Postoperative complications are a significant concern following major obstetric and gynecological surgeries, impacting patient recovery, prolonging hospital stays, and increasing healthcare costs¹. These complications can arise due to a variety of factors, including patient demographics, surgical techniques, pre-existing medical conditions, and intraoperative management². Identifying and mitigating these risks is crucial in improving surgical outcomes and reducing morbidity and mortality³.

Obstetric surgeries, particularly Lower Segment Cesarean Section (LSCS), and gynecological procedures such as hysterectomy, laparoscopic sterilization, and cystectomy are commonly performed worldwide⁴. Despite advancements in surgical techniques, anesthesia, and postoperative care, complications such as febrile morbidity, surgical site infections (SSI), urinary tract infections (UTI), excessive blood loss, and thromboembolic events continue to pose challenges⁵. The incidence and severity of these complications can vary based on patient characteristics, the urgency of the surgery (elective vs. emergency), and perioperative care protocols⁶.

Several studies have examined risk factors contributing to surgical complications, highlighting the role of body mass index (BMI), hemoglobin levels, duration of surgery, and comorbid conditions in influencing postoperative outcomes⁷. However, there is limited hospital-based data analyzing these factors in the context of a tertiary care setting in India.

This study aims to evaluate the frequency and types of postoperative complications following major obstetric and gynecological surgeries, identify key risk factors, and assess the impact of surgical characteristics on patient outcomes. The findings will contribute to enhancing preoperative assessment strategies, optimizing perioperative protocols, and minimizing postoperative morbidity in surgical patients.

Study Design and Setting

This study was a prospective hospital-based observational study conducted in the Department of Obstetrics and Gynecology at Konaseema Institute of Medical Sciences and Research Foundation (KIMS), Amalapuram, India. The study was carried out over a period of two years, from December 1, 2020, to November 30, 2022.

Study Population

The study included 200 patients who underwent major obstetric and gynecological surgeries at KIMS. Patients were selected based on the inclusion and exclusion criteria outlined below.

Inclusion Criteria

Patients undergoing major obstetric and gynecological surgeries on an elective or emergency basis.

Surgeries requiring general or regional anesthesia, involving incision, excision, manipulation, or suturing of tissues.

Patients who provided informed consent to participate in the study.

Exclusion Criteria

Patients undergoing minor procedures such as dilatation and evacuation, cervical cerclage, amniocentesis, or endometrial aspiration.

Patients who were unwilling to participate in the study.

Data Collection

Each patient was evaluated preoperatively and postoperatively for complications. Data was collected using a structured proforma, including:

Demographic details (age, BMI, hemoglobin levels)

Surgical details (type of surgery, elective vs. emergency, duration, intraoperative blood loss)

Postoperative outcomes (complications such as febrile morbidity, urinary retention, surgical site infections, and thromboembolic events)

Statistical Analysis

Descriptive statistics were used to summarize the frequency and percentage of complications. Chi-square test was used to analyze categorical variables. Analysis of variance (ANOVA) was conducted to assess correlations between surgical characteristics and complication rates. A p-value < 0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS 20.0 and Microsoft Excel 2016.

Ethical Considerations

Ethical approval was obtained from the Institutional Ethics Committee at KIMS. All participants provided written informed consent, ensuring confidentiality and adherence to ethical research guidelines.

A prospective hospital-based observational study was conducted among 200 patients who underwent major obstetric and gynecological surgeries at KIMS, Amalapuram. The results of the study are presented in the following sections.

Demographic Characteristics

The mean age of the study participants was 29.54 ± 22.60 years, ranging from 18 to 54 years. The majority of the patients (56%) were under the age of 30, followed by 19% in the 31–35 age group, 8% in the 36–40 age group, 7.5% in the 41–45 age group, and 9.5% aged 46 or above (Table 1).

Table 1: Distribution of Patients According to Age

Regarding body mass index (BMI), the mean BMI was 24.61 ± 3.85 kg/m², with a minimum of 19 kg/m² and a maximum of 47.3 kg/m². The majority of the patients (66%) had a BMI below 25 kg/m², followed by 26.5% with BMI in the range of 25.1–30 kg/m², and 7.5% with BMI greater than 30 kg/m² (Table 2).

