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Section 2: Gynecology

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    AMA Citation
    Gynecology. In: Szymanski LM, Bienstock JL. Szymanski L.M., Bienstock J.L. Eds. Linda M. Szymanski, and Jessica L. Bienstock.eds. The Johns Hopkins Handbook of Obstetrics and Gynecology New York, NY: McGraw-Hill; 2016. http://obgyn.mhmedical.com/content.aspx?bookid=1657&sectionid=107290350. Accessed January 22, 2019.
    MLA Citation
    . "Gynecology." The Johns Hopkins Handbook of Obstetrics and Gynecology Szymanski LM, Bienstock JL. Szymanski L.M., Bienstock J.L. Eds. Linda M. Szymanski, and Jessica L. Bienstock. New York, NY: McGraw-Hill, 2016, http://obgyn.mhmedical.com/content.aspx?bookid=1657&sectionid=107290350.

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GYN SURGERY: PREOPERATIVE CONSIDERATIONS

Antibiotic Prophylaxis for Gynecologic Procedures

  • Antimicrobial Prophylactic Regimens by Procedure (Table 2-1)

TABLE 2-1

ANTIMICROBIAL PROPHYLACTIC REGIMENS BY PROCEDURE

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TABLE 2-1

ANTIMICROBIAL PROPHYLACTIC REGIMENS BY PROCEDURE

Procedure

Antibiotic

Dose

  • Hysterectomy

  • Urogynecology procedures, including those involving mesh

Cefazolin1 (preferred)

 

If PCN allergic:

Clindamycin2 plus

Gentamicin3 (preferred for PCN allergic)

OR

Metronidazole2 plus

Gentamicin3 (alternative for PCN allergic)

Weight <120 kg: 2 g IV

Weight ≥120 kg: 3 g IV

 

600 mg IV

5 mg/kg IV4

 

500 mg IV

5 mg/kg IV4

  • Laparoscopy

    • Diagnostic/Operative

    • Tubal sterilization

None

  • Laparotomy

None

  • Hysteroscopy

    • Diagnostic/Operative

    • Endometrial ablation

    • Essure

None

  • Hysterosalpingogram or chromotubation

Doxycycline5

100 mg orally twice daily for 5 days

  • IUD insertion

None

  • Endometrial biopsy

None

  • Induced abortion/D&C

Doxycycline

100 mg orally 1 hour before procedure and 200 mg orally after the procedure

Metronidazole

500 mg orally twice daily for 5 days

  • Urodynamics

None

1Acceptable alternatives: Cefotetan, cefoxitin, cefuroxime, ampicillin-sulbactam.

2Antimicrobial agents of choice if history of immediate hypersensitivity to penicillin (PCN). Combination of drugs recommended to broaden coverage.

3Quinolones (cipro-, levo-, moxi-floxacin) or aztreonam (1 g IV) can be alternatives to gentamicin.

4Gentamicin is recommended as a single dose preoperatively based on actual body weight (ABW) unless ABW is >20% above ideal body weight (IBW); in this case, calculate weight for dose by IBW + 0.4 (ABW-IBW).

5If history of PID or dilated fallopian tubes. No prophylaxis is indicated for a study without dilated tubes.

Data from ACOG Practice Bulletin No. 104, May 2009, Reaffirmed 2011; Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013;70:195–283.

Key Points to Remember

  • Antibiotics must be given within 1 hour prior to skin incision. Anesthesia induction is a convenient time

  • Give repeat dose of antibiotic if

    • Long procedure (over one to two times antibiotics half-life; ex: re-dose cefazolin at 3 hours)

    • EBL over 1500 cc

  • Neither treatment for several days before a procedure nor subsequent doses after procedure are indicated for prophylaxis

  • Prophylactic antibiotics are recommended for induced abortion/dilation and curettage (D&C) even if negative gonorrhea/chlamydia (GC/CT) testing

Endocarditis Prophylaxis

  • Cardiac conditions associated with the highest risk of adverse outcomes from endocarditis that require antibiotic prophylaxis are shown in Table 2-2. Suggested antibiotics are listed in Table 2-3

TABLE 2-2

CARDIAC CONDITIONS REQUIRING ENDOCARDITIS PROPHYLAXIS

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TABLE 2-2

CARDIAC CONDITIONS REQUIRING ENDOCARDITIS PROPHYLAXIS

  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

  • Previous infective endocarditis

  • Congenital heart disease (CHD)*

  • Unrepaired cyanotic CHD, including palliative shunts and conduits

    • Completely repaired CHD with prosthetic material or device, whether placed by surgery ...

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