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MRCOG PART 2 SBAs and EMQs

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Essay 218 - post-op complications

Posted by kiria O.
The most likely couses are uterine perforation and bowel injury or post operative endometrites. However, other couses such as sever UTI need to be excluded.

Examination of the pateint general condition, her pulse, blood pressure, temperture and repiratory rate must be assessed. any swelling in the lower limb should be notcied, may indicate DVT.

Her chest examination for equal breath sounds, may be pateint unable to take deep breath due to diphragmatic irritation which occure in peritonites.
Abdominal examination for site of tendrness, localised or generalised, renal angle tendreness, presence of rebound tendrness, gaurding is idication for peritonites and high suspcion of bowel injury.Bowel sounds need to be checked, could be absent like in cases of paralytic illius.
Pelvic examination should include speculum exam for any offensive vaginal discharge, visulisation of the cervix for any bleeding or discharge and taking swabs( endocervical and high vaginal) and from any dicharge found. Bimanual examination for cervical irritation any pelvic collection, uterine tendrness, could be very difficult if pateint have sever lower abdominal pain.

The essential investigation such as CBC for heamoglobine as pateint may need surgery, any anaemia must be corrected and lucocytosis is likely whether the couse is peritonites or endometrites. Urea and electrolytes to assess kidny function and exclude electrolyte disturbane which is likely to be associated with peritonites.
Urine for microscopy, culture sensitivity to exclude UTI also Blood culture is essential to taken at hight of temperture to exclude septicemia.
High vaginal and endocervical swabs for culture and sensitivity especially if pelvic infection is highly suspected.
Ultrasound scan is of limited value if abdominal or pelvic examination is not informative however, it could be justified if pelvic collection or abdominopevic mass is detected in clinical examination.
Laporoscopy is a gold standred to visulise whole pelvis for evidence of uterine perforation and bowel injury even thermal injury could be detected after 48 h post operative.

Treatment options would depend on the cause however, conservative option when pelvic infection is the couse icluding analgesia and antipyritic to relive her symptoms with broad spectrum parantral antibiotics until she is afebrile for 48h then continue oral antibiotics for 10 to14 days. In case of pelvic abscess,laproscopic drainage is essential and must be performed under broad spectrum antibiotic coverage.
Other option is laporatomy which is very essential in some situation where diagnosis couldnot be reached or may be needed very urgently in critically ill pateint, so its some time essential for diagnosis and treatment of post operative complication.
Posted by Ibo I.
The possible and more likely cause of this patient symptom will include uterine perforation and peritonitis.She may also have injury to bowel or other abdominal viscera.Consideration must also be given to all other possible causes including urinary tract infection/pyelonephritis,pelvic vein thombosis/thrombophlebitis, appendicitis, diverticulitis, Inflammatory bowel disease/irritable bowel syndrome.
This patient assessment include immediate rescuscitation if necesary and detailed history and phisicai examination(including vaginal and per rectal examination) and consultation with the medical and surgical team
Investigations will include a Complete blood count, BUN, LFT, Serum Amylase, MSSU for m/c/s and blood cultures.Abdominal Xray.Abd/Tvs uss.She may subsequently require Laparoscopy/Laparotomy.
Treatment will depend on findings after initial assessment. A full discussion of evaluation procedures and possibilities with the patient should be done.It may include Nil by mouth, analgesics/antipyretic, ivfluids, Broad spectrum parenteral antibiotics, Dvt prophylaxis/treatment if indicated, laparoscopy and/ or laparotomy in liason with the surgical team if indicated.A full documentation of findings should be done and patient folowed-up closely.
Posted by Sreekala S.

a) The most likely causes for abdominal pain, fever and rigors following TCRE include post operative endometritis, UTI, perforation of uterus and peritonitis. However, ther causes of abdominal pain like PID, pelvic vein thrombosis, appendicits, pancreatitis, cholecystitis, diverticulitis should be considered.

b) A detailed history regarding the onset, exact site, severity, nature and radiation of the pain should be taken. Enquiry about foul smelling vaginal discharge, bleeding Per vaginum should be made. Symptoms suggestive of urinary tract infection like frequency, urgency and dysuria should be asked. Enquiry should also be made whether she has passed urine and stools postoperatively and whether she is passing flatus or not. History of nausea, vomiting and abdominal distention should be taken. Examination should include checking for pallor, recording BP, temperature, PR, RR and oxygen saturation. Abdominal examination should be done to look for tenderness, any rebound tenderness, guarding, rigidity and any masses or abdominal distension. Bowel sounds should be checked to rule out peritonitis and intestinal obstruction.
Vulva and vagina should be inspected and speculum examination should be done to to look for any abnormal vaginal discharge. Bimanual examination should be done to check for any cervical tenderness, forniceal tenderness and to detect any pelvic masses.

c) A mid stream specimen of urine should be sent for analysis, microscopy and culture/sensitivity to rule out the possibility of Urinary tract infection. FBC and CRP should be done as white cell count and CRP are usually elevated in the presence of infection and can be used to monitor the progress of treatment. Blood cultures should be sent to rule out the possibility of a systemic infection and to help commence the appropriate antibiotic. Urea and electrolytes should be checked as they can be abnormal following fluid overload after TCRE and abnormal values are associated with paralytic ileus. High vaginal swab and endocervical swabs should be obtained. Abdominal x ray should be done if intestinal obstruction or peritonitis is suspected. Chest x ray may be required in the presence of ARDS or chest symptoms. Ultrasound pelvis/TVS should be done to look for any free fluid, haematoma or any adnexal masses.