Table 2: Distribution of Patients According to BMI

Types of Surgeries

Among the 200 surgeries, 47% were obstetric procedures, while 53% were gynecological surgeries (Table 3).

Table 3: Distribution of Surgeries Among the Study Population

Obstetric surgeries included primary and repeat emergency Lower Segment Cesarean Section (LSCS) and elective LSCS (Table 4).

Table 4: Distribution of Obstetric Surgeries

Figure No:1. Distribution of Obstetric Surgeries

The most frequent gynecological procedure was laparoscopic sterilization (33%), followed by total abdominal hysterectomy (22.6%), diagnostic laparoscopy (11.3%), laparoscopic cystectomy (7.5%), and other procedures such as vaginal hysterectomy and exploratory laparotomy (Table 5).

Table 5: Distribution of Gynecological Surgeries

Figure No:2. Distribution of Gynecological Surgeries

Postoperative Complications

A total of 50 cases (25%) developed postoperative complications (Table 6). The most common complication was febrile morbidity (8.5%), followed by urinary retention (6%), blood transfusion requirement (2%), surgical site infections (1.5%), and urinary tract infections (1.5%). Other complications observed included:

• Vault hemorrhage: 1%
• Pulmonary embolism: 1%
• Bowel injuries, bladder injuries, and paralytic ileus: 0.5% each
• Conversion from laparoscopy to laparotomy: 1%

Table 6: Postoperative Complications Distribution

Figure No:3. Postoperative Complications Distribution

Correlation Between Hemoglobin Levels and Postoperative Complications

A significant correlation was found between low hemoglobin levels and an increased risk of postoperative complications (p = 0.027). Patients with hemoglobin levels greater than 10 g/dL had lower rates of complications, whereas those with hemoglobin levels between 7.5–10 g/dL had higher incidences of febrile morbidity (2.0%), surgical site infections (1.0%), and blood transfusion requirement (2.0%) (Table 7).

Table 7: Correlation Between Postoperative Complications and Hemoglobin Levels

Figure No:4. Correlation Between Postoperative Complications and Hemoglobin Levels

Surgical Duration and Blood Loss

The relationship between surgical duration and blood loss was analyzed, revealing that: Patients with surgeries exceeding 120 minutes had higher rates of significant blood loss (>1000 mL). Patients whose surgeries lasted 61–120 minutes experienced blood loss in the range of 300–800 mL. Shorter surgeries (<60 minutes) had minimal blood loss (<300 mL). A statistically significant correlation was observed between surgical duration and intraoperative blood loss (p < 0.0001).

Comparison of Complication Rates in Elective vs. Emergency Surgeries

When comparing elective vs. emergency surgeries: Elective surgeries had a higher rate of urinary retention (4.5%) and febrile morbidity (4.5%), whereas emergency surgeries had a slightly higher occurrence of surgical site infections (1%) and blood transfusion requirement (1.5%). However, no statistically significant difference was found between the complication rates of elective and emergency surgeries (p = 0.716).

Postoperative complications remain a significant concern in obstetric and gynecological surgeries, contributing to increased morbidity, prolonged hospital stays, and healthcare costs (Erekson et al⁸., 2011). This study aimed to assess the incidence, types, and risk factors associated with postoperative complications in patients undergoing major obstetric and gynecological surgeries at a tertiary care center.

Incidence and Nature of Postoperative Complications

In this study, 25% of patients (n=50) developed postoperative complications (Table 6). The most common complications were febrile morbidity (8.5%), urinary retention (6.0%), and surgical site infections (1.5%). These findings align with previous research, which reported similar trends in postoperative febrile morbidity and infection rates (Erekson et al⁸., 2011). Febrile morbidity has been associated with prolonged surgical duration, intraoperative infections, and patient comorbidities (Leonard et al¹⁰., 2000).

Urinary retention was observed in 6% of patients, consistent with earlier studies (Kaya et al⁹., 2021). Prolonged catheterization, spinal anesthesia, and pain-related voiding difficulties have been identified as key contributors to this complication. Proper perioperative catheter management and timely removal can reduce urinary retention rates (Nelson et al¹³, 2016).

