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MRCOG PART 2 SBAs and EMQs

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Essay 352

Ans Posted by UwaChuks U.
a) Detect anaemia and treat. This could be gotten from the history by looking for signs and symptoms of anaemia. FBC should be done Weight loss. Patient should be informed that losing weight could help resolved the heavy periods.patient should therefore be referred to dietitian for advice on weight loss. Moderate exercise but not vigorous ones should be encouraged NSAIDS especially mefanemic acid can be tried on this patient. Mefanemic acids reduces menorraghea by 20-25%. However the long use of this medical is associated with gastric ulcer and other GI problems. Therefore patient should be counselled accordingly. Tranexamic acid can also be used. Tranexamic acids reduces heavy menstrual bleeding by 60-80%.However patient should be counselled about the side effects which retinopathy etc COCP, low dose COCP can be used. This has a significant effect in reduction of heavy periods especially if contraception is desired. This helps to resolve anovulatory bleeding associated with PCOS. However risk factors of contraindication should be sort before starting it eg previous hx of Unprovoked VTE, VTE associated with oestrogen ,hx thrombophillia, smoking at the age > 35yrs and three moderate risk factors like morbid obesity + HTN + DM Depo-progestogen can be used to induce ammenorrhea like depo- provera every 3 months can be given. Patient should be counselled the side effects which abnormal bleeding at the beginning of it's use, this resolves with time IUS . Levostrogestrel intra uterine system can be used to managed abnormal uterine bleeding. Patient should be informed that it may not be successful if there is irregular cavity. There is bleeding problem at the initial time of the insertion, therefore patient should be counselled accordingly .this device is expensive but is cost effective over 5yrs GnRH, zoladex or other GnRH analogue can be given monthly. This create menopause state leads ammenorrhea side effects like hot flush, mood swing, vaginal dryness, etc should be explained to the patient. Patient should also be told that this side effects abate about 6 months to 1 yr after stoppage of the medication. Fertility also returns. GnRH should not be used for more than 6 months because it is associated with breast cancer and ovarian cancer. Danazol can also be used for treatment of heavy periods However this is associated with adrogenic effect leading development of deep voice and masculinezation of female fetus, so barrier contraception should be advised for at least 1 yr after stoppage of treatment. Danazol has also be associated with reduced bone densities VTE...counselling needed b) Anaesthetics risk. Patient is high risk of anaesthetic complications like difficult / failed intubation , difficult or failed both spinal and epidural anaesthesia. So senior Anaesthetist should review this patient Availability of facilities in theatre like strong sand big theatre table and strong attendant to carry the patient. Therefore theatre should be informed few days before surgery so that these equipment will be sourced Patient is high risk of VTE, therefore prophylactic heparin should be given 2 hrs before the surgery and to started back 4-6 hrs after surgery according to unit protocol. Early mobilisation should be encouraged. Note that this should be given 12hrs before spinal or epidural anaesthesia and 4 hrs after the removal of epidural catheter Poor wound healing and wound breakdown is associated with obesity. Prophylactic antibiotic immediately before induction of anaesthesia is beneficial. Also closing of subcutaneous space reduces formation hematoma ...improves wound healing Excessive bleeding is associated with obesity. Precautions to avoid excessive blood loss maintained .there should be good IV access and group & cross matched 4 units and inform Hematologist incase blood products are needed. Surgical expertise needed. Senior Obstetrician is needed
Posted by UwaChuks U.

 

a) Detect anaemia and treat. This could be gotten from the history by looking for signs and symptoms of anaemia. FBC should be done

Weight loss. Patient should be informed that losing weight could help resolved the heavy periods.patient should therefore be referred to dietitian for advice on weight loss. Moderate exercise but not vigorous ones should be encouraged NSAIDS especially mefanemic acid can be tried on this patient.

Mefanemic acids reduces menorraghea by 20-25%. However the long use of this medical is associated with gastric ulcer and other GI problems. Therefore patient should be counselled accordingly.

 Tranexamic acid can also be used. Tranexamic acids reduces heavy menstrual bleeding by 60-80%.However patient should be counselled about the side effects which retinopathy etc

 COCP, low dose COCP can be used. This has a significant effect in reduction of heavy periods especially if contraception is desired. This helps to resolve anovulatory bleeding associated with PCOS. However risk factors of contraindication should be sort before starting it eg previous hx of Unprovoked VTE, VTE associated with oestrogen ,hx thrombophillia, smoking at the age > 35yrs and three moderate risk factors like morbid obesity + HTN + DM

Depo-progestogen can be used to induce ammenorrhea like depo- provera every 3 months can be given. Patient should be counselled the side effects which abnormal bleeding at the beginning of it's use, this resolves with time

IUS . Levostrogestrel intra uterine system can be used to managed abnormal uterine bleeding. Patient should be informed that it may not be successful if there is irregular cavity. There is bleeding problem at the initial time of the insertion, therefore patient should be counselled accordingly .this device is expensive but is cost effective over 5yrs

 GnRH, zoladex or other GnRH analogue can be given monthly. This create menopause state leads ammenorrhea side effects like hot flush, mood swing, vaginal dryness, etc should be explained to the patient. Patient should also be told that this side effects abate about 6 months to 1 yr after stoppage of the medication. Fertility also returns. GnRH should not be used for more than 6 months because it is associated with breast cancer and ovarian cancer.

Danazol can also be used for treatment of heavy periods However this is associated with adrogenic effect leading development of deep voice and masculinezation of female fetus, so barrier contraception should be advised for at least 1 yr after stoppage of treatment. Danazol has also be associated with reduced bone densities VTE...counselling needed

screening for chlamydia and its treatment should be done

 

 

 b) Anaesthetics risk. Patient is high risk of anaesthetic complications like difficult / failed intubation , difficult or failed both spinal and epidural anaesthesia. So senior Anaesthetist should review this patient

 Availability of facilities in theatre like strong sand big theatre table and strong attendant to carry the patient. Therefore theatre should be informed few days before surgery so that these equipment will be sourced

 Patient is high risk of VTE, therefore prophylactic heparin should be given 2 hrs before the surgery and tobe started back 4-6 hrs after surgery according to unit protocol. Early mobilisation should be encouraged. Note that this should be given 12hrs before spinal or epidural anaesthesia and 4 hrs after the removal of epidural catheter

  Poor wound healing and wound breakdown is associated with obesity. Prophylactic antibiotic should be given immediately before induction of anaesthesia.. Also closing of subcutaneous space reduces formation hematoma ...improves wound healing

Excessive bleeding is associated with obesity. Precautions to avoid excessive blood loss should be carried out .There should be large bore hole IV access and group & cross matched should be sent and inform Hematologist incase of any blood product is needed.

Surgical expertise needed. Senior Obstetrician should perform the operation.
 

 
 
 
 
 

 

 
 
