Postoperative complications in gynecologic surgery US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Postoperative complications in gynecologic surgery. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Postoperative complications in gynecologic surgery US Medical PG Question 1: A 56-year-old previously healthy woman with no other past medical history is post-operative day one from an open reduction and internal fixation of a fractured right radius and ulna after a motor vehicle accident. What is one of the primary ways of preventing postoperative pneumonia in this patient?
- A. Shallow breathing exercises
- B. Incentive spirometry (Correct Answer)
- C. Outpatient oral antibiotics
- D. Hyperbaric oxygenation
- E. In-hospital intravenous antibiotics
Postoperative complications in gynecologic surgery Explanation: ***Incentive spirometry***
- **Incentive spirometry** is a cornerstone of postoperative care, actively encouraging patients to take slow, deep breaths. This expands the lungs and prevents the collapse of alveoli, reducing the risk of **atelectasis** and subsequent **pneumonia**.
- Its effectiveness lies in promoting lung aeration and clearing secretions, which are crucial after anesthesia and surgery, especially in patients with reduced mobility or pain.
*Shallow breathing exercises*
- **Shallow breathing** is insufficient for adequate lung expansion and can actually contribute to **atelectasis** and the pooling of secretions in the lungs.
- Effective pulmonary hygiene requires **deep breaths** to maximize alveolar recruitment and prevent respiratory complications.
*Outpatient oral antibiotics*
- **Prophylactic antibiotics** are typically given around the time of surgery to prevent surgical site infections, not primarily to prevent postoperative pneumonia in an outpatient setting.
- Administering antibiotics without a diagnosed infection can lead to **antibiotic resistance** and is not a standard practice for preventing pneumonia unless a specific risk factor or existing infection is identified.
*Hyperbaric oxygenation*
- **Hyperbaric oxygenation** involves breathing 100% oxygen in a pressurized chamber and is used for conditions like **decompression sickness**, non-healing wounds, or severe infections.
- It is not a standard or primary method for preventing postoperative pneumonia, as its mechanism of action is unrelated to common pulmonary hygiene techniques.
*In-hospital intravenous antibiotics*
- While antibiotics can treat pneumonia, their routine, **prophylactic use** intravenously in-hospital solely for preventing postoperative pneumonia is generally unwarranted and can contribute to **antibiotic resistance**.
- Antibiotics are indicated if there is evidence of an active infection, but the primary prevention of pneumonia focuses on mechanical lung expansion and airway clearance.
Postoperative complications in gynecologic surgery US Medical PG Question 2: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
- A. Prostatitis
- B. Seminoma
- C. Testicular torsion
- D. Sperm granuloma (Correct Answer)
- E. Inguinal hernia
Postoperative complications in gynecologic surgery Explanation: **Sperm granuloma**
- A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction.
- This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue.
*Prostatitis*
- **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy.
- It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation.
*Seminoma*
- **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy.
- The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation.
*Testicular torsion*
- **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis.
- This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma.
*Inguinal hernia*
- An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal.
- Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.
Postoperative complications in gynecologic surgery US Medical PG Question 3: Three days after undergoing laparoscopic colectomy, a 67-year-old man reports swelling and pain in his right leg. He was diagnosed with colon cancer 1 month ago. His temperature is 38.5°C (101.3°F). Physical examination shows swelling of the right leg from the ankle to the thigh. There is no erythema or rash. Which of the following is likely to be most helpful in establishing the diagnosis?
- A. D-dimer level
- B. Compression ultrasonography (Correct Answer)
- C. CT pulmonary angiography
- D. Transthoracic echocardiography
- E. Blood cultures
Postoperative complications in gynecologic surgery Explanation: ***Compression ultrasonography***
- This patient's presentation with **unilateral leg swelling and pain** after surgery, especially given his recent **colon cancer diagnosis** (a hypercoagulable state), is highly suspicious for a **deep vein thrombosis (DVT)**.
- **Compression ultrasonography** is the gold standard, non-invasive imaging modality for diagnosing DVT, allowing direct visualization of thrombi and assessing venous compressibility.
*D-dimer level*
- While a **positive D-dimer** indicates recent or ongoing clot formation, it is **non-specific** and can be elevated in many conditions, including surgery, cancer, and infection.
