Antibiotic Prophylaxis for Gynecologic Procedures

• 
  

  Antimicrobial Prophylactic Regimens by Procedure (Table 2-1)

Key Points to Remember

• 
  

  Antibiotics must be given within 1 hour prior to skin incision. Anesthesia induction is a convenient time

  
  
• 
  

  Give repeat dose of antibiotic if

  
  
  
  
  • 
    

    Long procedure (over one to two times antibiotics half-life; ex: re-dose cefazolin at 3 hours)

    
    
  • 
    

    EBL over 1500 cc

  
  
• 
  

  Neither treatment for several days before a procedure nor subsequent doses after procedure are indicated for prophylaxis

  
  
• 
  

  Prophylactic antibiotics are recommended for induced abortion/dilation and curettage (D&C) even if negative gonorrhea/chlamydia (GC/CT) testing

Endocarditis Prophylaxis

• 
  

  Cardiac conditions associated with the highest risk of adverse outcomes from endocarditis that require antibiotic prophylaxis are shown in Table 2-2. Suggested antibiotics are listed in Table 2-3

Venous Thromboembolism (VTE) Prophylaxis

• 
  

  Risk factors for VTE include, but are not limited to, surgery, immobility, trauma, cancer, previous VTE, estrogen-containing medications, obesity, inherited or acquired thrombophilia, pregnancy and the postpartum period, erythropoiesis-stimulating agents, nephrotic syndrome, myeloproliferative disorders, and central venous catheterization

  
  
• 
  

  Prevalence of VTE in patients that undergo major gynecologic surgery is 15–40%

  
  
• 
  

  Risk of VTE and subsequent prophylaxis recommendations depend on

  
  
  
  
  • 
    

    Patient’s age and associated risk factors

    
    
  • 
    

    Type and duration of procedure

  
  
• 
  

  VTE prophylaxis

  
  
  
  
  • 
    

    Recommended according to risk classification (Table 2-4)

Common Abdominal Incisions in Gynecologic Surgery

• 
  

  Midline vertical: Start 3–4 cm above pubic symphysis and extend superiorly in midline; provides excellent exposure and ability to extend superiorly to xyphoid; less bleeding

  
  
• 
  

  Pfannenstiel: Horizontal incision 3–4 cm above pubic symphysis; keeping incision within lateral rectus border and curving incision cephalad will help to avoid ilioinguinal/iliohypogastric nerve injuries (see Table 2-5). Cosmetic, however, more bleeding, and less exposure

  
  
• 
  

  Maylard: Wide horizontal skin incision (anterior inferior iliac spine (ASIS) to ASIS), dissection of rectus sheath, followed by transection of rectus muscles and possible suture ligation of inferior epigastric vessels. Cut ends of muscle are transfixed to the rectus sheath to prevent retraction and permit closure at end of case. Provides exposure

  
  
• 
  

  Cherney: Horizontal skin/fascial incision; tendons of rectus and pyrimidalis are transected 1–2 cm above their attachment to the pubic symphysis and are reapproximated at end of case. Provides exposure

Complications of Gynecologic Surgery

• 
  

  Intestinal injury (less than 1% risk)

  
  
  
  
  • 
    

    Repair with suture line perpendicular to long axis of bowel to prevent narrowing of bowel lumen

  
  
• 
  

  Urologic injury (approximately 1% risk)

  
  
  
  
  • 
    

    Increased risk when surgery indicated for malignancy or prolapse

    
    
  • 
    

    Small bladder injury (<1 cm) in the dome of the bladder may be treated with Foley for 7–10 days or repaired

    
    
  • 
    

    Larger bladder injury (≥1 cm) requires repair; two layer closure

    
    
  • 
    

    Ureteral injury may not be apparent until 1–5 days after surgery (urinoma or ascites develops)

    
    
  • 
    

    Cystoscopy can be helpful to assess for bladder defects and ureteral function

    
    
  • 
    

    See Figure 2-1—Path of Ureter

  
  
• 
  

  Fistula formation: Relatively rare; may be urologic or gastrointestinal

  
  
• 
  

  Fascial dehiscence

  
  
  
  
  • 
    

    Can occur early or late, average 4–14 days postoperatively

    
    
  • 
    

    Risk factors: Chronic pulmonary disease, post-op cough, ascites, malignancy, obesity, wound infection, poor nutrition, history of radiation

    
    
  • 
    

    Diagnosis: “Popping” sensation, copious serosanguinous discharge from wound, bulge at incision; may be partial or complete opening of fascia

    
    
  • 
    

    Treatment: Surgical emergency; moist dressing over wound and go to OR; 10% mortality

    
    
  • 
    

    Prevention: Proper fascial closure without tension and delayed absorbing suture; postoperative teaching and precautions

  
  
• 
  

  Evisceration: Dehiscence with protrusion of abdominal contents out of incision

  
  
• 
  

  Wound infection (cellulitis, abscess); hematoma/seroma

  
  
• 
  

  Wound hematoma/seroma

  
  
• 
  

  Incisional hernia

  
  
• 
  

  VTE

  
  
• 
  

  Nerve injury: Risk can be reduced by knowledge of anatomy, careful positioning of patient and retractors (in open surgery) (Table 2-5)

Suture Selection

Suture Types (Table 2-6)

• 
  

  Absorbable (monocryl, vicryl, chromic, PDS) versus nonabsorbable (nylon, gortex, silk, fiberware, ethibond, prolene, steel)

  
  
• 
  

  Braided (silk, vicryl, ethibond) versus nonbraided/monofilament (monocryl, PDS, ethilon/nylon)

  
  
  
  
  • 
    

    Nonbraided may cause less tissue reactivity/tearing; knots more likely to loosen

Suture Size

• 
  

  More zeroes, the smaller the diameter (eg, 4-0 or 0000 is larger than 5-0 or 00000)

  
  
• 
  

  Then sizes are 0, #1, #2, etc (larger the number, larger the diameter)

  
  