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HMB Posted by HAnaa B.
The non surgical treatement of HMB includes the MEDICAL TREATMENT for the accompanied anemia if ever due to bleeding by iron supplements either oral or prentral in cases not tolerating oral iron, it needs some tine to improve her hb level increase constipation should be taken after food.It also includes medication that can be used to reduce blood loss with the menstruation such as Tranexamic acid - anti-fibrinolytic agent - reduces menstrual loss by ~50% . Not associated with an increased risk of DVT. Side effects nausea / vomiting / diarrhoea; disturbance in colour vision needs to discontinue therapy. NSAIDS - mefenamic acid commonly used, reduces menstrual loss by ~25%; have a better side-effect profile compared to tranexamic acid. Can be used both as a primary treatement should be stopped after 3 month of use and no improvement Combined oral contraceptive pill - reduces menstrual blood loss by ~50%. Cann’t be used in her case as it is considered UKME3 and 4 Systemic progestogens such as norethisterone it is effective if given at higher doses (5mg three times a day) for three weeks out of four (days 5-26 of the cycle)Has the side effect of bloating , breast pain and weight gain Depo-medroxyprogesterone acetate is associated with amenorrhoea (30% after one injection, 55% after 12 months) but there is the risk of irregular vaginal bleeding which can last for the whole 3 month They may not be used in obese women , they may need double dose , Danazol which is a Synthetic androgen with anti-oestrogenic and anti-progestogenic activity; inhibits pituitary gonadotrophin release and has direct suppressive effect on endometrium. Reduces menstrual loss but is associated with androgenic side-effects: weight gain of 2-4kg with 3 months treatment, acne, hirsutism, seborrhoea, irritability, musculoskeletal pains, fatigue, hot flushes and breast atrophy. These side effects are reversible on discontinuation of therapy - voice changes may occur and may not be reversible. Women must be advised to use barrier contraception as danazol can virilise a female fetus if pregnancy occurs. The recommended duration of treatment is up to 6 months GnRH analogues Result in amenorrhoea but are associated with menopausal symptoms and loss of bone mineral density.May be used over the short-term for intractable menorrhagia .seldom used if no cause like fibroids. Gestrinone 19-nortestosterone derivative, androgenic anti-oestrogen and anti-progestogen.Significantly reduces menstrual loss but not first line therapy.Not licensed for the treatment of menorrhagia.Associated with androgenic side-effects (milder than danazol) and can virilise female fetus therefore barrier contraception is essential. Levonorgestrel intra-uterine system realesing 20ug/day of levonorgesterel hormone in the endometrial lining Associated with a reduction in menstrual loss of ~80%. Irregular bleeding during the first 3-4 months after insertion –needs good motivation and counseling before use .Recommended by NICE as first line treatment for women who are going to use it for over 1 year considered one of the non contraceptive benifts.it also reduces dysmenorrheal accompanied by the bleeding, has the advantages if decreased risk if PID and ectopic pregnancy in users , has the side effect of increase ovarian cyst formation, has some androgenic side effect due to minor absortion of the levonorgesterel, perforation during application, migration and expelsion, should be insered while open cervix as pain full due to its size. B Risks posted with hysterectomy may involves patients risks such as risk of anathesia can be reduced by consulting senior anathesia, use of spinal anathaesia better than general . Risk of VTE which can be reduced by good hydration during surgery with the use of elastic stocking and pneumatic boats during surgery and the use of post operative LMWH and early ambulation post operative . Risk of infection can be reduced by the use of preoperative Antibiotic single dose in case of vaginal hystrectiomy. Risk of wound dehiscence in case of abdominal hysterectomy needs to close the subcutaneous fat if more than 2 cm. Risk of diffuclt operation with deep pelvic structures , bleeding , slpit ligature ,bowel and bladder injury needs Good light exposure , experienced surgon , assistance and the use of long instruments . Risks related to failure of introduction of the trocar and pnumopretnum in case of Laproscopic removal of the utres. Risk of early menupuase and the need for HRT in case of removal of the ovaries during hysterectomy. Risk of blood transfusion and be reduce3d by preoperative treatement of anemia and use of cell salvage intraoperative. Diffuclties posed by her obesity over hospital sitting , like in need of special operation table weight bering, big culf for blood pressure
Posted by HAnaa B.
there is big problem in posting the anwer , it came as whole block , i alreadyseparted them in my writing , may be techiniqal diffuclties
chandu S Posted by Sailaja C.
A) Anaemia should be treated with haematinics. NSAIDS- Mefenamic acid reduces menstrual loss by 25% have better side effect profile compared to tranexamic acid. Tranexamic acid – antifibrinolytic agent reduces menstrual loss by 50% and more effective than NSAIDS. Not associated with increased risk of DVT. The side effects include nausea, vomiting, diarrhoea and disturbances of colour vision. Although combined oral contraceptive pills are effective in reducing menstrual loss , for this woman usage of COCP cannot be considered as risks outweigh the benefits ( UKMEC 3) Systemic progestogens such as norethisterone is effective in higher doses ( 5 mg three times a day) from 5- 25 days. Injectable progestogen like Depot medroxy progesterone and Danazol( synthetic androgen with anti- oestrogenic and anti progestogenic activity) may not be considered as a choice of the treatment for her as both are associated with increased risk of furher weight gain. GnRH analogues result in amenorrohea but are associated with menopausal symptoms and loss of bone mineral density. May be used for short term use. Gestrinone a 19- nor testosterone derivative significantly reduces menstrual loss but not licensec for the treatment of menorrhagia. LNG IUS associated with a reduction of menstrual loss of 80%. Appropriate counseling is required about irregular bleeding during first 3-4 months. Associated with hormone related side effects like breast tenderness, acne and rarely uterine perforation at the time of insertion. B) Regarding abdominal hysterectomy, incision is the first challenge. Transverse incision below the pannus would be tempting for the surgeon due to less adipose tissue but associated with increased risk of infection because of anaerobic moist environment of subpannicular fold. A transverse incision higher on the abdominal wall require division of rectus muscle and tend to be more vascular. A midline incision give good access and pannus can be retracted caudally to enable such incision. Midline incision is associated with risk of wound breakdown requires mass closure using delayed absorbable sutures placed 1 cm from the edge of the rectus sheath. Pre-operative evaluation of the abdominal wall anatomy, along with senior colleague is required for selection of appropriate incision. At laparotomy, access to the pelvis can be challenging. Good assistance, retraction and lighting are essential. Flexible illuminators can provide good light in deep cavities . Long instruments are helpful to work in deep cavities. Panniculectomy can be considered to achieve good access but associated with significant increase of opertating time, trasfusion requirement and requires plastic surgeon's assistance. Difficulty in haemostasis is another challenge particularly while removing the cervix and suturing the vaginal vault. Blind clamping to control bleeding puts uteters at risk of injury. Palpation, identification of urerters should minimise the risk. Requires experienced surgeon and assistance from urologist to handle the situation. Subtotal hysterectomy is an alternative in case of difficulty experienced during total hysterectomy. Vaginal route for hysterectomy has low rate of complications but adequate exposure to carry out the surgery is question. Laparoscopic surgery is associated with high rate of failed entry and difficulty in ventilation particularly in steep head down position. But in skilled hands, laparoscopic surgery has additional benefits like less post operative ileus, fewer wound infections and early post operative mobility. The standard technique of entry by verees needle would be sufficient but if difficulty encountered, Palmer's point entry or open technique can be chosen.
ADIL Posted by Adil H.
A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. A) Tranxemic acid when used during the periods reduces menstrual blood loss by 50 percent , it does not carry side effects of increasing risk of thromboembolism . If tried and found suitable can be prescribed over long term during the menstrual cycle to reduce the blood loss. NSAID are also first line with mefenemic acid leading to 25% reduction in blood loss. Mirena is a very suitable option to be explored the UKMEC class should be noted and if she falls in class I , II, it should be offered in the absence of history of active breast disease , viral hepatitis or liver disease , and cardiovascular disease, history of MI, stroke. LNG IUS should be offered, not only it will reduce the menstrual blood loss, in addition it will provide contraceptive benefit as well. The efficacy in reducing the bleeding is comparable to hysterectomy, and yet it is non surgical option. This will avoid numerous surgical risks, which the lady poses in view of her morbid obesity. It is also known to allieviate the symptoms of PMS which is an additional benefit. With Mirena , there is risk of irregular heavy bleeding , moderate abdominal discomfort in the first 06 months can be dealt with use of additional progestogens, NSAIDs and Combined pills for a short period , to give regularity, however once settled there is proven benefit of mirena. It can be fitted in the outpatient department, does not require anaesthesia. Progestogens, like 3 monthly injections of DMPA, will also reduce heavy blood loss and almost 70% women are ammenorrhic after 1 years usage. They provide excellent contraceptive benefit, and are safe to use in a variety of medical conditions including smokers, can be used upto menopause. There is risk of osteoprosis , and reduction in BMD which limits its long term usage. b. She has morbid obesity , and this in itself poses surgical risks. Proper pre-operative evaluation, staring from history of co-morbid conditions, like diabetes , hypertension, cardiovascular status etc. should be enquired, and investigated. Anemia needs to be corrected and preoperative Hemoglobin should be over 11gms/dl, blood group need to be done cross matched blood to be arranged An attempt to reduce weight , by referring to dietician or a considering use of weight reduction drugs, barriatric surgery all can be explored as options to reduce weight and of course reduce postoperative morbidity. A multidisciplinary approach involving medical specialist, consultant anaesthetist, haematologist, cardiologist, pulmonologist, operation theatre paramedical staff , should be involved in the management. Aneasthesia consultation by consultant should be undertaken, ASA scoring to be performed. Medical problems should be looked into and controlled. She has a risk of intra-operative problems pertaining to the procedure like bowel damage, vessel damage, heavy blood loss. Laparoscopic approach once considered dangerous in obese ladies is now proving to be safer while employing open Hasons technique, and reduce postoperative morbidty by infection associated with large incision, in trained hands it is a useful technique. There is risk of VTE and it needs to be further explored by additional factors. If she is taking combined oral contraceptive pills these should be stopped 4weeks before surgery. She should be given LMWH in therapeutic weight adjusted dosage 4 hours after surgery and this should be continued for 4weeks. The use of aseptic techniques, and intraoperative antibiotics can reduce the high risk of infection asscociated with morbid obesity. Early mobilization , in addition placement of incision above the pannus is proposed to help in reducing wound infection and wound breakdown. (TOG). Opertation theatre staff should be informed about the patient to make necessary arrangements in the OT, regarding OT tables, provision of extension, provision of extra large BP cuffs. A bed in the HDU /ICU may be arranged to cater to the extra postoperative monitoring requirements of this patient. Senior gynaecologist should perform the surgery and , Mass closure of the abdominal wall is recommended in case of vertical incision to prevent burst abdomen. Early mobilization , respiratory excercises, physiotherapy all contribute to quicker recovery. Evidence based unit protocols and audit , training of staff can greatly help in reducing overall morbidity.
ADIL Posted by Adil H.
A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. A) Tranxemic acid when used during the periods reduces menstrual blood loss by 50 percent , it does not carry side effects of increasing risk of thromboembolism . If tried and found suitable can be prescribed over long term during the menstrual cycle to reduce the blood loss. NSAID are also first line with mefenemic acid leading to 25% reduction in blood loss. Mirena is a very suitable option to be explored the UKMEC class should be noted and if she falls in class I , II, it should be offered in the absence of history of active breast disease , viral hepatitis or liver disease , and cardiovascular disease, history of MI, stroke. LNG IUS should be offered, not only it will reduce the menstrual blood loss, in addition it will provide contraceptive benefit as well. The efficacy in reducing the bleeding is comparable to hysterectomy, and yet it is non surgical option. This will avoid numerous surgical risks, which the lady poses in view of her morbid obesity. It is also known to allieviate the symptoms of PMS which is an additional benefit. With Mirena , there is risk of irregular heavy bleeding , moderate abdominal discomfort in the first 06 months can be dealt with use of additional progestogens, NSAIDs and Combined pills for a short period , to give regularity, however once settled there is proven benefit of mirena. It can be fitted in the outpatient department, does not require anaesthesia. Progestogens, like 3 monthly injections of DMPA, will also reduce heavy blood loss and almost 70% women are ammenorrhic after 1 years usage. They provide excellent contraceptive benefit, and are safe to use in a variety of medical conditions including smokers, can be used upto menopause. There is risk of osteoprosis , and reduction in BMD which limits its long term usage. b. She has morbid obesity , and this in itself poses surgical risks. Proper pre-operative evaluation, staring from history of co-morbid conditions, like diabetes , hypertension, cardiovascular status etc. should be enquired, and investigated. Anemia needs to be corrected and preoperative Hemoglobin should be over 11gms/dl, blood group need to be done cross matched blood to be arranged An attempt to reduce weight , by referring to dietician or a considering use of weight reduction drugs, barriatric surgery all can be explored as options to reduce weight and of course reduce postoperative morbidity. A multidisciplinary approach involving medical specialist, consultant anaesthetist, haematologist, cardiologist, pulmonologist, operation theatre paramedical staff , should be involved in the management. Aneasthesia consultation by consultant should be undertaken, ASA scoring to be performed. Medical problems should be looked into and controlled. She has a risk of intra-operative problems pertaining to the procedure like bowel damage, vessel damage, heavy blood loss. Laparoscopic approach once considered dangerous in obese ladies is now proving to be safer while employing open Hasons technique, and reduce postoperative morbidty by infection associated with large incision, in trained hands it is a useful technique. There is risk of VTE and it needs to be further explored by additional factors. If she is taking combined oral contraceptive pills these should be stopped 4weeks before surgery. She should be given LMWH in therapeutic weight adjusted dosage 4 hours after surgery and this should be continued for 4weeks. The use of aseptic techniques, and intraoperative antibiotics can reduce the high risk of infection asscociated with morbid obesity. Early mobilization , in addition placement of incision above the pannus is proposed to help in reducing wound infection and wound breakdown. (TOG). Opertation theatre staff should be informed about the patient to make necessary arrangements in the OT, regarding OT tables, provision of extension, provision of extra large BP cuffs. A bed in the HDU /ICU may be arranged to cater to the extra postoperative monitoring requirements of this patient. Senior gynaecologist should perform the surgery and , Mass closure of the abdominal wall is recommended in case of vertical incision to prevent burst abdomen. Early mobilization , respiratory excercises, physiotherapy all contribute to quicker recovery. Evidence based unit protocols and audit , training of staff can greatly help in reducing overall morbidity.