- A normal D-dimer can rule out DVT in low-probability patients, but a high D-dimer in a high-probability patient (like this case) requires further imaging for confirmation, making it less definitive than ultrasound.
*CT pulmonary angiography*
- This imaging is used to diagnose a **pulmonary embolism (PE)**, which is a complication of DVT, but the primary symptoms here are localized to the leg.
- While PE is a concern, diagnosing the source (DVT) in the leg is the immediate priority for treatment and prevention of future complications.
*Transthoracic echocardiography*
- **Echocardiography** evaluates cardiac structure and function and can sometimes detect large clots in the right heart leading to PE, but it is not the primary diagnostic tool for DVT in the leg.
- It would be done if signs of cardiac strain or shunting associated with acute PE were prominent, which is not the case here.
*Blood cultures*
- **Blood cultures** are used to diagnose **bacteremia or sepsis**, which might explain a fever, but the prominent, unilateral leg swelling and pain are not typical for a primary infectious cause in the leg without local signs of cellulitis or abscess.
- While a low-grade fever is present, the absence of erythema or rash makes a primary infectious etiology less likely than DVT given the risk factors.
Postoperative complications in gynecologic surgery US Medical PG Question 4: Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?
- A. Administer tamsulosin
- B. Administer intravenous furosemide
- C. Obtain an abdominal CT
- D. Start ciprofloxacin
- E. Administer intravenous fluids (Correct Answer)
Postoperative complications in gynecologic surgery Explanation: ***Administer intravenous fluids***
- The patient's **oliguria** (20 mL urine over 3 hours, ~7 mL/hour) post-surgery, elevated **BUN (30 mg/dL)**, and **creatinine (1.3 mg/dL)** with a **BUN:Cr ratio >20:1** suggest **prerenal acute kidney injury** due to **hypovolemia**.
- Post-operative fluid losses from **third-spacing**, blood loss, and insensible losses commonly cause hypovolemia after major abdominal surgery.
- **Intravenous fluids** are the most appropriate initial step to restore intravascular volume and improve renal perfusion.
*Administer tamsulosin*
- **Tamsulosin** is an alpha-blocker used to relax smooth muscle in the prostate and bladder neck, primarily for **urinary retention** due to benign prostatic hyperplasia.
- This patient's oliguria is due to **prerenal azotemia** from hypovolemia, not prostatic obstruction, and the catheter flushes easily without obstruction.
*Administer intravenous furosemide*
- **Furosemide** is a loop diuretic that increases urine output, but administering it in the context of **prerenal acute kidney injury** can worsen hypovolemia and further compromise renal function.
- Diuretics are generally contraindicated in oliguria due to hypovolemia and should only be considered after volume resuscitation.
*Obtain an abdominal CT*
- While an abdominal CT can diagnose surgical complications, there are no immediate signs of a surgical emergency like **anastomotic leak** or **bowel obstruction**.
- Addressing the likely **hypovolemia** is more urgent and should precede further imaging in this scenario.
*Start ciprofloxacin*
- The patient does not show signs of infection, such as fever or localized signs of bacterial peritonitis, making **antibiotics** like ciprofloxacin inappropriate as the initial management step.
- The elevated BUN and creatinine are more indicative of volume depletion than infection.
Postoperative complications in gynecologic surgery US Medical PG Question 5: A 19-year-old woman with no known past medical history presents to the emergency department with increasing lower pelvic pain and vaginal discharge over the last several days. She endorses some experimentation with marijuana and cocaine, drinks liquor almost daily, and smokes 2 packs of cigarettes per day. The patient's blood pressure is 84/66 mm Hg, pulse is 121/min, respiratory rate is 16/min, and temperature is 39.5°C (103.1°F). Physical examination reveals profuse yellow-green vaginal discharge and severe cervical motion tenderness. What is the most appropriate definitive treatment for this patient’s presumed diagnosis?
