Examkin

Question

Difficulty: MediumGynecologic Procedures and Complications

A 35-year-old woman is evaluated in the surgical ward 14 hours after undergoing an uncomplicated laparoscopic myomectomy for symptomatic uterine leiomyomata. She reports sudden-onset severe lightheadedness and expanding lower abdominal pain. Preoperative hemoglobin was 13.2 g/dL. Her temperature is 36.8°C (98.2°F), blood pressure is 78/45 mm Hg, pulse is 128/min, and respiratory rate is 22/min. Physical examination demonstrates pale conjunctivae and a visibly distended abdomen that is rigid and diffusely tender with involuntary guarding. The surgical incisions are intact with no active drainage. An immediate intravenous bolus of 1 liter of normal saline is administered, but her blood pressure only improves to 82/50 mm Hg. Which of the following is the most appropriate next step in management?

  1. Urgent exploratory laparotomyAnswer
  2. B
    Computed tomography scan of the abdomen and pelvis
  3. C
    Transfusion of packed red blood cells and serial abdominal examinations
  4. D
    Administration of empiric broad-spectrum antibiotics
  5. E
    Formal transvaginal ultrasonography

Answer

Urgent exploratory laparotomy
The correct answer is to perform an urgent exploratory laparotomy. This patient is presenting with classic signs of acute hemoperitoneum and hemorrhagic shock shortly after a major pelvic surgery. The key finding driving the management is her hemodynamic instability (tachycardia and hypotension) that does not appropriately respond to initial fluid resuscitation. In any postoperative patient with suspected active, severe intra-abdominal bleeding and hemodynamic instability, immediate surgical exploration is the standard of care to rapidly identify and ligate the bleeding vessel (e.g., slipped pedicle ligature or unrecognized uterine vessel injury).

Step-by-Step Solution

1
Identify the patient's clinical state.
The patient is experiencing hypovolemic shock (hypotension, tachycardia) and an acute abdomen (rigid, distended).
Vital signs and physical exam findings 14 hours post-myomectomy strongly indicate massive internal bleeding.
2
Assess the response to initial resuscitation.
The patient remains hypotensive (82/50 mm Hg) despite a 1-liter fluid bolus.
Failure to stabilize after initial fluid resuscitation indicates ongoing, active severe hemorrhage.
3
Determine the definitive management step.
Select urgent exploratory laparotomy.
Hemodynamically unstable patients with suspected active intra-abdominal bleeding require immediate surgical exploration to achieve hemostasis.

Key Concept

Management of acute postoperative hemorrhage and hypovolemic shock in gynecologic surgery.
Rate this question

Topics

Gynecologic Procedures and Complications

More questions from this topic