1. SEMINAR TITLE: PRE OPERATIVE
CARE FOR GYNECOLOGIC PATIENT
Prepared by :mekonnen mengistu
and mengistu kassa
Moderator: Dr samartha

2. OUTLINE
• INTRODUCTION
• PREOPERATIVE EVALUATION
HISTORY
PHYSICAL EXAMINATION
ANESTHESIOLOGIC EXAMINATION
INVESTIGATION
• PREOPERATIVE PREPARATION

3. INTRODUCTION
• Preoperative care is the preparation and
management of a patient prior to surgery.
• It includes both physical and psychological
preparation.
• Surgical treatment of the patients with
gynecologic diseases is warranted only when
all the conservative treatment approaches
have been exhausted.

4. • Many postoperative problems can be
anticipated preoperatively, and eliminated or
minimized.
• There are two groups of indications for
gynecological surgery:
Absolute - when surgery must be undertaken,
when its cancellation is life threatening.
Relative - when surgery can be postponed till the
most appropriate occasion for its performing.

5. • The surgeon is obliged to introduce to the
patient all the reasons of the surgical
treatment.
INFORMED CONCENT:
• The patient must submit an informed written
consent to confirm that she takes the risk of
the planned surgical treatment.
• discussion regarding consent should be held
with a qualified interpreter present.

6. • The presence of an interpreter should be
included in the documentation.
• The informed consent discussion should include
the following:
– Rationale
– Complications
– Unexpected findings at surgery
– Personnel who will be involved in the surgery.
– Documentation

7. PREOPERATIVE EVALUATION
• Used to addresses issues that will potentially
affect the woman during her surgical
procedure and recovery.
• The surgeon should use this time to review:
– the patient's history
– physical examination
– identify physical limitations

8. – gather information required to plan surgery
– optimize medical status, and
– educate about what to expect from the
procedure and during the recovery period.
Patient history
• A comprehensive history is the first step
helping surgeons to determine the scope of
general physical examination, laboratory, and
radiologic tests.

9. • The patients undergoing minor surgery can be
examined by their surgeon and
anesthesiologist on the operation day during
preoperative preparation but
• those with more serious conditions should be
examined at least a week before surgery,
allowing the time for risk assessment,
specialist consultations, and preparation.

10.  General medical history: includes
• Personal and family diseases
• History of drug use
• Allergies to drugs, foods, and other environmental
allergens
• Hospitalizations
• Earlier diseases (including previous operations and
tolerance of anesthetics).
• Important family data refer to
malignancies, cardiovascular diseases, diabetes
mellitus, cerebrovascular diseases, and osteoporosis.

11. Gynecologic and obstetric history
• should contain the data about major
complaints of the current disease (beginning,
duration, symptoms).
• past pregnancies (description of each,
duration, complications, type of delivery)

12. • menstrual cycle data (intervals, duration,
copiousness, dysmenorrhea, premenstrual
syndrome, intermenstrual bleeding)
• menarche; data on the last menstruation
• if the patient is age at menopause, recent
vaginal bleeding, vasomotor symptoms,
hormone replacement therapy.

13. • birth control (if sexually active - active
contraception, methods in the past; if
sterilized - time and mode of sterilization).
• sexual history
• birth control (conception difficulties, infertility
treatment)
• infections (vaginal discharge, previous vaginal
infections, sexually transmitted diseases).

14. Clinical (physical) examination
• The aim of the physical examination is to
establish the physical, health status, in view of
history and medical condition.
• Full physical examination is needed.
• detailed exam of the abdomen and pelvis, as
the main component of the procedure.

15.  Anesthesiologic preoperative examination
• An anesthesiologist has to examine the patient
before her operation.why?
– b/c it helps him to get an insight into the general health
condition, and
– to assess whether the patient is able to tolerate the risks and
duration of anesthesia for the planned surgery.
• A special stress is put on the state of
consciousness and vital functions of the heart,
blood vessels, liver, and kidneys.

16.  Anesthesiologic surgical risk is assessed based on
the assessment of physical status created by the
American Society of Anesthesiology – ASA:
• Group I- original disease, if it is without a
systemic im-pact
• Group II - moderate systemic disease without
functional impediments
• Group III - severe systemic disease with serious
functional impediments
• Group IV- severe systemic life-threatening disease

17. • Group V- moribund patient, with 24 hours;
and
• Group VI- confirmed brain death
 INVESTIGATION
• Preoperative indications for laboratory tests
– Patient age
– diagnosis of the disease and
– risk of the procedure with careful and detailed
history and physical examination.

