Complications of Gynecologic Procedures

This section focuses on complications particular to gynecologic procedures that one might encounter in the ED setting and their evaluation and management (Fig. 125.1). Many complications of gynecologic procedures may go unrecognized before discharge, only to be seen later in the ED (Box 125.1). Box 125.2 lists the typical timing of these complications.

Fig. 125.1 Suggested algorithm for the evaluation and treatment of postoperative gynecologic patients.

ABCs, Airway, breathing, and circulation; Gyn consult, gynecology consultation; OR, operating room; US, ultrasonography; UTI, urinary tract infection.

Differential Diagnosis and Medical Decision Making

During the evaluation of postoperative patients it is essential to avoid narrowing the differential diagnosis to postoperative complications alone. Other conditions, particularly preexisting ones that may have served as the original indication for surgery (e.g., malignancy, anemia) must be taken into consideration. Laboratory testing and imaging studies should be guided by the differential diagnoses under consideration (see the Priority Actions box).

For patients with complications after a gynecologic procedure, bedside ultrasonography (US) in the hands of a skillful operator can provide rapid recognition of intraabdominal and intrapelvic pathology. Possible ultrasonographic findings include free fluid heralding leakage from a perforated vessel, urinary tract, or viscus (Fig. 125.2); hydronephrosis as a result of ureteral obstruction; a full bladder secondary to urinary retention; fluid collections; and intrauterine contents. US can also be used to guide paracentesis for definitive fluid diagnosis or for the drainage of subcutaneous abscesses. It is important to remember that sensitivity and accuracy are very dependent on the user and interpreter and that anatomy, habitus, and elements such as bowel gas can greatly interfere with adequate imaging. US is a poor modality for evaluating the bowel or retroperitoneal space.

Fig. 125.2 Transvaginal ultrasound image showing free fluid in the cul-de-sac consistent with hemorrhage.

When a patient with postprocedural complications is seen in the ED, the physician who performed the procedure should be contacted; definitive management often requires gynecologic or other surgical intervention.

 Priority Actions

Differential Diagnosis: Complications of Gynecologic Procedures

Abnormal Symptoms or Vital Signs?

Anemia, bleeding

• Hemorrhage may be internal or exsanguinating; emergency resuscitation and exploratory laparotomy are required if unstable. Bedside US for detection of free intraabdominal fluid. For emergency transfusion, use O-negative blood in women with childbearing potential; otherwise, use O positive blood.

Fever

• Consider septic shock, toxic shock syndrome, and necrotizing fasciitis; administer broad-spectrum antibiotics and search for the source of infection. Emergency surgical débridement is required for necrotizing fasciitis.

Abdominal distention

• Consider bowel obstruction or injury to the vasculature, bowel, or urinary tract; bedside US to evaluate for free fluid; upright chest and abdominal radiographs; antibiotics; abdominal/pelvic CT with contrast enhancement if stable; and early surgical evaluation.

Shortness of breath

• Consider pulmonary embolism, fluid overload, and aspiration pneumonia.

• If occurring after laparoscopy, also consider pneumothorax.

Vaginal Bleeding—Is It Cervical or Uterine in Origin?

Cervical or vaginal lacerations: Controlled by simple measures in the ED?

• If yes, discharge with close follow-up with gynecology.

• If not or if after conization, pack and gynecology consultation for management in the operating suite.

Uterine bleeding: Is retained tissue or hemometra noted on ultrasound imaging?

• If yes, gynecology consultation for definitive care.

• If not, consider uterine perforation, and if uterine perforation is present, maintain high suspicion for a perforated viscus and obtain abdominal/pelvic CT. Consider other specific evaluation of nearby structures (i.e., cystoscopy).

Abdominal Pain with Distention?

Ileus or small bowel obstruction on radiography? Nasogastric tube if excessive vomiting; surgical consultation required.

If not, consider intestinal, urinary, or vascular injury. Abdominal/pelvic CT imaging.

Unable to Urinate?

Postvoid catheterization or bedside US:

• >500 mL of urine noted? Maintain the urinary catheter and check for a UTI. Substitute a leg bag and treat the UTI if present; discharge to follow-up with urology.

• <200 mL, consider renal failure from medications or bilateral ureteral obstruction. Renal function tests, US to evaluate for hydronephrosis or free fluid. Admit for further evaluation.

Dysuria?

Hematuria and abdominal pain? Persistent or recurrent UTI? Suspect urinary tract injury; obtain imaging to evaluate for ureteral or bladder compromise.

