Complications (Gynaecology)

Obesity - Fertility and Pregnancy Related Problems

  • Clinical examination and assessment difficult in obese women.

  • Polycystic ovary syndrome worsened by obesity – reduce fertility, increases long-term problems, blood pressure, risk of diabetes and also increased risk to the heart and blood vessels.

  • Reduced fertility due to irregular or infrequent periods and decreased ovulation rates.

  • Reduced response rate to fertility treatments – to drugs and IVF treatment.

  • Obesity makes investigations such as ultrasound CT and MRI scanning difficult.

  • Obesity associated with a significantly increased miscarriage rate.

  • Obesity causes problems to the womb – fatter women have thickened endometrium (lining of the womb).  This leads to conditions like endometrial hyperplasia, which can increase the risk of endometrial (womb) cancer in the long term.  Also increased risk of breast cancer.

  • Laparoscopy is performed to assess the tubes in infertility cases.  This operation can be risky if the BMI is over 30.

  • Pregnancy related problems – increased miscarriage rate, blood pressure problems, diabetes, increased Caesarean sections, thrombosis etc.

Definition

Obesity is a chronic condition characterised by an excess of body fat.  It is most often defined by the body mass index (BMI) a mathematical formula that is highly correlated with body fat.  BMI is weight in kilogram, divided by height in metres squared (kg/m2). In the USA and the UK, people with BMIs between 25-30 kg/m2­ are categorised as overweight and those with BMIs above 30kg/m2­­  are categorised as obese.


Complications of Loop Excision/Cone Biopsy

High Risk

  • Excessive bleeding from cervix – either immediate or delay – may necessitate a blood transfusion and a further operation to stop this.

  • Bleeding from vaginal wall, which will require suturing

  • Infection of cervix or pelvis

  • Incomplete excision of areas with abnormal cells – requiring further colposcopy/treatment in the future.

  • First few periods may be painful

  • May be associated with slight increased risk of miscarriage/premature labour

  • Bleeding and pain after sexual intercourse

Medium Risk

  • Future smears may be reported as ‘inadequate’ causing anxiety


Complications of Hysteroscopy

High Risk

  • Small risk of uterine infection, bleeding and blood transfusion

  • Inadequate view of inside of uterus due to bleeding

  • Risk of pelvic infection

  • Failure to perform hysteroscopy if cervix stenosed (narrow)

Medium Risk

  • Risk of uterine perforation, which can sometimes require hysterectomy if bleeding is exessive.

  • Other uncommon complications

The risk of the above complications are increased in the following: obesity, chronic heart and lung problems, previous abdominal operations

It is important for patients to understand risks in order to compare them with potential benefits of any operation or procedure.  Medicine deals with uncertainty all the time and patients may find this concept difficult to accept .


Complications of Major Gynaecological Operations

High Risk Complications (1 in 100 or higher)

  • Bleeding – may occur early or late.  If excessive this will require blood transfusion.  Sometimes a further anaesthetic and operation may be necessary to stop the bleeding.

  • Bleeding can cause collections of blood (haematomas) in the pelvis and can become infected.

  • Bladder and kidney problems – you may have problems emptying the bladder (retention), bladder infections, incontinence, damage to bladder and ureters (kidney tubes) which can also cause leakage of urine (fistula formation).

  • Adhesions – laparotomies can cause adhesions (stickiness) which in turn can lead to bowel obstruction, colic etc.  A further operation may be required to correct this.

  • Peritonitis – laparotomies can lead to peritonitis (infection in the abdomen) which can make you seriously ill.

  • Wound complications – these include infection, abscess formation, wound breakdown, formation of excessive scar tissue, formation of unsightly scars, pain around the scars, discolouration and hernia formation.  Patients who are overweight (raised BMI) and those who have had previous operations are more at risk.

  • Thrombosis (blood clots) – clots can form in the legs or thigh or pelvis.  These can spread to the lungs which can be life threatening.  Obese patients, cancer patients, smokers and elderly patients are at increased risk.

  • Thrombophlebitis – inflammation of veins can occur.  This is a painful condition.

  • Vaginal discharge and bleeding – this occurs in about 10% of patients and the bleeding can persist for 2-3 weeks.

  • Recurrence of endometriosis – this condition can recur because it is impossible to remove endometriosis totally.

  • Recurrence of adhesions (scar / tissue) – operations are sometimes performed to try and reduce pain due to adhesions. These operations can sometimes lead to more scar tissue being formed, thereby causing more problems in the long term.

  • Pelvic Pain - when a hysterectomy is performed for pelvic pain it may provide only temporary relief for this condition.  The pain can sometimes recur or become worse.

  • Early Menopause – This can happen if ovaries are removed before the menopause.

Low Risk Complications (1 in 1,000 to 1 in 10000)

  • Risks of death  – the risk of death is about 1:2000 – 1:3000.  A hysterectomy should only be undertaken if absolutely necessary.  The risk is increased in the conditions listed below.