Posted by ani S.
a)Non steroidal anti-inflammatory agents such as mefenamic acid can reduce bloss loss up to 25 %. It also reduces dysmenorrhoea. Side effects are gastrointestinal disturbance and can lead to peptic ulcer disease. It should be taken during menses and if no effect is seen after 3 months of use, then it should be stopped. Tranzenemic acid which is an antifibrinolytic has been shown to be effective in reducing menstrual blood loss up to 50%. It is also associated with gastrointestinal side effects and should not be used in people with high risk of developing or having venous thromboembolism. If ineffective after 3 months it should be stopped. Both are non contraceptive. Hormonal methods available in oral form such as combined oral contraceptive is an option. It gives good cycle control, reduces menstrual blood loss, is a contraceptive and has other benefit in protection against ovarian malignancy and benign breast disease. However, it might not be suitable in this patient due to her morbid obesity which is at high risk of developing venous thromboembolism. Oral progestogens such as noerthisterone decreases blood loss by thinning the endometrial lining. It is taken from day 5 to 26 of the cycle. Disadvantages are weight gain, headache, bloated feeling, breast tenderness and rarely depression. Injectable progestogens are another option and would result in amennorhoea after 2nd or 3rd dosage. It is a contraceptive and there maybe a delay in fertility resuming after stopping the drug. Similar side effects as oral but also causes reversible bone mineral loss. GnRH analogues is an option however, it would induce a menopausal state and cause undesired side effects of hot flushes, decreased libido, vaginal dryness, headache and insomnia. If used more than 6 months, it would cause irreversible bone mineral loss and add back therapy with HRT, tibolone or progestogens is needed. May not be a suitable option in this patient and can cause early onset osteoporosis. Levonorgestrel intrauterine system is the most effective and first line treatment of heavy menstrual bleeding. It significantly reduces blood loss and decreases dysmenorrhoea. Side effects are irregular bleeding and spotting, acne, breast tenderness and headaches. Insertion maybe difficult in this patient and a pelvic exam including suitable instruments would be required for insertion. It is licenced up to 4 years for use in treatment of menorrhagia and 5 years as contraceptive. Danazol which is androgenic is not recommended due to its virilising side effects. b) Surgery in a morbidly obese patient is associated with high morbidity and mortality. Patient would need medical evaluation for clearance for surgery. She is at increased risk for diabetes mellitus, hypertension, ischaemic heart disease, obstructive sleep apnoea. A full blood count, liver and renal function, coagulation test, ECG, chest x ray, pulmonary function test would be required. If on hormonal medication, it should be stopped 4 weeks prior to operation. Anesthetic review preoperatively is essential. Patient has to be informed of the risk of general anesthetic, problems with intubation and airway management. Regional anaesthesia maybe beneficial as it can provide anaesthesia as well as post op analgesia and aid in early mobilisation, hence reducing risk of deep vein thrombosis. A senior anaesthetist is more appropriate to handle the difficulty that would be faced in establishing regional or general anesthesia. There would be difficulty in obtaining peripheral line and central venous line, arterial line is needed to aid in effective fluid infusion as well as monitoring blood pressure and pulse. The OT staff and personnel need to be aware of the case in advanced in order to plan and ensure staff are trained in manual handling to protect the patient and themselves. There should be adequate staff for transporting, positioning and lifting the patient and operation should ideally be done daytime during office hours. The operation table, bed and trolley should be labelled with its maximum weight capacity. Pressure areas has to be padded to prevent nerve injury and muscle entrapment. The operation should be carried out by an experienced senior surgeon. A minimal invasive approach like laparoscopy is advantageous as it leads to faster recovery, mobilisation, reduced hospital stay. However, only certain surgeons whom are competent and has the expertise and skills and anaesthetist whom can manage the respiration which would be compromised due to pneumoperitoneum should manage the case. It may require the surgeon to refer the case to a colleague who has the appropriate skill to perform the surgery. During laparotomy, surgeon with expertise, good assistants and lighting is essential. Long instruments and retractors to access deep cavity. It maybe justified to perform a subtotal hysterectomy as it would cause lesser bleeding from the vault and prevent difficulty in suturing the vaginal vault, provided smears have been normal. Risk of bleeding is there and so, it would be advisable to have the blood in OT during operation. Mass closure of the abdominal wall with non absorbable( ethilon) suture material is preferred to prevent wound break down. Hemostasis with cautery but not excessively as dead tissue is prone for infection. Pad of subcutaneous fat would need suturing. Pre operative intravenous antibiotics 1 hour before and LMWH 2 hours prior to surgery would prevent infection and deep vein thrombosis respectively. Post operatively, she should be managed in a high dependency unit. Effective analgesia would aid in early mobilisation. Adequate hydration, feeding, antibiotic and VTE prophylaxis with TED stockings, LMWH and pneumatic compression device, chest physiotherapy can prevent post op morbidity.
Posted by BHAWANA  P.
Mirena coil should be offered as first line non-surgical treatment to this woman. It controls menorrhagia in majority of cases. Periods can be irregular or heavy in initial 6 months but then periods become lighter or even amenorrhoea occurs. Insertion can be difficult because of raised BMI but can be done by experienced personnel in theatre. Combined oral contraceptive pill should not be given to her because of BMI =45 (UKMEC1 ). Progesterone only pills ( D5- D26 ) and injectables can be given to her. Compliance can be a issue and side-effects like mood disturbances, acne, headache can occur. GnRH analogues suppress ovulation and create artificial menopause and control menorrhagia. They are expensive, cause reduced bone mineral density and long term use is not advisable. After 6 months, HRT need to be supplemented. Use beyond 2 years even with HRT is not recommended. Danazol can also menorrhagia . It is not widely used because of androgenic side effects like hirsutism ,voice changes. Patient should be advised to use effective contraception as it can cause virilisation of female fetus. All the above methods are not suitable if she wishes to have children. Tranexemic acid can decrease menstrual flow and with mefenemic acid can reduce dysmenorrhoea as well. They need to be used with every cycle. Side- effects are headache, diarrhoea. Hysterectomy can be done vaginally which has least complications but pre-op assessments for suitability to perform it need to be done. It can be difficult to perform in raised BMI and because of access may not be possible. Abdominal hysterectomy can be performed. Because of increased risk of thromboembolism, TED stockings and appropriate low molecular weight heparin need to be prescribed. Because of large pannus, site of incision can be difficult to define. If transverse incision is given on the crease under pannus, there is increased risk of infection. Landmarks like suprapubic bone need to be palpated and appropriate incision should be made. Vertical incision can give better access but associated with increased risk of wound dehiscence.Good access with extra assistant or even holding fat with instruments and gauze hanged with weight can give better access and save assistant from getting tired. Appropriate light source, good exposure, sound knowledge of anatomy helps preventing injury to surrounding structures especially ureters are quite vulnerable to injury. She is at increased risk of bleeding and prompt identification of bleeding points and appropriate use of diathermy can minimize these risks. These cases should be done by experienced surgeon or if any difficulty, appropriate help from senior colleagues should be sought.Pre-operative antibiotics and if needed post-operative antibiotics like augmentin should be given to prevent infection.Appropiate use of drain, suturing fat layer and interrupted sutures or staples for skin can provide better healing of wound. Laparoscopic assisted vaginal hysterectomy can overcome some of these complications but it need to be performed by experienced surgeon.
answer amendment Posted by BHAWANA  P.
sorry paul my answer did not appear properly . Answer b starts from the word hysterectomy. I don't know proper paragraphs did not appear though I did in word document.
essay352- ans Posted by Chetna K.
Ans a) Aim should be to reduce the bleeding and simultaneously give her symptomatic treatment. General measures like advice regarding weight loss , exercise, dietary modifications and behavioral changes given sinc e all these have an impact on her long-term health as well as her treatment options .Treatment depends on the impact of her problem on her quality of life, her fertility plans , contraception needs, co-morbidities and her wishes. If she wants contraception also, her options are LNG-IUS, Combined oral contraceptives (COCs), Progesterone preparations and GnRH analogues .First line treatment is LNG-IUS (Mirena). It is meant to deliver progesterone harmone intrauterine. It releases the harmone at a slow steady rate and cause endometrial thinning. It has the advantages of reducing the bleeding by almost 60- 70% and can cause amenorrhea after 9 – 12 months of use. It thus optimizes Hb levels & increases ferritin levels. Very effective if bleeding is associated with pain, very effective long- term contraception by its mechanical and hormonal effects, no delay in return of fertility once removed. Not advisable if planning pregnancy. Causes irregular bleeding for 3-6 months for which proper counseling needs to be done, inceased risk of benign ovarian cysts which generally resolve spontaneously. Second line of treatment inc ludes Combined oral contrac eptives(COCs). COCs have the advantage of oral route, cheap, effective contraception. But is contraindicated for her BMI and especially if she is smoking also, and has hypertension. It is associated with increased risk of stroke, deep vein thrombosis. Oral and Intramuscular progestogens , used as third line treatment. Patient should be counselled for progestogenic side effects like weight gain, depression , breast pain, nausea. IM preparations cant be used for long term since it reduc es bone mineral density and with her BMI she is already prone for osteoporosis. Next is GnRH analogues which causes artificial menopause by downregulating GnRH receptors. It has advantages of stopping the bleeding, but associated with menopausal side- effects like hot flushes, breast atrophy, vaginal dryness and osteoporosis. Therefore has to be supplemented with combined HRT. It requires addition of contraception also. Her options if she doesn’t want contraception are Non- hormonal treatment like tranexamic acid ( antifibrinolytic), and mefenamic acid (anti – prostaglandin) Tranexamic acid substantially reduces bleeding (around 50 – 75%), especially if doesn’t want contraception. Dose is 500 – 1000mg tds, it is safe, oral cheap, effective. Side effects include nausea, vomiting, diarrhea. NSAIDs (antiprostaglandins) are preferred when bleeding is associated with pain (dysmenorrhea). Dose 500 mg bd, blood loss is reduc ed but less as compared to tranexamic acid. Side effects are nausea, vomiting diarrhea and peptic ulcers with long-term use. Finally if her symptoms are affecting her quality of life and her Hb is <8gm/dl , she may require parenteral iron or even blood transfusion for which again her wishes are important. Ans b) Surgical challenges inc lude problems with equipments, anesthesia, skin incision , surgical technique(route) and wound healing. Due to her morbid obesity, proper detailed planning is required with protocols in place. Her Hb should be optimized and cross matched, compatible blood arranged. Proper arrangements for equipments including anesthetic machines and lat eral and other manual handling equipments must be ensured. Responsibility has to be delivered to named person or nurse. Problems with venous access, type of anesthesia, and intra- operative monitoring are anticipated. A senior anesthetic consultant must be involved who assesses her preoperatively including co-morbidities and properly plan out and write down the detailed plan in her case sheet. With her BMI, spinal and epidural anesthesia has more chanc es of failure , and therefore GA will be more suitable. With GA also , induction and reversal both can be difficult and there is high risk of aspiration and Mendelson’s syndrome. Fasting for at least 8 – 10 hours pre-operatively, use of antacids and entiemetics , will reduce the risk. Central venous line should be put to ensure proper intra and post- operative monitoring. Laproscopic route for surgery is preferable due to morbid obesity but requires expertise and has higher chances of failure to gain entry . Alternate routes of entry e.g Palmar’s point can be used. Vaginal route has limited exposure due to her obesity especially with undescended uterus. If abdominal route is decided for, type of incision also poses great challenge. Vertical midline incision will allow good exposure, short operative time, but is not cosmetic and has high risk of wound disruption, burst abdomen and post-operative pain. If this looks more feasible these problems can be overcome by using mass closure technique and selection of proper suture material like Prolene (non- absorbable), and use of analgesics with anesthetist’s advice. With transverse incision like Pffanenstiel, there are cosmetic advantages, better wound healing , and less post- operative pain. It is posed with limited exposure and there can be difficulties with extension of incision if required. Basic principles of surgery like good hemostasis, less handling, prophylactic antibiotics, use of fine instruments and fine suture material should be followed . Need for good assistance , proper lighting and appropriate instruments is must. Finally use of subcutaneous wound drain will help as wound hematoma/collection is anticipated. Use of skin staples is preferable for the same.o, Thromboprophylaxis again poses challenge as due to obesity ,chanc es of wound hematoma are there . Early ambulation, prevention of dehydration , TED stockings advised to prevent thrombosis and Low molecular weight heparin started as soon as risk of hematoma seems to be less. Post operative antibiotics should be given and she may require longer hospital stay and discharged after ensuring proper recovery.
value Posted by K9 S.

