12th EVALUATION
TOPICS:
● Pre-op and Post-op Counseling and Management (Dr. Crisostomo)
● Hyperandrogenism (Dr. Dichoso)
● Infertility (Dr. Dichoso)
● Primary & Secondary Amenorrhea/ Precocious Puberty/ Hypeprolactenemia (Dr. Dichoso)
QUESTIONS
PRE-OP AND POST-OP COUNSELING AND MANAGEMENT (Dr. Crisostomo)
1. A 48 year old patient came because she was diagnosed
of myoma uteri and was advised surgery by another
gynecologist. The patient wants you to perform the surgery.
What is the next best thing for you to do?
A. Do your own history taking and physical examination
B. Schedule the patient for operation
C. Call her former doctor to confirm her findings on the
patient
D. Refer her back to the first doctor who saw her
2. A 70 year old patient with ovarian cyst has to undergo
surgery. She has no previous hospitalization nor surgery.
There is family history of hypertension and diabetes mellitus.
An ECG is requested preoperatively because:
A. She is 70 years old.
B. She has no previous hospitalization that will rule out
a heart disease.
C. All patients for surgery require an ECG.
D. She has family history of hypertension and diabetes.
3. A diabetic, obese, asthmatic patient on steroid medication
underwent a total abdominal hysterectomy for endometriotic
ovarian cyst. She is at high risk to develop pelvic cellulitis
with later abscess formation because of:
A. Extensive pelvic dissection
B. Diabetes mellitus
C. Use of immunosuppressive drug
D. All of the choices
RATIONALIZATION
ANSWER: A
You do your own history and PE to know about current
medications, allergies, previous surgeries, the disease
course or any complications already present, that may
affect the needed surgery. Elicit past medical history, family
history, nutritional assessment. With the PE, there are 3
questions that should be answered when it comes to
surgeries, (1) has the primary gynecologic disease process
changed since the initial diagnosis?, (2) what is the effect of
the primary gynecologic disease on other organ systems?,
and (3) what deficiencies in the other organ system may
affect the proposed surgery and hospitalization?.
ANSWER: A
There are routine screening tests to be done for patients >
40 years old.
● CBC, blood typing
● Urinalysis
● Chest x-ray
○ if with findings
○ smokers
○ cardiac or pulmonary symptoms
○ >70 years old
● ECG
○ history of smoking, diabetes or renal
disease
ANSWER: D
Pelvic cellulitis and abscess
● Infections of the contiguous retroperitoneal space
immediately above the vaginal apex are common
complications following abdominal or vaginal
hysterectomy.
● These soft tissue infections range in severity from
localized minor cellulitis to large pelvic abscesses
and have many names, from cuff cellulitis to
infected hematoma.

4. A patient with cardiovascular disease who is about to
undergo a major gynecologic procedure should:
A. Discontinue all her anti-hypertensive medications
B. Postpone the operation at least six weeks between
recent MI and elective surgery
C. Be evaluated if there is a need for intra-operative
cardiac monitoring
D. All of the choices are correct
5. A preoperative patient for an elective procedure is found
to be hyperglycemic. What will be the most appropriate step
to do?
A. Postpone the surgery and refer patient to an
endocrinologist.
B. Perform the surgery 6-8 hours after placing the
patient on NPO (nothing per orem) when the blood
glucose is expected to decrease.
C. Give insulin and perform the surgery after an hour.
D. Repeat blood determination once patient is less
anxious.
6. After the total abdominal hysterectomy with bilateral
salphingooophorectomy with extensive adhesiolysis, the
patient complaint of continuous vaginal drainage of
serosanguinous fluid, abdominal, back and flank pains.
● Pathophysio: The classic “clamp, crush, cut, and
tie technique” used in pelvic surgery produces an
abundance of hypoxic and anoxic tissue that helps
establish an optimal environment for infection. In
addition to this anoxic tissue, the retroperitoneal
tissue produces an average of 40 mL of
serosanguineous fluid daily during the first 72
postoperative hours. When the endogenous flora of
the upper vagina colonize and multiply in this
retroperitoneal serosanguineous fluid or pelvic
hematoma, a pelvic cellulitis and possibly a pelvic
abscess can form.
Extensive pelvic dissection is due to the surgery done to
the patient. If diabetes is not properly treated or controlled,
the immune system can be weaker, and can lead to
infections.
Risk factors for cellulitis include diabetes mellitus,
lymphedema, venous stasis or insufficiency, immune
suppression, injection drug use, malnutrition, peripheral
vascular disease, and previous skin diseases.
ANSWER: C
For patients with cardiovascular diseases in need of
surgery
● Postpone the surgery for 6 months from the time
the patient had MI - the patient will be stable
enough for the surgery
● Evaluated for the need for intraoperative cardiac
monitoring
● Control of hypertension preoperatively
● Use of prophylactic antibiotic
ANSWER: A
In cases of hyperglycemia on a preoperative patient, there
is inceased risk for surgical site infection (SSI), myocardial
infarction, stroke, and death. SO it is better to postpone the
surgery and refer to an endocrinologist to control the blood
sugar. When it is controlled, then do surgery.
ANSWER: D
Case points:
● TAHBSO
Postoperative complication that should be highly considered ● With extensive adhesiolysis
on this patient is: ● Continuous vaginal drainage of serosanguinous
fluid
A. Ureterolithiasis ● Abdominal, back and flank pains
B. Urinary tract infection
C. Colonic perforation Serosanguinous fluid: there is a wound draining serum and
D. Vesicovaginal fistula blood cells. It’s draining into the vagina.