• 
  

  Typically, 0 is for fascia

Needle Types

• 
  

  Tapered: Used on tissue that is more easily pierced (eg, bowel, fascia, muscle)

  
  
  
  
  • 
    

    TP or CTX—fascia

    
    
  • 
    

    CT or CT1—suprafascial deep tissue layers

    
    
  • 
    

    CT2—uterus

    
    
  • 
    

    SH—bowel

    
    
  • 
    

    CV or BV—vessel and nerve repair

  
  
• 
  

  Cutting: Used on skin and other tough tissue

  
  
  
  
  • 
    

    GS—fascia or soft tissue

    
    
  • 
    

    FSLX—large skin closure when tension present

    
    
  • 
    

    FSL—for sewing drains to skin or skin closure needing higher tension closure

    
    
  • 
    

    FS2 or PS2—skin closure

Types of Hysteroscopes

• 
  

  Diagnostic

  
  
  
  
  • 
    

    Flexible (2.8–5.0 mm in diameter)

    
    
  • 
    

    Rigid (1.0–5.0 mm in diameter; 12 degrees, 30 degrees most common)

  
  
• 
  

  Operative (8.0–10.0 mm in diameter)

  
  
  
  
  • 
    

    Electrosurgical resectoscopes: Monopolar, bipolar (Versapoint)

    
    
  • 
    

    Hysteroscopic morcellators (Smith & Nephew TRUCLEAR^™, Hologic MyoSure^®)

    
    
  • 
    

    Operative sheath with instruments inserted through channels

Preoperative/Intraoperative Considerations

• 
  

  Optimal timing is during follicular phase of menstrual cycle

  
  
• 
  

  If performing operative (not diagnostic) hysteroscopy such as myomectomy, essure, or ablation, consider preoperative Depo-Provera several weeks ahead of time to thin endometrial lining and aid visualization

  
  
• 
  

  Consider use of misoprostol (eg, 200 or 400 μg orally or vaginally) for cervical ripening if cervical stenosis is anticipated (evidence-based only for premenopausal women)

  
  
• 
  

  Distension of uterine cavity typically requires 60–70 mm Hg

  
  
• 
  

  Keeping intrauterine pressure less than mean arterial pressure (MAP) will decrease fluid intravasation

  
  
• 
  

  If using monopolar energy, patient must be grounded

Contraindications

• 
  

  Pregnancy; active genital tract infections; active herpetic infection

Media: Table 2-7

Complications (Primarily with Operative Hysteroscopy)

• 
  

  Hemorrhage 2.4%, uterine perforation 1.5%, cervical laceration 1–11%

  
  
• 
  

  Air embolism: Decrease risk by avoiding Trendelenburg position, prime tubing, limiting CO₂ flow; treatment if air embolism is suspected is left lateral decubitus position, head tilted down 5 degrees, aspiration of air from right ventricle

  
  
• 
  

  Fluid overload: Check electrolytes, consider furosemide (Lasix) 20–40 mg IV; if Na is less than 125 mEq/L, stop procedure

Selecting Patients for Laparoscopy

• 
  

  Prior abdominal surgery: Greater than 20% risk of adhesions of omentum and/or bowel to the anterior abdominal wall. Consider left upper quadrant (LUQ) entry

  
  
• 
  

  Pulmonary disease: Hypercarbia and decreased ventilation associated with laparoscopy may be problematic for patients with pulmonary disease

Setting up the OR

• 
  

  Antibiotics: Not needed unless doing hysterectomy or dealing with infected tubes

  
  
• 
  

  Bowel prep: Does not decrease incidence of complications, but useful if bowel resection required, so consider if complicated case. No longer standard practice prior to routine gynecologic surgery

  
  
• 
  

  Have nasogastric (NG) tube orogastric (OG) tube placed for decompression (especially with LUQ entry)

  
  
• 
  

  Positioning

  
  
  
  
  • 
    

    Consider placing the patient on a “bean bag,” gel, or foam pad to limit sliding while in deep Trendelenburg

    
    
  • 
    

    Lithotomy: Thigh should be slightly flexed, no more than 90 degrees from the plane of the abdomen. Avoid hyperextension to reduce chance of nerve injury

    
    
  • 
    

    Buttocks slightly over table edge (allows for uterine manipulation); sacrum should be completely supported by table to reduce chance of back strain

    
    
  • 
    

    Tuck both or one arm(s) with padding; arms should be supported in a neutral position with hand against thigh to avoid ulnar nerve injury

    
    
  • 
    

    The patient should be flat (not in Trendelenburg) for umbilical trocar placement to minimize chance of injury to aorta/iliacs

Uterine Manipulation

• 
  

  A variety of uterine manipulators are available. Several examples are shown in Figure 2-2

Options for Creating Pneumoperitoneum

• 
  

  Use Veress needle: Two “pops”—first, the fascia; second, the peritoneum; DO NOT wiggle needle side to side after entry—can enlarge an inadvertent injury

  
  
• 
  

  Direct visual entry using trocar with transparent tip (Xcel^®, Visiport^TM, Optiview^®)

  
  
• 
  

  Open laparoscopy and place Hassan trocar, then insufflate

  
  
• 
  

  Insufflate to 12–15 mm Hg. (Can start with 20 mm Hg and decrease to 12–15 mm Hg)

Confirming Access to Peritoneal Cavity

• 
  

  Plunger on syringe attached to Veress is withdrawn to make sure no blood (indicating a vessel injury) or brown/green content (bowel injury) appear

  
  
• 
  

  Hanging drop test: Drop of normal saline is sucked into abdominal cavity (negative pressure)

  
  
• 
  

  Low intra-abdominal pressure (ideally below 7 mm Hg)

Trocar Placement

• 
  

  Umbilicus: Distance between skin and peritoneal cavity is shorter at umbilicus than any another site—there is no fat or muscle between skin and peritoneum

  
  
  
  
  • 
    

    In average weight patients, insert Veress toward hollow of sacrum

    
    
  • 
    

    In obese patients (BMI ≥30), use a more vertical approach

    
    
