Post-operative complications in gynaecology — structured SAQ (15 marks)

(a) Immediate assessment and differential diagnosis (5 marks)

One mark per element, maximum five. ^[2]

• Structured ABCDE assessment — airway, breathing, circulation, disability, exposure; NEWS2 score 6 indicates urgent response (senior clinical review within 30 minutes, increased monitoring frequency, consider critical care outreach). ^[2]
• Focused abdominal examination — inspection (distension, surgical dressing, drain), palpation (tenderness, guarding, masses), percussion (tympany, dullness), auscultation (silent in ileus, high-pitched in obstruction); inspect the wound and the drain.
• Review the chart for the day-of-onset differential — day 5-8 with tachycardia out of proportion, ileus, and drain fluid change is the classic presentation of anastomotic leak.
• Differential diagnosis — anastomotic leak (most likely), intra-abdominal collection, paralytic ileus (most day 5 become self-resolving), VTE with ileus from immobility, surgical site infection with concomitant ileus, pneumonia with sepsis-related ileus, line infection, C. difficile.
• Assess for sepsis — qSOFA ≥2 (RR ≥22, altered mentation, SBP ≤100), lactate >2 mmol/L, organ dysfunction; the Sepsis-3 criteria require SOFA ≥2 for sepsis. ^[3]

Bands: state the NEWS2 score and the action it triggers; name the diagnosis you suspect and why (the day-of-onset logic); assess for sepsis using the Sepsis-3 frame.

(b) Investigations (4 marks)

One mark per investigation with rationale. ^[1]

• CT abdomen and pelvis with IV and rectal contrast — the workhorse for day 5-8 post-op complications; identifies anastomotic leak (extraluminal contrast, free air, perianastomotic collection), intra-abdominal abscess, transition point in obstruction, free fluid. ^[1]
• Blood tests — FBC (leucocytosis, falling Hb), U&E (renal function, K+), CRP (rising or plateaued at day 5 is a red flag), lactate (sepsis screen, perfusion), coagulation panel (fibrinogen in sepsis), blood cultures (before antibiotics).
• Wound swab and drain fluid — wound culture for purulent discharge; drain fluid amylase and culture for enteric content.
• Erect CXR — free air under the diaphragm (anastomotic leak) or pneumonia/atelectasis as a source of sepsis.

(c) Initial management and criteria for surgical re-look (4 marks)

One mark per aspect, marked for specificity. ^[4]

• Sepsis bundle (hour-1) — measure lactate, blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour (e.g. piperacillin-tazobactam 4.5 g IV q8h + metronidazole 500 mg IV q8h), 30 mL/kg crystalloid if hypotensive or lactate ≥4, vasopressors if MAP under 65. ^[4]
• Resuscitation — IV access, IV fluids, supportive care, correct electrolytes (K+), analgesia, NG tube on free drainage, hold opioids if possible, urinary catheter with hourly output monitoring.
• Tranexamic acid if bleeding — 1 g IV over 10 minutes within 3 hours of bleeding onset (WOMAN trial). ^[5]
• Criteria for surgical re-look — peritonitis, undrained collection, failure to improve within 4-6 hours of resuscitation, haemodynamic instability, anastomotic dehiscence on CT, progression to septic shock; source control is the principle. ^[1][4]

(d) Discharge planning and safety-netting (2 marks)

One mark per item, marked for safety-netting depth. ^[1][6]

• Future monitoring — serial CRP, drain output criteria (output under 30 mL/24 h, clear fluid, no leak on drain contrast study), drain removal criteria, mobility progression, VTE prophylaxis review (resuming once bleeding is secure), wound surveillance.
• Safety-netting for the next four weeks — written, named contact for the team; explicit criteria for re-presentation (fever, wound breakdown, calf pain, breathlessness, distension, new bleeding); planned follow-up in 4-6 weeks with histology review for malignancy; mental health check (post-op blues vs post-op depression); documentation of the complication in a structured morbidity record; morbidity and mortality review for the case. ^[1][6]