Vesicovaginal Fistula
● Allows the continuous involuntary discharge of
urine into the vaginal

7. All of the following risk factors predispose a patient to ANSWER: C

develop urinary tract infection after a gynecologic surgery,
EXCEPT: Urinary tract infection
● Most common infection
A. Ureteral injury or obstruction ● Risk factors:
B. Prolonged use of indwelling catheter ○ prolonged use of indwelling catheter
C. Prolonged NPO (nothing per orem) after surgery ○ pre-existing UTI
D. Preexisting UTI ○ ureteral injury or obstruction
○ older age
○ diabetes mellitus

8. At the recovery room, the patient who underwent surgery ANSWER: C

suddenly developed tachycardia, hypotension, decrease in
urine output and pallor. Primary consideration will be: Post-operative Hemorrhage
● usually occur during the FIRST 48 HOURS
A. Thrombophlebitis ● significant arterial bleeding in the first 24 hours
B. Ureteral resection often require reoperation (usually vascular pedicle
C. Post-operative hemorrhage becoming freed from its ligature)
D. Abdominal dehiscence ● could be intraperitoneal, retroperitoneal, vaginal
bleeding
● SIGNS AND SYMPTOMS
○ tachycardia
○ hypotension
○ decrease urine output
● LOW URINE OUTPUT
○ EARLIEST SIGN of decreased
intravascular volume (N = 0.5 mL/kg/hr)

9. Bacterial pneumonia can be prevented after a major ANSWER: B. EARLY AMBULATION

gynecologic surgery by:
BACTERIAL PNEUMONIA
A. Early intubation RISK FACTORS
B. Early ambulation ● prolonged atelectasis
C. Placing the patient on NPO (nothing per orem) ● pre-existing COPD
immediately post operatively ● debilitating illness
D. Using a mechanical ventilator ● neurologic diseases causing inability to clean
oropharyngeal secretions
● use of nasogastric suction
● mechanical ventilation
● tracheal intubation
SIGNS AND SYMPTOMS
● high fever
● cough
 ● dyspnea
● tachypnea
● purulent sputum
● back/chest pain
PHYSICAL EXAMINATION
● coarse rales over infected area
LABORATORY WORKUPS
● chest x-ray
● leukocytosis on CBC
● Gram staining/C & S of sputum
MANAGEMENT
● Antibiotics

If you intubate or put in a ventilator, these increases the risk

for bacterial infection.

10. Febrile morbidity is best defined as temperature greater ANSWER: C

than or equal to:
A. 40oC on 4 occasions excluding the first 24 hours
B. 38oC on 2 occasions during the first 24 hours
C. 38oC on 2 occasions at least 4 hours apart excluding
the first 24 hours
D. 40oC on 4 occasions at least 4 hours apart excluding
the first 24 hours
Post-operative Fever
Febrie morbidity
● temperature ≥38 C on 2 OCCASIONS AT LEAST 4
HOURS APART EXCLUDING the first 24 hours
● fever following the surgery may resolve
spontaneously within the first 24 hours post-op or
herald serious post-op complication
● intraoperative factors that increase the risk of post-
operative fever
○ intraoperative time >2 hours intraoperative
transfusion due to intraoperative blood loss
● need to determine if fever
○ is due to infection or non-infectious cause
○ necessitate active intervention or self-
limiting
○ is SIMPLE or COMMON (dehydration or
microatelectasis) or UNUSAL (malignant
hyperthermia or septicemia)
● INITIAL WORKUP for post-operative fever (5 W’s)
○ WIND – atelectasis
○ WATER – UTI
○ WOUND – infection or hematoma
○ WALK – superficial or deep vein phlebitis
○ WONDER DRUGS – drug-induced fever

