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28/9/2017 Overview of preoperative evaluation and preparation for gynecologic surgery - UpToDate

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Overview of preoperative evaluation and preparation for gynecologic surgery

Author: William J Mann, Jr, MD


Section Editor: Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor: Kristen Eckler, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: Sep 06, 2017.

INTRODUCTION — The preoperative evaluation and preparation prior to gynecologic surgery 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 and physical examination, identify physical limitations, gather
information required to plan surgery, optimize medical status, and educate about what to expect from the
procedure and during the recovery period.

Many postoperative problems can be anticipated preoperatively, and eliminated or minimized; systematically
addressing these issues at the preoperative evaluation may result in a shorter hospitalization with fewer
complications and a more satisfied patient. The surgeon may also rethink the aggressiveness and necessity
of a planned operative procedure after thoughtful discussion with patients who have severe medical
problems. As an example, a woman with symptomatic congestive heart failure and uterine procidentia may
be better served with a pessary than by vaginal hysterectomy and sacrospinous suspension. This discussion
is mainly regarding scheduled surgery. Urgent cases require an expedited preoperative evaluation process to
provide appropriate care.

The preoperative evaluation and preparation of women for gynecologic surgery will be reviewed here.
General principles of preoperative evaluation and preparation are discussed separately. (See "Overview of
the principles of medical consultation and perioperative medicine" and "Preoperative medical evaluation of
the adult healthy patient".)

INFORMED CONSENT AND PATIENT EXPECTATIONS — The preoperative process should include
comprehensive counseling of the patient regarding alternative treatment options (including expectant
management) and risks and benefits of the procedure. For some procedures, particularly those that have
variable outcomes and impact quality of life (eg, pelvic organ prolapse repair), patient expectations and goals
should be discussed in detail. The expected duration and requirements of the recovery period should also be
reviewed. Anticipatory guidance during preoperative office visits will enhance a patient's acceptance and
compliance during the immediate postoperative period and may help to shorten hospital stay [1].

The surgeon should confirm that the patient has understood the discussion and desires to proceed with the
procedure. This discussion should be documented in the medical record and on the procedure consent form.

Informed consent is discussed in detail separately, including issues related to incompetent or incapacitated
patients, adolescent patients, and issues regarding patients who refuse blood transfusion. (See "Informed
procedural consent" and "Consent in adolescent health care" and "The approach to the patient who refuses
blood transfusion".)

PREOPERATIVE EVALUATION — Preoperative evaluation should identify areas that may emerge as
intraoperative or postoperative problems. The surgeon can use this information to prepare the woman for
surgery and plan for any perioperative measures needed to avoid or manage complications.

An overview of the evaluation of a patient prior to gynecologic surgery is discussed in this section. The
preoperative evaluation of a healthy patient for any type of surgery is discussed in detail separately. (See
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"Preoperative medical evaluation of the adult healthy patient".)

History — The preoperative medical history should include the basic elements of the history (medical
conditions, surgical history, medications, allergies), as well as those related to the following:

● Medical condition for which the procedure is performed


● Medical conditions and risk factors that increase the risk of perioperative complications
● Personal or family history or risk factors for thromboembolism
● Personal or family history of anesthesia-related complications

General questions for the preoperative patient are shown in the table (table 1).

Medical comorbidities — Women with known or suspected medical comorbidities should be identified
prior to surgery and referred for appropriate consultation regarding surgical clearance and perioperative
management. These issues are discussed in detail separately:

● (See "Overview of the principles of medical consultation and perioperative medicine".)


● (See "Evaluation of cardiac risk prior to noncardiac surgery".)
● (See "Perioperative management of hypertension".)
● (See "Evaluation of preoperative pulmonary risk".)
● (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep
apnea".)
● (See "Perioperative management of blood glucose in adults with diabetes mellitus".)
● (See "Medical management of the dialysis patient undergoing surgery".)
● (See "Assessing surgical risk in patients with liver disease".)
● (See "Perioperative care of the surgical patient with neurologic disease".)

Physical examination — Prior to gynecologic surgery, a complete pelvic examination should be performed
by the surgeon. In many cases, the pelvic examination is repeated after induction of anesthesia. (See "The
gynecologic history and pelvic examination" and "Pelvic examination under anesthesia".)

Further components of the physical examination should be performed that are related to the condition for
which the procedure is performed. As an example, if malignancy is suspected, the preoperative examination
should include site of potential lymph node metastases. In addition, the physical examination should be used
to evaluate the patient’s ability to tolerate surgery or anesthesia.

Laboratory tests — Further testing of the preoperative patient depends upon the procedure and medical
comorbidities. Routine testing in healthy preoperative patients is discussed in detail separately. (See
"Preoperative medical evaluation of the adult healthy patient".)

Pregnancy test — Pregnancy should be excluded prior to gynecologic surgery in all women of
reproductive age (table 2). This also applies to patients for whom there is uncertainty about sexual activity,
effectiveness of contraception, or about menopausal status. (See "Clinical manifestations and diagnosis of
early pregnancy", section on 'Human chorionic gonadotropin'.)

If the patient is pregnant, procedures that may cause fetal harm or loss should be cancelled or postponed.
Decisions regarding nonelective procedures that do not interfere with the pregnancy should be individualized
and surgical planning should include measures to safeguard and monitor the pregnancy. (See "Preoperative
medical evaluation of the adult healthy patient", section on 'Pregnancy testing'.)

The prevalence of unrecognized pregnancy was illustrated in a prospective study that performed pregnancy
tests on all women of childbearing potential (defined as menstruating women without prior hysterectomy or
tubal ligation) scheduled for ambulatory surgery [2]. Testing revealed 7 previously unrecognized pregnancies
in 2056 women (0.3 percent), including 2 patients scheduled to undergo fertility procedures. All of the
pregnant women cancelled or postponed their procedures.
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Issues regarding surgical procedures in pregnant women are discussed in detail separately. (See
"Management of the pregnant patient undergoing nonobstetric surgery".)