\r\n A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks

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\r\n Non surgical options probably better in her case as there is a morbid obesity, but they vary in terms of side effects, patient acceptability and satisfaction and long term effects.
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\r\n Hx. in regards to impact of heavy menstrual period on quailty of life( days off work, patients refrain from usual activities) and symptoms and signs of anaemia should be sought, FBC to determine Hb level and treat anaemia if present.
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\r\n Patient is involved in decision and her prefernces are taken into consideration after providing full information about options of treatment
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\r\n COC are effective in reducing menstrual flow by 30% and are a good choice if the patient is eligible ( UKMEC 1-2) and not planning for pregnancy. COC increase the risk of VTE and already there is a morbid obesity so if previous hx or fam hx. of VTE, smoking, IHD, or documented thrombophillia � I would advise against against COC. If eligible I would use low dose EE ( 20-30 mcg) in combination with second generation progestogen.
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\r\n Mefenamic acid during menstrual bleeding can decrease blood loss,good choice if dysmenorrhea is present. No long term effects and �contraindicated in presence of peptic ulcer and renal impairment.
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\r\n Antifibrinolytic agents such as Tranexamic Acid taken during bleeding reduces the blood loss by 30%, superior to Mefenamic acid but more side effects mainly visual disturbances and has to be stopped if they occur
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\r\n progestogen depo injections can achieve amenorrhea in up to 50% after one year of use, �it is contraceptive and can delay infertility up to 2 years after stopping the treatment, �common side effect are irregular unpredictable bleeding and it can lead to stop treatment in good percentage of women.
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\r\n Progestogen only pill given for 3 weeks a month (day 5-day26) is contraceptive, significantly reduce blood flow, but again it can lead to irregular spotting and for contraception purposes it has to be taken in 3 hr window so needs patients compliance if contraception desired.
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\r\n Mirena (LNG) device is very effective in reducing blood flow and 70% are amenorrheic at one year, it is contraceptive but no delay in fertility, it needs to be inserted by proffesionals trained to insert and associated with discomfort, very small risk of perforation, PID so chlamydia status should be known in high ris group. risk of expulsion esp in the first 3 months.
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\r\n Endometrial ablation using second generation is effective with 80% patient satisfaction, 75% �amenorrheic at one year. It is not a contraceptive method but has impact on fertility so careful counselling. it can lead to cyclical pain. difficulties in biopsing endometrium in the future if concerns about �endometrial pathology
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Answer Posted by Kim M.
A Non surgical treatments include non hormonal and hormonal methods. Tranexamic and mefanamic acid can be used if the patient prefers non hormonal methods to control her menorrhagia or wants to retain her fertility. When taken together they can reduce blood loss by up to 60% however if there is no improvement in 3 months they should be discontinued. They are also associated with indigestion and diarrhoea. Hormonal methods include the mirena coil, COCP, cyclical NET, injectable progesterones and GnRH analogues possibly with add back HRT depending on the duration of treatment. The mirena coil is the 1st line treatment for menorrhagia assuming that the patient will continue with this for over 12 months. It reduces blood loss in 80% of women and can cause amenorrhoea. Some patients do not like the mirena as it can cause breast tenderness, irregular bleeding particularly in the first 6 months and acne. The combined oral contraceptive pill (COCP) can reduce heavy periods, there is less irregular bleeding than is asscociated with progesterone only preparations however this method to control menorrhagia would not be appropriate in this case as her BMI would make this disadvantages outweigh the advantages. Cyclical norethisterone (15mg taken from days 5 to 26) and injectable progesterones have similar mechanisms of action and reduce bleeding as they prevent proliferation of the endometrium. The downsides particularly in this case is that there is an association with weight gain and fluid retention, these doses of progesterones are larger than the mirena coil and can have more side effects. As with other progesterone preparations these also cause irregular bleeding. GnRH analogues would be a way of shutting down the ovaries and controlling the menorrhagia however this can cause menopausal symptoms and after 6 months the patient would need to take HRT due to the risks of reduced bone mineral density assocoated with GnRH analogues. As this patient is also young this would not be the best long term method to control her menorrhagia. B The surgical risks for this patient are increased mainly bacause of her BMI. Pre-operatively this patient could attend a dietician to try and reduce her weight before surgery which would decrease her risks fo DVT, PE, intraoperative comlications, haemorrhage and post operative infection. Pre-operatively the patient may also need to see an anaesthetist to determine the best anaesthetic for her and also so they can examine her jaw to ensure ease of potentially general anaesthetic. This will also facilitate having an appropriate anaesthetist present for the surgery Due to her increased risks of DVT and PE I would give her LMWH injection preoperatively and postoperatively for up to 6 weeks. I would advise her to stay adequately hydrated, wear TED stockings whilst in hospital and mobilise as soon after the surgery as possible. Theatres should be prepared prior to the patient arriving - there should be an operating table that can take the weight of the patient and enough staff to facilitate moving the patient without injury to themselves. Intraoperatively her risks of complication could be reduced by having a skilled and experienced surgeon operating on her with an adequate amount of assistants. The route of surgery would also be important as a laparoscopic approach would decrease her risk of would infections and recovery time. It would be important to have adequate instruments including longer length ports and trochars to facilitate this. As the surgery is more complicated due to her BMI it would be important to anticipate problems and ensure a group and save is sent and the lab has received it to enable cross match if necessary. Post operatively the patient should be encouraged to mobilise as soon as possible and also have input from physiotherapists particulary if she has had a general anaesthetic for the procedure. She should be encouraged to keep the would clean and dry to reduce her risk of postoperative infection and if she smokes this should be discouraged as it increases the risk of wound breakdown.
Posted by Sweta P.
A) Levonorgesterol intrauterine susytem (LNG IUS) is the first line in treatment of heavy menstrual period. Though it results in reduced menstrual blood loss (30-40%) and in some cases amenorrhoea (20-30%), there is a high discontinuation rate due to initial irregular bleeding and spotting in the first 3-6 months. It can also give rise to other progestogenic side effects such as mood changes and weight gain. Second line treatment is Tranexemic acid and non-steroidal anti-inflammatory drugs (NSAIDs) such as mefanamic acid, either alone (low efficacy, tranexemic acid better than NSAIDs) or in combination, with improved efficacy. Side effects of tranexemic acid is nausea, vomiting, GI disturbances and cautious use with history of DVT. NSAIDs can cause GI ulcers and is contraindicated in severe asthma. Should be discontinued if no benefit in 3 months. Combined oral contraceptive pills is also a second line treatment to control heavy periods. In addition to the above, it also provides contraception and regularises the menstrual cycles. Given the BMI of this woman (45 = morbid obesity), its contraindicated (UKMEC 4). it can increase the risk of VTE, strokes and myocardial infarction. Third line of treatment is oral progestogen and injectable progestogen. Norethisterone can be used orally in high doses for 21 days of the cycle or continuously. No long term benefit noted as ceasing the progestogens will worsen the period. Progestogenic side effects such as weight gain, mood changes, breast tenderness can be deterrent to its use and not recommended more than 6 months. Injectable depot medroxy progesterone acetate can cause irregular bleeding, mood changes, weight gain and loss of bone mineral density , hence long term use is not advised. Gonadotropin releasing Hormone agonist (GnRHa) can be used as third line medication. It can completely cease ovarian function, hence period but long term use is not recommended as menopausal symptoms such as hot flushes (can be alleviated by add back HRT) and loss of bone mineral density. Advised maximal usage for 6-12 months. In addition to above, advice regarding lifestyle changes such as weight loss (referral to dietician) and exercise should be given. If anemia suspected and subsequently confirmed on full blood count, iron sulphate should be commenced. B) Surgical challenges during hysterectomy ranges from anaesthesia to post operative recovery and complications, and she should have a frank and realistic discussions regarding them. Intubation during general anaesthesia will be difficult depending on the adipose tissue around the neck and amount of mobility of the neck. Regional anaesthesia would be preferred but will be difficult due to the difficulty to palpate the iliac crest and spine to position the spinal/epidural needle. Presence of a senior Anaesthetic consultant with special interest in obese women would be helpful. Intravenous access may be difficult to site and monitoring during anaesthesia would be difficult in this morbidly obese patient. Central venous line may be needed for monitoring. Logistics of moving and handling the patient needs to be considered. The operation theatre bed generally can take weight unto 130-160 kg, so it may be adequate for her but ensure no overhanging of adipose tissue from sides of operating table and all pressure points should be guarded. One option is to operate not the ward bed which is broader but difficult access for the surgeon and the anaesthetist. Gluteal muscle rhabdomyolysis can lead to renal failure hence prevent by soft bed. Local infiltration of anaesthetic agent at the wound site for block can promote adequate analgesia hence early mobilisation. Intra -operative antibiotic before the incision can decrease the wound infection. Flowtrons should be used to minimise the risk of deep vein thrombosis. Placement of incision for the actual operation can be difficult due to the overhanging pannus. Temptation to lift the pannus up to make the incision at the thinnest area should be avoided as it can lead to infection and poor healing due to anaerobic environment and decreased immunological response. It would be ideal to make the incision on the pannus if transverse incision though it increases the layer of fat needed to reach the rectus sheath and would involve muscle cutting incision. Ensure homeostasis but over cautery should be avoided as it can lead to schema and wound dehiscence. Midline incision without lifting the pannus is warranted and once the fat layer is incised, the rectus sheath can be incised to pubic symphysis. Mass closure of the wound with delayed absorbable suture with approximation (not tight) is advocated to prevent ischemia. The fat should be approximated to get adequate wound closure. Use of long instruments, adequate lighting and trained staff is helpful. Drain should be inserted to minimise risk of re-laparotomg for intra abdominal haemorrhage. Adequately trained surgeon is needed to undertake the procedure, especially closure of the vault as adequate hemostasis is needed. Sub total hysterectomy may be considered in difficult procedures if no malignancy suspected and cercial smears have been normal. Laparoscopic hysterectomy should be considered as it minimises the intra operative bleeding, quick recovery and mobilisation though tredelenberg's position would compress the chest and make the ventilation difficult for the anaesthetist as general anaesthesia would be needed. Post operatively, HDU or ITU bed should be available for initial intensive monitoring. Adequate analgesia for early mobilisation, adequate hydration, thromboembolic deterrent stockings and thromboprophylaxis is mandatory. Wound should be kept dry and clean to avoid infection and antibiotics for 5-7 days post operatively should be considered to minimise the risk of wound infection.