d)The treatment options include conservative and surgical management. Conservative management involves symptomatic treatment with IV fluids to maintain adequate hydration, Broad spectrum IV antibiotics, antipyretics, tepid sponging and adequate pain relief. IV antibiotics should be commenced immediately and changed depending on the blood culture and urine culture results.. If bowel perforation, intestinal obstruction or peritonitis are suspected she should be nil by mouth and given Intra venous fluids. Advice from the surgeons should be sought.
Laparoscopy may be required if there is a suspicion of uterine perforation with or without bowel involvement. It has the risks of injury to bowels/bladder, infection and haemorrhage. Laparotomy may be required if there is suspicion of bowel injury and this should be done with the involvement of the surgeons.
Posted by Srivas  P.
a)The most likely causes are uterine perforation, Bowel injury with peritonitis, endometritis, pelvic haematocele.

b)Severity of pain, associated abdominal distension, vomiting and its severity, passage of flatus should be asked for as indication for peritonitis and paralytic ileus. Vaginal bleeding or discharge may indicate uterine infection or perforation. Urinary complaints will help rule out urinary infection. She may present with diarrhea and malaena with gut perforation. History of faintness, fever, and rogors may indicate septicaemia. Incidental occurrence of other causes of abdominal pain like cholesystitis, appendicitis should be assessed.

Examination should include temp, pulse, B.P. R.R, varicose veins, edema and any signs of thromboembolism which is always possible after prolonged operation with woman in leg straps and lithotomy position. Chest examination should be done and per abdominal examination should look for bowel sounds, guarding, rigidity, direct and rebound tenderness, shifting dullness and abdominal distension, liver dullness. Perspeculum and pervaginal examination should be done to look for uterine tenderness suggesting infection, any fullness in POD suggesting collection of blood.

c)Complete blood to look for anemia suggesting hemorrhage, TLC for signs of infection, and clotting profile to look for signs of DIC associated with septicemia or thromboembolism. Her urine examination for microscopy and culture, to rule out urinary infection, blood culture to detect septicaemia should be done. Serum electrolytes, blood urea should be done as it may be deranged due to excess fluid absortion during hysteroscopy and also wit peritonitis and ileus. Chest radiograph may show gas under the diaphragm and rarely may show signs of thrombo-embolism. Abdominal X-ray can show signs of perforation and peritonitis? free intra peritoneal air, multiple fluid level, small and/or large bowel dilation suggestive of ileus or obstruction and gas under the diaphragm.

CT abdomen is best to detect bowel perforation and may detect it in 96-97% cases. It may show free air, free fluid, abnormal bowel wall enhancement, bowel wall thickening and contrast can show site of bowel perforation. Diagnostic laproscopy may be indicated in suspected uterine perforation, subsequent haematoma and peritonitis. Ultrasound transabdominal and transvaginal is not very sensitive to detect bowel perforations but can be done if she is not for CT scan. It can detect adnexal masses and intraperitoneal fluid. Intravaginal swab should be taken to detect cause for pelvic infection.