Testing for genital tract infection — Preoperative screening for genital tract infections is generally not
necessary; women with symptoms or risk factors for infections should be tested and treated as part of usual
gynecologic care. Certain types of infections are clinically important for particular procedures, including:

● Bacterial vaginosis is associated with an increased risk of vaginal cuff infection following hysterectomy.
Women with symptoms or pelvic examination findings consistent with bacterial vaginosis should be
evaluated and treated prior to hysterectomy. (See "Bacterial vaginosis: Treatment", section on 'Women
undergoing gynecologic procedures'.)

● Cervical infections with Chlamydia trachomatis or Neisseria gonorrhea are associated with an increased
risk of endometritis following surgical pregnancy termination. These infections are managed with
universal use of prophylactic antibiotics prior to the procedure rather than a screen and treat strategy.
(See "Overview of pregnancy termination", section on 'Antibiotic prophylaxis'.)

Other testing — Other testing (eg, pelvic imaging) should be performed as needed based upon the
indication and procedure. Routine pelvic imaging is not required if there is no clinical indication [3].

PREOPERATIVE PREPARATION — Preoperative preparation includes issues that are addressed in the
clinic and operating room prior to surgery.

Operating room safety is discussed in detail separately. (See "Operating room hazards and approaches to
improve patient safety".)

Medication management — A discussion of perioperative medication management can be found separately.


(See "Perioperative medication management".)

Blood loss preparation

Correction of anemia — Preoperative correction of anemia for gynecologic surgery is discussed in detail
separately. (See "Management of hemorrhage in gynecologic surgery" and "Management of hemorrhage in
gynecologic surgery", section on 'Correction of anemia' and "The approach to the patient who refuses blood
transfusion".)

Autologous blood transfusion — If significant blood loss is anticipated, preoperative preparations can
be made to use autologous blood in the event a transfusion is necessary. (See "Management of hemorrhage
in gynecologic surgery", section on 'Autologous transfusion methods'.)

Wrong person, site, procedure prevention — Practicing safe, high-quality operating room care begins with
accurately identifying the patient, surgical site, and procedure. The United States Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery is shown in the table (table 3). (See "Operating room hazards and
approaches to improve patient safety", section on 'Wrong procedure or wrong site surgery'.)

Smoking cessation — The preoperative evaluation provides an opportunity to discuss the benefits of
smoking cessation. Current cigarette smokers have an increased risk for postoperative pulmonary
complications, although the incremental risk is small in the absence of chronic lung disease. (See "Strategies
to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation'.)

Piercings and umbilical jewelry — Oral and nasal jewelry (eg, tongue and nose rings) can interfere with
intubation during administration of general anesthesia and body piercing at any site can conduct electric
current if electrosurgery is performed [4-6]. It is recommended that all metallic jewelry be removed to prevent
complications, as well as loss of the jewelry [4]. (See "Body piercing in adolescents and young adults",
section on 'Removal'.)

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The presence of umbilical jewelry, such as rings, is relatively common in women. Our preference is to have
the patient remove the ring the day prior to the procedure and cleanse the umbilicus thoroughly. An
alternative approach is temporary removal of the jewelry and replacement with a nonmetallic spacer (eg,
sterile plastic sutures or thin tubing) [7]. Postoperatively, most navel jewelry can be replaced after the skin of
the laparoscopy incision has sealed (preferably after two or more days) [4]. We ask the patient not to replace
the ring until after follow-up examination five to seven days postoperatively. Both the jewelry and skin site
should be disinfected prior to reinsertion. Antibiotics are not necessary and ointments should be avoided
because they clog the piercing tract.

Intrauterine device — For procedures not including the uterine cavity, intrauterine devices (IUDs) do not
need to be removed prior to surgery, including for LEEP procedures. For procedures involving the uterine
cavity (eg, dilation and curettage, endometrial polyp removal), the IUD is removed prior to the surgery.

SURGICAL SITE INFECTION PREVENTION — The most important factors in the prevention of surgical site
infection (SSI) are timely administration of effective preoperative antibiotics and meticulous operative
technique.

Bundled interventions — In response to data from varying surgical specialities suggesting that bundled
interventions aimed at reducing SSI were effective [8-10], the American College of Obstetricians and
Gynecologists convened the Council on Patient Safety in Women's Health Care. After reviewing existing
guidelines and evidence-based recommendations, the Council released practice recommendations for a
patient care bundle that, while aimed at preventing SSI in women undergoing hysterectomy, can be applied to
all gynecologic surgery [11]. The bundle is divided into four domains: readiness, recognition and prevention,
response, and reporting and systems learning. Key features include patient education, assessment of
preoperative patient risk (table 4), standardization of perioperative antibiotics and normothermia, and data
collection and evaluation (table 5). One limitation of this approach is that the specific intervention(s) that
resulted in the decreased infection rate are not known, and therefore the entire package of interventions must
be implemented in order to reduce infection.

As an example of a bundled intervention and its impact from the gynecologic surgery literature, a
retrospective review of 825 open gynecologic cancer surgeries for uterine or ovarian cancer reported the
overall risk of SSI dropped 82 percent after initiation of an SSI intervention bundle, with the absolute percent
of cases dropping from 6 to 1.1 percent [12]. Preintervention steps to reduce SSI included patient education,
4% chlorhexidine gluconate shower before surgery, antibiotic administration, preoperative skin preparation
with 2% chlorhexidine gluconate and 70% isopropyl alcohol, and cefazolin re-dosing three to four hours after
incision. The bundled intervention consisted of these elements plus sterile closing tray and staff glove change
for fascia and skin closure, dressing removal at 24 to 48 hours postoperatively, patient shower with 4%
chlorhexidine gluconate after dressing removal, and a follow-up nursing phone call. Of note, approximately
40 percent of women undergoing surgery for ovarian cancer required bowel resection.