  • 
    

    See Figure 2-3

  
  
• 
  

  LUQ entry at Palmer’s point: Left hypochondrium, two fingerbreadths below the left costal margin in the midclavicular line

  
  
• 
  

  Secondary trocars

  
  
  
  
  • 
    

    In midline, 3 cm above pubic symphysis

    
    
  • 
    

    Laterally, approximately 8 cm from the midline and 8 cm above pubic symphysis to avoid inferior epigastric vessels (inferior epigastrics are approximately 5 cm from midline and 3 cm above symphysis; on laparoscopic view, are medial to lateral insertion of round ligament and just lateral to the obliterated umbilical vessels.). See Figure 2-4 for location of anterior abdominal wall blood vessels

Energy Sources

• 
  

  Monopolar: Risk of injury to adjacent structures if instrument touches them

  
  
• 
  

  Bipolar: Offers a greater margin of safety. Damage is limited by thermal spread (approximately 22 mm) rather than by electrical current; cutting ability is reduced

  
  
• 
  

  Laser: Offers a precise, rapid, and accurate method of thermally destroying the tissue, although hemostatic effects are less and the cost is more

  
  
• 
  

  Advanced bipolar sealing devices: Enseal, plasma kinetic dissection forceps (Gyrus), and LigaSure™ use pressure and pulsed current to seal vessels with minimal lateral thermal spread

  
  
• 
  

  Harmonic scalpel: Blade vibrates at 55.5 mHz to break hydrogen bonds in tissue, resulting in cutting or coaptation of vessels

Principles of Electrosurgery

• 
  

  Dissection of tissue using high-energy alternating currents

  
  
  
  
  • 
    

    Cut mode: Low voltage, continuous current; deeper tissue penetration, less lateral spread

    
    
  • 
    

    Coagulation mode: High voltage, interrupted current; superficial tissue penetration, more lateral spread

  
  
• 
  

  Monopolar (example: Bovie)

  
  
  
  
  • 
    

    Instrument contains a single active electrode

    
    
  • 
    

    Path of energy: Generator → active electrode → tissue → dispersed through the body to the return electrode (ie, grounding pad) → generator

  
  
• 
  

  Bipolar (example: Kleppinger)

  
  
  
  
  • 
    

    Instrument contains active and return electrodes

    
    
  • 
    

    Path of energy: Generator → active electrode → tissue → return electrode → generator and the intervening tissue is dessicated

Complications of Laparoscopy

• 
  

  Retroperitoneal vessel injury (aorta/iliacs): (risk approximately 0.1–1%)

  
  
  
  
  • 
    

    Treatment: Make midline vertical incision, transfuse blood products, call vascular surgeon, ask anesthesiologist to place central line

  
  
• 
  

  Abdominal wall vessel injury: (risk approximately 0.2–2%)

  
  
  
  
  • 
    

    Inferior epigastric (from external iliac), superficial epigastric (from femoral)

    
    
  • 
    

    Avoid injury: Transilluminate to see superficial epigastric; look intraperitoneally beneath the peritoneum between the insertion of the round ligament at the inguinal canal and the obliterated umbilical artery to see the inferior epigastric

    
    
  • 
    

    Treatment: Coagulate the vessel with electrosurgery from another port site, or place a Foley catheter through the trocar and inflate the balloon or place a transabdominal suture

  
  
• 
  

  Intestinal injury: (risk approximately 0.1–0.4%)

  
  
  
  
  • 
    

    May not be recognized at time of surgery. Usually manifests 24–48 hours post-op: fevers, leukocytosis, nausea/vomiting, distension, abdominal pain

  
  
• 
  

  Incisional hernia: (risk approximately 0.2–5%)

  
  
  
  
  • 
    

    May decrease risk by visualizing closure of the fascia for port sites larger than 10–12 mm

  
  
• 
  

  Gas embolism: (risk approximately 0.001–0.6%)

  
  
  
  
  • 
    

    Uncommon; may be caused by inadvertent placement of Veress in vessel

    
    
  • 
    

    Signs: Decreased end-tidal carbon dioxide, decreased oxygen saturation, a loud mill-wheel murmur, severe hypotension, and possible cardiac arrest

    
    
  • 
    

    Treatment: Stop insufflation, remove the needle, place the patient in the left lateral decubitus position, administer 100% oxygen, place a central line for aspiration of the gas from the right side of the heart and from the pulmonary vasculature

Important Points

• 
  

  Half-life of opioids is approximately 3 hours (takes approximately 15 hours to achieve steady state)

  
  
• 
  

  Acetaminophen + oxycodone (Percocet/Tylox): acetaminophen limits dose-maximum 4000 mg in 24 hours

  
  
  
  
  • 
    

    Tylox contains 5 mg oxycodone + 500 mg acetaminophen

    
    
  • 
    

    Percocet contains 5 mg oxycodone + 325 mg acetaminophen

  
  
• 
  

  If need more narcotic

  
  
  
  
  • 
    

    Oxycodone: 5–20 mg every 3–4 hours (often given without acetaminophen to avoid toxicity)

    
    
  • 
    

    Hydromorphone (Dilaudid) 1–4 mg every 3–4 hours

  
  
• 
  

  To switch to morphine sulfate controlled release (MS Contin), take last 24 hours cumulative dose of morphine and give one-half of that as MS Contin every 12 hours or one-third every 8 hours

  
  
• 
  

  Morphine sulfate immediate release (MSIR): 30–60 mg orally every 3–4 hours

  
  
• 
  

  See Table 2-8 for equivalent analgesic dosing for various narcotic medications

Low Urine Output

• 
  

  Definition: Less than 0.5 cc/kg/hour, or less than 30 cc/hour for 60 kg woman

  
  
• 
  

  Differential Diagnosis

  
  
  
  
  • 
    

    Prerenal: Dehydration, hemorrhage

    
    
  • 
    

    Renal: Acute tubular necrosis (ATN), acute interstitial nephritis

    
    
  • 
    

    Postrenal: Obstruction, retention

  
  
• 
  

  Physical Exam

  
  
  
  
  • 
    

    Vital signs (orthostatics, fever, tachycardia), ins/outs (I/Os), heart, lungs, abdomen, extremities

    
    
  • 
    

    Is Foley catheter working? Flush! Unkink! Replace!