d)The treatment options are dictated by examination and investigation reports and likely cause for her condition. If urinary infection is likely, antibiotics should be given. Conservative option for uterine perforation is possible if bleeding is contained, bowel perforation can be ruled out and peritonitis settles with supportive treatment and antibiotics. She would need to be kept nil per orally, I/V fluids, Ryles tube aspiration maybe needed and she should be monitored for increasing abdominal girth. This avoids laparotomy with coincident complications of another procedure. If bowel perforation is suspected on CT scan, Laparoscopy or on deteriorating condition while on conservative treatment she should have broad spectrum antibiotics and a laparotomy done by surgical team. Thromboprophylaxis should be considered as she is high risk for VTE due to prolonged hospitalization. The chain of events should be properly documented and incident report should be written.
Posted by Abi T.
a)Likely causes are postoperative endometritis, bowel injury and peritonitis secondary to uterine perforation and urinary tract infection.
b)Initial clinical assessment would be to determine if she is in hemodynamic compromise secondary to septicemia and to institute prompt resuscitaion. This is indicated by flushed skin, tachypnoea, tachycardia pyrexia or hypothermia and hypotension.
Otherwise a good history should be obtained to determine the site and severity of pain,eg. suprapubic or central abdominal pain may indicate either a pelvic or abdominal cause. Flank pain may indicate pyelonephritis. Associated urinary symptoms eg. dysuria and frequency are suggestive of a UTI. Nausea, vomiting or no passage of flatus are suggestive of bowel involvement. Any vaginal bleeding or foul smelling discharge might point towards pelvic infection. It is important to exclude other causes of fever such as chest symptoms or calf/groin pain (indicative of pelvic/lower limb DVT).
Clinical examination should include general assessment looking for pallor, cold and clammy skin or flushing. Pulse, temperature, blood pressure and respiratory rate should be recorded.
The chest should be auscultated. Abdominal examination includes looking for distension, presence of a rigid abdomen and site of maximal tenderness indicating peritonitis. Renal angle tenderness suggests pyelonephritis. Bowel sounds should be auscultated, if absent may suggest an ileus. Pelvic examination should include a speculum examination to confirm presence of vaginal discharge. A bimanual examination is done to elicit presence of cervical excitation tenderness and uterine tenderness and also to determine if any pelvic masses are felt which may indicate a pelvic collection.
Calves should be examined, if indicated by history to rule out a DVT.
c) A full blood count should be done as a drop in hemoglobin as compared with pre-operative Hb would support a diagnosis of pelvic hematoma and the severity of blood loss. A leucocytosis and raised CRP would support an infective cause and also useful in monitoring response to treatment with antibiotics. Blood cultures are necessary if pyrexia is above 38 degrees celsius as septicemia may be likely.
Dipstick urinalysis would be a useful screen to indicate a UTI if it is nitrite, blood and leucocyte positive and prompt an MSU to be sent for cultures and sensitivities.
A high vaginal swab should also be taken and sent for cultures and sensitivities to treat a pelvic infection appropriately however broad spectrum antibiotic cover for pelvic infection should not be witheld till results are available.
An erect chest x-ray would be useful to confirm a diagnosis of bowel perforation by presence of air under the diaphragm. An abdominal x-ray would confirm bowel obstruction if air-fluid levels and distended bowels are present, again to support a diagnosis of bowel injury secondary to perforation.
A pelvic ultrasound scan should be done as it is the gold standard in demonstrating a pelvic collection and the size of this which would influence management.
d) Th treatment options are either conservative or surgical. Conservative management involves fluid resuscitation, analgesia, antipyretics and broad spectrum antibiotics and should be first line management. This would prevent worsening infection leading to a septicemia and also indicated prior to any surgical intervention if necessary. Uterine perforations,Endometritis, pelvic collections and UTIs also resolve spontaneously with time and conservative treatments avoid the risks of surgery.
Surgical management is indicated if there are obvious signs of bowel perforation. If a large pelvic collection is noted and patient condition does not improve ie, remains pyrexial despite optimum antibiotics or further drop in hemoglobin or hemodynamic compromise indicating a substantial pelvic hematoma then a pelvic or abdominal drainage of the collection is recommended.
Posted by Badi A.
healthy 47 year old woman complains of abdominal pain, fever and rigors 48h after TCRE for dysfunctional uterine bleeding. (a) List the most likely causes of her symptoms [2 marks]. (b) Systematically outline your clinical assessment.[5 marks] (c) Justify the investigations that are necessary to reach a definitive diagnosis. [8 marks] (d) Evaluate the treatment options [5 marks].

a) the most likely the cause is perforation and peritonitis secondry to bowel injury, other causes like UTI, abdominal collection with abscess formation should be kept in mind as well.

b)clinical assessment should be started with history and physical examintion.
nature of the pain whether generalized or localized, urinary and bowel symptoms and if there is any symptoms of anemia.
on examination vital signs pulse , blood pressure, temperature are very important and will reflect how sick is she;
hypotension, tachycardia, tachypnea and fever namely.
chest and cardiovascular examination followed by abdominal examination will be conducted. generalized tenderness and distention goes with perforation and preitonitis while flank or suprapubic tenderness goes with UTI.

c)FBC will show if there is a leukocytosis, anemia or thrmbocytopenia. urea and creatinine to eleminate any renal insult ( acute renal faliure) 2ndy to bleeding or shock.electrolytes which may need to be corrected if there is an imbalance.coagulation profile to rule out any coagulopathy because of bleeding.blood type and screen for possibiity of tranfusion.
urinalysis and c/s .
radioogical investigations including KUB to look for air under diaphragm, U/s abdomen and pelvis to rule out collection and finally CT scan if highly suspected bowel injury.