If not, treat the UTI with antibiotics, urine culture, and close follow-up.

Wound Redness and Drainage?

Localized? If so, check the fascia; if it is intact, treat as a superficial wound infection with packing and close follow-up. If the fascia is not intact, consider a subfascial abscess, early necrotizing fasciitis, or hernia or evisceration; make sure that it is not an incarcerated hernia; gynecology consultation and possible surgical evaluation are required.

Widespread? Consider cellulitis or fasciitis; administer antibiotics and hospitalize the patient. If only mild cellulitis is present, oral antibiotics, very close follow-up, and explicit return instructions are required (consider priming with first dose of intravenous antibiotics).

CT, Computed tomography; ED, emergency department; US, ultrasound; UTI, urinary tract infection.

Urinary Tract Injury

The incidence of urinary tract injury in gynecologic surgery is between 0.33% and 4.8%. The great majority (80%) of these injuries involve the bladder. Ureteral injuries occur in just 0.3% to 1.0% of cases, but unilateral injury is discovered postoperatively in the majority of cases.³ This delayed recognition leads to increased morbidity. As a result, ureteral injury has become the leading cause of legal action against gynecologic surgeons.

Typical symptoms are fever, flank pain, prolonged ileus, and prolonged abdominal distention. Unexplained hematuria or watery vaginal discharge may be present as well. The most common causes of these symptoms are cystitis and pyelonephritis secondary to perioperative bladder catheterization.

Inability to urinate may represent anuria or urinary retention, which are differentiated by postvoid urinary catheterization or US. No output at all indicates anuria as a result of bilateral compromise or renal failure. Urine residual volume greater than 500 mL suggests urinary retention instead. Bedside US can also detect intraabdominal fluid or hydronephrosis.

Laboratory testing includes a complete blood count and differential, electrolytes, kidney function tests, preoperative blood assays, urinalysis, and urine culture. If ascites or other fluid is obtained, fluid creatinine levels should be measured to determine whether it is urinary in origin. Imaging to evaluate the urinary system is indicated, such as intravenous urography, abdominal/pelvic computed tomography with contrast enhancement, or renal US with retrograde ureteropyelography.

Complications of ureteral obstruction (secondary to ligation, stricture, or external compression by another structure) include hydronephrosis and progressive kidney damage, which ultimately leads to failure of the ipsilateral kidney if treatment is delayed. Bilateral injury (or unilateral injury to a solitary functioning kidney) may simply manifest as anuria and subsequent total renal failure. Urinary leakage from ureteral disruption can cause urinary ascites or an enclosed urinoma.

Months to years after the procedure, watery drainage from the vagina heralds an ureterovaginal or vesicovaginal fistula, whereas watery wound drainage suggests a ureterocutaneous or vesicocutaneous fistula (Table 125.1).

Table 125.1 Clinical Findings and Bedside Diagnosis of Pelvic Fistulas

TYPE OF FISTULA	FINDINGS	BEDSIDE DIAGNOSIS
Ureterovaginal	Copious, watery vaginal discharge; multiple urinary tract infections	To confirm and differentiate these fistulas: 1. Place a tampon in the vagina. 2. Administer phenazopyridine, 200 mg orally. 3. Instill normal saline tinted with methylene blue into the bladder. Results: Orange tampon = a ureterovaginal fistula. Blue tampon = a vesicovaginal fistula. Note that both types may be present concurrently and that blue may overpower orange.
Vesicovaginal	Copious, watery vaginal discharge; multiple urinary tract infections
Enterovaginal	Vaginal discharge may contain intestinal contents; severe vaginovulvar irritation may be present because of the pH	Acidity can be tested with litmus paper or the pH portion of a urine dipstick. Place a tampon in the vagina and administer oral activated charcoal. A stained tampon is diagnostic.
Colovaginal	Brown, feculent vaginal discharge	Place a tampon in the vagina and instill normal saline tinted with methylene blue into the rectum. A stained tampon is diagnostic of a rectovaginal fistula. Higher colonic lesions may be diagnosed by oral administration of activated charcoal.
Vesicocutaneous	Copious watery suprapubic wound discharge	Place a clean wound dressing and administer saline tinted with methylene blue into the bladder. A blue-stained dressing is diagnostic. To differentiate from ureterocutaneous fistulas, insert a urinary catheter, instill methylene blue via the catheter and clamp it off, wait hour, and then drain the bladder until clear and perform the test described below.
Ureterocutaneous	Copious, watery wound drainage	Place a clean dressing and then administer methylene blue intravenously. A blue-stained dressing is diagnostic.