Risk Factors Influencing Postoperative Complications

1. Hemoglobin Levels and Complications

A significant correlation was observed between low preoperative hemoglobin levels and increased risk of complications (p = 0.027, Table 7). Patients with hemoglobin <10 g/dL had higher rates of febrile morbidity (2.0%), surgical site infections (1.0%), and blood transfusion requirements (2.0%). Anemia is a well-established risk factor for impaired wound healing, increased infection risk, and hemodynamic instability (Kulkarni & Kothari¹¹, 2023). Optimizing hemoglobin levels through preoperative iron supplementation or transfusions can significantly reduce complications.

2. Surgical Duration and Blood Loss

Prolonged surgical duration was significantly correlated with higher blood loss and increased postoperative complications (p < 0.0001). Patients undergoing surgeries lasting >120 minutes had a greater likelihood of significant blood loss (>1000 mL). Patients with shorter surgeries (<60 minutes) had minimal blood loss and lower rates of complications.

Several studies have reported that extended surgical time increases infection risk, thromboembolic events, and hemorrhagic complications (Dencker et al¹²., 2021). Reducing surgical duration through efficient techniques and perioperative planning may help lower these risks (Nelson et al¹³., 2016).

3. Elective vs. Emergency Surgeries

While elective surgeries had higher rates of urinary retention (4.5%) and febrile morbidity (4.5%), emergency surgeries showed a higher occurrence of surgical site infections (1%) and blood transfusion requirements (1.5%). However, no statistically significant difference was found between complication rates of elective and emergency surgeries (p = 0.716). This suggests that preoperative patient condition and intraoperative factors play a more significant role in determining postoperative outcomes than the urgency of the procedure alone (Jiménez Cruz et al¹⁴., 2021).

Comparison with Existing Literature

Previous studies have reported postoperative complication rates in obstetric and gynecological surgeries ranging from 20–30%, which aligns with the 25% complication rate observed in this study (Erekson et al⁸., 2011). Research has shown that BMI, surgical site infections, prolonged operative time, and anemia significantly impact patient recovery, findings that are consistent with this study (Leonard et al¹⁰., 2000).

Boulanger et al. (cited in Kaya et al⁹., 2021)reported an infection rate of 20.6% for cesarean deliveries, whereas this study observed a significantly lower 1.5% incidence of surgical site infections, likely due to stringent antibiotic prophylaxis and improved infection control protocols. Similarly, urinary retention rates (6%) observed in this study align with global estimates ranging between 5–10% (Jiménez Cruz et al¹⁴., 2021).

Clinical Implications and Recommendations

This study highlights key factors influencing postoperative outcomes, emphasizing the need for:

Preoperative Optimization – Correcting anemia and improving nutritional status before surgery to reduce complications (Kulkarni & Kothari¹¹, 2023).

Strict Infection Control Measures – Ensuring preoperative antibiotic prophylaxis and adherence to aseptic techniques to minimize surgical site infections (Leonard et al¹⁰., 2000).

Enhanced Perioperative Monitoring – Regular assessment of urinary retention, blood loss, and fever post-surgery for early intervention (Nelson et al¹³., 2016).

Minimization of Surgical Time – Using advanced minimally invasive techniques where applicable to reduce blood loss and postoperative complications (Dencker et al¹²., 2021).

Study Limitations

Despite its strengths, this study has some limitations: It was conducted at a single tertiary care center, which may limit the generalizability of results to other hospital settings. The sample size (n=200) is relatively small, and larger multi-center studies are needed to validate findings. Long-term follow-up was not performed to assess delayed complications or recurrence of conditions post-surgery.

This study highlights that febrile morbidity (8.5%), urinary retention (6%), and surgical site infections (1.5%) are the most common postoperative complications following major obstetric and gynecological surgeries. Low hemoglobin levels (<10 g/dL), prolonged surgical duration (>120 minutes), and high BMI (>30 kg/m²) were identified as significant risk factors influencing complication rates. The findings emphasize the need for preoperative anemia correction, intraoperative efficiency, and postoperative infection control to enhance patient outcomes. While elective and emergency surgeries showed no statistically significant difference in complication rates, early intervention remains crucial. Future studies should focus on multi-center trials to develop standardized perioperative protocols that minimize complications and optimize surgical recovery in obstetric and gynecological procedures.