ESSAY-352 Posted by lamia T.
a) First I will take full menstrual history LMP,cycle length,regular or irregular.I will also take her contraceptive history,wishes for further pregnancy because it will help in choice of treatment. Before starting treatment I have to check her Hb level and if anaemia detected it should be corrected with oral or parental(if needed) iron therapy. She can start Tranexamic acid (antifibrinolytic agent) two tablets orally 3 to 4 times a day from day 1 of the cycle for upto 4 days.It will reduce bleeding around 58%. I have to inform her that it is not a contraceptive and diarrhea,indigestion,headache these are possible side effects of medicine. Nonsteroidal anti-inflammatory drugs reduce bleeding up to 49%.I will advice her to take tablet orally from day 1,until heavy blood loss has stopped.Indigestion,diarrhea,worsening of asthma,peptic ulcers these are possible unwanted effects. Combined oral contraceptive is another choice of therapy.This patient is morbidly obese,so it is contraindicated(UKMEC 4) for her.Again age>35 and if smoking >15 cigarettes per day then it is another contraindication(UKMEC 4). Tranexamic acid, Mefenamic acid and COCP are RCOG recommended first line treatments in primary / secondary care. Referral for gynaecologinal review or further investigations should be considered if symptoms do not improve after three months therapy or therapy is discontinued because of side-effects. Levonorgestrel-releasing intra-uterine system(LNG-IUS) prevents proliferation of endometrium and thus reduce bleeding by upto 95%.I have to inform her that irregular bleeding may last for over 6 months and breast tenderness,acne,headache these are progestational side effects.If she wants contraception then only I will advise this and it is cost effective.Other options are oral progesterone(norethisterone)and injectable or implanted progesterone.Oral progesterone tablet 15mg from day 5 to day 26 will reduce bleeding 83%.Side effects are weight gain,bloating,headache,breast tenderness,acne .Depo medroxy progesterone acetate injection every 12 weeks or Implanon subdermal implant for 3 years can stop bleeding almost completely.Irregular bleeding and amenorrhoea could be the side effects and should be informed.DMPA can cause small loss of bone mineral density.Review should be done after 6 months of treatment, if no improvement further investigations should be done. Gonadotrophin-releasing hormone analogue(GnRH-a) stops production of estrogen and progesterone and stops bleeding completely in 89% of women.It is not a contraceptive and monthly injection for 6 months can be used.If used >6 months then ‘add-back’ therapy is recommended.Side effects are menopausal like symptoms and osteoporosis if >6 months used. Danazole,Gestrinone these are other alternative treatment.With these barrier contraceptive should be used as it can cause virilisation of female fetus. Patient should be advised to loose weight as it can improve her symptoms. b) Surgry in morbidly obese patient is associated with high morbidity and mortality.As the patient wishes for hysterectomy all advantages , disadvantages,risk associated with surgery,other alternatives everything should be discussed with her and documented in consent form.I have to discuss in detail about route either abdominal or vaginal,type of surgery total or subtotal and decision about conservation verses removal of overy. Preoperative evaluation of cardiovascular and respiratory history and relevant investigations should be done.Any comorbid conditions like diabetes,hypertention cardiovascular impairment should be documented and properly investigated.Height,weight should be clearly documented in her file.She should be reviewed in anaesthetic review clinic.Anaemia should be corrected and blood group and crossmatching ,arrangement for blood and blood products should be done. An attempt to reduce weight by referring to dietician ,drugs or bariatric surgery can reduce her complications.A multidisciplinary approach should be taken for better management. Regional anaesthesia should be encouraged as well as anaesthetic benefits it will ensure postoperative analgesia,reduction of thromboembolism.Low moleculr heparin-enoxaperin 40 mg daily should be started atleast 2 hr before surgery and continued throughout hospital stay and 1 week after surgery.TED stockings also should be used. Clear and early communication should be done between staff involved in management of this patient.Manual handling training,leveling of all weightbearing bed,trolly,operating table should be done.All pressure points should be secured.Peripheral venous cannulation ,induction of anaesthesia,endotracheal intubation can be difficult. Abdominal incision and closure both are difficult in obese patient.Wound infection and wound failure more common so adequate antisepsis required.Although a subpannicular incision has less vascularity but more chance of infection because of anaerobic moist environment.Antibiotics before incision is necessary to reduce infection.Transeverse incisions higher on abdominal wall require division of rectus muscle and more vascular.The pubis has to be considered as a landmark to decide where to perform the incision.A midline incision in extremely obese person cangive easy access.At laparotomy access to pelvis can be difficult and chance of intraoperative complications.Difficulty with haemostasis particularly during removing the cervix,suturing the vault needs expert.Subtotal is preferred in case of negative cervical smear.Long instruments,good lighting,flexible illuminator may be needed.Good haemostasis,avoiding excess cautery is important in wound closure. Mass closure with delayed absorbable suture 1 cm from rectus sheath can reduce fascial breakdown. Obese women undergoing vaginal surgery has less complications.In laparoscopy assisted vaginal hysterectomy difficult entry,poor view,hindered manipulation could be a cause of relative contraindication.During veress needle insertion open technique or palmer’s point can be selected.With skilled hand it can provide advantages like less postoperative ileus,fewer wound infection,less hospital stay,early mobilization. During post operative period she should be admitted in high dependency unit.Good nursing care ,chest physiotherapy,early feeding and mobilization should be advised. Overall if risk is assessed too high gynaecologist can refuse surgery for best interest of patient and a second opinion should be taken.
Posted by H H.
XXXX A) No treatment is an option provided there is no effect on quality of life or wellbeing. She is advised to loose weight and to exercise ,she might not be able to do so.The help of dietician and use of appetite suppressant drugs may help ,but there is risk of side effects of these drugs such as depression. Mirena coil can be used as first line therapy ,can reduce heavy periods through local progesterone effect on endometrial,so reduce systemic side effects, but there is risk of irregular period,spotting,difficulty in application in such morbidly obese patient,risk of uterine perforation and expulsion.. It will reduce menstrual loss by 97% after 12months of insertion. Patient should know that it is contraceptive. Mefenemic acid can be used to reduce heavy menstrual loss by 30% and reduce menstrual pain,however it is associated with gastrointestinal irritation. Tranexamic acid which is an antifibrinolytic agent can reduce menstrual loss by 50% ,but better avoided in such morbidly obese patient for fear of increasing risk of venous thrombosis. It can cause nausea vomiting diarrhea and visual disturbances. The last two agents are not contraceptive. Combined oral contraceptive pills are contraindicated in such patient as risks outweigh benfit(UKMEC 3). Progesterone only pills can be used ,but only effective in heavy menstrual bleeding if used at higher doses and long duration. Side effects include bloating, depression and acne. Depot prover a ( medroxy progesterone acetate), will produce amenorrhea in 55% of patients after the 4th injection. Risk of weight gain which patient would not accept. There is risk of irregular bleeding and spotting during 1st three months of use.There is also risk of delayed fertility after stopping it. Danazole can be used to reduce heavy menst bleeding,but limited by its virilising effect. GNRH analouges are used in resistant cases, associated with menopausal symptoms, risk of osteoporosis if used more than 6 monthes.Add back therapy in the form of Tibolone is needed if used for more than 6 monthes. With all treatments, sympathetic approach, proper explanation, support from medical team and written information and leaflets given. Patient choice and wishes respected. B) There are anesthetic risks including difficulty in intubation and regurgitation resuling in respiratory embaressment. A senior staff of ST6 or more grade should undertake her care. Preoperative anesthetic preparation with antiacids. Anesthetic guide wire to aid in intubation available. Manual handling of obese patient through a team who already has drills and training in handling and lateral movement of obese patient. High risk of infection in that patient ,will be reduced by the use of preoperative antibiotics 2 hrs before surgery, proper hemostasis and proper surgical skills reducing dead space formation and proper dissection of tissue. Risk of venous thrombosis is reduced in such high risk patient by prophylactic low molecular wt heparin 2 hr before opration in two doses 12hr apart till discharge. Use of flowtron boots at surgery. Use of TED stockings,proper mobilisation and hydration. Preperative cathetrisation to reduce risk of bladder injury. Two wide bore intravenous lines should be secured in such obese lady ,in case there is bleeding and she need blood transfusion. FBC and group and save. Operation should be done by the consultant gynecologist, and proper assistants(might need 2 well traind assistants). Transverse suprapubic incision is preferred to midline vertical incision,due to less wound dehiscence,infection, and less post operative pain. However should midline incision be needed , which allow more exposure, mass closure with non absorbable suture is needed to reduce wound dehiscence. Exposur of pelvic organs can be difficult and the use of deep retractors is needed. Non closure of peritoneum will reduce ileus, post operative pain, adhesions,and post operative stay. Should the laparoscopic route be used,use of open peritoneal technique is advised by RCOG guidelines. Exposure is good. Need proper skills.Ports more than 10mm should close the sheath to avoid hernia.Less post operative pain and hospital stay. Vaginal hysterectomy , will need expertise, long retractors and proper assistanse. Bleeding more than with abdominal rout and can lead to convert the procedure to abdominal route.
ans 352 Posted by Nabila A.