18. • blood group determination
• complete blood count with the leukocyte
formula, sedimentation, bleeding and
coagulation time, thrombocytes, fibrinogen.
• Renal function test
• liver function test
• Blood glucose level
• General analysis of the urine and urine culture

19. • Pregnancy test
 Pregnancy testing should be performed shortly
before surgery on all fertile women who could be
pregnant.
• Imaging studies
 are often performed to select patients who will
not benefit from surgery (eg, metastatic disease)
or
 to help biopsy tissue for diagnosis of suspicious
masses

20. • Imaging study includes




An intravenous pyelogram (IVP)
Computed tomography (CT)
magnetic resonance imaging (MRI), and
Ultrasound
NB:Preoperative chest x-rays should not be
routinely performed.
• Investigation specific to patients problem.

21. PREOPERATIVE PREPARATION
• It is important to allow adequate time for
preparation prior to surgery. This includes:
1-Correction of anemia: Strategies to correct
anemia preoperatively are: Iron supplementation
 Medical treatment of abnormal uterine
bleeding
 Erythropoiesis-stimulating agents
 Blood transfusion

22. 2-Smoking cessation:
 Patients undergoing elective surgery should
be advised to stop smoking at least eight
weeks before surgery.
 Preoperative smoking cessation may decrease
wound complications, particularly wound
infection.

23. 3-Medical consultation and stabilization
 The consultant should be asked specific
questions, such as
is thyroid replacement adequate
 hypertension well controlled
CHD optimally managed, and
diabetes under control

24. 4-Bowel preparation:
 The gynecologic surgery literature does not
address the safety and efficacy of mechanical
bowel preparation.
 In general, you can expect to:
 Modify the diet
Take a laxative or bowel preparation medication
 Increase fluid intake

25. 5-preoperative antibiotics:
 Provision of optimal local immunity to
infection is primarily a surgical task.
 A single dose of antibiotic immediately before
the operation is sufficient for most surgical
procedures.
 If the operation is going to take more than 3
hours, administration of antibiotics should be
repeated.

26. • In time consuming interventions
intramuscular administration of antibiotics is
preferred.
• Prophylactic use of antibiotics have been
demonstrated to be more successful for
vaginal compared to abdominal operations.
• Adequate use of antibiotics is able to reduce
the rate of infections, as well as morbidity and
associated costs .

27. Recommendation for choosing antibiotcs in
postoperative infection prophylaxis:
• Cephalosporins first generation: up to 2,0
grammes
• Metronidazole 0,5 - 1,0 grammes +
gentamicin 1,5 mg/kg iv.
• Clindamycin 600 - 900 mg iv + Gentamicin 1,5
mg/kg
• Ciprofloxacin 400 mg iv

28. Thromboprophylaxis:
 reduces the incidence of symptomatic DVT or
pulmonary embolism.
 Types of thromboprophylaxis —
pharmacologic or
 mechanical

29.  Pharmacologic prophylaxis includes
Low-dose unfractionated heparin (LDUH) —
5000 units subcutaneously (SC) every 8 to
12 hours.
Low molecular weight heparin (LMWH) —
Dalteparin 2500 units or enoxaparin 40 mg
SC daily.
NB: The use of aspirin for prophylaxis is
NOT recommended, as other
measures are more efficacious.

30. • Mechanical methods of thromboprophylaxis
are placed on the patient just prior to the start
of surgery and used continuously until
hospital discharge.
• Most commonly used methods in gynecologic
surgery are:
Intermittent pneumatic compression boots (IPC)
Graduated compression stockings (GCS)

31. Which patients need thromboprophylaxis?
 The ACCP recommendations for women undergoing
gynecologic surgery are:
 Low risk (ie, minor surgery in mobile patients) AND/OR
entirely laparoscopic procedures with NO additional VTE
risk factors — Do not require specific prophylaxis, but early
and frequent ambulation is advised.
 Entirely laparoscopic procedures WITH additional VTE risk
factors — Mechanical, pharmacologic thromboprophylaxis,
or both.

32. Major gynecologic surgery for benign disease with
NO additional risk factors — IPC or pharmacologic
thromboprophylaxis.
Major gynecologic surgery for malignancy
AND/OR in patients WITH additional risk factors —
Pharmacologic therapy (LDUH should be given
every eight hours).
Patients who have undergone major surgery for
malignancy AND/OR have a previous history of
VTE should continue LMWH for up to 28 days.

33. CONCLUSION
• Preoperative patient preparation for
gynecologic surgery is
to avoid or minimize both intra and
postoperative complications, and
enabling a successful outcome of
surgery.

34. Reference
• Up to date 19.3; Preoperative evaluation and
preparation of women for gynecologic surgery.
Author:William J Mann, Jr, MD.
• Danforth's Obstetrics & Gynecology, 9th
Edition
• Clinic of Gynecology and Obstetrics
• Bailey & Love’s short practice of surgery 25th
ed