11. Immediately after surgery, the patient’s vital signs are ANSWER: B
monitored in the recovery room every:
Post-operative Period
A. 1 minute 1st phase - Perioperative Stabilization (24-48 hours)
B. 15 minutes ● resumption of normal physiologic function of the
C. 1 hour respiratory, cardiovascular and neurologic
D. Nurse’s shift (8 hours) ● recovery from anesthesia and stabilization of
hemostasis with resumption of oral intake
● when we put patient in the recovery room, they will
say monitor vital signs q 15 for the 1st 1 to 2 hours.
Take BP, HR, temp, RR, and UO

12. Post operatively, the patient developed ileus. The next
step to do would be any of the following EXCEPT:
A. Placing patient on NPO
B. Fluid and electrolyte replacement
C. Exploratory laparotomy
D. Insertion of NGT
13. Prior to surgery, patient who is on anti-diabetic and
antihypertensive medications should:
A. Continue all her medications
B. Stop all her previous medications and resume them
after surgery
C. Continue all medications that the patient needs to
take and discontinue temporarily those that may
affect the surgery
D. Continue all her medications but to be given
intravenously because she has to be placed on
NPO.
14. Prophylactic antibiotic was given to the patient prior to
the surgery. Post operatively, the patient developed
infection. The most appropriate management is to:
A. Extend the duration of the administration of the
2nd phase - Post-operative Recovery (1-4 days)
● hospital or at home
● regular diet, ambulation shift from parenteral to oral
meds
● post-operative complications become apparent
3rd phase - Return to Normalcy (1-6 weeks)
● out-patient setting
● increase in strength, back to normal activity
● minor surgery – 2 weeks
● major op – about 6 weeks
ANSWER: C
Ileus
● arrest and disorganized gastrointestinal motility
● refers to an impairment of intestinal motility
ETIOLOGY/RISK FACTORS
● opening of abdominal cavity
● aggressive manipulation of intestinal tract and
prolonged surgical procedure
● infection
● electrolyte imbalance
SIGNS AND SYMPTOMS
● abdominal distention
● belching
● cramping and pain
● decreased bowel sounds
● nausea and vomiting
● could resolve within 2-3 days (relative ileus) or
continue past several days post operation
You have to put the patient on NPO and insert NGT, since
the GIT is dysfunctional, the food cannot pass through the
tract properly. Give fluids and electrolytes to serve as
nutrition.
ANSWER: C
Not all medications should be stopped prior to surgery.
Antihypertensive medications can be continued. There are
a number of oral glycemic control drugs, like Metformin,
that should be discontinued before surgery due to renal
function complications that may arise intraoperatively (such
as hemodynamic instability or decreased renal perfusion),
increasing the risk of lactic acidosis.
ANSWER: C
Antibiotic prophylaxis
● given without evidence of pelvic infection to prevent
postoperative morbidity related to infection
 antibiotic
B. Increase the succeeding doses of the antibiotics
C. Discontinue and change the antibiotic
D. Add another antibiotic
● prevent infection by the endogenous flora of the
reproductive tract coming from the vagina –
coliforms, streptococcus, fusobacteria, bacteroides
● given when the incidence of post op infection is low
but the result of surgery would compromise if
infection would occur
● GUIDELINES
○ procedure could carry a significant risk of
post op infection
○ surgery could involve considerable
bacterial contamination
○ antibiotic should be effective against most
contaminating organism (broad spectrum)
○ antibiotic should be present in tissue at
time of contamination (NOT LATER THAN
3 HOURS)
○ antibiotic should not be considered for
treatment if post op infection occurs
meaning the antibiotic prophylaxis is not
effective so you won’t use it again
○ risk of complication from antibiotic should
be low so consider the renal function of the
patient and also the liver
○ second generation cephalosporins
○ anaerobic drugs (Clindamycin and
Metronidazole)
○ GIVEN NOT >30 MINS OR >1 HOUR
PRIOR to the skin incision