1. Bahadur, A., et al. "Intraoperative and Postoperative Complications in Gynaecological Surgery: A Retrospective Analysis." Cureus, vol. 13, no. 5, 2021, p. e14885. doi:10.7759/cureus.14885.
2. Ohnesorge, H., et al. "Postoperative Pain Management in Obstetrics and Gynecology." J Turk Ger Gynecol Assoc., vol. 21, no. 4, 2020, pp. 287-297. doi:10.4274/jtgga.galenos.2020.2020.0024.
3. Shellhaas, C. S., et al. "The Frequency and Complication Rates of Hysterectomy Accompanying Cesarean Delivery." Obstet Gynecol, vol. 114, no. 2 Pt 1, 2009, pp. 224-229. doi:10.1097/AOG.0b013e3181ad9442.
4. Kayembe, A. T., and S. M. Kapuku. "Postoperative Maternal Complications of Caesarean Section: A Cross-Sectional Study at the Provincial General Hospital of Kananga in the Democratic Republic of Congo." Pan Afr Med J., vol. 47, 2024, p. 23. doi:10.11604/pamj.2024.47.23.40458.
5. Dencker, E. E., et al. "Postoperative Complications: An Observational Study of Trends in the United States from 2012 to 2018." BMC Surg., vol. 21, no. 1, 2021, p. 393. doi:10.1186/s12893-021-01392-z.
6. Collings, R., et al. "The Impact of Surgical Complications on Obstetricians' and Gynecologists' Well-Being and Coping Mechanisms as Second Victims." Am J Obstet Gynecol, vol. 232, no. 1, 2025, pp. 104.e1-104.e12. doi:10.1016/j.ajog.2024.07.043.
7. Levy, L., and J. Tsaltas. "Recent Advances in Benign Gynecological Laparoscopic Surgery." Fac Rev., vol. 10, 2021, p. 60. doi:10.12703/r/10-60.
8. Erekson, E. A., et al. "Postoperative Complications after Gynecologic Surgery." Obstet Gynecol, vol. 118, no. 4, 2011, pp. 785-793. doi:10.1097/AOG.0b013e31822dac5d.
9. Kaya, A. C., et al. "Intraoperative and Postoperative Complications of Gynecological Laparoscopic Interventions: Incidence and Risk Factors." Arch Gynecol Obstet, vol. 304, no. 5, 2021, pp. 1259-1269. doi:10.1007/s00404-021-06192-7.
10. Leonard, F., et al. "Perioperative Morbidity of Gynecological Laparoscopy: A Prospective Monocenter Observational Study." Acta Obstet Gynecol Scand., vol. 79, no. 2, 2000, pp. 129-134. doi:10.1034/j.1600-0412.2000.079002129.x.
11. Kulkarni, S. P., and O. Kothari. "Surgical Site Infection in Obstetric and Gynecological Surgeries: A Prospective Observational Study." Cureus, vol. 15, no. 2, 2023, p. e34855. doi:10.7759/cureus.34855.
12. Dencker, E. E., et al. "Postoperative Complications: An Observational Study of Trends in the United States from 2012 to 2018." BMC Surg., vol. 21, no. 1, 2021, p. 393. doi:10.1186/s12893-021-01392-z.
13. Nelson, G., et al. "Guidelines for Postoperative Care in Gynecologic/Oncology Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations—Part II." Gynecol Oncol, vol. 140, no. 2, 2016, pp. 323-332. doi:10.1016/j.ygyno.2015.12.019.
14. Jiménez Cruz, J., et al. "Acute Postoperative Pain in 23 Procedures of Gynaecological Surgery Analysed in a Prospective Open Registry Study on Risk Factors and Consequences for the Patient." Sci Rep., vol. 11, no. 1, 2021, p. 22148. doi:10.1038/s41598-021-01597-5.