Antibiotic prophylaxis — Antibiotics should be given to prevent SSI prior to gynecologic surgery or
procedures that enter the reproductive tract (eg, hysterectomy) or are likely to contaminate the peritoneal
cavity from the vagina (eg, surgical abortion, hysterosalpingogram). Guidelines are shown in the table (table
6) [13].

The efficacy of the preferred beta-lactam antimicrobial regimens (eg, cefazolin, cefoxitin or cefotetan) was
supported by a retrospective cohort study of over 21,000 women undergoing hysterectomy (abdominal,
vaginal, laparoscopic, and robotic) [14]. The women who received either alternative antibiotic regimens
(clindamycin with gentamicin or quinolone) or nonstandard regimens had a higher risk of SSI compared with
women who received preferred preoperative antibiotics (SSI odds ratio of 1.7 for alternative beta-lactam
regimens and 2.0 for nonstandard antibiotic regimens). In contrast, a subsequent retrospective cohort study
of over 18,000 women undergoing hysterectomy (all types) reported an increased risk of surgical site
infection in women receiving either cefazolin or second-generation cephalosporin agents compared with
women receiving cefazolin plus metronidazole (adjusted odds ratio 2.3 for both) [15]. However, we will
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continue to use preoperative beta-lactam antibiotics (eg, cefazolin) unless prospective comparative trial data
become available that compel a change in guidelines because of concerns that more broad-spectrum
antibiotic coverage could contribute to increased antibiotic resistance (table 6) [13].

General principles of SSI prevention have been published by the United States Centers for Disease Control
and Prevention (CDC) and are reviewed separately. (See "Antimicrobial prophylaxis for prevention of surgical
site infection in adults".)

Skin preparation — Preoperatively, the CDC advise that the entire body be washed (shower or tub) with
either soap (antimicrobial or nonantimicrobial) or an antiseptic agent on the night prior to surgery [16]. Some
practices give patients chlorhexidine gluconate solution at their preoperative evaluation to facilitate
appropriate preoperative skin cleansing.

Intraoperatively, we use 4 percent chlorhexidine gluconate solution with 70 percent isopropyl alcohol for
preoperative skin preparation [16]. Preoperative skin cleansing with chlorhexidine-alcohol is superior to
povidone-iodine and iodine-alcohol [17-20]. We do not ask women to perform a specific preoperative body
wash. In a meta-analysis of seven trials including over 10,000 participants, preoperative bathing or showering
with chlorhexidine or other products was not associated with reduced rates of surgical site infection [21]. (See
"Overview of control measures for prevention of surgical site infection in adults", section on 'Skin antisepsis'.)

Vaginal preparation — Either povidone-iodine (PVP-I) or chlorhexidine gluconate with a low (4 percent)
concentration of isopropyl alcohol is acceptable for vaginal preparation [22]. While PVP-I is commonly used
in the United States for vaginal preparation, chlorhexidine is commonly used elsewhere because it may
provide a greater reduction in skin flora than PVP-I and is not inactivated in the presence of blood. Despite
common use of chlorhexidine gluconate with 4 percent isopropyl alcohol outside of the United States, the
manufacturer's label states that chlorhexidine gluconate is for external use only and should not be used in
genital areas [23]. Generalized allergic reactions, irritation, and sensitivity have been reported. In addition, a
case report noted vaginal desquamation after application of chlorhexidine gluconate [24]. However, several
studies that totaled over 7000 women reported no significant adverse effects from vaginal application of
chlorhexidine [25-29]. One randomized trial (n = 50) comparing chlorhexidine (4 percent with 4 percent
isopropyl alcohol) with PVP-I for preparation for vaginal hysterectomy found no cases of vaginal irritation or
postoperative infection in either group [25]. Based on the above data demonstrating lack of adverse effects
with vaginal chlorhexidine, we support the use of chlorhexidine with 4 percent isopropyl alcohol for vaginal
preparation, although both PVP-I and chlorhexidine are reasonable options.

For surgeons who choose vaginal preparation with PVP-I, some use PVP-I gel in addition to PVP-I solution,
but there are conflicting data regarding this practice. It appears that bacterial counts return to near baseline
levels within 30 minutes after vaginal painting with PVP-I solution; however, vaginal PVP-I gel lowers
bacterial counts for at least three hours [30]. Randomized trials have yielded inconsistent results regarding
whether vaginal preparation with PVP-I in both solution and gel form compared with solution alone reduces
the overall risk of postoperative infectious morbidity [31,32]. One trial reported that combined use of solution
and gel reduced the risk of postoperative pelvic abscess [31].

When the patient is allergic to PVP-I and the vaginal use of chlorhexidine is prohibited, vaginal preparation
can be performed with sterile saline or baby shampoo. In our practice, if a saline preparation is used and the
peritoneal cavity is entered, we use prophylactic antibiotics and irrigate the field thoroughly at the conclusion
of the case. If the peritoneum is not entered and antibiotic prophylaxis is not typically required for the case,
then the risk of surgical site infection is balanced against the risks of Clostridium difficile infection and
antibiotic resistance.

Other measures — Additional measures for prevention of surgical site infection include skin antisepsis, hair
removal, drapes, surgical hand hygiene, and surgical technique. These interventions are presented
separately. (See "Overview of control measures for prevention of surgical site infection in adults", section on
'Hair removal'.)

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THROMBOPROPHYLAXIS — The risk of venous thromboembolism (VTE, ie, deep vein thrombosis [DVT] or
pulmonary embolism) is significantly increased during and after surgery. Surgery and other risk factors
associated with higher rates of thrombosis are listed in the table (table 7). (See "Overview of the causes of
venous thrombosis".)

Thromboprophylaxis reduces the incidence of symptomatic DVT or pulmonary embolism. Decisions


regarding the method, dose, and timing of prophylaxis depend upon balancing a patient's risk thrombosis
versus perioperative bleeding.

The use of thromboprophylaxis for patients undergoing surgery can be found separately. Issues particular to
gynecologic surgery are discussed here. (See "Prevention of venous thromboembolic disease in surgical
patients".)

