Download OB/GYN POST-OPERATIVE CARE AND COMPLICATIONS

11/24/2015
OB/GYN POST-OPERATIVE
CARE AND COMPLICATIONS
MICHAEL TING MD, FACOG
MAINEGENERAL OBSTETRICS AND GYNECOLOGY
MESPAN CONFERENCE
NOVEMBER 2015
I HAVE NO DISCLOSURES TO REPORT
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ESTIMATES OF COMPLICATIONS
• ABDOMINAL HYSTERECTOMY - 9%
• VAGINAL HYSTERECTOMY - 4.2%
• LAPAROSCOPIC HYSTERECTOMY (LAVH AND TLH) 5.3%
• ROBOTIC HYSTERECTOMY - 5.5%
• LAPAROSCOPIC PROCEDURES - 8%
• PELVIC SUPPORT PROCEDURES - 5%-10%
• OFFICE BASED PROCEDURES - 10X MORE ADVERSE
EVENTS COMPARED TO HOSPITAL BASED PROCEDURES
OFFICE BASED PROCEDURES
• THIS IS THE NEW TREND (30% OF GYNECOLOGICAL
SURGERIES)
• TRANSCERVICAL
STERILIZATION
- ESSURE
• LEEP
• IUD
• ENDOMETRIAL ABLATION
• SUBURETHRAL
VAGINAL SLINGS
• SAME INFORMED CONSENT PROCESS / TIMEOUT
• APPROPRIATE EQUIPMENT, STAFF ASSISTANCE, AND
GOOD TECHNIQUE
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TYPES OF COMPLICATIONS
• ORGAN INJURY
• VASCULAR
• BOWEL
• BLADDER
• URETERAL
• INFECTIOUS MORBIDITIES
• SEPSIS
• Neuropathies
• Other
• Thromboembolic
• Adhesions
• Fistulas
• Lymphedema
• Incisional Hernias
• WOUND INFECTION
• PNEUMONIA
• URINARY TRACT INFECTION
PERI-OPERATIVE STRATEGIES
• CONSENT PROCESS
• DESIGNATED APPOINTMENT FOR PREOPERATIVE DISCUSSION
• WRITTEN MATERIALS
• FAMILY INVOLVEMENT, POWER OF ATTORNEY
• BLOOD TRANSFUSION
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PERI-OPERATIVE STRATEGIES
• MEDICAL EVALUATION
• FOCUSED CARDIAC AND RESPIRATORY HISTORY (CARDIOVASCULAR DISEASE IS
LEADING CAUSE OF DEATH)
• SMOKING CESSATION
• RISK ASSESSMENT FOR DVT PROPHYLAXIS
• DISCUSSION OF CONTRACEPTIVES AND HORMONE REPLACEMENT
PERI-OPERATIVE STRATEGIES
• BOWEL, SKIN, AND VAGINAL PREPARATION
• LOW RESIDUE DIET, ORAL ANTIBIOTIC AND/OR MECHANICAL BOWEL
PREPARATION
• PERIOPERATIVE ANTIBIOTICS (ACOG PRACTICE BULLETIN # 74)
• TOPICAL ESTROGEN FOR ATROPHIC TISSUES (UNDERUTILIZED)
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BLEEDING
•
“EXCESSIVE” BLEEDING IN 1-3% OF HYSTERECTOMIES
GENERALLY
RECOGNIZED INTRAOPERATIVELY
•
•
POST OPERATIVE RECOGNITION
•
VITAL SIGN CHANGES
•
DECREASED
•
VAGINAL
•
FLANK
•
MONS PUBIS PAIN AND
SPACE OF RETZIUS
•
DECREASED HEMOGLOBIN/HEMATOCRIT
URINARY OUTPUT
BLEEDING
PAIN WITH RETROPERITONEAL BLEEDING
LABIAL SWELLING WITH BLEEDING INTO
POST OPERATIVE MANAGEMENT
•
PHYSICAL EXAM
•
RETURN TO OR
BOWEL INJURY AND ILEUS
• 4-5% INCIDENCE OF ILEUS AND 0.3% INCIDENCE OF BOWEL INJURY WITH
HYSTERECTOMY
• RECOGNITION AND MANAGEMENT OF ILEUS
• NAUSEA, VOMITING, AND DISTENDED ABDOMEN
• ADEQUATE HYDRATION AND ELECTROLYTE MANAGEMENT
• BOWEL REST AND CONSIDER USE OF NASOGASTRIC TUBE
•
RECOGNITION AND MANAGEMENT OF INJURY
• VISUALLY WITH IMMEDIATE REPAIR
• NAUSEA, EMESIS, FEVER, PERITONITIS
• DIFFICULT AT TIMES TO DISCERN INJURY VS. ILEUS
• DELAYED RECOGNITION REQUIRES RETURN TO OR
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VAGINAL CUFF DEHISCENSE
• OVERALL RATE- 0.39%
•
TLH/ROBOTIC 1.5%, LAVH 0.28%, TAH
0.15%, TVH 0.08%
•
RELATED
TO ENERGY USE, OBESITY,
VAGINAL ATROPHY, PELVIC ACTIVITY
• SYMPTOMS
•
EXCESSIVE VAGINAL BLEEDING, WATERY
DISCHARGE, PELVIC PRESSURE
•
BOWEL
EVISCERATION IN
66%
• TREATMENT
•
SURGICAL EMERGENCY,
RETURN TO
OR
FOR CUFF REVISION AND REPAIR, POSSIBLE
BOWEL RESECTION
BLADDER INJURIES
• 0.1 TO 0.5% INCIDENCE
• RECOGNITION
• VISUAL
INSPECTION
• RETROFILLING (INFANT
FORMULA,
DILUTED METHYLENE BLUE)
•
CYSTOSCOPY
• CT CYSTOGRAM (URINOMA)
• MANAGEMENT
• SURGICAL
REPAIR IMMEDIATELY
• POSTOPERATIVE DRAINAGE (FOLEY
CATHETER FOR 7-14 DAYS)
• FISTULA
REPAIR - COLOVESICAL /
ENTEROVESICAL (POPPY SEED TEST1.25 OZ MIXED WITH YOGURT AND
VISUALIZE URINE IN 48 HOURS.