- A. Cefoxitin × 14 days
- B. Single-dose ceftriaxone IM
- C. Clindamycin + gentamicin × 14 days (Correct Answer)
- D. Exploratory laparotomy
- E. Levofloxacin and metronidazole × 14 days
Postoperative complications in gynecologic surgery Explanation: ***Clindamycin + gentamicin × 14 days***
- This combination is the recommended inpatient treatment for **severe pelvic inflammatory disease (PID)**, which this patient likely has given her symptoms of **pelvic pain**, **vaginal discharge**, **fever**, **tachycardia**, and **cervical motion tenderness**. The patient's **hypotension** and **fever** suggest systemic involvement and a need for inpatient IV antibiotics.
- **Clindamycin** provides coverage for **anaerobes** (important for treating tubo-ovarian abscesses) and some gram-positives, while **gentamicin** is a broad-spectrum antibiotic covering **gram-negative bacteria**, including *Neisseria gonorrhoeae* and *Chlamydia trachomatis*, which are common causes of PID.
*Cefoxitin × 14 days*
- While **cefoxitin** is a second-generation cephalosporin used in PID treatment, it is typically given in combination with **doxycycline** and for a shorter duration (e.g., 24-48 hours intravenously, transitioning to oral doxycycline) for less severe cases or as part of a regimen that does not include systemic signs like hypotension and fever.
- Using cefoxitin monotherapy for 14 days is not a standard or sufficiently broad-spectrum approach for severe PID requiring inpatient care, especially without anaerobic coverage.
*Single-dose ceftriaxone IM*
- **Single-dose ceftriaxone IM** is appropriate for uncomplicated **gonorrhea** but is insufficient for treating **PID**, especially in a patient with severe symptoms, fever, and signs of systemic inflammatory response (hypotension, tachycardia).
- PID requires a longer course of antibiotics to prevent long-term complications such as infertility and chronic pelvic pain.
*Exploratory laparotomy*
- **Exploratory laparotomy** is a surgical intervention and is typically reserved for cases of **suspected ruptured tubo-ovarian abscess (TOA)**, failure of medical management, or diagnostic uncertainty unresponsive to antibiotics.
- While a **tubo-ovarian abscess** can be a complication of severe PID, initial management is usually medical unless there are clear signs of rupture or sepsis unresponsive to antibiotics.
*Levofloxacin and metronidazole × 14 days*
- This oral regimen (levofloxacin combines well with metronidazole) could be used as an outpatient treatment for **mild to moderate PID** or as a step-down therapy after initial intravenous treatment.
- Given the patient's **hypotension** and **fever**, oral antibiotics alone are not appropriate for initial definitive treatment, which requires inpatient intravenous therapy to achieve adequate systemic levels rapidly.
Postoperative complications in gynecologic surgery US Medical PG Question 6: A 70-year-old man with a 2 year history of Alzheimer disease is brought in from his nursing facility with altered mental status and recurrent falls during the past few days. Current medications include donepezil and galantamine. His vital signs are as follows: temperature 36.0°C (96.8°F), blood pressure 90/60 mm Hg, heart rate 102/min, respiratory rate 22/min. Physical examination reveals several lacerations on his head and extremities. He is oriented only to the person. Urine and blood cultures are positive for E. coli. The patient is admitted and initial treatment with IV fluids, antibiotics, and subcutaneous prophylactic heparin. On the second day of hospitalization, diffuse bleeding from venipuncture sites and wounds is observed. His blood test results show thrombocytopenia, prolonged PT and PTT, and a positive D-dimer. Which of the following is the most appropriate next step in the management of this patient's condition?
- A. Cryoprecipitate, FFP and low dose SC heparin
- B. Start prednisone therapy
- C. Immediately cease heparin therapy and prescribe an alternative anticoagulant (Correct Answer)
- D. Splenectomy
- E. Urgent plasma exchange
Postoperative complications in gynecologic surgery Explanation: ***Immediately cease heparin therapy and prescribe an alternative anticoagulant***
- This patient presents with **disseminated intravascular coagulation (DIC)** secondary to severe **sepsis** (E. coli bacteremia), characterized by **thrombocytopenia**, **prolonged PT and PTT**, **positive D-dimer**, and **diffuse bleeding**.
- In DIC with active bleeding, **heparin must be stopped immediately** as it will worsen the bleeding by preventing clot formation.