The treatment options will depend upon the future fertility wishes,need for contraception,womens expectations for amenoorrhea,acceptibility for hormonal or nonhormonal treatment.If hormonal treatment is acceptable and long term use atleast for 12 months is expected then Levonornegestrel intrauterine system would be offered as the first option.NSAIDS and/or trenexamic acid or COCs or high dose norethisterone from 5 to 26 day of the cycle or long acting injectable progestogens(depo provera) offered as the next step. If non hormonal treatment is required then NSAIDS and or tranexamix acid is recommended.Both are used during the menstruation and generally well tolerated.Blood loss reduction is more with the antifibrinolytics than NSAIDS.These can be used for long term but recommended to be stopped if not effective within 3 months of use.No evidence of increase in the risk of thrombosis with tranexamic acid. Levonorgesterol intrauterine system is a highly effective treatment forHMB.Blood loss reduction is more than NSAIDS ORor tranexmic acid.It reduces the blood loss to more than 80% after 3-6 months and more than 90% at 12 months .There is 25-55% risk of breakthrough bleeding....patricularly in the first 6 months so the patients need to persevere for 6 months to be able to feel the benefits of the system.There is 3-6% of risk of expulsion.progestogenic side effects like bloating,acne ,breast tenderness will be felt more than the high dose norethisterone but the satisfaction rates were more with intrauterine system.It is also compared to hysterectomy...quality of life assessment is the same after 1 year except the pain scores were less with hysterectomy and LNG;IUS more cost effective.LNG-IUS is mre effective than oral or depot progestogens. Long acting high dose progestogens(depo provera) may induce amenorrhea but its use is limited by its side efffects including breakthrough bleeding. Because of her BMI being >45 kg/m2 which is aUKMEC category 3 for the use of CHC...LNG-IUS seems to be an effective non surgical treatment. In case the above options are ineffective then androgens i.e danazol or gestrinone can be recommended as second line treatment in case of severe anemia or as these effectively produce ammenhoea. GnRH analogues can also be used but only for short term because of the risk of bone loss and menopausal symptoms .If required to be use dfor more than 6 months , it can be used along with hormonal add back therapy. considering her BMI > 45kg/m2 she is a high risk patient to undergo surgery.The indication for such a patient should be carefully reviewed to be appropriate .Communicating risks of her morbid obesity should be carefully and sensitively done .If he is willing to undergo weight loss program ,dietary changes and exercise would be the best but it is time consuming.Briatric surgery can be considered . She is at risk of having comorbidities ...diabetes ,hypertension ,ischemic heart disease which should be evaluated pre operatively and treatment optimised by the involement of the multidisciplinary team involving specialist physicians,anaesthetists,plastic surgeons.nutritiontists ,specialist gynaecologists. Evaluation by the anaesthetist regarding difficulty in intubation and ventilation peroperatively.Induction of anaestheia is also slow in obese .General anaesthesia to be replaced by regional anaestheis a which will halve the risk of thromboembolism.Regional anaestheis would be technically difficult but an experienced anaesthetist can overcome.Regarding the abdominal surgery,as ther is a high risk of wound infection ...meticulous cleaning of the skin under pannus and the groins is required.Antibiotcs before the incision will reduce the morbidity.incision beneath the pannus os more prone to infection .Incision above will be be high and tend to cut rectus muscle...consequently more bleeding.Midline incision in obese will give good access,to the pelvic cavity .However mass enclocure of the abdomen with non absorbable suture involving 1 cm of the rectus sheath will reduce the risk of burst abdomen.Closure of the super ficial subcutaneous tissues will reduce incidence of wound hematoma.Excessive cautery should be avoided during hemostasis as it tend to cause necrosis of tissue and nidus for infection. It is technically difficult to access the pelvic organs in obese...good lighting ,appropriate retraction,good assistance ,long instruments can help the surgeon make the technically difficult surgery possible Total abdominal hysterectomy can be reduced to sub total hysterectomy due to risks of damaging bladder and difficulty in reaching deep provided her cervical smears are adequate .Laproscopic route in experienced hands can avoid the risks of wound infection although in obese entry is difficult for which open hassen s technique or entry at palmers point can be used .Vaginal route can be used if there is no previous surgery.Post operatively adequate hydration,appropriate sized elastic stockings ,intermittent pneumatic compression ,thromboprophylaxis with 60 mg enoxaparin s/c daily till the hospital stay and 1 week after the surgery
zainab Posted by Zainab I.
(A)first non hormonal option which may be offered to her is tranexamic acid,which is an antifibrinolytic agent,reduces the menstrual blood loss by 50%, taken orally during periods only,and is cost effective.however it causes gastrointestinal disturbace and is contraindicated in this patients as she is at risk of thromboembolism. Second non hormonal option ‘ mefanemic acid’is a non steroidal anti inflamatory drug,which reduces the menstrual blood loss by 25%,used during periods only and is effective for dysmenorrhoea as well. However,it has side effects such as nausea,vomiting,gastric ulceration and GI bleeding ,which may limit its use If she has any GIT disturbance. Combined oral contraceptive pills are effective,easy,oral preparation with additional benefits of effective contraception and relief of dysmenorrhoea,but is unsuitable option for this women as she is at risk of thromboembolism and cardiovascular disease. Progesterone only pill,norethisteron 5 mg ,three times a day for 21 days may be effective for this woman to reduce the blood loss.however ,are associated with progestogenic side effects e.g bloatedness,depression,breast tenderness,headach, and functional ovarian cysts formation. Gonadotrphin releasing hormone analogue are effective to reduce menstrual blood loss but are,expensive,used parenterally and are associated with menopausal symptoms and bone loss. Danazole is an androgenic hormone which reduces the menstrual loss effectively and is licensed ,however due to its adverse side effects such as virilisation,voice changes and liver dysfunction it is not recommended in practice. Levonorgestril intrauterine system(mirena)is a progesterone containing device ,licensed for treatment of menorrhagia ,is highly effective and provide additional advantage of effective contraceptive. It is expensive but cost effective as useful for five years.disadvantages include progestogenic side effects ,functional ovarian cyst ,irregular bleeding,and difficult and painful insertion and removal. Last option which should be offered to her are haematinics,as she would be anaemic ,due to heavy menstrual loss.this can be given in the form of ferrous sulfate tabets 200 mg three times a day.if she can tolerate as some women develops constipation .in that case parentral preparation can be offered. (B) Major surgery in this morbidly obese woman is associated with high mortality and morbidity ,which may be due to anesthetic complications or surgery itself. Anesthetic problems which may be encountered are difficulty in peripheral venous cannulation, central venous access may be required.endotracheal intubaion may be challenging.arterial monitoring may be needed.adeuate preop evaluation ,preparation ,use of regional anesthesia, and training may lead to safe surgery. During surgery ,access to pelvis can be challenging due to distorted anatomy .good assistance,retract-ion,lighting,use of flexible illuminators ,may overcome these problems.midline incision and panniculectomy may provide better exposure. She is at high risk of haemorrhage during surgery.Securing haemstasis is challenging .Good knowledge and expertise may play a role to minimize blood loss .subtotal hysterectomy or vaginal hysterectomy are acceptable alternative in the absence of malignancy. She is at higher risk of thromboembolism .Preoperative risk assessment,use of thromboprophylaxis in the form of low molecular weight heparin starting 2 hours preoperatively and continued post operatively for 1 week ,appropriate size antithromboembolic stockings,and mechanical devices such as intermittent pneumatic compression ,post op mobilization and adequate hydration are the measures which may minimize her risk. Risk of infection and wound dehiscence is very high in this woman .aseptic technique,use of antibiotics,midline incision with mass closure may reduce the risk .Good nursing care is paramount.adequate analgesia,will allow early mobilization .physiotherapy will reduce chest complications . Overall,to reduce the complications of hysterectomy,preop evaluation ,counseling of the woman and family regarding decision,encourangement to reduce weight,alternative route of hysterectomy by laproscoy , by experienced surgeon,with use of appropriate equipment are the important measures which may be undertaken .
nee p Posted by nee P.
Nonsurgical options involve prescribing tablet Tranexamic Acid 1gm TDS . Tranexamic acid is antifibrinolytic agent and is associated with 50-90% reduction in blood loss. Its adverse effects should be taken into account like nausea, vomiting, diarrhoea and visual disturbances esp. Colour vision. Tablet Mefenamic acid the NSAID(nonsteroidal anti-inflammatory agent) is also an option. It is useful in reducing bloodloss by 25%. This also has an advantage of treating associated dysmenorrhoea. Drug related adverse effects like gastritis, nausea, vomiting should be considered. Patients wishes and response to drug treatment to be taken into account. Combined oral contraceptive an option to treat menorrhagea can not be used in this woman because of her morbid obesity . COCs can cause increased risk of thrombosis in this particular patient. Progesterone like Norethisterone 5mg TDS from day 5 – 25 is useful in reducing blood loss. There is no role of progesterone if used in last 10 days in reducing blood loss.LNG IUS is an intrauterine device is associated with reduction in blood loss by 80%after 12 months of use. But LNG IUS is associated with irregular bleeding PV in intial 3-6 months of use. It is associated with formation of ovarian cysts. There are minimal systemic progestogenic adverse effects. It is not protective for venous thromboembolism. It is associated with less risk of Pelvic inflammatory disease but insertion associated infection risk is there. It has an added advantage of contraception. Being morbid obese anaesthesia risk is increased. General anesthesia risk because of webbed neck associated with obesity. Also the risk of difficult spinal/epidural anaesthesia because of obesity. Therefore preoperative discussion & involvement of senior anesthetist is necessary. Preoperative availability of working load, lateral shift, appropriate operation table, B>P apparatus & bed which is appropriate if prolonged immobility is considered. Involvement of senior Gynaecologist owing to difficult surgery in this patient. Risk of thromboembolism is reduced by adequate hydration, using pneumatic compression device intraop, Thromboembolic deterrant stockings poat op period & using prophylactis dose of low molecular weight heparin preoperatively & continued during postoperative period. Treatment of infection as infection risk increases with obesity so using prophylactic antibiotics within two hours of incision & following aseptic precautions will reduce infection morbidity. During surgery the choice of incision , if vertical gives good exposure but associated with more pain & incisional hernia so low transverse incision can be made to avoid post-op pain & hernia. So seniors involvement is necessary.patients wishes also to be taken into account, Risk of bleeding , injury to bladder, ureter or bowel owing to deep pelvis & inadequate exposure. Therefore involvement of urologist if ureteric injury noticed will prevent further complications like urinoma or fistula. Suturing peritoneum to be avoided to reduce postop pain & ileus as general measure or suturing enmass peritoneum and sheath to reduce postoperative wound dehiscence. Taking informed consent and handing over patient information leaflets , appropriate documentation and incident reporting of adverse event should be in place as part of risk management.
Essay 352 Posted by Dr.P.Vijaya P.