  
  
• 
  

  Labs: If cause is obvious, go to management. Otherwise consider

  
  
  
  
  • 
    

    CBC to check hematocrit if concerned about bleeding or patient is orthostatic

    
    
  • 
    

    Send urine for specific gravity, sodium (less than 20 mEq/L generally indicative of hypovolemia), and creatinine (to calculate fractional excretion of sodium (FENa); see below)

    
    
  • 
    

    Need basic metabolic panel labs if doing FENa (for serum Na and Cr)

    
    
    
    
    • 
      

      Findings suggestive of

      
      
      
      
      • 
        

        Prerenal: Urine specific gravity (>1.025), BUN/Cr >20, urine Na <20 mEq/L, FENa <1%

        
        
      • 
        

        Renal: Normal to low specific gravity, BUN/Cr <20, urine Na >40 mEq/L, FENa >2%

• 
  

  Management

  
  
  
  
  • 
    

    Strict I/O’s (monitor with Foley)

    
    
  • 
    

    Prerenal: If patient is obviously dry with no signs of acute blood loss, give IV fluid bolus and follow urine output. The healthy patient should tolerate a fluid challenge of 10 mL/kg of NS or LR run over 20–30 minutes; fluid resuscitate, rule out bleeding (hematoma), rule out sepsis. Consider CT scan if concerned about bleeding

    
    
  • 
    

    Renal: Stop nephrotoxic medications (ketorolac, ibuprofen, gentamicin)

    
    
    
    
    • 
      

      ATN: May be caused by sepsis, shock, toxins (radio-contrast dye, amino-glycosides). Presence of large amounts of tubular epithelial cells and epithelial cell (granular) casts pathognomonic for ATN (ischemic damage)

    
    
  • 
    

    Postrenal: Place/flush Foley, rule out ureteral obstruction (renal sono)/injury. If evidence of pulmonary edema, diurese (ie, Lasix, follow K+)

Postoperative Fever

• 
  

  Definition

  
  
  
  
  • 
    

    ≥38.0°C (100.4°F) on two occasions at least 4–6 hours apart and more than 24 hours after surgical procedure. EXCLUDES fever during first 24 hours post-op

    
    
  • 
    

    ≥39.0°C (102.2°F) recorded on any occasion in post-op period

  
  
• 
  

  Causes

  
  
  
  
  • 
    

    20% due to infection; 80% due to noninfectious causes

    
    
    
    
    • 
      

      Noninfectious: Atelectasis, hypersensitivity reactions to medications, pyrogenic reaction to tissue trauma, hematoma formation

      
      
    • 
      

      Infectious: Aspiration pneumonia, wound infection, abscess formation

    
    
  • 
    

    Most early post-op fevers are caused by inflammatory stimulus and resolve spontaneously

    
    
  • 
    

    Increased risk of post-op fever with operative time over 2 hours and intraoperative transfusion

    
    
  • 
    

    Think about the 5 Ws: Wind (atelectasis), water (UTI), wound (infection/hematoma), walk (superficial/deep vein thrombophlebitis), wonder drugs (drug-induced fever)

    
    
  • 
    

    See Figure 2-5 for timing of fever onset with various complications

  
  
• 
  

  Evaluation

  
  
  
  
  • 
    

    Careful history and exam guides which lab tests, IF ANY, are indicated

    
    
  • 
    

    Study of post-op GYN patients

    
    
    
    
    • 
      

      Urine culture positive in only 9% of patients cultured and less than 2% of febrile patients

      
      
    • 
      

      Chest x-ray with significant findings in 1.5% of febrile patients

      
      
    • 
      

      Blood cultures—none were positive

    
    
  • 
    

    In the first 48 hours

    
    
    
    
    • 
      

      Nonseptic causes most common. Atelectasis causes up to 90%

      
      
    • 
      

      Diagnostic studies performed have a very low yield

      
      
    • 
      

      Evaluate: History, vital signs, urine output, physical exam: pharynx; lungs, back for costovertebral angle (CVA) tenderness, incision, extremities (DVT, thrombophlebitis), drains, IV sites

      
      
    • 
      

      Keep in mind: In post-hysterectomy patients, vaginal cuff cellulitis/hematoma/abscess may be a fever source

    
    
  • 
    

    After the first 48 hours

    
    
    
    
    • 
      

      Most common sites of infection in post-op laparotomy patient are pulmonary system, wounds, and urinary tract

      
      
    • 
      

      “Fever Workup” (if indicated)

      
      
      
      
      • 
        

        Consider CBC with differential, basic metabolic panel, chest x-ray, urinalysis with culture

        
        
      • 
        

        Blood cultures two times (if fever ≥39°C, or HIV-infected, or Oncology patient, patient with central line)—realize they have very low yield in the majority of instances

        
        
      • 
        

        Sputum culture if respiratory symptoms; wound culture

        
        
      • 
        

        If exam warrants, consider pelvic ultrasound, CT scan, lower extremity Dopplers, etc

    
    
  • 
    

    Consider drug fever

    
    
    
    
    • 
      

      May take several days or weeks to develop

      
      
    • 
      

      Fever is usually constant, not spiking

      
      
    • 
      

      Generally improves

  
  
• 
  

  Be more aggressive if persistent fever, immunosuppressed (Oncology patients), frail/unstable patients, unusual signs/symptoms

  
  
• 
  

  Treatment: Depends on the suspected source

Gynecologic Infections

Cuff cellulitis

• 
  
  
  
  • 
    

    Infection of surgical margin in upper vagina

    
    
  • 
    

    Signs/symptoms: Can begin late hospital course or after discharge: Lower abdominal pain, back pain, fever, vaginal discharge