d)treatment will depend on what was the cause and how ill is the the patient?
if the patient in shock, resuscitation is mandatory before any intervention, an intensivist should be consulted and the patient should stabilized.
if there is a bowel injury senior surgeon should be informed and lapratomy should be carried with entire bowel examination, resection and anastomosis.
if the cause was uTI the patient should be started on i.v antibiotic, hydration and antipyretic.
Posted by neera  B.
Causes could be gynecological or non gynecological. Uterine perforation with bowel injury and endometrits with septicemia are the most likely causes of her symptoms. Acute pyelonephritis, severe urinary trach infection, appendicitis, PID and malaria are other possible causes.
I shall take history of vomiting and shoulder tip pain as pointers of bowel injury. The exact site of pain, severity, radiation, aggravating and relieving factors will be asked. History of bleeding and discharge from vagina will be inquired. Urinary frequency, burning, hematuria will sugest UTI or pyelonephritis. A recent trip to malaria endemic region is suggestive of malaria. I shall take her pulse and blood pressure to ascertain hemodynamic stability as shock may occur in septicemia. Temperature, respiratory rate will be recorded. Abdominal examination will be performed to look for tenderness, guarding, rigidity, rebound tenderness as they indicate peritonitis. Shifting dullness will be felt for free fluid in peritoneal cavity which may occur in uterine perforation. Lump abdomen would be looked for, tenderness in renal angle will be felt for pyelonephritis. Sterile speculum examination to look for bleeding or foul smelling discharge from the cervix would be done. Vaginal examination for uterine tenderness, bogginess in POD or adnexal mass would be performed. Opinion of bowel surgeon will be sought in case of doubt.
Full blood count, blood culture, U & E should be done. Leucocytosis and positive blood culture indicate septicemia, leucopenia may be found in appendicitis, bowel injury with peritonitis causes leucocytosis with deranged U & E. Urine for leucocytes and nitrites is positive in UTI which is confirmed on culture of mid stream urine. Plain X-ray of abdomen may show fluid air levels in bowel perforation. Ultra-sound abdomen and pelvis would be done as gas under diaphragm is seen in bowel injury, fluid in POD is seen in perforation, inflamed appendix may be seen. At times diagnostic laparoscopy is indicated if perforation is suspected. A negative laparoscopy is better than no laparoscopy.
The treatment options are conservative (expectant), laparoscopy and laparotomy. Expectant management may avoid operative intervention as the partient responds to antibiotics if the cause was UTI or pyelonephritis but it carries the risk of worsening of patient\'s condition if she had bowel injury.So careful monitoring is essential.Laparoscopy reliably picks up uterine perforation and bowel injury however itis an operative procedure with anaesthatic risk, procedure related bowel injury. risk of in fection and bleeding. A repair can also be carried out through laproscope. Laprotomy involves bigger incirsion, longer period of recovery, more analgesia, greater post operative morbidity, cosmatically less apealing incision compared to loparoscopy but it is indicated if the patient has large hemoperitoneum, has contra indication to laprocopy or patient condition is very serious. Informed choice should be taken by the patient.
Posted by Sarwat F.
Most likely causes of her symptoms include pelvic infection, uterine perforation and bowel perforation, urinary tract infection, coincidental pathologies for example appendicitis and less likely infection in any other area of body for example respiratory tract infection.
Clinical assessment include reviewing her notes to identify any complication during surgery, any additional procedures done, risk factors for infection like long duration of procedure. Clinical examination is done to check blood pressure, pulse and temperature to exclude any shocked state, chest is ausculcated to identify any respiratory tract infection. Abdominal examination is done to identify any signs of peritonism, guarding and rigidity, any masses or lump palpable. Superficial and deep palpation will help to identify area of maximum tenderness to locate the origin of pain. Bowel sounds are auscultated o identify paralytic ileus or mechanical bowel obstruction. Per speculum examination will help in identifying any abnormal, foul smelling discharge indicative of pelvic infection.
Investigations include full blood picture which will help to establish degree of anemia, a risk factor for infectious complications. Full blood picture will also tell white cell count a marker of infection. CRP is done which is a nonspecific inflammatory marker. It can be false positive after surgery. Midstream specimen of urine is sent for culture and sensitivity and direct microscopy to identify urinary tract infection. Blood group and hold is done in case she needs blood transfusion.
Abdominal ultrasound to identify any mass or abcess. Endocervical swab and high vaginal swabs are sent for culture and sensitivity. Transvaginal ultrasound may be needed to identify any pelvic pathology. CT/MRI may be needed in case of complex masses which are hard to define clearly on ultrasound. Surgical opinion may be needed if any bowel injury is suspected.
Trearment options depends on the cause of symptoms. It may be as simple as treating a urinary tract infection to operative approach including laparotomy and colostomy. For cases of acute abdomen if the patient is in going in shock, wide bore intravenous access is maintained, make sure that airway is patent and patient is maintaining breathing. Intravenous fluids are started. Patient is kept nil per oral. If bowel perforation is suspected consultant gynaecologist is informed and surgical doctors are involved. Laparotomy is done after informed consent regarding need for colostomy.
If pelvic infection is suspected broad spectrum antibiotics are started and these can be changed depending on culture and sensitivity results of urine and swabs. Patient is fully involved at each step of management explaining all treatment options. Blood pressure, pulse, temperature, input, output is monitored regularly. After discharge a followup appointment is arranged to discuss any further problems.
Posted by Freha Z.
(a)This presentation is suggestive of uterine perforation with or without bowel injury and peritonitis, endometritis or haematometria. Other causes include UTI and thromboembolism.

(b)Urgent assesment of localization , nature & radiation of pain. Constant pain worse on movement is due to peritonitis. Pain in loin and burning micturition is due to UTI and may be associated with nausea and vomiting. General state of the patient including pulse, BP and temperature is important. Hypotension, bradycardia and high temperature may be seen in septic shock which warrants resuscitation. Signs of thromboembolism like leg tenderness, swelling should also be lookrd for.
Abdominal tenderness, rebound tenderness and guarding with absent bowel sounds indicate peritonitis. Spaculum examintion to see any discharge and high vaginal swab should be taken.On pelvic examinationcervical excitation indicates intra-abdominal bleeding. Size of uterus may be increased in haematometria.

(c)Baseline investigations like FBC,Hb, urea& creatinine and liver function tests should be performed. High TLC and CRP indicates acute infection. Blood culture should be sent before commencing antibiotics. MSU for microscopy and culture. Errect chest X-ray may show gas under diaphragm as an indication of perforation. Pelvic ultrasound may show haematometria or pelvic abscess.
If there is suspicion of perforation and signs of peritonitis laparoscopy would assist in diagnosis and . Laproscopy may miss visceral injury.