The most highly regarded guidelines regarding perioperative thromboprophylaxis are published by the
American College of Chest Physicians (ACCP) [33]. Based on the ACCP guidelines, surgical patients are
classified into risk categories (table 8). Use of thromboprophylaxis is then guided by the risk category. (See
"Prevention of venous thromboembolic disease in surgical patients", section on 'Surgical risk groups'.)

Issues in gynecologic surgery patients that may increase the risk of thromboembolism include pregnancy, use
of hormonal contraceptives or postmenopausal hormone therapy, and gynecologic malignancy [34]. These
factors are included in the risk classification.

The ACCP guidelines differ somewhat from the guidelines from the American College of Obstetricians and
Gynecologists (ACOG) [35]. Both guidelines define a minor procedure as lasting less than 30 minutes,
however, the ACCP differentiates between open and laparoscopic surgery, effectively classifying all entirely
laparoscopic procedures as minor (regardless of duration or complexity). The ACOG guidelines divide
patients into risk categories according to duration of surgery, age cut-offs (<40 years, 40 to 60 years, and >60
years), and individual VTE risk factors that are either not evidence-based or are based on data which are 25
or more years old [33].

Regarding laparoscopic surgery, some of the considerations are that abdominal wall tissue trauma is
decreased with a laparoscopic approach, but activation of the coagulation system is similar to laparotomy. In
addition, laparoscopic procedures may be as long or longer than open surgeries, and the use of
pneumoperitoneum and reverse Trendelenburg contribute to venous stasis and, possibly, thrombosis.
However, patients regain mobility more rapidly after laparoscopy compared with laparotomy.

There are no high-quality studies which have addressed the question of thromboprophylaxis for gynecologic
laparoscopy. In a retrospective study of over 10,000 women after hysterectomy, the rate of women who
received thromboprophylaxis varied somewhat for those undergoing a laparoscopic, abdominal, or vaginal
procedure (22, 38, or 47 percent, respectively); the incidence of VTE for the three procedures did not differ
significantly (0.3, 0.2 or 0.2 percent) [36]. Another retrospective review of over 800 patients who underwent
gynecologic laparoscopy for benign or malignant indications reported that the rate of VTE increased with
increasing complexity of the procedure: low (diagnostic laparoscopy; no VTE events); intermediate (ovarian
cystectomy, salpingo-oophorectomy, tubal ligation, hysterectomy; 0.5 percent); and high (radical
hysterectomy, lymphadenectomy, splenectomy, small bowel/colon resection; 2.8 percent) [37]. Interestingly,
malignancy was not significantly associated with an increased risk of VTE, but this was likely because there
were only six VTE events. Further study is needed.

The management of women already on anticoagulants for coexistent conditions is reviewed separately. (See
"Perioperative management of patients receiving anticoagulants" and "Complications of abdominal surgical
incisions", section on 'Morbid obesity'.)

MEASURES FOR SELECTED USE OR THAT ARE NO LONGER RECOMMENDED

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Stress dose glucocorticoids — Use of stress doses of glucocorticoids has become a common
perioperative practice for patients on glucocorticoid therapy. However, use of “stress dose” glucocorticoids is
not necessary for all patients with recent glucocorticoid use. The current approach is to determine
glucocorticoid coverage based upon the patient’s history of glucocorticoid intake, as well as the type and
duration of surgery. (See "The management of the surgical patient taking glucocorticoids".)

Bowel preparation — Bowel preparation is no longer standard practice prior to gynecologic surgery [38].
Bowel preparation may be performed prior to procedures with the potential for injury to the bowel (eg,
patients with advanced endometriosis, staging for gynecologic malignancies).

Endocarditis prophylaxis — The American Heart Association (AHA) guidelines do not classify any
gynecologic procedures as high risk for resulting in infective endocarditis and therefore do not recommend
routine use of antibiotic prophylaxis, even in patients with the highest risk cardiac conditions. (See
"Antimicrobial prophylaxis for bacterial endocarditis", section on 'Clinical approach'.)

SPECIAL ISSUES

Suspected malignancy — If gynecologic malignancy is suspected, the surgery should be performed by a


surgeon with experience with surgical staging, typically a gynecologic oncologist. (See "Management of an
adnexal mass", section on 'Referral to a specialist' and "Abdominal hysterectomy", section on 'Malignancy'.)

Older adults — The number of women over the age of 65 years will grow from 32 million in 1990 to 40
million in 2010 and 75 million in 2050 [39]. Consequently, the gynecologic surgeon must develop competency
dealing with geriatric surgical patients. In the United States, a 75-year-old female can expect an additional
12.4 years of life [40]. During most of these years, the women will be functional and independent [41].

Age alone is not a contraindication to surgery. Decisions on operability should be based upon health status
and discussion of treatment options with the patient; family members or other caregivers should be involved if
they participate in the care of the patient [42,43]. Appropriate preoperative medical consultations should be
obtained to address medical comorbidities. (See 'Medical comorbidities' above.)

The evaluation of the status of the older adults and management of anesthesia and hospital care in this
patient population are discussed in detail separately. (See "Comprehensive geriatric assessment" and
"Anesthesia for the older adult" and "Hospital management of older adults".)

Obesity — In addition to routine planning, preoperative preparation of obese women (defined as body mass
index [BMI] of 30 or greater) includes evaluation by history and physical examination for comorbidities that
may increase the risk of perioperative complications (eg, diabetes, hypertension, obstructive sleep apnea,
cardiac disease) and relevant surgical planning (eg, choice of incision, special equipment needs) [44].
Women are counseled that the risk of surgical site infections [45], wound complications [46], and venous
thromboembolism [47] increases as BMI rises. There are no specific preoperative ancillary tests
recommended for the obese patient [44].

Preoperative consultation with an anesthesiologist is requested for patients with obstructive sleep apnea,
cardiac disease, or a difficult airway [44]. Management of anesthesia in obese patients is discussed in detail
separately. (See "Anesthesia for the obese patient".)

