can also lead to a decrease in the morbidity of these infections.
ACOG Practice Bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. ACOG Committee on Practice Bulletins–Gynecology. Obstet Gynecol
Gallup DG, Freedman MA, Mequiar RV, et al. Necrotizing fasciitis in gynecologic and obstetric patients: a surgical emergency. Am J Obstet Gynecol
Larsen JW, Hager WD, Livengood CH, et al. Guidelines for the diagnosis, treatment and prevention of postoperative infections. Infect Dis Obstet Gynecol