(d)If there is no suspicion of perforation and clinical condition of patient is indicating infection with no collection in adenexa conservative approach should be adopted. Broad spectrum I/v antibiotcs should be started for at least 48 hours or until apyrexial and continued upto 14 days. Antibiotics may need to be changed according to blood or urine culture report. I/v fluids and analgesia should be given.
If there is suspicion of perforation surgical colleagues and senior colleagues should be involved. If diagnosis is in doubt laproscopy can be performed first before embarking on laparotomy. Written informed Consent should be taken and discussion of possible procedures including blood transfusion, hysterectomy, bowel resection and colostomy should be taken. Postoperative HDU management may be required and incident form should be filled.
Posted by M M A.
a)The causes are likely to be endometritis , pelvic infection, Uterine perforation with bowel injury. Also Urinary tract infections could be a cause for her symptoms.
b)Appropriate history should be taken, we ask her about the site of pain, its nature, radiation and duration, also ask about vaginal discharge and if it is present whether it is offensive or not.
Urinary and gastrointestinal tract symptoms are also important like nausea, vomiting, rectal bleeding and maleana..
are also important to exclude other non Gynecological causes of abdominal pain like appendicitis or renal stone, etc.we also try to find if there is other cause for her fever like Symptoms of chest infection or sore throat.

On examination, we should assess patient general condition and check vital signs: pulse rate, blood pressure and temperature.
We examine her abdomen for site of tenderness and presence of rebound tenderness, guarding and rigidity, also for the presence of bowel sounds.
Pelvic examination should include speculum and bimanual examination to assess uterine size, adnexal mass or tenderness and cervical excitation can be elicited also.
c)A base line investigations are done for her, FBC can give an idea about her blood loss and it helps in monitoring of the patient if there is any suspicion of internal bleeding . Blood grouping and cross matching of blood are important because we may need blood transfusion or operative intervention at any time.
WBC can reflect presence of infection when there\'s leukocytosis; however, this is not conclusive, also we can check C- reactive protein.
If there is a suspicion of septicemia we can do blood culture and sensitivity test to detect presence of specific offending micro-organism and also help selection of suitable antibiotic.
Other bacteriological investigations like high vaginal swab and endocervical swab for culture and sensitivity can reveal also the presence of genital tract infection.
Urine for microscopical examination, culture and sensitivity is also indicated to exclude urinary tract infections.
Liver function test, Blood urea and electrolyte should be done to rule out electrolyte imbalance .
Ultrasonography; it can show if there is haematometra or pyometra, also can show the presence of pyosalpinx or pelvic abscess .In addition it show if there is any free fluid or blood in the peritoneal cavity or if there\'s bowel distention.
An abdominal X-ray in erect position could reveal air under diaphragm, although this sign is not present in all cases of perforation.
If there is suspicion of uterine perforation, laparoscopy is indicated, we can allocate site of injury and whether there is active bleeding from it not.
Regarding bowel injury, explorative laparotomy only can ascertain the diagnosis.

d)We treat endometritis and pelvic sepsis by broad spectrum antibiotic, parentally, treatment should be started immediately and then changed according to result of culture and sensitivity, also we can shift to oral antibiotics if the patient become a febrile after 48 hours.
Adequate analgesia will also be required like NSAIDs and if the patient is hypotensive or dehydrated IV crystalloid fluid can be given, blood transfusion may be needed for correction of anemia or any loss.
Specific management will be accordingly, if there is suspicion of uterine perforation alone with no active bleeding and no suspicion of bowel injury, we can treat the patient expectantly with close observation, if patient condition deteriorates ,a laparoscopy can be done to confirm diagnosis and we should proceed to laparotomy if there is evidence of perforation.
If there is suspicion of bowel injury, we should request assessment by consultant
general surgeon with the possibility of bowel resection and colostomy.
In the presence of clinical evidence of peritonitis, an immediate laparotomy with general surgical assistance.
In cases irreparable uterine injury; hysterectomy will be the final step.The patient should be counseled carefully about that, given written and verbal information with clear documentation.
Multidisplinary team will be helpful including consultant Gynecologist, Senior anesthetist, physician and Consultant general surgeon .
Posted by SWATI M.
a) The most likely causes for her symptoms are endometritis with pelvic infection,uterine perforation with bowel injury,urinary tract infection.

b) The clinical assessment involves review of records ,preop screening for pelvic infection,results and any treatment received. Intraop whether she received prophylactic antibiotics ,any difficulties encountered during procedure.History of current symptoms duration and severity.Details about the abdominal pain ?location, type of pain ?constant /intermittent ,radiation.Enquire for any associated symptoms such as vomiting, constipation, urinary frequency/burning, abdominal distension, vaginal discharge.
Clinical examination includes pulse ,BP, temp, RR, O2 saturation.Abdominal examination ,if any distension, tenderness, rebound tederness, guarding, rigidity and bowel sounds.During speculum examination look for any discharge, amount, colour, odour.Pelvic examination to look for uterine tenderness, adnexal masses, collection in POD.Surgical opinion should be obtained if bowel injury is suspected.

c) FBC with WCC as WCC will be increased during infection.CRP is increased if infection. Urine microscopy and culture to exclude UTI .U&E ,coagulation profile as severe infection can lead to ARF and DIC. Blood culture should be done to exclude systemic infection in severe cases.
HVS and intracervical swab to diagnose pelvic infection and will help use of appropriate antibiotics.Chest and abdominal Xray in standing position will help diagnose bowel perforation/injury and will reveal gas under diaphragm.Ultrasonography will help to diagnose any pelvic collection, TO abscess.CT scan will help to diagnose pelvic collection if ultrasonography is not very informative and clinically suspicious.
Diagnostic laproscopy is gold standard to exclude uterine perforation and pelvic collection.