\r\n Essay 352

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  1. \r\n I will explain the woman all �the available options for non surgical treatment� for Heavy Menstrual Bleeding and involve her in the decision making.LNG IUS� levonorgetrel releasing intrauterine system is the best option it releases 20 micrograms daily into the intrauterine cavity and prevents the proliferation of endometrium.It controls bleeding in 95%, can be used for 5yrs , side effects are irregular bleeding occurs for 6 months, bloating, breast tenderness, headache, amenorrhoea. Rarely uterine perforation in inexperienced hands.For insertion and removal needs trained person..Non hormonal treatmens are Tranexamic acid, NSAIDS.Tranexamic acid is a competitive inhibitor of plasminogen and acts as a antifibrinolytic agent. Given as 1gm, 3-4 times per day from 1-4days of the cycle.Controls bleedin g in 58%.Side effects are indigestion, diarrhoea.Nsaids like Mefenemic acid acts by reducing the PGs by cyclooxygenase.Controls bleeding by 49%.Side effects are indigestion , diarrhoea but avoided in asthmatics and peptic ulcer patients.COCP( 3rdgeneration progesterones� not used because of risk of thromboembolism) �prevents proliferation of endometrium, controls bleeding in 43%.Daily one tablet for 21 days. Side effects are mood changes,boating , fluid retention, breast tenderness. POPs prevents proliferation of endometrium , 15mg/day given from 5-26thday of the cycle.Stops bleeding completely. Side effects are breast tenderness, fluid retention weight gain , depression.Injectable progestogens and implants- side effects are breast tenderness, PMS like symptoms, rarely bone mineral loss.GnRH anologues prevent estrogen and progesterone production given as injections for 3-6 months.Produces menopausal like symptoms like hot flushes, increasing sweating , vaginal dryness.If more 6 months treatment needed add back therapy .Other options are Danazol it is a synthetic androgen with antiestrogenic and antiprogestogenic activity., side effects like hirsutism limits its use.Gestrinone it can be given twice a week.
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  2. \r\n B)I will counsel the woman about the problems fof morbid obesity related to surgery.Multidisciplinary approachwith dietician, physiotherapist,Anaesthetist and Senior consultant Gynaecologist.In the anaesthetic review clinic difficulty of intubation,peripheral venous canulation is explained,benifits of regional anesthesia for good analgesia� are also explained.Trained staff and personnel handling the women informed earlier for proper equipment.� If the women is on COCP,must be stopped 4 weeks before surgery.LAP hysterectomy in experienced hands is better in morbid obese patients,it reduces the post-op ileus,wound infections and hospital stay.� Incision for TAH mid line is preferred for exposure and wound dehiscence which is common can be prevented by mass closure. Antibiotics before incision help in preventing infection and provide asepsis. Any type of hysterectomy is difficult in morbid obese patients.Subcutaneous fat must be sutured which prevents wound dehiscence. In Vaginal hysterectomy in obese patients� incidence of infections and pelvic heamatoma is more. Sub total abdominal hysterectomy requires less time but patient is liable to bleeding� later. Operative difficulties can be avoided by flexible illuminators and long instruments. At the time of removal of the cervix and vault closure experienced assistance is needed. Post operative care by dedicated nursing staff in the intensive care unit. Special attention to the pressure sores with padding along with good analgesia helps in early mobilisation and feeding. Use of antithrombotic stockings and mechanical devices like intermitant pneumatic compression provides better outcome. To prevent thromboembolic risk ENOXAPARIN 40 mg IM 2 hrs after post-op and daily for 7days.
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Essay 352 Posted by Dr Dyslexia V.
Essay 352 Gynaecological obesity with menorrhagia A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. a) Non surgical option include weight reduction which sometimes may improve heavy menstrual bleed. It also has other additional benefits such as reducing surgical morbidity, future onset of diabetes, hypertension and cardiovascular disease. The use of Non Steroidal anti inflammatory drug (NSAID) such as mefenamic acid, ibuprofen and naproxen sodium could reduce up to 60% of menstrual flow. But it has the undesirable side effects such as gastro intestinal disturbances and could potentially cause gastritis. The use of antifibrinolytic such as tranexamic acid is also useful and it has similar side effects profile such as the NSAID but less intensity. Combined oral contraceptive pills is however could not be used with her as with a BMI more than 40 puts her in a UKMEC category 4 as there is an increased risk of Venous thromboembolism (VTE). Howevever progestogens such as Northisterone could be used in her as there is no contraindication and reduces the menstrual flow. It is however associated with the side effects such as bloating, water retention, mastalgia and irregular scanty bleed. Other progestogenic alternatives include depo provera which could provide amenorrhea up to 50 % of the users. But it also has the side effect of irregular bleed , osteoporosis and some weight gain. The other drug which could be used is the Gonadotropin Releasing hormone agonist (GnrH). It does effectively reduce menorrhagia but however it causes climacteric like symtoms in its usage and could cause osteoporosis after 6 month of usage. The other disadvantage include that you cannot use it indefinitively due to side effect profile. More commonly used method is the Levonogesteral intrauterine system. It is effective and its usage provides contraception for 5 years and decrese in menstrual flow for up to 4 years usage. It reduces the need for hysterectomy up to 50% of patient and amenorrhea to about 20% of the users. It has the side effect of irregular bleed as well. It could be technically difficult for insertion in an obese patient and sometime anesthesia may be required. Other modalities include endometrial ablation which the 2nd generation endometrial ablation could be done in an outpatient however may be difficult to be done on a obese patient. The use if 1st generation endometrial ablation with direct vision would be more appropriate and need to be done with anesthesia to avoid complication. b) The risk include anaesthetic risk and surgical risk. The anaesthetic risk include difficult cannulation of blood vessels , difficult intubation and difficulty maintaining ventilation during surgery and analgesia post operatively. This risk could be addressed and reduced by weight loss by the patient and to be seen by the anaesthetist before operation. The case should be handled by a senior consultant anaesthetist, and a intensive care bed should be available post operatively for recovery. The surgery could be technically demanding and should be done by a senior consultant as there is high risk of morbidity. Surgical access in a obese patient would be difficult due to the thick subcutaneous layer and adequate exposure could be difficult with standard surgical instruments and thus appropriate retractors and instruments should be made available prior to the operation. A lower tranverse incision would be beneficial as reduce the risk of wound breakdown and dehiscence and faster healing. Meticulous hemostasis is important as the increase risk of bleeding and formation of hematoma in obese patient mainly in the subcutaneous layer. Proper visualisation , transfixing and ligation is important so that there would be no inadvertent injury to other structures such as the ureter, bladder and bowel. Infection is also more common in this to patients and the use of proper antiseptics such as clorhexidine for skin preparation and use of intraoperative antibiotic would be used to reduce it. VTE is also and important risk associated with mortality in this patient thus adequate hydration, TED socks and low molecular weight heparin such as clexane in high prophylactic dose should be employed till patient is discharged from the hospital. Another important aspect also proper swab counts should be checked due to increased risk of misplacing it in a obese patient.
essay 352 Posted by Astha T.
A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. A)The woman suffers from menorrhagia.Her first line treatment options should include Mirena coil(LNGIUS).This can decrease menstrual blood flow by 80%,acts as a contraceptive,can be inserted as an outpatient procedure, has no gastric side effects, no regular intake and compliance problems.however,it leads to irregular menses for about six months, and the patient should be warned about it.Amennorhoea occurs in the majority by one year. There is a small risk of perforation of uterus and pain during insertion or infection can occur.It is highly effective and has prevented hysterectomy in many cases. She may consider tranexemic acid(an antifibrinolytic)or NSAIDS(mefenemic acid)during menses.These measures are effective in about 40to 50% cases, medication is not needed all through the month, NSAIDS also provide pain relief.However, they have GI side effects(nausea, gastritis) and tranexemic acid has a theoretical possibility of being thrombogenic(which is risky in a morbidly obese woman). Oral cantraceptives help in cycle control and menorrhagia, but are not a good option in a morbidly obese woman as estrogen increases the risk of DVT. Progesteron only pills(norethisterone, medroxyprogesterone)may be taken from day 5to25 bot can cause bloating, depression, acne, nausea.Injectable progesterones(DMPA 12 weekly im) can be used and also acts as a contraceptive, but has similar side effects and can cause irregular bleeding which may be unacceptable and doesnt settle with time. Endometrial ablation is a good option,as it is minimally invasive,is a day case,effective in most cases,can lead to amennorhea but additional contraception would be required.It can lead to uterine cramping and vaginal discharge, and the rare possibility of uterine perforation. GnRH analogues are an effective in almost 100% cases but a temporary option.They can be used for upto six months to decrease bleeding and build up hemoglobin before surgery.Hypoestrogenic side effects(hot flushes, vaginal dryness and osteoporosis) limit its use.Danazol is also effective, but limited by virilizing side effects. Besides the above non surgical options, the patient shuold be given lifestyle modification advice, to reduce wieght and hematinics(iron tablets) to replenish her stores. B)The woman is morbidly obese, which makes her high risk for surgery.For an optimal outcome, she should be assessed for other comorbidities and reviewed by a senior anesthetist preop. Surgery is challenging due to difficulty in visualisation and handling tissues and has high risk of infection and thrombosis.It should be done by a senior experienced surgeon.The route of surgery should preferably be vaginal.This could be difficult due to accesibility, size and mobility of the uterus,needs good assistance and lighting. Gnrh analogues should be used preop to reduce uterine size and vascularity and improve anemia. Laparoscopic surgery is not contraindicated, and is infact better, as it leads to better visualisation(due to distention of the peritonial cavity), less blood loss, less infection, early recovery and mobilization.But longer operative time and trendlenberg position may put pressure on the lungs and may be difficult to maintain.LAparoscopic entry would also be difficult,an intra umblical approach should be used instead of subumblical as the abdominal wall is thinnest at the base of the umblicus.Bowel preparation should be done preop to improve visualisation and decrease risk of bowel injury. If a laparotomy has to be done, a pfannensteil incision is better than a midline vertical incision(less chances of hernia), but the incision should not be given at the base of an abdominal fold due to in creased risk of infection.Incising on the panniculus can cause delayed healing and infection. Hemostasis shuold be ensured. Mass Closure would be a preferred technique as it reduces the rate of wound dehiscense.Abdominal drains should be inserted. Prophylactic antibiotics reduce infections. TED stockings, early mobilization, hydration, thromboprophylaxis with LMWHeparin should be used to prevent DVT . Swab counts should be ensured due to risk of a misplaced swab in obese patients.
Posted by Muthu M.
The options are non-hormonal. Hormonal and change in life style. Patient’s desire for future pregnancy or completion family should be taken into account when discussing the options. Drugs such as Tranxemic acid (1gram 3times a day) and Mefanemic acid (500mg 3times a day) can be given at the time of cycle, like Day 1-5days. We have to make sure there is no history of hypercoagulable blood disorders, antiphospholipid syndrome where the tranxemic acid is contraindicated. With regard to hormonal treatment, Oral Combined contraceptive pills (COC)are an option, however it is contraindicated due to raised BMI. Also we need to make sure that there is no family or personal history of thrombosis before, history of smoking needs to be checked. Then, definitely COC pills should not be given with thrombosis history and with smoking after the age of 35years. The next option is Progesterone only pills, she needs 2tablets a day instead of one to be effective. The difficulty with POP is it needs to be taken at a regular time every day to avoid having the break through bleed. This can be avoided by giving the drug, cerezette which has more flexibility upto 12hours. The next option is Depo-provera injection, which needs to be given every 11-12weeks. But her case it may cause still poor cycle control and may need to be given earlier. There is also risk of weight gain and osteoporosis. So, it cannot be permanently given or needs bone density scan at a regular interval. The return of ovulation would be delayed upto a year on stopping the Depo injection. Implanon is another option. It has to be inserted under local in arm. The patient should be informed about the procedure and need for change and removal every 3years. We can give Norethisterone 5-10mg, three times a day from day 5-day 21 to be effective in controlling the bleed. All the above progesterone type contraception have the side effect of irregular bleed or breakthrough bleed, breast tenderness and weight gain risk possible. Patient should be counseled appropriately, and these side effects may not be acceptable. Most of the oral medication, like COC pills, POP pills and norethisterone, if the patient has a busy life style or not a good regular pill taker, it will not work and also will cause irregular bleed. In this scenario, such as Depo, Imlplanon and Mirena coil may be the better choice. The other option is having a Mirena coil, which has 30% chance of improving the bleeding. But still has the risk of irregular bleed. Also, it may be difficult in inserting the coil and need trained people to do it. The patient should be counseled about the above risks and also about risk of perforation and the need for a change every 5years. If the patient never had vaginal deliveries before, inserting mirena coil may be difficult, may require anesthesia to do it and anesthtic risks shoud be discussed. Out of the entire above, Mirena coil may be better option. Due to her raised BMI, she may be at risk of having endometrial hyperplasia, so progesterone method may be useful to avoid that risk, mainly Mirena coil. Whichever route it would be done, the surgeon should be experienced such as Consultant level and the assistant should be at registrar level in view of difficulties that would arise during the procedure. The operative time may be prolonged and consider epidural which will be also useful as postop analgesia. When considering the hysterectomy, the options are Transabdominal, vaginal and laparoscopic hysterectomy. Choosing the correct entry method is important, it should be based on clinical history and examination findings preferably under anesthesia before the start of operation. In terms of surgical options, vaginal hysterectomy may be better. But one would need good uterine descent, which is possible if she is a parous woman. And the pedicle may slip and bleed, consider tie each pedicle twice. As she is young, ovaries should be preserved. But, it would be better looked at it, at the time of operation; this option is not possible with vaginal hysterectomy, so consider doing transvaginal scan before the operation. There will be limited access by vaginal route as well, but positioning the patient appropriately the operative table may help at certain extent. By transabdominal operation, the access may be difficult and slow postoperative recovery. So consider midline laparotomy to improve access. There is risk of wound infection and bleeding and hernia formation. For infection, antibiotic prophylaxis should be given during the induction. The fat layer should be closed separately, with intermittent suture using such as 2vicryl. For rectus sheath closer, consider sutures which take longer to absorb and make sure both angles are secured avoid hernia formation. With midline, laparotomy, use 1loop PDS or equivalent and mass closure to be done. There may be difficulty with removal of cervix, so needs to check previous smear results and if they are normal and difficulty with access, consider doing subtotal hysterectomy. But patient should be counseled before the operation and consented appropriately. She should be clearly informed the need for regular smears and risk of minimal cyclicial bleed should be informed. The blood loss should be measured and replaced if necessary. We should consider leaving urometer and patient needs close observation in the immediate postoperative period for pulse, Blood pressure, temperature, oxygen saturation and input and output- these will help to pick-up like internal bleed, atelectasis or thrombosis early. And this can be treated early. If it is being done by laparoscopic assisted hysterectomy, it needs to be done by trained professional. Patient should be counseled with regard to; not able to do laparoscopic entry and anesthetic risk, procedure risk specifically related to laparoscopy and do consent appropriately. There is a possibility the instrument may not be long enough. With regard to surgery, the risks are anesthetic risk, risks related to operation and thrombosis. With regard to thrombosis, we need to make sure patient receives early mobilization, correct size ted stockings and postop thromboprophylaxis. Anesthesia point of view, the co-morbid conditions, smoking should be checked, patient should be reviewed by anesthetist at pre-operative clinic including regional anesthesia and a plan of care should be made. There is risk of atelectasis, routine postoperative review by physiotherapist may be an option. If we elect to do under laparoscopic hysterectomy, the head down and increase in abdominal pressure may be limited due to anesthetic compromise, need to liaise with anesthetist.
value Posted by nada S.

\r\n Iwill review her history as regard her blood pressure and history of diabetes��� .if un controlled Iwillrefer her to internist to be controlled .Iwill treat anaemia Iwill treat any haematological disorder.as von willbrand disease.or thrombocytopenia. Iwill start anti fibrinoltic as tranxamic acidas it decrease blood loss by50% butting in concern its side effect as nausia and vomitingand gastric up set.NSAID can be� used as mefanamic acid keeping in mind its side effect and contraindication aspeptic ulcer ,asthma.COCP can be used and it is very helpful but� it is cotra indicatedwith high body mass index due to thrombophilia.IUS.levonorgestrilis very promising asitcause amenorrhea in12monthsin 70%of cases.depoprovera150 mg can be used