    
    
  • 
    

    Diagnosis: Erythema of cuff on vaginal exam

    
    
  • 
    

    Management: Broad spectrum coverage (amoxicillin/clavulanate (Augmentin), levofloxacin/metronidazole, etc)

Pelvic Abscess/Cuff Abscess/Infected Cuff Hematoma

• 
  
  
  
  • 
    

    Tender, fluctuant mass near vaginal cuff, possible purulent drainage

    
    
  • 
    

    Signs/symptoms: Pain, fever, drainage

    
    
  • 
    

    Diagnosis: Pelvic exam findings, imaging (CT scan or pelvic ultrasound)

    
    
  • 
    

    Management: Culture for aerobic/anaerobic pathogens; consider drainage, broad spectrum IV coverage (ertapenem, piperacillin/tazobactam (Zosyn)/vancomycin, etc)

Septic Pelvic Thrombophlebitis

• 
  
  
  
  • 
    

    Complicates 0.1–0.5% of gynecological surgical procedures

    
    
  • 
    

    Signs/symptoms: Often occurs 2–4 days post-op; fever, tachycardia, GI distress, unilateral abdominal pain

    
    
  • 
    

    Diagnosis: May be confirmed by CT scan or MRI—but, can be missed by imaging. Diagnosis of exclusion when fevers do not respond to appropriate antibiotic treatment in absence of abscess or infected hematoma

    
    
  • 
    

    Management: Some suggest extended antibiotic coverage; others anticoagulate with UFH or LMWH; however, optimal duration of anticoagulation has not been identified

Wound Infection

• 
  
  
  
  • 
    

    Signs/symptoms: Erythema, warmth, swelling, tenderness

    
    
  • 
    

    Diagnosis: Exam findings; consider imaging if high-grade fever or drainage

    
    
  • 
    

    Management

    
    
    
    
    • 
      

      Cellulitis/no drainable fluid collection: Oral cephalosporin, clindamycin or trimethoprim/ sulfamethoxazole (Bactrim DS) for 7–10 days

      
      
    • 
      

      Drainable fluid collection: Open incision; clean/pack. Wound care consult as needed; IV versus oral antibiotics depending on clinical presentation

Necrotizing Fasciitis

• 
  
  
  
  • 
    

    Severe complication from synergistic bacterial infection of fascia, subcutaneous tissue, and skin. More common in diabetics, immunocompromised

    
    
  • 
    

    Signs/Symptoms: Pain out of proportion to exam, clinical signs of sepsis, viscous, cloudy, malodorous drainage. Wound edges may be purple or necrotic. May see bullae of skin; crepitus in subcutaneous tissue

    
    
  • 
    

    Diagnosis: Exam; consider CT scan to confirm/determine extent

    
    
  • 
    

    Management: Prompt and extensive resection of involved tissue. Broad IV coverage (Zosyn/vancomycin/clindamycin)

  
  
• 
  

  Oncology patients often have more complicated infections and you should have a low threshold for work up, including imaging

See Figure 2-6.

Definitions

• 
  

  Normal menses: Generally menses every 21–35 days, lasting 2–7 days

  
  
• 
  

  Abnormal uterine bleeding (AUB):

  
  
  
  
  • 
    

    Cycle less than 21 days or more than 35 days, bleeding more than 8–10 days

    
    
  • 
    

    Menstrual blood loss over 80 mL/cycle OR subjectively heavy menses; some sources suggest soaking through more than six tampons or pads in a day is abnormal

    
    
  • 
    

    Intermenstrual bleeding

Diagnostic Workup

• 
  

  History

  
  
  
  
  • 
    

    Previous menstrual bleeding patterns versus current pattern

    
    
  • 
    

    Underlying endocrine conditions

    
    
  • 
    

    Screen for bleeding disorder (present in up to 20% women with heavy menses)

    
    
  • 
    

    Medications (ie, anticoagulants, hormones), herbal remedies

  
  
• 
  

  Physical Exam

  
  
  
  
  • 
    

    Height, weight, BMI (obesity associated with anovulation)

    
    
  • 
    

    Clinical signs of androgen excess (hirsutism, acne) or insulin resistance (acanthosis nigricans)

    
    
  • 
    

    Thyroid enlargement/nodularity

    
    
  • 
    

    Findings suggestive of prolactinoma: Visual field defect, nipple discharge

    
    
  • 
    

    Pelvic exam: Look for cervical/vaginal lesions and pelvic mass or tenderness, and assess uterine size

  
  
• 
  

  Labs (consider based on clinical presentation)

  
  
  
  
  • 
    

    β-hCG, CBC, TSH, prolactin, pap, GC/CT, wet mount

    
    
  • 
    

    Suspect PCOS: FSH, LH, estradiol, DHEA-S, free and total testosterone

    
    
  • 
    

    Suspect coagulopathy: CBC with platelets, PT/PTT, including tests for von Willebrand disease (VWD) (vWF—ristocetin cofactor activity, vWF antigen, and factor VIII activity)

    
    
  • 
    

    Endometrial biopsy for

    
    
    
    
    • 
      

      Women with AUB 45 years of age or older

      
      
    • 
      

      Women under 45 years old with risk factors for hyperplasia such as unopposed estrogen exposure (obesity/PCOS), failed medical management, persistent AUB

      
      
    • 
      

      Pipelle samples 5–15% of cavity, but sensitivity for diagnosis of cancer/hyperplasia is approximately 80–90%

  
  
• 
  

  Imaging

  
  
  
  
  • 
    

    Pelvic ultrasound (most helpful immediately after menses)

    
    
  • 
    

    Consider hysteroscopy, sonohysterogram, MRI if additional info needed

Differential Diagnosis

• 
  

  Uterus: Pregnancy, anovulation, polyps, fibroids, endometrial hyperplasia, cancer, adenomyosis, endometritis, retained products of conception

  
  
• 
  

  Cervix: Cervicitis, polyps, cervical intraepithelial neoplasia (CIN), cancer, cervical endometriosis, trauma