- The primary management of DIC is **treating the underlying cause** (sepsis with antibiotics and IV fluids, already initiated) and **supportive care** with blood product replacement as needed.
- Alternative anticoagulation is generally **not needed acutely** in DIC with bleeding, but stopping heparin is the critical first step to prevent further hemorrhage.
*Cryoprecipitate, FFP and low dose SC heparin*
- **Cryoprecipitate** (source of fibrinogen and factor VIII) and **FFP** (contains all clotting factors) are appropriate for severe DIC with bleeding to replace consumed coagulation factors.
- However, continuing **low-dose subcutaneous heparin** is contraindicated in a patient with active diffuse bleeding from DIC, as it will worsen the hemorrhage.
- The correct approach is blood product replacement WITHOUT ongoing anticoagulation when bleeding is the dominant feature.
*Start prednisone therapy*
- **Corticosteroids** have no role in the management of DIC, which is a consumptive coagulopathy triggered by systemic activation of coagulation.
- Steroids are used for immune-mediated thrombocytopenias like **ITP**, not for DIC where platelets are consumed in microthrombi.
- The treatment focus in DIC is addressing the underlying trigger (sepsis) and replacing consumed factors.
*Splenectomy*
- **Splenectomy** is used for refractory immune-mediated conditions like chronic **ITP** or certain hemolytic anemias, not for consumptive coagulopathy.
- DIC is managed medically by treating the underlying cause and providing supportive care; surgical intervention has no role.
- The spleen is not involved in the pathophysiology of DIC.
*Urgent plasma exchange*
- **Plasma exchange (plasmapheresis)** is the emergent treatment for **thrombotic thrombocytopenic purpura (TTP)**, which presents with the classic pentad: thrombocytopenia, microangiopathic hemolytic anemia, fever, neurologic symptoms, and renal dysfunction.
- While some features overlap (thrombocytopenia, altered mental status), this patient's presentation with **sepsis**, **prolonged PT/PTT**, **positive D-dimer**, and **diffuse bleeding** is diagnostic of **DIC**, not TTP.
- TTP typically has **normal coagulation studies** (PT/PTT), distinguishing it from DIC.
Postoperative complications in gynecologic surgery US Medical PG Question 7: Four hours after undergoing an abdominal hysterectomy, a 43-year-old woman is evaluated in the post-anesthesia care unit because she has only had a urine output of 5 mL of blue-tinged urine since surgery. The operation went smoothly and ureter patency was checked via retrograde injection of methylene blue dye mixed with saline through the Foley catheter. She received 2.4 L of crystalloid fluids intraoperatively and urine output was 1.2 L. She had a history of fibroids with painful and heavy menses. She is otherwise healthy. She underwent 2 cesarean sections 8 and 5 years ago, respectively. Her temperature is 37.4°C (99.3°F), pulse is 75/min, respirations are 16/min, and blood pressure is 122/76 mm Hg. She appears comfortable. Cardiopulmonary examination shows no abnormalities. There is a midline surgical incision with clean and dry dressings. Her abdomen is soft and mildly distended in the lower quadrants. Her bladder is slightly palpable. Extremities are warm and well perfused, and capillary refill is brisk. Laboratory studies show:
Leukocyte count 8,300/mm3
Hemoglobin 10.3 g/dL
Hematocrit 31%
Platelet count 250,000/mm3
Serum
_Na+ 140 mEq/L
_K+ 4.2 mEq/L
_HCO3+ 26 mEq/L
_Urea nitrogen 26 mg/dL
_Creatinine 1.0 mg/dL
Urine
_Blood 1+
_WBC none
_Protein negative
_RBC none
_RBC casts none
A bladder scan shows 250 mL of retained urine. Which of the following is the next best step in the evaluation of this patient?
- A. Check the Foley catheter (Correct Answer)
- B. Return to the operating room for emergency surgery
- C. Perform ultrasound of the kidneys
- D. Administer 20 mg of IV furosemide
- E. Administer bolus 500 mL of Lactated Ringers
Postoperative complications in gynecologic surgery Explanation: ***Check the Foley catheter***
- This patient presents with signs of **urinary retention** (low urine output, palpable bladder, retained urine on bladder scan) despite methylene blue injection confirming ureter patency. The most common and easily reversible cause of low urine output post-hysterectomy is a **kinked or obstructed Foley catheter**.