d) Treatment options include conservative treatment with broad spectrum antibiotics including metronidazole. This is appropriate if endometritis / pelvic infection is suspected and uterine perforation is excluded.It avoids need for invasive procedure but if she does not improve /deteriorate, laparoscopy/laparotomy may be needed to drain collection.It may be cost effective if she improves earlier without need for invasive procedures but if prolonged hospitalization is required ,may be more expensive.Adhesions formation may lead to long term morbidity.
USG guided drainage of collection avoids need of invasive procedures but may have to be repeated or need invasive procedures. It needs experienced ultrasonographer.
Laparoscopy with drainage of collection will avoid need for laparotomy which is associated with more morbidity.Postop recovery is quicker ,need less analgesia,lesser adhesion formations.It needs expertise,instruments and more expensive.Also it is difficult to exclude bowel perforation and has inherent risk of bowel/visceral injury.
Exploratory laparotomy should be preferred treatment if bowel injury is suspected/ diagnosed as whole bowel can be explored and repair can be undertaken.Also any collections can be drained.It adds to the morbidity especially increase risk of VTE and need inpatient stay.
Posted by neera  B.
sir, when we are asked to \"evaluate treatment options\", does it mean that we tell the advantages of each treatment options where as when we are asked to \"critically evaluate treatment options\" then we tell both the advantages as well as disadvantages of each treatment option.
If this is true then I have perhaps critically evaluated the treatment options in the present questions.
I shall be grateful if you could reply this question.
Thanx Neera.
Posted by Yasser S.
list of causes includs :
1.uterine perforation.
2.UTI.
3.bowel injury.
4.pelvic vein thrombosis.
5.pelvic infection.
6.peritonitis due to thermal injury.

clinical assessment will include intiially detailed history regarding the onset,site,sevirity,type ,any aggrevating factor,if the pain localized or radiating.if any associated abnormal vaginal bleeding or foul smelling discharges.ifany history of urinary symptomes like dysuria or urgency.if any nausea or vomiting or if she opend her bowel either flatus or stool or not yet.then after that operation notes should be reviwed for that finding intraoperatively and type of procedure done and if any introperative complication like bleeding or perforation .then complete detailed physical examination including inspection if patient looks pallor ,toxic or if in pain and score of pain .recording vital sign like tempratre pattren if at specific time or swinging like in abcess formation.and pulse rate if tachycardiac in in cases of shock or just increse once increase temp.also blood pressure if hypotensive as in sepsis.respiratory rate and oxy sat. if increse indicating respiratory stress or diaphragmatic irritation.then to proceed with chest examination if any abnormal pathology detected like dec. air entry or cripitation basally.after that proper abdominal examination to be done starting by inspection for distension then palpation generaly or any sign of peritoneal irritation if any generalized tenderness or gurdning, rigidity, rebound or localized tenderness or any masses palpabel for any collection .to palpate the renal angles foe any tenderness or palpable kidney tendernes.then detail pelvic exam will be done for any collection or abecess in vulva or vaginasecondary to procedure.then bimanual examination for any pelvic tenderness and if any collection or any fullness in forncises or POD.if any abnormal bleeding or discharge indicating infection.

investigation will include FBC to look for if there is leuckocytosis due to infection and if any significant drop of thr HB indicating any belvic collection . urea and electrolytes for assessing patient in cases of sepsis .midstream urine to roule out suspecion of UTI. blood culture in cases of high temp. with suspecion of sepsis. abdominal x-ray erect and supin for any air fluid level in cases of suspecion of utrine perforation and collection. also pelvic ultrasound in cases of collection with out bowel injury suspecion. CT abdominn and pelvis as avery good tool for assessing if bowel injury suspected as it help in detecting bowel perforation and localize it. then final laparoscopy is the best diagnostic tool for deticting any pelvic injury , collectionor viscral perforation with possibility of treatment.