15. The most common cause of late post-operative fever is: ANSWER: B

A. Microatelectasis URINARY TRACT INFECTION

B. Urinary tract infection ● MOST COMMON INFECTION
C. Blood transfusion reaction ● RISK FACTORS
D. Operative wound infection ○ prolonged use of indwelling catheter
○ pre-existing UTI
○ ureteral injury or obstruction
○ older age
○ diabetes mellitus

16. The most common urinary tract injury in a gynecologic ANSWER: B

surgery is:
CYSTOSTOMY
A. Urethrovaginal fistula ● MOST FREQUENT URINARY TRACT INJURY
B. Cystostomy ● more common in patients who just went low CS
C. Ureteral resection and then you have done TAHBSO and dissection,
D. Vesicovaginal fistula if masyadong madikit, you can have this problem.
● DIAGNOSIS – cytogram
● MANAGEMENT
○ repair with absorbable suture and
continuous drainage for 5-6 days post
operation
○ if unrepaired, spillage of urine into
peritoneal cavity
17. The most important factor in the prevention of ANSWER: B
postoperative infection is:
Hydration would not do much. Prophylactic antibiotics is
A. Adequate hydration of patient preoperatively used before the surgery. Frequent change in wound
B. Practice of strict aseptic techniques dressing would actually prevent postoperative infection.
C. Administration of prophylactic antibiotics The best, however, is practice of strict aseptic techniques.
D. Frequent change of wound dressing

18. The patient is placed on NPO (nothing per orem) for 8 ANSWER: D
hours before surgery primarily to prevent:
ASPIRATION PNEUMONIA
A. Fluid overload ● chemical pneumonitis due to aspiration of gastric
B. Post-operative ileus fluid leading to destructive inflammatory response
C. Hyperglycemia leading to adult respiratory distress syndrome
D. Aspiration pneumonia ● RISK FACTORS
○ older women
○ obese
○ hiatal hernia
○ emergency surgery done on patient with
full stomach – hindi na prepare for surgery.
This is also the reason why we put the
patient on NPO prior to surgery
● PREVENTION
○ early removal of nasogastric suction
○ antacid ingestion
○ H2 blockers during perioperative period
○ NPO prior to surgery
● TREATMENT
○ antibiotics
○ ventilator support

19. When the possibility of colonic perforation due to ANSWER: A

extensive pelvic adhesiolysis is anticipated, it is important to:
COLONIC PERFORATION
A. Do bowel preparation ● due to difficult dissection
B. Transfuse blood pre and post operatively ● importance of mechanical bowel preparation
C. Give prophylactic dose of antibiotic a day prior to ● spillage of feces is life threatening
surgery to be repeated after 24 hours if the patient ● MANAGEMENT
developed fever. ○ repair of perforation
D. All of the choices are correct ○ colostomy

20. Which of the following postoperative findings is a cause ANSWER: B

for concern?
POST-OPERATIVE HEMORRHAGE
A. The vital signs are as follows: BP = 110/70 mmHg; ● usually occur during the FIRST 48 HOURS
PR = 85 beats/min; RR = 18 cycles/minute. ● significant arterial bleeding in the first 24 hours
B. The urine output is 10 cc per hour for the last 3 often require reoperation (usually vascular pedicle
hours becoming freed from its ligature)
C. The patient is febrile with temperature of 37.7 C. ● could be intraperitoneal, retroperitoneal, vaginal
D. The patient pushes the oral airway with her tongue. bleeding
● SIGNS AND SYMPTOMS
○ tachycardia
○ hypotension
 ○ decrease urine output
● MANAGEMENT
○ blood transfusion
○ correction of coagulopathies
○ surgical reexploration
○ resuturing of vaginal cuff
● LOW URINE OUTPUT
○ EARLIEST SIGN of decreased
intravascular volume (N = 0.5 mL/kg/hr)
● normal response to stress and tissue destruction is
increased levels of aldosterone, cortisol and
antidiuretic hormone
○ increase sodium and water retention (Ebb
phase) thus decreased hematocrit on first
post op day is misleading
○ hematocrit on 3rd day is more accurate
because of normal diuresis (Flow phase)