Perioperative considerations specific to obese patients include preventing venous thromboembolism, dosing
of prophylactic antibiotics, positioning the patient on the operating table, and facilitating surgical access.
Obese women are considered to have baseline moderate risk for venous thromboembolism and should
receive prophylaxis, unless contraindicated by risk of bleeding [44]. Prophylactic measures are typically
continued postoperatively until the woman is fully ambulatory. (See "Prevention of venous thromboembolic
disease in surgical patients", section on 'Surgical risk groups'.)

Routine prophylactic antibiotic dosing recommendations may not result in adequate tissue levels in obese
patients [48]. Prophylactic cefazolin is given at doses of 2 g intravenously for patients weighing more than 80
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kg and 3 g intravenously for patients who weigh more than 120 kg [49] (see "Antimicrobial prophylaxis for
prevention of surgical site infection in adults", section on 'Antibiotic administration').

Surgical positioning faces the dual challenges of providing surgical access and protecting the patient from
injury [44]. The operating table needs to accommodate the size and weight of the patient and provide secure
belts or pads to prevent patient movement during the surgery, particularly if the patient is to be placed in
Trendelenburg or reverse Trendelenburg positions. The stirrup must accommodate the patient’s weight and
avoid pressure that could lead to nerve injury. In addition, tucking the patient’s arms parallel to, rather than
perpendicular to the operating table, may improve access to the patient. (See "Patient positioning for surgery
and anesthesia in adults".)

Obese patients may have a very large panniculus which can limit the surgeon’s ability to get to the operative
site. Panniculectomy has the advantage of removing the panniculus from the operative field, which may allow
use of standard sized instruments and retractors, and facilitate the entire operation. However,
panniculectomy is associated with a significant blood loss within the tissue being removed, usually requires
placing closed suction drains at the conclusion of the procedure, may require removing or moving the
umbilicus, and can be associated with very long postoperative healing. (See "Complications of abdominal
surgical incisions", section on 'Morbid obesity'.)

Orthopedic issues or physical disabilities — Women planning gynecologic surgery should be asked about
orthopedic issues (eg, chronic back pain, recent hip or knee surgery) that may affect positioning during
surgery. Appropriate positioning to avoid neural injury is discussed separately. (See "Nerve injury associated
with pelvic surgery".)

Women with physical disabilities may require perioperative accommodations, including alternative positions
or equipment. In addition, limited mobility is a risk factor for thromboembolism. Planning for surgery should
include discussions with the patient, her caregivers and operating room personnel with experience with the
logistics and regulations regarding these issues. Consultation regarding thromboprophylaxis should be
obtained, if necessary. (See 'Thromboprophylaxis' above.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”
and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)

● Basics topic (see "Patient education: Questions to ask if you are having surgery or a procedure (The
Basics)")

SUMMARY AND RECOMMENDATIONS

● The preoperative evaluation and preparation for gynecologic surgery addresses issues that will
potentially affect the woman during her surgical procedure and recovery. (See 'Introduction' above.)

● The informed consent process should include comprehensive counseling of the patient regarding
alternative treatment options (including expectant management) and risks and benefits of the procedure.
Patient expectations and goals and the expected duration and requirements of the recovery period
should also be reviewed. (See 'Informed consent and patient expectations' above.)

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● The preoperative evaluation should include a medical and surgical history, medications, and allergies, as
well as a detailed history regarding the indication for the procedure and risk factors for surgical or
anesthetic complications. A focused physical examination should be performed. (See 'History' above and
'Physical examination' above.)

● Medical consultation should be obtained for patients with medical comorbidities and regarding
perioperative management of medications. (See 'Medical comorbidities' above and 'Medication
management' above.)

● Pregnancy testing should be performed prior to gynecologic surgery in all women of reproductive age.

● Preoperative screening for genital tract infections is generally not necessary. The exception to this is
bacterial vaginosis; women with symptoms or pelvic examination findings consistent with bacterial
vaginosis should be evaluated and treated prior to hysterectomy. (See 'Testing for genital tract infection'
above.)

● Use of “stress dose” glucocorticoids is not necessary for all patients with recent glucocorticoid use. The
current approach is to determine glucocorticoid coverage based upon the patient’s history of
glucocorticoid intake, as well as the type and duration of surgery. (See 'Stress dose glucocorticoids'
above.)

● Bowel preparation is not required prior to gynecologic surgery. (See 'Bowel preparation' above.)

● Antibiotics should be given prior to gynecologic procedures to prevent surgical site infection if the
reproductive tract is entered (eg, hysterectomy) or there is likely to be contamination of the peritoneal
cavity from the vagina (eg, surgical abortion, hysterosalpingogram in patients with risk factors for
infection) (table 6).

● We suggest sterile preparation of the vagina if a procedure includes a vaginal incision or transvaginal
use of instruments (Grade 2C). (See 'Vaginal preparation' above.)

● Use of thromboprophylaxis is guided by the risk category based on characteristics of the patient and
procedure (table 8). (See 'Thromboprophylaxis' above.)