- Given the smooth intraoperative course and adequate urine output during surgery, a quick check and potential **repositioning or flushing of the catheter** is the immediate and most appropriate first step before considering more invasive interventions.
*Return to the operating room for emergency surgery*
- This is a drastic step and is not indicated at this stage. There is no evidence of a **surgical complication** requiring emergency intervention, such as a ureteral injury (which was checked intraoperatively) or active hemorrhage.
- The patient's vital signs are stable, and she appears comfortable, which makes an emergency surgical re-exploration highly unlikely as the initial best step.
*Perform ultrasound of the kidneys*
- While a renal ultrasound can assess for **hydronephrosis** or other kidney abnormalities, it is a delayed step. Given the clear evidence of bladder retention and the possibility of a simple catheter malfunction, performing an ultrasound without first addressing the catheter would be premature.
- The patient's **creatinine is normal**, making acute kidney injury due to obstruction less likely as an immediate concern.
*Administer 20 mg of IV furosemide*
- Furosemide is a **loop diuretic** that increases urine production. However, it would be ineffective and potentially harmful if the issue is a mechanical obstruction of urine outflow, as appears to be the case here.
- Administering a diuretic without addressing the outflow problem would only worsen bladder distension and potentially stress the renal system without resolving the underlying issue.
*Administer bolus 500 mL of Lactated Ringers*
- This patient has already received 2.4 L of crystalloid fluids intraoperatively and has stable vital signs, indicating she is likely **euvolemic**.
- Giving another fluid bolus would not address the observed urinary retention and could lead to **fluid overload** if the urine outflow obstruction persists.
Postoperative complications in gynecologic surgery US Medical PG Question 8: Three days after undergoing coronary artery bypass surgery, a 72-year-old man has severe right upper quadrant pain, fever, nausea, and vomiting. He has type 2 diabetes mellitus, benign prostatic hyperplasia, peripheral vascular disease, and chronic mesenteric ischemia. He had smoked one pack of cigarettes daily for 30 years but quit 10 years ago. He drinks 8 cans of beer a week. His preoperative medications include metformin, aspirin, simvastatin, and finasteride. His temperature is 38.9°C (102°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/60 mmHg. Auscultation of the lungs shows bilateral inspiratory crackles. Cardiac examination shows no murmurs, rubs or gallops. Abdominal examination shows soft abdomen with tenderness and sudden inspiratory arrest upon palpation in the right upper quadrant. There is no rebound tenderness or guarding. Laboratory studies show the following:
Hemoglobin 13.1 g/dL
Hematocrit 42%
Leukocyte count 15,700/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 20%
Monocytes 3%
Eosinophils 1%
Basophils 0.5%
AST 40 U/L
ALT 100 U/L
Alkaline phosphatase 85 U/L
Total bilirubin 1.5 mg/dL
Direct 0.9 mg/dL
Amylase 90 U/L
Abdominal ultrasonography shows a distended gallbladder, thickened gallbladder wall with pericholecystic fluid, and no stones. Which of the following is the most appropriate next step in management?
- A. Intravenous heparin therapy followed by embolectomy
- B. Careful observation with serial abdominal examinations
- C. Endoscopic retrograde cholangiopancreatography with papillotomy
- D. Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy (Correct Answer)
- E. Immediate cholecystectomy
Postoperative complications in gynecologic surgery Explanation: ***Intravenous piperacillin-tazobactam therapy and percutaneous cholecystostomy***
- The patient presents with **acalculous cholecystitis**, characterized by severe RUQ pain, fever, leukocytosis, elevated transaminases, and ultrasonographic findings of a distended gallbladder with a thickened wall and pericholecystic fluid, but no stones.
- Given his comorbid conditions (diabetes, PVD, recent CABG) and the severity of his illness, empirical **broad-spectrum antibiotics** (like piperacillin-tazobactam) along with image-guided **percutaneous cholecystostomy** for gallbladder decompression are the most appropriate management, avoiding the high risks of immediate surgery.