treatment options including conservative managment especialy in cases of UTI or conservative treament for non bleeding utrine perforation providing no bowel injury suspected in this case intravenous antibiotics till patient afebril for atleast 24 hours then shifting to oral antibiotics for 10 to 14 days and covring patient with thromboprophylaxis for prolong hospatlization.
other option in cases of possibility of bowel injury then multidiscplinary approch involving senior gyncologist and general surgery and anesthecist laparscopy and possibility of laparotomy and exploration of bowel with resection of perforation and end to end anastamosis and possibility of iliostomy or clostomy if needed,and need of prolong hospatalizatin , thromboprophylaxis and risk should be discussed and explaind to patient and informed consent shold be taken all that should be decoumented in patient chart.
Posted by Parveen  Q.
The likely causes for her symptoms may be1. related to the procedure, like uterine perforation, bowel injury 2. exacerbation of previous pelvic infection,endometritis, pelvic abscess3. diathermy injury 4. non gynaecological causes, like UTI, thromobophlebitis, chest infection, appendicitis.
Clinical assessment begins with the apearance of the patient, if she is acutely ill, anaemic, dehydrated due to fever and exhaustion. Her B.P, pulse, temperature noted down, and verified with previous recordings. Abdominal examination by inspection to rule out grossly distended abdomen, palpation for both localised and generalised tenderness, guarding . percussion for any free fluid, and ausculation for bowel sounds. Pelvic examination bimanual examination for the uterine size and postion, cervical excitation, adnexal tenderness and fullness of the fornices. Per-speculam examination to look for inflammed cervix, disharge, and swabs taken, for triple swabs test , culture and sensitivity. Cardiovascular and chest examination and look for any tenderness or tightness in the calf muscles.
Next procedure is to review the patient\'s operative record to note down the duration of surgery, any abnormal or special findings mentioned by the operator, and the condition of the patient at the end of procedure. fbc, Hb, haemotocrit which gives an idea of haemodilution or concentration, elevated lecocyte countwill piont towards infection , also CRP. Urine examination for microscopy and culture and sensitivity, to rule out UTI. Vaginal swabs for triple swab test to rule out clamydia, and for culture and sensitivity. Microscopy of vaginal discharge for clue cells for bacterialvaginosis, and vaginal ph which is high in pelvic infection.Bloodurea,electrolytes,coagulation profile to be performed. Plain x-ray to look for gas under the diagphram, abdominal x-ray for distended bowels and fluid level.Abdominal ultrasound for liver and collection in the rt costophrenic angle and pelvic Ultrasound for any pelvic collection, adnexal mass, uterine size. If there is any difficulty in visualisation CT scan or MRI can done.Laprocopy after informed consent done if the patient condition doesn\'t improve with simple measures and medical managemment for further investigation and management.
Treatment depends on patient\'s condition,.simple measures like analgesics, antipyretics, iv fluids to correct dehydration and antibiotics as per culture results, will be enough. If suspicion of perforation , nasogastric suction and iv fluids, and referral to surgeon undertaken and cross matched blood kept if there is any need for surgery.Thrombo prophylaxis undertaken as per risk factors. laproscopy and proceed to laprotomy if patient \'s condition doesn\'t improve. patient should be fully informed by the consulatant and consent taken for further procedures like colostomy if need be. Bowel surgeon should be present in the theatre. During the post operative period, patient should be fully informed by the consultant about the findings and procedure done. This should be done as soon as possible to avoid litigation. Adequate documentation and incidental form prepared. At the time of discharge, her discharge summary and the letter to the G.P should include all the details and further follow up arranged.
Posted by urmee A.
The most likely causes of her symptoms are uterine perforation which may lead to bowel injury with peritonitis,endometritis, pelvic abscess,urinary tract infection.Before clinical assessment,operation note should be reviewed to check any complication during the procedure like uterine perforation and measure taken for this.During clinical assessment,history should include location of pain,nausea,vomiting,rectal bleeding,burning sensation during micturation,foul smelling vaginal discharge. Temperature,pulse,blood pressure,dehydration should be measured during general examination.Abdominal examination should include tenderness,guarding,rebound tenderness,bowel sound.Per speculum vaginal examination should be done to see any foul smelling discharge(endometritis) and vaginal swab should be taken.Full blood count ,ESR,CRP should be done to confirm infection.blood culture for septicaemia.U&E,LFT should be assessed,Blood should be sent for cross matching.Urine should be sent for microscopy and culture to exclude UTI.Vginal swab sent to exclude endometritis.Only Diagnostic laperoscopy is not justified if bowel injury suspected rather than laperotomy.Treatment should be started with I/V access and fluid and electrolyte imbalance should corrected if dehydrated.I/V broad spectrum antibiotic should be commenced.Surgical specialist should be involved if bowel injury suspected and immediate laperotomy should be arranged.Thorough inspection of the bowel and repair any injury.findings of laperotomy should be discussed with patients and incident form should be filled.For UTI and endometritis antibiotic should be enough andFollow up should be done to check clinical improvement.If pelvic abscess suspected and not resolved with antibiotic drainage should be arranged.
Posted by Olubunmi O.
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a) Endometritis
Uterine perforation
Peritonitis/perforated viscus
Pelvic abcess
Urinary tract infection
VTE
Chest infection

b)History of symptoms including:
-Onset of pain and nature, localised/generalised, colicky/ constant, renal angle tenderness
-PV loss, bleeding, discharge, colour, quantity and if offensive
-Nausea, vomiting, abdominal distension.
-Bowel motions and history of diarrhoea , if bowels have not been opened, has flatus been passed.
-Urinary symptoms, dysuria, frequency
-Chest pain, cough, sputum and shortness of breath
-Leg /groin swelling, pain, redness

Examination
-Pulse , temperature, blood pressure, oxygen saturation, pallor, dehydration
-abdomen: distension, tenderness + rebound, mass, guarding, bowel sounds
-Speculum examination for bleeding/discharge
-Bimanual examination for uterine / adnexae tenderness and mass/collection
-Chest sounds, air entry and added sounds
-legs for swelling hotness, redness, girth and pulses.
Operation notes should be obtained if available and any entry suggesting perforation noted

C)Raised WCC and CRP will help in diagnosing infections and may be raised in uti, endometritis or peritonitis. FBC will show anaemia, Electrolytes & Urea with creatinine are essential to diagnose imbalance secondary to intestinal obstruction and ileus and if additional surgery is contemplated. Abnormal LFT could indicate intra abdominal pathology.
Blood culture, sputum culture and High vaginal swabs would help in diagnosing sepsis as well as antibiotic sensitivities. Urine dipstick for leucocytes and nitrites are indicative of a UTI and a sample should be sent for MCS.
An erect abdominal X ray with multiple fluid levels indicates perforated viscus perforaton and ileus.
Chest X ray could consolidation in infection and PTE, or collapse.
An abdominal altrasound will help to detect pelvic and intra abdominal collections.
A diagnostic laparoscopy may help to definitively diagnose perforated uterusor viscus , intra abdominal spillage, or pelvic collection and treatment undertaken for collection as same time. Laparoscopy may also be done before proceeding to Laparotomy..
A laparotomy may be necessary to identify and treat perforated viscus.
D dimers could be raised post operatively but a normal level would be reassuring. A thrombophilia screen could shed more light on the aetiology of a VTE.Dopplers will help to confirm DVT and a VQ scan will detect PTE.