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REFERENCES

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3. Ramm O, Gleason JL, Segal S, et al. Utility of preoperative endometrial assessment in asymptomatic
women undergoing hysterectomy for pelvic floor dysfunction. Int Urogynecol J 2012; 23:913.
4. Jacobs VR, Morrison JE Jr, Paepke S, Kiechle M. Body piercing affecting laparoscopy: perioperative
precautions. J Am Assoc Gynecol Laparosc 2004; 11:537.
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6. Rosenberg AD, Young M, Bernstein RL, Albert DB. Tongue rings: just say no. Anesthesiology 1998;
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7. Muensterer OJ. Temporary removal of navel piercing jewelry for surgery and imaging studies. Pediatrics
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8. van der Slegt J, van der Laan L, Veen EJ, et al. Implementation of a bundle of care to reduce surgical
site infections in patients undergoing vascular surgery. PLoS One 2013; 8:e71566.
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9. Waits SA, Fritze D, Banerjee M, et al. Developing an argument for bundled interventions to reduce
surgical site infection in colorectal surgery. Surgery 2014; 155:602.
10. Cima R, Dankbar E, Lovely J, et al. Colorectal surgery surgical site infection reduction program: a
national surgical quality improvement program--driven multidisciplinary single-institution experience. J
Am Coll Surg 2013; 216:23.
11. Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections
After Major Gynecologic Surgery. Obstet Gynecol 2017; 129:50.
12. Johnson MP, Kim SJ, Langstraat CL, et al. Using Bundled Interventions to Reduce Surgical Site
Infection After Major Gynecologic Cancer Surgery. Obstet Gynecol 2016; 127:1135.
13. ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin No. 104: antibiotic
prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180. Reaffirmed 2016.
14. Uppal S, Harris J, Al-Niaimi A, et al. Prophylactic Antibiotic Choice and Risk of Surgical Site Infection
After Hysterectomy. Obstet Gynecol 2016; 127:321.
15. Till SR, Morgan DM, Bazzi AA, et al. Reducing surgical site infections after hysterectomy: metronidazole
plus cefazolin compared with cephalosporin alone. Am J Obstet Gynecol 2017.
16. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention
Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152:784.
17. Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-
Site Antisepsis. N Engl J Med 2010; 362:18.
18. Dumville JC, McFarlane E, Edwards P, et al. Preoperative skin antiseptics for preventing surgical wound
infections after clean surgery. Cochrane Database Syst Rev 2015; :CD003949.
19. Tuuli MG, Liu J, Stout MJ, et al. A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean
Delivery. N Engl J Med 2016; 374:647.
20. Uppal S, Bazzi A, Reynolds RK, et al. Chlorhexidine-Alcohol Compared With Povidone-Iodine for
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21. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site
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23. 4% chlorhexidine gluconate skin cleansing kit. US Food and Drug Administration (FDA) approved produ
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25. Culligan PJ, Kubik K, Murphy M, et al. A randomized trial that compared povidone iodine and
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28. Gaillard P, Mwanyumba F, Verhofstede C, et al. Vaginal lavage with chlorhexidine during labour to
reduce mother-to-child HIV transmission: clinical trial in Mombasa, Kenya. AIDS 2001; 15:389.
29. Saleem S, Rouse DJ, McClure EM, et al. Chlorhexidine vaginal and infant wipes to reduce perinatal
mortality and morbidity: a randomized controlled trial. Obstet Gynecol 2010; 115:1225.

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30. Monif GR, Thompson JL, Stephens HD, Baer H. Quantitative and qualitative effects of povidone-iodine
liquid and gel on the aerobic and anaerobic flora of the female genital tract. Am J Obstet Gynecol 1980;
137:432.
31. Eason E, Wells G, Garber G, et al. Antisepsis for abdominal hysterectomy: a randomised controlled trial
of povidone-iodine gel. BJOG 2004; 111:695.
32. Buppasiri P, Chongsomchai C, Wongproamas N, et al. Effectiveness of vaginal douching on febrile and
infectious morbidities after total abdominal hysterectomy: a multicenter randomized controlled trial. J
Med Assoc Thai 2004; 87:16.
33. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e227S.
34. Clarke-Pearson DL, Abaid LN. Prevention of venous thromboembolic events after gynecologic surgery.
Obstet Gynecol 2012; 119:155.
35. Committee on Practice Bulletins--Gynecology, American College of Obstetricians and Gynecologists.
ACOG Practice Bulletin No. 84: Prevention of deep vein thrombosis and pulmonary embolism. Obstet
Gynecol 2007; 110:429.
36. Mäkinen J, Johansson J, Tomás C, et al. Morbidity of 10 110 hysterectomies by type of approach. Hum
Reprod 2001; 16:1473.
37. Nick AM, Schmeler KM, Frumovitz MM, et al. Risk of thromboembolic disease in patients undergoing
laparoscopic gynecologic surgery. Obstet Gynecol 2010; 116:956.
38. Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. Am J Obstet Gynecol
2011; 205:309.
39. Markus GR. The graying of America: major Social Security and Medicare battles are just beginning. Bull
Am Coll Surg 1997; 82:25.
40. National Center for Health Statistics. www.cdc.gov/nchs/data/hus/tables/2003/03hus027.pdf. (Accessed
on March 08, 2005).
41. Guralnik JM, Land KC, Blazer D, et al. Educational status and active life expectancy among older
blacks and whites. N Engl J Med 1993; 329:110.
42. Lubin MF. Is age a risk factor for surgery? Med Clin North Am 1993; 77:327.
43. Parker DY, Burke JJ 2nd, Gallup DG. Gynecological surgery in octogenarians and nonagenarians. Am J
Obstet Gynecol 2004; 190:1401.
44. Committee on Gynecologic Practice. Committee opinion no. 619: Gynecologic surgery in the obese
woman. Obstet Gynecol 2015; 125:274. Reaffirmed 2017.
45. Olsen MA, Higham-Kessler J, Yokoe DS, et al. Developing a risk stratification model for surgical site
infection after abdominal hysterectomy. Infect Control Hosp Epidemiol 2009; 30:1077.
46. Nugent EK, Hoff JT, Gao F, et al. Wound complications after gynecologic cancer surgery. Gynecol Oncol
2011; 121:347.
47. Parkin L, Sweetland S, Balkwill A, et al. Body mass index, surgery, and risk of venous
thromboembolism in middle-aged women: a cohort study. Circulation 2012; 125:1897.
48. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of
prophylactic cefazolin during cesarean delivery. Obstet Gynecol 2011; 117:877.
49. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195.

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GRAPHICS

Preoperative medical evaluation questions for a healthy patient

Questions
1. Do you usually get chest pain or breathlessness when you climb up two flights of stairs at normal speed?

