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Need your help (long)From: Richard Chudacoff (rchudacoff@houston.rr.com)Mon Jun 19 22:08:49 2000
Just a baffling case for me. 24 yo G4P4 s/p TVH/ A&P repair for prolapse and dyspareunia. Operation went textbook perfect, with 150 cc blood loss. I saw her about 6 hours post-op, where she looked pale, hypotensive and was tachycardic. When asked why I was not notified, the nurses said that is how she looked when she arrived from the PACU. I transfused her and followed serial hemoglobin, which stabilized, and a CT scan revealed a left hematoma, partially retroperitoneal. I watched her for 48 hours and she was stable, but unable to void, so I sent her home with a leg bag/foley catheter. Two days later I see her in my office for a trial of void. Now she is complaining of left leg pain and weakness. She is unable to lift her leg without help, but can walk on it. She has good dorsal pedis pulses bilaterally, normal capillary refill and warm to touch. My thought is there is a hematoma on the genitofemoral or superficial femoral nerve(s) or something in going through the obturator canal. Repeat CF scan shows an organizing clot left, retroperitoneal, no free fluid in the abdomen. The urethra is severely displaced to the right (explaining the failed trial of void.) Temperature in the office is 99.1 F. I decide that I want to admit her and laparoscopically remove the hematoma, but my general surgery consults (three actually) are not inclined stating that the risk of exposing a bleeder, thus requiring laparotomy, and/or the increase risk of adhesions with the exposure of this organizing clot, is not worth the benefit, and recommend watching her up to two weeks. Now though, in the hospital, her temperature is 102.3. Physical exam is essentially normal: lungs clear, no palpable cords in the lower extremities, no evidence of infected IV sites. Minimal vaginal discharge, and maybe slightly more than normal tenderness of the cuff, but how often do you do a digital exam of the cuff? Nonetheless, CT did not show a perivaginal abscess or collection. U/A shows blood, but negative for nitrites and leukocyte esterase. Chest exam is pending. White count is 7.8 with 77% bands. She has passed gas and had a normal bowel movement. I think that everything can be explained by the resolving hematoma, such as it is the cause of the fever, but it could be a cuff cellulitis. I do believe that the neuropathy is a result of the pressure retroperitoneally. Chicken as it may sound, I put her on Ampicillin and Gentamicin, and will add anaerobic coverage as needed. Blood cultures and urine cultures are pending. Neuro consult has also been requested. I'm baffled as I have not had this type of post-op course since residency. Any thoughts? Rick --
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