Vaginal Bleeding

Bleeding from the vagina must be evaluated in the context of the procedure performed. A careful history and speculum examination are key to determining the source, quantity, and persistence of the bleeding.

Blood flowing from the cervical os implies a uterine cause. It may be a result of hemometra (intrauterine hematoma), retained tissue, retained foreign bodies, infection, or uterine injury. Bimanual examination helps ascertain the size and tenderness of the uterus. A pelvic US scan must be performed to assess the uterine contents. It can be done at the bedside if the patient is unstable. An acute abdominal radiographic series (flat and upright abdominal views with an upright chest radiograph) to look for signs of perforation may be obtained, but it must be kept in mind that residual pneumoperitoneum from laparotomy or laparoscopy often persists for at least 24 hours and may be present for up to 72 hours.

Uterine perforation is manifested as pelvic cramping and vaginal bleeding. It is of serious concern because of risk for associated injury to adjacent bowel, pelvic vessels, bladder, or other structures. Rapid bedside US by the emergency physician (EP) can be useful to assess for free pelvic fluid suggesting hemorrhage or bladder leakage.

Symptoms of acute hemometra include severe, progressive, cramping pelvic pain. Vaginal bleeding may be minimal if the os is obstructed by the enlarging hematoma. The total blood loss is usually insufficient to cause hypotension or anemia. An extremely distended and tender uterus on bimanual pelvic examination is diagnostic, and bedside US can be used to further support the diagnosis.

In rare cases of persistent bleeding without explanation, an unrecognized bleeding diathesis must be considered. von Willebrand disease is the most common bleeding disorder in women of childbearing age.

Endometritis

Patients with endometritis are typically initially seen 3 to 7 days after instrumentation with fever and pelvic or lower abdominal pain and tenderness. Vaginal bleeding is frequently present. Potential pathogens are those of pelvic inflammatory disease, in addition to organisms that may have been introduced during the procedure. Risk factors include retained tissue, as well as pelvic inflammatory disease and insufficiently aseptic operating conditions.

Evaluation consists of pelvic US to assess for retained products and laboratory tests, including a complete blood count and assay for the β subunit of human chorionic gonadotropin (β-hCG).

Wound and Abdominal Wall Infections

Superficial wound infections occur in up to 10% of patients who have undergone gynecologic surgery without perioperative antibiotics. The most common causes are Staphylococcus aureus and vaginal or enteric flora. The great majority of these infections are minor, although systemic toxicity or extensive infection may occur if the initial infection is neglected or in patients who are immunosuppressed, have diabetes, or are obese.

Thorough evaluation requires opening the wound for drainage and examination for deep fascial or muscular involvement. Superficial wound infections can be managed without antibiotics by meticulous wound care, irrigation with diluted hydrogen peroxide or Dakin solution four times per day, and dry gauze packing. Delayed wound closure can be performed if necessary. Table 125.2 details the clinical findings, evaluation, and treatment of wound infections, dehiscence, and necrotizing fasciitis.

Table 125.2 Wound and Abdominal Wall Infections

Vaginal Evisceration

Vaginal evisceration (bowel and organs protruding from the vagina) is rare, yet dramatic and has a mortality of up to 10% because of associated intestinal necrosis, peritonitis, or other underlying or global illness. It occurs as a result of increased intraperitoneal pressure in the setting of a ruptured vaginal enterocele or unrecognized uterine perforation. The diagnosis is based on findings on physical examination.

Complications Specific to Laparoscopy

Laparoscopic procedures are characterized by more rapid recovery and lower complication rates than seen with open surgical procedures. However, unique complications are associated with needle or trocar insertion, induced pneumoperitoneum, and extensive use of electrocautery^4,5 (Box 125.3). Most catastrophic complications are recognized intraoperatively. Management in the ED in the first month postoperatively is usually for wound complaints or symptoms caused by injury to the bowel, bladder, or ureters. Remote complications include hernias.

Bleeding

Abdominal wall hematomas may occur as a result of damage to superficial vessels at laparoscopic sites. If the injury is extensive or if the size cannot be estimated because of habitus, a complete blood count can be obtained to estimate and track the blood loss, although the blood lost is not usually sufficient to require transfusion.

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