Complications of gynaecological procedures

History

• Procedure performed
• Route of procedure – Abdominal, vaginal, laparoscopic
• Reasons for procedure
• Timing of symptom onset
  • <24 hours fever: Atelectasis, hypersensitivity reactions to antibiotics, pyrogenic reaction to trauma or haematoma formation
  • Day 3-5 fever: UTI
  • Day 4-6 fever: VTE
  • >7 day fever: Surgical site infection
• Proximity of symptom to surgical site
• Complications already experienced
• Medications prescribed

Examination

• If patient undergoing fertility treatment, defer pelvic examination until gynaecology consult due to risk of rupture of enlarged ovarian follicles
• After vaginal hysterectomy, no special precautions re: speculum examination are required
• Look for cervical discharge, introitus inflammation, intact vaginal cuff/cervix and adnexal/uterine tenderness

Labs

• FBC, beta-hCG, urine MCS, wound swabs, BC and cervical swabs if febrile
• UEC/LFT
• CXR
  • Air or insufflated CO2 should be entirely resorbed by third post-operative day
• US may be helpful for pelvic structures
• CT is gold standard for most post-operative abdominal complications (sensitivity and specificity >90%)
• MRI can rule out septic pelvic thrombophlebitis

Post-laparoscopy

• Gynaecological indications
  • Sterilisation
  • Adhesiolysis
  • CO2 laser ablation of endometriosis
  • Uterine surgery
  • Tubal surgery
  • Ovarian surgery
  • Paraovarian cyst excision
  • Hysterectomy

Post-laparoscopy

• Patients with greater than expected abdominal pain after laparoscopy have a bowel injury until proven otherwise
  • Traumatic bowel injury
  • Thermal bowel injury – Can be easily missed at the time. Patients may only develop symptoms weeks later. Damage is usually more extensive than it appears
  • Vascular injury – Uncommon and usually recognised during the operation. May present later with post-operative haematoma
• UTI
  • 4% incidence rate post-laparoscopy
  • Injuries to renal tract can be traumatic or thermal
  • Mechanical obstruction of ureter by staples, sutures may present up to 1 week post-operatively with flank pain and fever
• Incisional hernias and dehiscence
  • Rare after laparoscopy but more common if defect >10mm
• Wound infection
  • Mostly minor skin infections
  • Pelvic cellulitis/abscess/necrotising fasciitis is rare but should be considered

Hysteroscopy

• Uterine perforation is rare and is usually recognised at the time of operation
• Infection is very rare
• Cervical lacerations can occur
• Uterine bleeding can occur following resection procedures
• Gas embolism is the most feared with CO2 embolism to lungs or arterial circulation if PFO
  • Usually noted at time of or shortly after insufflation

Post-major abdominal surgery

• Wound infection
  • Need swabs, removal of sutures, drainage, washout and IV antibiotics
• Wound seroma
  • Usually self-resolving but large ones can be drained
• Vaginal cuff cellulitis and pelvic abscess
  • Post-hysterectomy vaginal cuff cellulitis can occur with fever, purulent discharge and pelvic/back/abdominal pain
  • Need IV antibiotics and drainage of any collections (must cover gram-positive, negative and anaerobes)
• Dehiscence
  • Abdominal wall dehiscence usually day 5-18 post-operatively
  • Vaginal cuff dehiscence usually 2 months post-hysterectomy with postcoital bleeding, watery discharge and pelvic pain

Genitourinary injury

• Suspect ureteral injury if present with flank pain in days after surgery
• Vesicovaginal fistulas
  • May present 10-14 days after surgery with watery vaginal discharge
  • Can confirm with methylene blue via IDC then see if drains into vagina with tampon

PE

• Accounts for 40% of deaths after gynae surgery
• Prevalence of post-operative DVT is 11-25%
• 50% occur in first 24 hours; 75% in first 3 days
• Risk factors include age >60, cancer and other comorbidities

Septic pelvic thrombophlebitis

• 0.1-0.5% of all gynaecological procedures
• More common after C/S than hysterectomy
• Ovarian vein and deep variants and often occur together
• Negative CT and MRI cannot rule out disease
• Treatment is heparin and IV antibiotics
• Long-term anticoagulation is only required if septic PE develop

Post-conization bleeding

• Most common complication is bleeding, which can be rapid and severe
• Delayed haemorrhage can occur 7-14 days post-op
• Visualisation of the cervix is key to diagnosis and treatment
• Direct pressure for 5 minutes with large cotton tip swab can be effective
• Silver nitrate cautery is another option (but need to have dry field)
• Can pack vagina with gauze if necessary while awaiting surgery

Induced abortion

• Immediate (within 24 hours)
  • Nausea, vomiting, diarrhoea, headache, dizziness and fatigue are common side effects of medical abortion
  • Bleeding, pain
  • Consider uterine perforation or cervical lacerations (with surgical abortion)
• Delayed (24 hrs to 4 weeks)
  • Bleeding
  • Retained POC in 0.5% of all medical abortions
  • Retained POC have open cervix and boggy, enlarged, tender uterus
  • Post-abortive endometritis without retained POC have closed cervix and firm, yet tender uterus
• Late (>4 weeks)
  • Amenorrhoea
  • Psychological issues
  • Rh isoimmunisation

IUD

• <1% of patients suffer serious complications
• PID, ectopic pregnancy and uterine perforation are possibilities
• Risk of PID is related to underlying risk of STI rather than IUD

Endometrial ablation

• 1-2% infection rate with fever, uterine/adnexal tenderness and vaginal discharge usually within 3 days of surgery
• Pregnancy incidence is 0.7% with much higher risk of ectopic pregnancy, preterm birth, intrauterine scarring and PPH

Assisted reproductive technology

• TVUSS-guided oocyte aspiration can result in ovarian hyperstimulation syndrome, pelvic infection, intraperitoneal bleeding, adnexal torsion
• Ovarian hyperstimulation syndrome
  • 1/10 women undergoing IVF
  • Can be life-threatening
  • Mild symptoms include abdominal distension, ovarian enlargement, weight gain
  • May suffer rapid weight gain, tense ascites, third spacing, pleural effusions, tachypnoea, orthostatic hypotension, tachycardia, progressive oliguria and electrolyte disturbance
  • Moderate-severe form seen in 1-2% of women undergoing IVF
• Bimanual exam is contraindicated in this setting due to fragile ovarian follicles at risk of rupture or haemorrhage
• FBC, UEC, LFT, VBG, ECG, type and X-match + antibodies
• IV volume repletion and Ix suspected adnexal torsion with USS

Post-embolisation syndrome

• Uterine artery embolisation utilised for uterine fibroid management
• Presents with abdominal pain, fever and leukocytosis in 2.8% of patients
• Likely due to inflammatory response to fibroid ischaemia and necrosis
• Symptoms begin 1-2 days after procedure and can last 7 days
• Treat pain and consider endometritis (+- IV antibiotics)
• CT scan may assist in ruling out alternative pathologies
• 1% of patients require hysterectomy for infection

Last Updated on July 19, 2021 by Andrew Crofton