This document outlines preoperative care for gynecologic patients. It discusses preoperative evaluation including obtaining a comprehensive medical history, physical examination, anesthesiology examination, and necessary investigations. Preoperative preparation is also covered, such as correcting anemia, smoking cessation, medical consultation, bowel preparation, use of antibiotics and thromboprophylaxis. The goal of preoperative care is to avoid or minimize both intra- and postoperative complications and enable a successful surgical outcome.

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