  
  
• 
  

  Vagina: Vaginitis, benign growths, vaginal intraepithelial neoplasia (VAIN), cancer, atrophy, trauma

  
  
• 
  

  Vulva: Cysts, dermatitis, herpes simplex virus (HSV), vulval intraepithelial neoplasia (VIN), cancer, trauma

  
  
• 
  

  Ovary: Granulosa cell tumors

  
  
• 
  

  Fallopian tubes: Malignancy can result in abnormal bleeding

  
  
• 
  

  Outside the genital tract: Urethritis, bladder cancer, UTI, inflammatory bowel disease, hemorrhoids, colon cancer

  
  
• 
  

  Systemic disease: Thyroid disease, hyperprolactinemia, liver disease, renal disease, hormone releasing tumors, coagulopathies (ie, VWD), Crohn’s disease, Behçet’s disease, Cushing’s disease, etc

  
  
• 
  

  Drugs: Hormonal contraception, paraGard^® IUD, hormone therapy, anticoagulation, Tamoxifen, steroids, chemotherapy, antipsychotics

  
  
• 
  

  Age-specific considerations

  
  
  
  
  • 
    

    Children: Rectal or urethral prolapse, trauma, foreign body

    
    
  • 
    

    Adolescents: Anovulation, coagulopathy

    
    
  • 
    

    Reproductive-aged women: Pregnancy!

    
    
  • 
    

    Perimenopausal: Anovulation

    
    
  • 
    

    Postmenopausal: 30–90% from atrophy

  
  
• 
  

  Consider abuse and sexually transmitted infections (STIs) in differential for ALL ages

Treatment

• 
  

  Based on the cause. See Table 2-9 for general management guidelines

Structural causes

• 
  
  
  
  • 
    

    Endometrial polyps

    
    
    
    
    • 
      

      Generally benign; remove for therapeutic purposes or if postmenopausal and bleeding

      
      
      
      
      • 
        

        Postmenopausal, no bleeding, risk of hyperplasia/carcinoma about 1.5% (up to 3%)

        
        
      • 
        

        Postmenopausal, with bleeding, risk of hyperplasia/carcinoma 4–5% (up to 11%)

      
      
    • 
      

      Hysteroscopy to identify and resect

    
    
  • 
    

    Uterine leiomyoma

    
    
    
    
    • 
      

      Benign growths, present in up to approximately 80% of women

      
      
    • 
      

      Submucosal, intramural, or subserosal

      
      
      
      
      • 
        

        Management based on size and location of leiomyoma

        
        
      • 
        

        Medical management

        
        
        
        
        • 
          

          GnRH agonists: Approximately 30–60% reduction in size in 3 months; may cause initial increase in bleeding followed by amenorrhea

          
          
        • 
          

          Options listed in Table 2-9 may help to control associated bleeding

        
        
      • 
        

        Surgical management: Uterine artery embolization, myomectomy, hysterectomy

    
    
  • 
    

    Adenomyosis

    
    
    
    
    • 
      

      Endometrium invades underlying stroma; common and present in 20–30% hysterectomy specimens

      
      
    • 
      

      Medical management: Continuous oral contraceptive pills (OCPs), Depo-Provera, high-dose progestins, Mirena^® IUD, GnRH agonists

      
      
    • 
      

      Surgical management: Uterine artery embolization, hysterectomy

Suspected coagulopathy

• 
  
  
  
  • 
    

    Von Willebrand disease

    
    
    
    
    • 
      

      Affects 1% general population; only 1% of those are symptomatic

      
      
    • 
      

      Work with hematologist for management; desmopressin acetate typically used for prevention of bleeding/flares

      
      
    • 
      

      Menstrual control: Hormonal options versus nonhormonal (tranexamic acid)

      
      
    • 
      

      Avoid NSAIDs/ASA (medications that interfere with platelet function)

Ovulatory dysfunction

• 
  
  
  
  • 
    

    Treat underlying cause if able (hyperprolactinemia, hypothyroidism, etc)

    
    
  • 
    

    Hormonal management to regulate cycles/control bleeding/decrease risk of hyperplasia

Management of Acute Heavy Bleeding

• 
  

  Determine stability of patient

  
  
  
  
  • 
    

    Orthostatics

    
    
  • 
    

    Hematocrit/hemoglobin compared to baseline if available

    
    
  • 
    

    Consider age, medical co-morbidities, and blood dyscrasias

Management of Unstable Patient (orthostatic and/or dropping hemoglobin)

• 
  

  Two large bore IVs, IV fluids, type and cross, strict vitals and I/Os

  
  
• 
  

  Can consider uterine tamponade with packing or Foley balloon

  
  
• 
  

  Estrogen 25 mg IV every 4 hours (up to 24 hours)

  
  
  
  
  • 
    

    Can consider if patient stabilizes with IV hydration, etc

    
    
  • 
    

    Need to consider medical contraindications to estrogen (VTE/stroke risk, etc)

    
    
  • 
    

    May cause nausea, prescribe antiemetic

    
    
  • 
    

    Once bleeding is controlled with high-dose estrogen, transition to oral regimen

  
  
• 
  

  Uterine curettage (in operating room)

  
  
• 
  

  Uterine Artery Embolization

  
  
• 
  

  Hysterectomy

Management of Stable Patient

• 
  

  No orthostatic hypotension hemoglobin over 10 g/dL, hospitalization not required

  
  
• 
  

  OCP taper (use MONOPHASIC pill containing at least 30 μg ethinyl estradiol.)

  
  
  
  
  • 
    

    A variety of tapers exist; one example is:

    
    
    
    
    • 
      

      4 pills for 4 days (every 6 hours)

      
      
    • 
      

      3 pills for 3 days (every 8 hours)

      
      
    • 
      

      2 pills for 2 days (every 12 hours)

      
      
    • 
      

      1 pill daily thereafter

    
    
  • 
    

    Provide antiemetics!