100% SENSITIVE AND SPECIFIC)
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URETERAL INJURIES
• 0.2%-1.3%
INCIDENCE
• LOWEST WITH VAGINAL
APPROACH
• HIGHEST WITH LAPAROSCOPIC
APPROACH
• RECOGNITION AND MANAGEMENT
• VISUALIZE AND PALPATE URETERS
• STENTS NOT PROVEN TO BE HELPFUL
• CYSTOSCOPY WITH INDIGO
CARMINE, ORAL PYRIDIUM
• SURGICAL REPAIR (DEPENDS ON
LOCATION OF INJURY)
INFECTIOUS MORBIDITIES
• COMBINED 9% INCIDENCE OF WOUND INFECTION, PELVIC CELLULITIS, VAGINAL CUFF
ABSCESS, AND PELVIC ABSCESSES AMONG WOMEN WHO RECEIVED PROPHYLACTIC
ANTIBIOTICS WITH HYSTERECTOMY (VAGINAL FLORA)
• 1-5% RATE OF SYMPTOMATIC URINARY TRACT INFECTION
• 30-50% OF WOMEN UNDERGOING HYSTERECTOMY DEVELOP A FEVER POST
OPERATIVELY
• RECOGNITION AND MANAGEMENT
• REMEMBER 6WS (WIND, WOUND, WATER, WALK, WONDER DRUGS,
WHOPPERS)
• HISTORY, PHYSICAL EXAM, AND LABS/RADIOLOGICAL STUDIES
• TREAT WITH INCENTIVE SPIROMETRY, AMBULATION, AND ANTIBIOTICS
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THROMBOEMBOLIC COMPLICATIONS
• DEEP VENOUS THROMBOSIS
• 7-45% INCIDENCE IN GENERAL AND
MALIGNANT GYNECOLOGIC SURGERIES
• ASYMMETRIC EDEMA, WARMTH, TENDERNESS
• ULTRASOUND (90% SENSITIVE FOR PROXIMAL
LEG VEINS)
• ANTICOAGULATION
• PULMONARY EMBOLUS
• 0.1-5% INCIDENCE
• TACHYCARDIA, TACHYPNEA, DECREASED
OXYGEN SATURATION
• SPIRAL CT, VQ SCAN, EKG (SINUS
TACHYCARDIA, S1Q3T3 PROMINENT S WAVE, Q
WAVE AND INVERTED T WAVE)
• ANTICOAGULATION
NEUROPATHIES AND NERVE ENTRAPMENT
• 1.9% INCIDENCE IN ONE UNIVERSITY OF FLORIDA STUDY
• GENERALLY RELATED TO POSITIONING AND RETRACTOR PLACEMENT
• PRESENTS WITH MOTOR WEAKNESS AND SENSORY DEFECTS, PHYSICAL
EXAM IS KEY
• COMPARTMENT SYNDROME
• TREATMENT WITH PHYSICAL THERAPY OR SOMETIMES EXPLORATION
FOR PAINFUL NERVE ENTRAPMENT
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COMPLICATIONS OF HYSTEROSCOPY
• PERFORATION OF THE UTERUS
•
COMPLICATIONS
RELATED TO DISTENDING MEDIA (NORMAL
SALINE FLUID OVERLOAD TERMINATE PROCEDURE IF FLUID
DEFICIT
> 1.5 L)
•
HIGH O2
•
HOSPITALIZATION
•
IV LASIX
•
THERMAL
•
HEMORRHAGE
FOR MONITORING
INJURY
•
INTRACERVICAL
•
INSERTION OF FOLEY WITH 13-30CC SALINE
VASOPRESSIN
FOR
6-8
HOUR AND SLOW DEFLATION
•
INFECTIOUS
•
HEMATOMETRA
OBSTETRICAL COMPLICATIONS
• POSTPARTUM HEMORRHAGE
• UTERINE ATONY
• LACERATIONS
• RETAINED PRODUCTS
• UTERINE INVERSION
• PLACENTA ACCRETA
• HEMATOMA
• EPIDURAL ANESTHESIA
• POSTDURAL PUNCTURE HEADACHE
• TRANSIENT BACK PAIN
• MENINGITIS
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CASE #1
• 24 YO FEMALE PRESENTS WITH NAUSEA, ANOREXIA,
AND ABDOMINAL PAIN. SHE IS NOW DAY # 3 FROM
A LAPAROSCOPIC LEFT OOPHORECTOMY AND A LYSIS
OF ADHESIONS FOR A DERMOID CYST.
• CYST RUPTURED DURING THE CASE
• BOWEL RESECTED
FROM THE CYST AND PELVIC SIDE WALL
• DISCHARGED 2 HOURS AFTER
SURGERY WITHOUT
COMPLICATIONS
THANK YOU
Questions?
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