d)IV access with IVF will correct electrolyte imbalance and dehydration.Blood transfusion will correct anaemia.
Broad spectrum antibiotics with cover for anaerobes will treat most infections, UTI ,chest infections and limit intra abdominal sepsis.
Patient should be kept nil by mouth in case additional surgery is needed and an NG tube passed in perforated viscus for decompression/ileus.
Analgesia should be provided for pain and paracetamol to control fever.
A multidisciplinary approach involving the general surgeons, anaesthetists and HDU physician is essential if there is perforated viscus, peritonitis or in the very ill patient.
Pelvic abcess should be treated antibiotics and may need drainage by ultrasound guided aspiration, laparocopy or laparotomy.
If perforated viscus is suspected, Exploratory Laparotomy should be arranged promptly in conjunction with the general surgeons after the patient has been stabilized to repair any damage. Informed consent should be taken mentioning additional procedures which may be necessary like stomas. If the patient is too ill , relatives should be kept informed.
In suspected VTEs, LMWH should be started while awaiting investigations and continued or changed to warfarin if the diagnosis is confirmed. TED stockings should be worn.
Thromboprophylaxis will be given if there is prolonged immobility to pevent VTEs.
Chest physiotherapy will aid recovery from chest infections and collapse/consolidations.
Posted by sailaja devi K.
The most likely causes of her symptoms are (1)uterine infection(2) perforation of uterus (3) bowel injuy (4) urinary tract infection (5) chest infection (6) pelvic infection (7) pelvic abcess(8) pelvic thrombophebitis


Clinical assessment consist of history about onset and duration of symptoms,history of frequency of urination ,history of diarrhoea , history of foul smell vaginal discharge ,history of leg pain and odema to rule out deep vein thrombosis. Vital signs monitoring consists of temperature ,pulse rate ,blood pressure.Examination of cardiovascular system ,respiratory system - check for bilateral air entry,ronchi, crepitations. Per abdomen examination consists of inspection to see for abdominal distension .Palpate abdomen for tenderness localized or generalised ,rigidity ,guarding .Percussion of abdomen to detect any fluid collection .Ascultate the abdomen for bowel sounds .Bowel sounds are absent in paralytic ileus .Renal angle tenderness to check for renal infection.Perspeculum examination to see for vaginal discharge , bleeding.Bimanual examination to check for uterine tenderness,adenexal mass,adenexal tenderness , collection in pouch of douglas.Examination of lower limb to check for odema,tenderness.

Investigations are complete blood picture to check haemoglobin,haematocrit .This help to look for anaemia ,to correct anaemia before planning any surgery to see if patient is fit for sugery.Total leucocyte count if raised indicate inflammatory response, continuing infection .Urine analysis see for prescence of pus cells ,helps to rule out infection.Urine culture & sensitivity helps to identify organism causing urinary infection , antibiotic sensitivity of organism. Ultrasound of abdomen & pelvis helps to identify adenexal mass ,any collection in pouch of douglas,any uterine perforaton ,distended bowel loops .Scan for kidneys to ruleout hydronephrosis . Blood culture sensitivity if not rsponding to treatment,helps to identify organism ,helps to direct treatment.High vaginal swab for culture sensitivity to ruleout genital tract infection.X-ray chest to rule out
congestion ,collapse of lung,consolidation.X-ray abdomen in erect posture look for air under diagphargm , multiple gas fluid levels .This helps to diagnose perforation of bowel.CT scan and MRI of abdomen to diagnose uterine ,bowelperforation, pelvic abcess,adenexal mass.Laproscopy to rule out perforation if unable to diagonse with above investigations.Serum electrolytes ,serum creatinine if suspecting fluid overload . Serum electrolytes to rule out paralytic ileus due to hypokelemia.

Symptomatic treatment consists of antipyretic to control fever ,antispasmodic for pain abdomen.Broad spectrum antibiotic by intravenous route , depending on culture report change the antibiotic .Monitor temperature ,pulse rate,input out put fluid chart.Treat the cause of symptoms .If perforation is suspected consult surgeon .Plan for laproscopy with surgeon standby. If uterine perforation is present close the perforation .If bowel is perforated do laprotomy close the perforation with surgeons help.If perforation suspected treat by multidisciplinary approach with consultant surgeon ,anaesthetist, consultant gynaecologist.If pelvic abcess is present drain the abcess by colpotomy .Chest physiotherpy if chest infection is prenent . Monitor oxygen saturation.If deep vein thrombosis with pelvic thombophebitis is suspected start low molecular weight heparin .Counsel the women about the causes of symptoms and need to monitor and about plan of management.
Posted by M M A.
Dear Dr Paul,]
I would like t ask about the following:
I found that adnexal and uterine necrosis are recognised complications of second generation ablasion....Do they occur in first generation also??
for your opinion please...
Posted by Olubunmi O.
Dear Paul,
I did not think I was giving a list to part b of the question,I thought I was giving an \"outline\".
I noticed someone else has answered the question nearly the same way as I have done and their answer has been marked.Its not very helpful if a whole section of the answer is not marked as I cannot see which points I have missed out.

Would you kindly mark my answer for the DVT question?
Bunmi