*Intravenous heparin therapy followed by embolectomy*
- This approach is indicated for **acute mesenteric ischemia with embolism**, which can present with severe abdominal pain and signs of hypoperfusion.
- While the patient has chronic mesenteric ischemia, his current symptoms and imaging findings are more consistent with cholecystitis, and there is no clear evidence of acute embolic event requiring embolectomy.
*Careful observation with serial abdominal examinations*
- This patient exhibits signs of a severe inflammatory process (fever, leukocytosis, RUQ tenderness, elevated LFTs, and sonographic findings of severe inflammation) and systemic illness, making **conservative observation insufficient** and potentially dangerous.
- **Acalculous cholecystitis** is a serious condition with a high risk of complications like perforation and sepsis, especially in critically ill patients, and requires prompt intervention.
*Endoscopic retrograde cholangiopancreatography with papillotomy*
- **ERCP with papillotomy** is indicated for conditions like **choledocholithiasis** (common bile duct stones) or **cholangitis**, which cause biliary obstruction.
- The ultrasound shows **no stones** and features specific to cholecystitis rather than common bile duct obstruction, making ERCP inappropriate as an initial step.
*Immediate cholecystectomy*
- While cholecystectomy is the definitive treatment for cholecystitis, immediate open or laparoscopic cholecystectomy in a critically ill patient with **acalculous cholecystitis** after recent CABG carries a **very high morbidity and mortality risk**.
- **Percutaneous cholecystostomy** offers a safer, less invasive alternative for source control and stabilizes the patient before potential delayed definitive surgery if needed, once the patient's condition improves.
Postoperative complications in gynecologic surgery US Medical PG Question 9: Two hours after undergoing a left femoral artery embolectomy, an obese 63-year-old woman has severe pain, numbness, and tingling of the left leg. The surgery was without complication and peripheral pulses were weakly palpable postprocedure. She has type 2 diabetes mellitus, peripheral artery disease, hypertension, and hypercholesterolemia. Prior to admission, her medications included insulin, enalapril, carvedilol, aspirin, and rosuvastatin. She appears uncomfortable. Her temperature is 37.1°C (99.3°F), pulse is 98/min, and blood pressure is 132/90 mm Hg. Examination shows a left groin surgical incision. The left lower extremity is swollen, stiff, and tender on palpation. Dorsiflexion of her left foot causes severe pain in her calf. Femoral pulses are palpated bilaterally. Pedal pulses are weaker on the left side as compared to the right side. Laboratory studies show:
Hemoglobin 12.1
Leukocyte count 11,300/mm3
Platelet count 189,000/mm3
Serum
Glucose 222 mg/dL
Creatinine 1.1 mg/dL
Urinalysis is within normal limits. Which of the following is the most likely cause of these findings?
- A. Reperfusion injury (Correct Answer)
- B. Cellulitis
- C. Cholesterol embolism
- D. Deep vein thrombosis
- E. Rhabdomyolysis
Postoperative complications in gynecologic surgery Explanation: ***Reperfusion injury***
- The patient's symptoms of **severe pain, numbness, and tingling** in the left leg following an embolectomy, along with **swelling, stiffness, and tenderness** of the extremity, and pain on passive dorsiflexion (**pain with passive stretch**), are classic signs of **acute compartment syndrome**.
- In this context, compartment syndrome is caused by **reperfusion injury** following prolonged limb ischemia. When blood flow is restored after prolonged ischemia, the reperfusion causes **oxidative stress, inflammatory mediator release, and increased capillary permeability**, leading to **tissue edema and elevated intracompartmental pressure** that compresses nerves and vessels.
- The **2-hour timeline** post-embolectomy and the clinical triad of pain out of proportion, pain with passive stretch, and paresthesias make reperfusion injury leading to compartment syndrome the most likely diagnosis.
*Cellulitis*
- While cellulitis causes **pain, swelling, and redness**, it typically has a more **gradual onset** and is associated with warmth, erythema, and signs of infection.
- The **acute onset** (2 hours post-surgery), **severe neurologic symptoms** (numbness, tingling), and **pain with passive stretch** are not characteristic of cellulitis.
- The absence of fever, significant leukocytosis, or spreading erythema makes cellulitis unlikely.