  
  
• 
  

  High-dose Progestins (5–10 day course)

  
  
  
  
  • 
    

    Megestrol acetate (Megace) 10–80 mg orally daily or every 12 hours

    
    
  • 
    

    Medroxyprogesterone acetate (Provera) 10–20 mg orally daily or every 12 hours

    
    
  • 
    

    Norethindrone (Aygestin) 5 mg daily or every 12 hours

    
    
  • 
    

    May cause nausea, headache, and in high doses may increase blood pressure

  
  
• 
  

  Tranexamic acid (Lysteda) (5-day course)

  
  
  
  
  • 
    

    Antifibrinolytic, acts within 2–3 hours

    
    
  • 
    

    1-1.5 g orally every 6–8 hours

    
    
  • 
    

    May cause nausea, dizziness, diarrhea

    
    
  • 
    

    Caution in patients at risk for VTE

  
  
• 
  

  GnRH agonist (Depo Lupron)

  
  
  
  
  • 
    

    Consider if other modalities have failed or are contraindicated; typically used following initial treatment of acute bleeding rather than as first line

  
  
• 
  

  Endometrial ablation

  
  
  
  
  • 
    

    Consider if medical management has failed or is contraindicated

• 
  

  Incidence: 15% women will experience sometime in their life; indication for 15–40% of laparoscopies and 12% of hysterectomies in the United States

  
  
• 
  

  Differential diagnosis: Table 2-10

  
  
• 
  

  History

  
  
  
  
  • 
    

    Comprehensive medical, surgical, gynecologic, obstetric, family, social history

    
    
  • 
    

    Specific pain questions: Age and timing of onset, exacerbating factors, prior treatments, position changes that have improved pain; providers seen

  
  
• 
  

  Physical: HEENT, heart, lungs, breasts, abdomen, back, extremities, pelvic exam

• 
  

  Incidence: 6–10% premenopausal women, increased prevalence in women with infertility or a family history of endometriosis

  
  
• 
  

  Common presentation: Pelvic pain or infertility

  
  
  
  
  • 
    

    Ask specifically about bowel/bladder-related symptoms as endometriosis may infiltrate either

  
  
• 
  

  Diagnosis: Biopsy of suspicious lesions at the time of laparoscopy confirming presence of endometrial glands and stroma

  
  
  
  
  • 
    

    Lesion appearance: Red, white, clear, or black powder-burn (classic)

  
  
• 
  

  Classification: ASRM classification used to record operative findings, but does not correlate with severity of symptoms or infertility

  
  
  
  
  • 
    

    Common implant locations: Uterosacral and broad ligaments, ovaries, posterior cul-de-sac

    
    
  • 
    

    Non-gyn organs to evaluate: Bowel/appendix, bladder, diaphragm, umbilicus, thorax, inguinal canal

  
  
• 
  

  Management

  
  
  
  
  • 
    

    Suspected endometriosis can be treated without definitive diagnosis; trial of continuous OCPs, NSAIDs; consider 3-month trial of GnRH agonist if initial regimen fails

    
    
  • 
    

    Medical

    
    
    
    
    • 
      

      Common first line: Continuous OCPs, NSAIDs, Depo-Provera

      
      
    • 
      

      Alternatives: Mirena^® IUD, etonogestrel implant (Nexplanon), oral progestins, GnRH agonist, danazol

      
      
    • 
      

      GnRH agonist: May cause vasomotor symptoms and bone loss with prolonged use; hormonal add back therapy may alleviate these effects

      
      
      
      
      • 
        

        Norethindrone 5 mg daily ± conjugated estrogen 0.625 mg daily

        
        
      • 
        

        Also recommend calcium supplementation 1000 mg daily

        
        
      • 
        

        GnRH agonist use FDA approved for approximately 12 months

      
      
    • 
      

      Aromatase inhibitors: Possible utility in resistant cases, evidence lacking thus far

    
    
  • 
    

    Surgical

    
    
    
    
    • 
      

      Surgical management may improve fertility rates in infertile couples

      
      
    • 
      

      Ablation of lesions: Laser vaporization, electrosurgical fulguration

      
      
    • 
      

      Resection of lesions

      
      
    • 
      

      Presacral neurectomy: May decrease midline pain, but may cause bowel/bladder dysfunction

      
      
    • 
      

      Hysterectomy plus/minus bilateral salpingo-oophorectomy (BSO)

      
      
      
      
      • 
        

        Women who retain ovaries at the time of hysterectomy may have an increased risk of recurrent symptoms (approximately 60%) and re-operation (approximately 30%)

        
        
      • 
        

        Hormone therapy following BSO has not been shown to increase risk of recurrent disease

• 
  

  Accounts for about 6% of all pregnancy-related deaths

  
  
• 
  

  Risk of recurrence: 8–15% if one previous ectopic (risk increased with salpingostomy); over 25% if two or more

  
  
• 
  

  Heterotopic pregnancy (occurrence of intrauterine and extrauterine pregnancy): Varying reports; approximately 1:3900 pregnancies overall to 1 in 100 assisted reproductive technology (ART) pregnancies

  
  
• 
  

  Interstitial pregnancies (some use the term “cornual”; some say they are not the same!). Tubal segment traversing muscular wall of uterus. Higher morbidity/mortality because interstitial portion of tube dilates more freely and painlessly than rest of the tube. Later clinical presentation and potential for massive hemorrhage. Diagnosis suggested when what appears to be an intrauterine pregnancy (IUP) is visualized high in fundus, not surrounded in all planes by 5 mm of myometrium. See Figure 2-7

  
  
• 
  

  Ectopic and IUD: Ectopic pregnancy unlikely in IUD users due to efficacy of IUD. But, if pregnancy occurs, 1/2 Mirena^® users and 1/16 ParaGard^® users will have ectopic pregnancies

  
  
• 
  

  Ectopic and bilateral tubal ligation (BTL): 1/3 pregnancies following BTL are ectopic. Increased risk if bipolar coagulation done

  
  
