One of the main purposes of the preoperative history and physical exam is to identify any preoperative medical comorbidity that may lead to an increased perioperative morbidity or mortality. If comorbidities are identified, the surgeon should obtain medical consultation to ensure that the patient’s medical conditions are optimized and stable enough to proceed with surgery at an acceptable risk.
Most gynecologic surgeries fall in the category of low (< 1%) or intermediate (1–5%) risk of cardiac death or nonfatal myocardial infarction (Table 47–1). It is crucial to obtain a careful preoperative history to discover cardiac and/or comorbid diseases that would place the patient in a high surgical risk category. If the patient is found to have active cardiac conditions, such as unstable coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular disease, the surgery should be delayed or cancelled (unless emergent), and the patient should be evaluated and treated (Table 47–2).
Table 47–1.Cardiac risk (cardiac death and nonfatal myocardial infarction) for noncardiac procedures. |Favorite Table|Download (.pdf) Table 47–1. Cardiac risk (cardiac death and nonfatal myocardial infarction) for noncardiac procedures.
|Risk Stratification ||Examples of Procedures |
|High (vascular surgery) (reported risk > 5%) || |
Aortic and other major vascular surgery
Peripheral vascular surgery
|Intermediate (reported risk 1–5%) || |
Head and neck surgery
|Low risk (reported risk < 1%) || |
Table 47–2.Clinical risk factors for increased perioperative cardiovascular complications (myocardial infarction, heart failure, death). |Favorite Table|Download (.pdf) Table 47–2. Clinical risk factors for increased perioperative cardiovascular complications (myocardial infarction, heart failure, death).
|Active cardiac conditions that requires intensive management and may result in delay or cancellation of surgery unless the surgery is emergent |
Unstable coronary syndromes
Including unstable or severe angina or recent myocardial infarction (within 30 days)
Decompensated heart failure
Including NYHA functional class IV or worsening or new-onset heart failure
Including high-grade AV block, Mobitz II AV block, third-degree AV block, symptomatic ventricular arrythmias, supraventricular arrythmias (including atrial fibrillation) with uncontrolled ventricular rate (> 100 bpm at rest), symptomatic bradycardia, newly recognized ventricular tachycardia
Severe valvular disease
Including severe aortic stenosis (mean pressure gradient > 40 mm ...