2. Do you have kidney disease?

3. Has anyone in your family (blood relatives) had a problem following an anaesthetic?

4. Have you ever had a heart attack?

5. Have you ever been diagnosed with an irregular heartbeat?

6. Have you ever had a stroke?

7. If you have been put to sleep for an operation were there any anaesthetic problems?

8. Do you suffer from epilepsy or seizures?

9. Do you have any problems with pain, stiffness or arthritis in your neck or jaw?

10. Do you have thyroid disease?

11. Do you suffer from angina?

12. Do you have liver disease?

13. Have you ever been diagnosed with heart failure?

14. Do you suffer from asthma?

15. Do you have diabetes that requires insulin?

16. Do you have diabetes that requires tablets only?

17. Do you suffer from bronchitis?

Data from: Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S. Validation of a pre-anaesthetic screening questionnaire.
Anaesthesia 2003; 58:874.

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Excluding pregnancy

The provider can be reasonably certain that the woman is not pregnant if she has no symptoms or signs
of pregnancy and meets any of the following criteria:

1. She has not had intercourse since her last normal menses.
2. She has been correctly and consistently using a reliable method of contraception.
3. She is within the first seven days after normal menses.
4. She is within four weeks postpartum (for nonlactating women).
5. She is within the first seven days post-abortion or miscarriage.
6. She is fully or nearly fully breastfeeding, amenorrhoeic, and less than six months postpartum.

A systematic review of studies evaluating the performance of a pregnancy checklist compared with urine
pregnancy test to rule out pregnancy concluded the negative predictive value of a checklist similar to the one
above was 99 to 100 percent.

Data from:

Tepper NK, Marchbanks PA, Curtis KM. Use of a checklist to rule out pregnancy: A systematic review. Contraception
2013; 87:661.
Curtis KM, Tepper NK, Jatlaoui TC, et al. United States Medical Eligibility Criteria for Contraceptive Use,
2016. MMWR Recomm Rep 2016; 65:1.

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JCAHO protocol for surgical timeout

1. Perform a preoperative verification process (ideally with the patient awake, aware
and involved)
Ensure that all relevant documents and studies are available prior to the start of the procedure. Identify the patient
with at least two patient identifiers (eg, name, number, telephone number).

Ensure that this information has been reviewed and is internally consistent as well as consistent with the patient's
expectations and with the surgical team's understanding of the intended patient, procedure, site and, as applicable,
any implants.

Missing information or discrepancies must be addressed before starting surgery.

2. Mark the operative site to unambiguously identify the intended procedure site
For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in
spinal procedures), the intended site must be marked. Ideally the surgeon in charge will mark the site. A procedure
must be defined for patients who refuse site marking.

The mark must be unambiguous (eg, use initials or "YES" or a line representing the planned incision; "X" may be
ambiguous). The mark must be visible after the patient has been prepped and draped (eg, use a permanent
marker). Nonoperative sites should not be marked.

3. The entire operating team takes a "time out" immediately before starting the
procedure to conduct a final verification of the correct patient, procedure, site and, as
applicable, implants.
The procedure is not started until any questions or concerns are resolved and all members of the surgical/procedure
team are in agreement. Identify the patient with at least two patient identifiers.

Adapted from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) at www.jcaho.org/index.htm.

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WASHING mnemonic for perioperative risk factors for surgical site infection
following gynecologic surgery

W Weight

A Antibiotic-resistant skin flora, methicillin-resistant Staphylococcus aureus

S Smoking cessation

H Hygiene (skin preparation)

I Immune deficiency status

N Nutritional status

G Glycemic control

Mnemonic to aid in identifying patient risk factors for surgical site infection.

From: Pellegrini JE, Toledo P, Soper DE, et al. Consensus bundle on prevention of surgical site infections after major
gynecologic surgery. Obstet Gynecol 2017; 129(1):50-61. DOI: 10.1097/AOG.0000000000001751. Copyright © 2017
American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott Williams & Wilkins.
Unauthorized reproduction of this material is prohibited.

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Data collection for surgical site infection risk review

Patient-level risk factors

Obesity
Diabetes mellitus
Smoking status
Steroid use
Nutritional status
American Society of Anesthesiologists Physical Status

Health care provider-level risk factors

Adherence with hand-washing and use of proper surgical attire

Surgical risk factors

Preoperative skin antisepsis


Preoperative hair removal
Operating room temperature
Type of surgery
Duration of surgery
Insertion of foreign material
Appropriate redosing of antibiotics (eg, owing to prolonged duration of surgery, excessive blood loss)

From: Pellegrini JE, Toledo P, Soper DE, et al. Consensus bundle on prevention of surgical site infections after major
gynecologic surgery. Obstet Gynecol 2017; 129(1):50-61. DOI: 10.1097/AOG.0000000000001751. Copyright © 2017
American College of Obstetricians and Gynecologists. Reproduced with permission from Lippincott Williams & Wilkins.
Unauthorized reproduction of this material is prohibited.

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Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*

Preferred Alternative
Procedure Dose Dose
regimen ¶ regimens Δ

Hysterectomy Cefazolin, cefoxitin Cefazolin: Regimen:


(abdominal, vaginal, or cefotetan <120 kg: 2 g IV Ampicillin- 3 g IV
laparoscopic, or
≥120 kg: 3 g IV sulbactam
robotic)
Regimen:
Urogynecology
Cefoxitin or
procedures including Clindamycin OR 900 mg IV ◊
cefotetan:
those involving mesh
Vancomycin ¶ 15 mg/kg IV (not to
2 g IV
exceed 2 g per dose)

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if


overweight or obese,
based on dosing
weight) §

Aztreonam OR 2 g IV

Fluoroquinolone ¶ ¥

Regimen:

Metronidazole 500 mg IV

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if


overweight or obese,
based on dosing
weight) §

Fluoroquinolone ¶ ¥

Cesarean section Cefazolin <120 kg: 2 g IV Regimen:


≥120 kg: 3 g IV Ampicillin- 3 g IV
sulbactam

Regimen:

Clindamycin OR 900 mg IV ◊

Vancomycin ¶ 15 mg/kg IV (not to


exceed 2 g per dose)

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if


overweight or obese,
based on dosing
weight) §

Aztreonam 2 g IV

Regimen:

Metronidazole 500 mg IV
PLUS

Gentamicin 5 mg/kg IV (if


overweight or obese,
based on dosing
weight) §

Abortion, surgical Doxycycline 100 mg orally one Metronidazole 500 mg orally twice
hour before daily for five days
procedure and 200
mg orally after Azithromycin 1 g orally one hour
procedure before procedure

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Hysterosalpingogram Doxycycline ‡ 100 mg orally twice
or chromotubation daily for five days

Laparoscopy None
(diagnostic, tubal
sterilization,
operative except for
hysterectomy)
Other transcervical
procedures:
Hysteroscopy
(diagnostic or
operative,
including
hysteroscopic
sterilization)
Intrauterine device
insertion
Endometrial biopsy

IV: intravenous.
* Common pathogens: Enteric gram-negative bacilli, anaerobes, group B Streptococcus, enterococci.
¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If
vancomycin or a fluoroquinolone is used, the infusion should be given over 60 to 90 minutes and started within 60 to 120
minutes before the initial incision.
Δ An alternative regimen should be used in women with history of immediate hypersensitivity to beta-lactam agents. Due
to increasing resistance of Escherichia coli to ampicillin-sulbactam and fluoroquinolones, local sensitivity profiles should be
reviewed prior to use.
◊ When clindamycin prophylaxis is warranted, UpToDate authors prefer a single dose of 900 mg based upon
pharmacokinetic considerations according to 2013 IDSA/ASHP surgical antibiotic prophylaxis guidelines. [1] However, a
600 mg dose consistent with ACOG guidance may be sufficient. [2,3]
§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Based on
evidence from colorectal procedures, a single dose of approximately 5 mg/kg gentamicin appears more effective for the
prevention of surgical site infection than multiple doses of gentamicin 1.5 mg/kg every eight hours [4] and data on fetal
and newborn safety of a maternal 5 mg/kg dose are reassuring. [5] However, a lower dose of 1.5 mg/kg, consistent with
ACOG guidance, may be adequate. [2,3] For overweight and obese patients (ie, actual weight is >125% of ideal body
weight), a dosing weight should be used. A calculator to determine ideal body weight and dosing weight is available in
UpToDate.
¥ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones are contraindicated in
pregnancy and in women who are breastfeeding.
‡ Prophylaxis is warranted for patients with history of pelvic inflammatory disease or if the procedure demonstrates
dilated fallopian tubes. No prophylaxis is indicated for patients without dilated tubes.

References:
1. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
2. ACOG practice bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009;
113:1180.
3. ACOG practice bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol
2011;117:1472.
4. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind study of single
high dose versus multiple standard dose gentamicin both in combination with metronidazole for colorectal surgical
prophylaxis. J Hosp Infect 2000; 46:135.
5. Locksmith GJ, Chin A, Vu T, Shattuck KE, et al. High compared with standard gentamicin dosing for
chorioamnionitis: a comparison of maternal and fetal serum drug levels. Obstet Gynecol 2005; 105:473.
Adapted from: Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.

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Risk factors (causes) for the development of venous thrombosis

Inherited thrombophilia
Factor V Leiden mutation

Prothrombin G20210A mutation

Protein S deficiency

Protein C deficiency

Antithrombin (AT) deficiency

Other disorders and risk factors


Malignancy

Presence of a central venous catheter

Surgery, especially orthopedic

Trauma

Pregnancy

Oral contraceptives

Hormone replacement therapy

Certain cancer therapies (eg, tamoxifen, thalidomide, lenalidomide)

Immobilization

Heart failure

Congenital heart disease

Antiphospholipid syndrome

Myeloproliferative neoplasms
Polycythemia vera
Essential thrombocythemia

Paroxysmal nocturnal hemoglobinuria

Inflammatory bowel disease

Nephrotic syndrome

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Modified Caprini risk assessment model for VTE in general surgical patients

Risk score

1 point 2 points 3 points 5 points

Age 41 to 60 years Age 61 to 74 years Age ≥75 years Stroke (<1 month)

Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty

BMI >25 kg/m 2 Major open surgery (>45 Family history of VTE Hip, pelvis, or leg fracture
minutes)

Swollen legs Laparoscopic surgery (>45 Factor V Leiden Acute spinal cord injury
minutes) (<1 month)

Varicose veins Malignancy Prothrombin 20210A

Pregnancy or postpartum Confined to bed (>72 Lupus anticoagulant


hours)

History of unexplained or Immobilizing plaster cast Anticardiolipin antibodies


recurrent spontaneous
abortion

Oral contraceptives or Central venous access Elevated serum


hormone replacement homocysteine

Sepsis (<1 month) Heparin-induced


thrombocytopenia

Serious lung disease, Other congenital or


including pneumonia (<1 acquired thrombophilia
month)

Abnormal pulmonary
function

Acute myocardial infarction

Congestive heart failure


(<1 month)

History of inflammatory
bowel disease

Medical patient at bed rest

Interpretation

Estimated VTE risk in


the absence of
Surgical risk category* Score pharmacologic or
mechanical prophylaxis
(percent)

Very low (see text for 0 <0.5


definition)

Low 1 to 2 1.5

Moderate 3 to 4 3.0

High ≥5 6.0

VTE: venous thromboembolism; BMI: body mass index.


* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and reconstructive surgery. See
text for other types of surgery (eg, cancer surgery).

From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy
and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical guidelines.
Chest 2012; 141:e227S. Copyright © 2012. Reproduced with permission from the American College of Chest Physicians.

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Contributor Disclosures
William J Mann, Jr, MD Nothing to disclose Tommaso Falcone, MD, FRCSC, FACOG Nothing to
disclose Kristen Eckler, MD, FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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