• 
  

  Risk factors and associated Odds ratios are listed in Table 2-11

Location: See Figure 2-8 for sites and frequencies

Diagnosis

• 
  

  Classic presentation: Abdominal pain (97%), vaginal bleeding (79%), adnexal mass (study: approximately 14% of patients with classic presentation had ectopic)

  
  
• 
  

  Labs: Quantitative β-hCG, CBC, Type and Screen (if Rh negative, give RhoGAM), complete metabolic panel (CMP) (need AST/ALT, creatinine if giving methotrexate)

  
  
• 
  

  β-hCG: The minimum rise for a potentially viable IUP is 53% per 2 days. Intervention when β-hCG rises less than 66% over 2 days may result in interruption of a viable IUP. In 85% of viable IUPs, β-hCG rises by at least 66% every 48 hours during the first 40 days of pregnancy

  
  
• 
  

  Progesterone level: Generally, progesterone of 20–25 ng/mL is highly predictive (95–100%) of a normal IUP; levels less than 5 ng/mL are nearly 100% predictive of an abnormal pregnancy. Most women with an ectopic have progesterone level between these concentrations at presentation, limiting the diagnostic usefulness of progesterone

  
  
• 
  

  Sonograms: Traditionally, the discriminatory level of β-hCG (lowest level gestational sac should be visible) is noted to be about 6500 mIU/mL (7–8 weeks) for transabdominal sono; 1500–2000 mIU/mL (5–6 weeks) for transvaginal. More recent data suggests that although pregnancies may be detected at lower β-hCG thresholds, the discriminatory levels may be higher. See Table 2-12

  
  
  
  
  • 
    

    Intraperitoneal fluid on ultrasound: Free peritoneal fluid suggests intra-abdominal bleeding (as little as 50 mL of fluid can be detected on transvaginal ultrasound in the cul-de-sac of Douglas). See Figure 2-9. Fluid in right-upper-quadrant (Morison’s pouch) indicates significant hemorrhage (seen with about 400–700 mL hemoperitoneum)

Keys to Recognizing an IUP

• 
  

  “Double sac or double decidual sign” (Figure 2-10). Two rings surround gestational sac (GS)—inner sac is decidua capsularis (DC); outer layer is the decidua parietalis (DP). Present at approximately 4.5 weeks. Not visible in all early pregnancies. Do NOT diagnose IUP with this finding

  
  
• 
  

  Gestational sac

  
  
  
  
  • 
    

    Mean sac diameter (MSD) = (L + W + D)/3

    
    
  • 
    

    Should see live pregnancy when MSD >18 mm

    
    
  • 
    

    Should see yolk sac when MSD 8–10 mm

    
    
  • 
    

    General rule: EGA in days = MSD + 30

  
  
• 
  

  IUP

  
  
  
  
  • 
    

    Well-defined gestational sac with a yolk sac, confirming IUP (Figure 2-11)

    
    
  • 
    

    Fetal pole is first seen on transvaginal ultrasound about 6 weeks. When approximately 5 mm, fetal heart beat can be detected (9 mm transabdominal)

    
    
  • 
    

    Average fetal heart rate is 110 bpm at 6 weeks; 170 bpm by 8 weeks; 160 at week 14. If less than 100, poorer prognosis

Ectopic Pregnancy Evaluation Algorithm:

• 
  

  If patient presents with a positive pregnancy test and abdominal cramping and/or vaginal bleeding, an algorithm may be followed (Figure 2-12)

Treatment of Ectopic Pregnancy

• 
  

  Expectant management: Consider only for patients with low and declining β-hCG. Women must be carefully informed of risks and followed closely. Overall success for expectant management is approximately 57% with major risk for morbidity in those who fail

  
  
• 
  

  Rates of tubal patency (62–90%) and recurrence of ectopic (8–15%) are similar after medical and surgical treatment

Medical Management

• 
  

  Methotrexate (MTX): Folic acid antagonist, inhibits DNA synthesis and repair and cell replication. Stop all folinic acid supplements if administering MTX. OBTAIN CONSENT!

  
  
  
  
  • 
    

    Dose: Methotrexate: 50 mg/m² intramuscular for single-dose treatment

    
    
  • 
    

    Success rate varies with β-hCG level (Table 2-13)

    
    
  • 
    

    Contraindications to MTX are listed in Table 2-14

    
    
  • 
    

    Protocols: Three regimens are available (Table 2-15)

    
    
    
    
    • 
      

      Single dose protocol (Table 2-16)

      
      
    • 
      

      Multiple dose protocol (Table 2-17)

    
    
  • 
    

    Complete resolution of ectopic takes between 2 and 3 weeks but can take as long as 6–8 weeks when pretreatment β-hCG levels are in higher ranges

    
    
  • 
    

    When declining β-hCG levels again increase, diagnosis is persistent ectopic pregnancy

    
    
  • 
    

    Inform patient of MTX treatment effects and side effects (Table 2-18)

    
    
  • 
    

    Other information for patient

    
    
    
    
    • 
      

      Advise women not to use alcohol or NSAIDs (due to GI side effects)

      
      
    • 
      

      Patient should receive antiemetic prophylaxis (ondansetron (Zofran) or compazine for 3 days)

      
      
    • 
      

      Avoid sun exposure to limit risk of MTX dermatitis

      
      
    • 
      

      Avoid intercourse until β-hCG is undetectable

      
      
    • 
      

      Avoid pelvic exams and ultrasound during surveillance of MTX therapy

      
      
    • 
      

      Avoid gas-forming foods; they produce pain

      
      
    • 
      

      Avoid another pregnancy until β-hCG is undetectable

    
    
  • 
    

    Sonography of patients treated with MTX is complicated because most patients show a worsening appearance, with increased hemorrhage around ectopic. There may be an initial increase in size of tubal mass after MTX and an adnexal mass may be visible up to 3 months after treatment. The increase in tubal size and vascularity, despite the decreased β-hCG, represents a healing process and should not cause concern unless patient is clinically unstable or has persistent symptoms