*Cholesterol embolism*
- **Cholesterol emboli** can occur after vascular procedures and typically present with **livedo reticularis**, **"blue toe" syndrome**, **renal impairment**, or **eosinophilia**.
- While possible after arterial manipulation, the acute presentation with signs of **elevated compartment pressure** (pain with passive stretch, swelling, paresthesias) points to a pressure-related compartment issue rather than distal microembolization.
*Deep vein thrombosis*
- **DVT** causes **unilateral leg swelling, pain, and tenderness** but typically presents with a more **gradual onset** over hours to days.
- DVT would not explain the **acute severe pain with passive stretch**, **rapid neurologic symptoms** (paresthesias), or the **compartment syndrome findings** seen immediately (2 hours) post-procedure.
- The clinical picture of acute compartment syndrome better fits ischemia-reperfusion injury.
*Rhabdomyolysis*
- **Rhabdomyolysis** involves muscle breakdown due to prolonged ischemia or trauma and is characterized by **elevated creatinine kinase (CK)**, **myoglobinuria**, and potentially **acute kidney injury**.
- While rhabdomyolysis can occur **secondary to** both the initial ischemia and subsequent compartment syndrome, it is a **consequence or complication** rather than the **primary cause** of the acute compartment syndrome findings.
- The immediate clinical presentation (severe pain with passive stretch, paresthesias, swelling) reflects **elevated intracompartmental pressure from reperfusion injury**, not rhabdomyolysis itself.
Postoperative complications in gynecologic surgery US Medical PG Question 10: A 33-year-old woman comes to the emergency department because of severe right flank pain for 2 hours. The pain is colicky in nature and she describes it as 9 out of 10 in intensity. She has had 2 episodes of vomiting. She has no history of similar episodes in the past. She is 160 cm (5 ft 3 in) tall and weighs 104 kg (229 lb); BMI is 41 kg/m2. Her temperature is 37.3°C (99.1°F), pulse is 96/min, respirations are 16/min and blood pressure is 116/76 mm Hg. The abdomen is soft and there is mild tenderness to palpation in the right lower quadrant. Bowel sounds are reduced. The remainder of the examination shows no abnormalities. Her leukocyte count is 7,400/mm3. A low-dose CT scan of the abdomen and pelvis shows a round 12-mm stone in the distal right ureter. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows RBCs and no WBCs. 0.9% saline infusion is begun and intravenous ketorolac is administered. Which of the following is the most appropriate next step in management?
- A. Ureteral stenting
- B. Ureteroscopy (Correct Answer)
- C. Observation
- D. Extracorporeal shock wave lithotripsy
- E. Thiazide diuretic therapy
Postoperative complications in gynecologic surgery Explanation: ***Ureteroscopy***
- **Ureteroscopy** is the most appropriate next step for a 12-mm symptomatic distal ureteral stone, especially given its size.
- It allows for direct visualization of the stone and immediate fragmentation or extraction, providing rapid relief of symptoms and addressing the obstruction.
*Ureteral stenting*
- **Ureteral stenting** is primarily used to relieve obstruction and pain, or to bypass the stone, but it does not remove the stone.
- It is often considered a temporary measure to decompress the kidney, particularly in cases of infection or severe obstruction, but definitive treatment for the stone would still be needed.
*Observation*
- **Observation** is generally reserved for smaller ureteral stones (typically <5 mm) that are likely to pass spontaneously.
- A 12-mm stone has a very low chance of spontaneous passage and would likely lead to prolonged pain, obstruction, and potential complications.
*Extracorporeal shock wave lithotripsy*
- **Extracorporeal shock wave lithotripsy (ESWL)** is less effective for larger stones (>10 mm) and stones located in the distal ureter, as successful fragmentation and passage are reduced.
- It is generally more effective for smaller, proximal ureteral or renal stones.
*Thiazide diuretic therapy*
- **Thiazide diuretics** are used as a preventative measure to reduce calcium excretion and thus decrease the risk of new calcium stone formation, but they are not a treatment for an acutely obstructing stone.
- This therapy would not alleviate the current acute pain or obstruction caused by the 12-mm stone.
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