Significant risk reduction can be achieved by:

  • Getting fit, taking Iron for anaemia

  • Reducing or stopping smoking

  • Losing weight before the operation

  • Stabilising any medical condition you may have

The risk of having complications is increased significantly in the following:

  • Smokers

  • Obese patients

  • Patients with chronic heart & lung problems, blood pressure, diabetes etc.

  • Previous abdominal or vaginal operations including Caesarean section.

  • Older patients

  • Serious conditions like endometriosis, cancer or recurrent cancer.

  • Patients on multiple medications

  • Patients on anti-coagulants (eg Warfarin) to thin the blood

  • Major operations involving more than one consultant

  • Repeated operations


Anaesthetic Complications

Common side effects and complications (less than 1 in 100)

  • Feeling sick and vomiting after surgery

  • Sore throat

  • Dizziness, blurred vision

  • Shivering

  • Headache

  • Itching

  • Aches, pains and backache

  • Pain during injection of drubs

  • Bruising and soreness

  • Confusion or memory loss

Uncommon side effects and complications (less than 1 in 1000)

  • Chest infection

  • Bladder problems

  • Muscle pains

  • Slow breathing (depressed respiration)

  • Damage to teeth, lips or tongue

  • Awareness

Rare or very rare complications (1 in 10,000 to 1 in 200,000)

  • Damage to the eyes

  • Serious allergy to drugs eg. Malignant hyperthermia

  • Nerve damage

  • Death – 5 deaths occur for every million anaesthetics given

  • Equipment failure

It is important for patients to understand risks in order to compare them with potential benefits of any operation or procedure.  Medicine deals with uncertainty all the time and patients may find this concept difficult to accept.


Obesity - Anaesthetic and Surgical Problems

High risk (1 in 100 or higher) of the following

  • Accessing veins for intravenous anaesthetic drugs can be a problem

  • Intubation problems when inserting airway (wind pipe) tube

  • Risk of upper airway (wind pipe) obstruction after extubation (removal of airway tube)

  • Respiratory (lung) problems in the first few days due to collapse of part of lungs

  • Increased risk of thrombosis (clots) after the operation

  • Excessive blood loss during operations

  • Increased risk of damage to the bladder, bowel, ureters (kidney tubes) and blood vessels

  • Operating time prolonged due to technical difficulty due to limited exposure (visibility) and limited access to pelvis

  • Difficulty in accessing lymph nodes and other tissues in cancer cases

  • Increased risk of blood collections (haematomas) in wounds and wound breakdown and infection.  Wound re-suturing under an anaesthetic is sometimes required.

  • Existing medical problems/conditions may get worse, this can prolong recovery time

Please also note that

  • The presence of obesity and other complications increases the risk of death many times -  In the UK probably 5 deaths occur for every million anaesthetics

  • Operating tables are often unable to accommodate the size and weight of morbidly obese patients – operations may have to be cancelled

  • CT scan, MRI scan and radiotherapy equipment have limits on weight and size


Obesity and Medical Problems

  • Obesity is a risk factor for coronary artery disease, diabetes, stroke, blood pressure problems and certain cancers (bowel, uterus and breast cancers).

  • Heart function can be compromised by obesity.  It can severely limit the reserves of the heart and can lead to failure of the heart to work as an effective pump.

  • Obesity also affects the lungs and respiration by restricting normal expansion of the lungs.  This can be further compromised by lying in a supine (flat) position on the operating table.  This can also lead to collapse of the lung. 

  • The risk of gastro-oesophageal reflux (acid) is increased by obesity.  This reflux and acid can sometimes damage the lungs.

  • Some obese patients develop insulin resistance and makes control of blood sugar more difficult.

  • The risk of thrombosis is increased in obese patients

Please note that other rare complications not listed above can occur.


Complications of Laparoscopic Operations

e.g Diagnostic Laparoscopy, Laparoscopic Sterilisation, Laparoscopic treatment of ectopic pregnancies, Laparoscopic removal of ovaries etc.

High Risk Complications (1 in 100 or higher)

  • Damage to blood vessels leading to excessive bleeding and unintended major open surgery and blood transfusion.

  • Damage to bladder, ureter (kidney tubes) and bowel.  Bowel injury can lead to peritonitis. A laparotomy (open surgery) may be necessary.

  • Failure to perform laparoscopy, particularly in obese patients.

Moderate Risk Complications (1 in 100 to 1 in 1000)

  • Pelvic infection and peritonitis

  • Risk of hernia formation and endometriosis at wound sites.

  • Risk of gas (Carbon Dioxide) embolism – gas in blood vessels, which can spread

  • Damage caused by electrical burns and other instruments to bladder, bowel and blood vessels

  • Formation of adhesions leading to chronic pelvic pain

  • 1 in 300 risk of sterilisation failure

The risk of the above complications are increased in the following: obesity, chronic heart and lung problems, previous abdominal operations

It is important for patients to understand risks in order to compare them with potential benefits of any operation or procedure.  Medicine deals with uncertainty all the time and patients may find this concept difficult to accept .

Page last updated 06/11/2006.