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essay Posted by vanosch M.
(a) This patient should be counsel about the findings and reassured, general advice regarding life style, diet and exersice and losing wight are given, as this may help in the managment of her disorder and elivates her anxity.may this only what she needs Medical treatments include non-hormonal and hormonal. iron supplementations is important as this patient may have anaemia NSAID is effective in reducing blood loss and its help in relifing pain associated with her periods if any, the most commmonly used is mefenamic acid. Tranexemic acid is another treatment that is effective in reducing blood loss,ptient should inform about side-effects and how she should take it. Hormonal treatment include COCP-progestogens -danazol and gnrh agonists. COCP is effective in managment .Another opton is progestogens which to be effective should be taken in high dose and for prolonged period. Danazol may be used .however, it used is restriccted by the adverse effects, mainly virilization and hirsutism, it is not used in UK for this indication anymore. Gnrh agonist is effective in reducing blood loss. however, it should not be used for more than 6 months, as this may be associated with decreased BMI, unless it is used with add back drugs such as estrogens. Another option is isertion of IUS (Mirena) which is effective and can be used for long time up to 3 years. complementory treatments such as chinease medications and herbal drugs can be used. However, there is insuffecient evidence for its efficacy. b) Hysterectomy as any other major surgery in morbidly obese patient is associated with increased morbidity and mortality. surgery associted complications may include increased risk of blood loss and the need for blood transfusion,difficulty in doing surgery and hoigher incidence of complications due to difficulty of controling bleeding with possible bowel,bladder and ureter injury. increased risk of post operative venouse thromboembolism VTE including DVT and pulmonary embolism. Higher incidence of woun infectin, gapping and dehiecinse. Morbidly obese patient has higher anaesthesia complications including difficult intubation and difficult recovery. To decrease these complications, other alternatives should be offer including medical or other surgical such as endometrial ablation. Any morbidly obese patient should be seen and assessed by senior anaesthesist and other specialist if required before surgery, idealy in pre-operation anaesthesia clinic, and loosing wieght is advisable specialy if surgery schedul is long. Cross match 2-4 PRBC before surgery and two IV lines should be scured. Pre-OP antibiotics is recomended. A senior gynicologist should be involved and suitable abdominal incision, medline is preffered if difficult surgery is expected. thromboprophylaxic shuld be given post OP according to local protocols.
HM Posted by HM ..
(a) This patient should have correction of any anaemia with Fe supplements given orally . Side effects (SEs) of this include epigastric upset, constipation and if intolerant of oral preparation, parenteral Fe will have to be considered. To reduce her blood loss, if there is no desire for a pregnancy for at least 1 year, LNG- IUS is recommended as first line . This reduces blood loss by about 80% . It may be difficult to isert in this woman given her size, in an outpatient setting, but it can be done with proper lighting , assistance if required. There is a risk of uterine perforation, and infection following insertion within first 3 weeks . This can be prevented with prophylactic antibiotic coverage. Irregular bleeding for 3-6 mths is common SE also. Tranexamic acid is an oral preparation , reduces blood loss by about 50% but associated with SEs of nausea, vomiting, diarrhoea and if visual disturbance occurs, it should be stopped. NSAIDS, mefenamic acid is an oral preparation , reduces blood loss by 25% has better SE profile than tranexamic acid. The COCP is not ideal option for this patient because she is morbidly obese and it is UKMEC3, especially because of VTE risk . It would be an option had she had weight reduction subsequently and not desirous of a pregnancy. It reduces loss by 50%. Progestogens, either oral preparation of medroxyprogesterone 15mg daily for 3 weeks (Day 5-26) or IM depot every 3 mths can be used but the SEs are of headache, mood swings, weight gain, acne ,bloating. With IM depot, patient will also likely become amenorrhoeic , occurs in about 55% cases after 1 year of use. GnRH agonists can be used if pregnancy not desirous and causes menopausal symptoms. It should not be used beyond 6 mths because associated with reduced bone mineral density and osteoporosis. (b) Hysterectomy can be offered either abdominally or vaginally with laparoscopic assistance. This patient is morbidly obese and there is significant VTE risk. Thromboprophylaxis involves a prophylactic dose of LMWH 12hrs prior and restarted 4 hrs postop. Intraoperatively, use of pneumatic compression stockings will further reduce risk . Postop, continued use of TEDS, hydration and early mobilization further reduces risk of VTE. LMWH can be continued for at least 7days if otherwise healthy. Infection is reduced with perioperative IV antibiotic given 1-2 hrs before sugery and can be continued postop if needed. Exposure for surgery will be difficult, especially if abdominal TAH done and assistants need to adequately retract the abdominal wall to provide visualization for the surgeon. The incision site will be discussed with patient before and although midline incision will have reduced blood loss compared to transverse incision, the risk of wound dehiscience may be greater. If laparoscopic sugery done to assist vaginal hysterectomy, the open Hassan technique will be required. Care must be taken to reduce blood loss in this patient as obesity associated with increased loss. Use of diathermy with caution and ligation of bleedig vessels may increase operating time. Surgery may need to be a subtotal if pelvis very deep or retraction / visualization difficult. Closure of abdominal wall should ideally be mass closure, or if not ensure the superficial fascia is closed. Staples to the abdominal wall will also reduce risk of dehiscience. Infrastructural challenges include ensuring the operating table can withstand the patient's weight.
Posted by Ranu R.
a) The aims of treating this woman would be reducing menstrual blood loss and correcting anaemia, thereby improving quality of life. The most effective non-surgical method is Levonorgestrel- releasing intrauterine system [LNG-IUS], which reduces bleeding by upto 95%. In addition, it may alleviate symptoms of dysmenorrhoea, reduce incidence of pelvic inflammatory disease & provide contraception. Main adverse effect is irregular bleeding which may last over 6 months. Other minor problems like breast tenderness, acne, ovarian cysts are usually transient. Rarely, perforation can occur during insertion. The non-hormonal medicines are first line therapy in primary care. They have the advantage of being used only during menstruation. Antifibrinolytics like Tranexamic acid reduce blood loss by 30-60% over a couple of cycles. NSAIDs like Mefenamic acid reduce blood loss by 20-40%. Both are effective in presence of copper or non-hormonal intrauterine devices. However, only Mefenamic acid has the added benefit of relieving dysmenorrhoea. Tranexamic acid is usually well tolerated with minor GI disturbances. NSAIDs commonly cause indigestion, though peptic ulceration can occur with prolonged use. Combined oral contraceptives are to be used with great caution [UKMEC 3] in this lady with BMI more than 45, as there is increased risk of deep vein thrombosis. Oral progestogens can reduce menstrual blood loss by about 80% in long term & can have minor transient side effects like bloatedness, weight gain, headaches. Depot injected or implanted progestogens may cause complete amenorrhoea. Common side effects include irregular bleeding, weight gain, premenstrual-like syndrome. Gonadotrophin releasing hormone analogues are mainly used to reduce fibroid associated blood loss. These can cause menopausal symptoms like hot flushes, vaginal dryness. It can also cause osteoporosis if used longer than 6 months. The clinical use of Danazol and Gestrinone are limited due to their androgenic side effects. b) Surgical challenges in obesity begins with incision placement as the common landmark, umbilicus is usually displaced. To overcome this, pubis is considered as a landmark for deciding incision. Transverse incision below pannus is better avoided as it is more prone to infection. A midline incision can provide adequate access. Meticulous anti-sepsis is required as there is increased risk of wound infection & dehiscence. Special care should be taken to clean groin and under the pannus. Antibiotics administered before incision also helps in reducing infection rates. Obesity also poses problems with access to the pelvis and identification of anatomical structures, which may result to inadvertent injury to neighbouring viscera. This can be reduced with good assistance, good retraction, good lighting & choosing long instruments which allow working in depth. Haemostasis may be difficult, mainly while removing cervix & suturing vaginal vault. In presence of normal cervical smear history, this lady may be offered a subtotal hysterectomy. Excessive cautery should be avoided as more dead tissue causes more infection. Wound disruption, which is again common in the obese, can be decreased by closure of superficial fascia & mass closure techniques. Closure of subcutaneous fat which is more than 2 cm also reduces wound infection. Higher risk of perioperative DVT & PE should be managed by appropriate sized anti-thromboembolic stockings, intermittent pneumatic compression and low molecular weight heparin. Vaginal surgery in obese women has low complication rates but increased rates of wound infection. Appropriate equipment and staff trained in manual handling must be available during surgery to ensure safety of the patient and theatre personnel.
NA Posted by naila A.
(A)In this case there are a number of nonsurgical treatment options which can be offered to her. Obesity is one of the causes for anovulatory cycles which may cause heavy menstrual bleeding. Counseling her for weight reduction and referring her to dietitian may solve the problem but it needs dedication and motivation from her side. I can offer her levonorgesteral intrauterine system as first line treatment if she want contraception also. It needs 12 months to be effective. She needs to be counseled about irregular vaginal bleeding for first three months and it may lead to complete amenorrhea after 12 months, which is not pathological. I can offer her medical treatment which consists of several types. Non hormonal treatment is first line medical treatment it consist of tranexamic acid and NSAIDS, tranexamic acid is preferred over NSAIDS. It can decrease blood loss up till 50%.The side effects are GI upsets and a small risk of VTE .NSAIDS can reduce bleeding up till 25% to 40%, can cause GI upsets and peptic ulceration. Hormonal treatment consist of norethisterone from day 5 to day 26.Blood loss is reduced up till 50%.side effects are of preogesterone ,that is mood swings, bloatedness , fluid retention and mastalgia. COCPS provide effective contraception and reduce blood loss effectively up till 50%. Should be prescribed with caution in women with obesity because of increased risk of thromboembolism. It is contraindicated in women over 35 who smoke because of unacceptable risk to health. It can lead to 3 fold increased risk of hypertension and 3 fold increased risk of myocardial infarction. GNRH analogues can lead to amenorrhea and can be used in cases of intractable vaginal bleeding side effects are hot flushes ,vaginal dryness and bone loss if used more than 6 months. Danzol can be used for a limited time period .Its use should not exceed 6 months due to virilizing effects of the drug. It can also cause photosensitivity ,muscle pain and benign liver adenomas. Medroxyprogesteronacetae can be used as 3 monthly injections . Can reduce blood loss effectively but associated with irregular bleeding an amenorrhea .Amenorrhea if exceeds more than one year can lead to loss of BMD. (B) There are several surgical challenges in this case due to her morbid obesity. Weight loss should be advised before any surgical intervention, although it is less likely that she may achieve the weight loss before the time of surgery. For her surgery the operating theater staff will need to make special preparations .The operating bed and shifting trolley should of adequate size. Long retractors to gain access in abdominal cavity will be needed. The preferred incision for the surgeon to make is low transverse incision due to low subcutaneous fat in this area but it is associated with more risk of wound infection because of moist environment in subpannicular area.The risk of wound infection can be decreased by advising prophylactic antibiotics within two hours of the abdominal incision. Antibiotics may be given for 48 to 72 hours post operatively. After making incision the major problem is to gain adequate access in deep cavity. Long retractors are required to reach in the depth of the cavity. If there is difficulty in reaching to the vault of vagina subtotal hysterectomy may be preferred over total hysterectomy. Due to working in deep cavity difficulty in securing homeostasis may be encountered therefore blood should be grouped and cross matched before surgery. Closing of abdomen should be with delayed absorbable sutures due to risk of wound dehiscence. There is excessive subcutaneous fat which can cause wound infections ,therefore the preferred method of skin closure is with staples or interrupted skin suters. Subcutaneous drains may be needed. The other serious post op risk is of VTE. To decrease this risk she should be given prophylactic low molecular weight heparin
Ans Posted by cLEMENT  F.
A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. I investigate and treat iron deficiency anaemia by giving oral iron supplements. Her options of treatment will be determined by her fertility intentions and wishes and may include the following; No treatment: this may be suitable if the patient is satisfied that objective menstrual loss is normal and there is no associated anaemia. It avoids the risk of drug treatment and associated side effects. She will however require regular follow up by GP to rule out anaemia. Mefenamic acid: this is a nonsteroidal antiinflammatory drug that is associated with about 30% reduction in menstrual blood loss. There is a small associated risk of nausea and vomitting, and gastric irritation, which is reduced by taking it after meals. Tranexamic acid: this is an antifibrinolytic drug that reduces menstrual blood loss by 20 to 40 percent. There have been concerns about a theoretical risk of thromboembolic disease and caution must be exercised in patients at very high risk of VTE, such as this patient with morbid obesity, particularly if therte are additional risk factors. COCP: this is highly effective in reducing heavy menstrual blood loss.It also has the added benefit being an effective contraceptive and reducing the lifetime risk of ovarian cancer. However it is associated with an increased risk of VTE, breast cancer and is not suitable if the patient has migraines with aura, hypertensive and diabetic disease, smokers, and age more than 35. Depo Provera: This a depo progesterone that effectively reduces menstrual blood loss. It is suitable in most people with contraindications for COCP, reduces the risk of endometrial hyperplasia and cancer, and is an effective contraceptive. It however has the side effects including breast tenderness, unscheduled bleeding and weight gain. Implannon: This is a long acting progestogen implant that is effective contraception for 3 years. Many users have amenorrhoea and most others have reduced menstrual blood loss. It however has to be inserted and removed by trained personnel. Miraena IUS: This is a highly effective form of contraceptive associated with significant reduction in menstrual blood loss with patient satisfaction rates of about 90%. It is a progestogen impregnated intrauterine device that releases progestogen locally into the uterus to reduce endometrial thisckness. It is also effective agains endometriosis pain and some cases of adenomyosis and small fibroids. It however caries a risk of unscheduled bleeding, breast dicsomfort, acne and oily skin, and coil expulsion. GnRh analogues: this is injected monthly over a 3 to 6 month period and suppresses ovulatory activity and induces a temporary menopause through competitive inhibition of GnRh receptors.It is highly effective treatment for HMB. It however carries the risk of severe menopausal symtoms such as hot flushes, irritability mood disturbances and osteoporosis. Laparoscopic Hysterectomy; This may be technically difficult and special operating table may be required. There is a recognised high risk of entry related injury to abdominal organs. This risk may be reduced by using the Hasson's technique or entry through Palmer's point. Abdominal hysterrectomy: this may be technically difficult due to difficult access into a deep pelvis. These may be overcome by making a generous initial abdominal incision, getting additional help with retraction, and using an abdominal pack for bowels and a self retained retractor. The procedure may be made easier by doing a subtotal hysterectomy first and then removing the cervix finally. Vaginal hysterectomy: This may be technically difficult due to access restriction by the patients thighs. Using two extra assistants to hold retractors and other instruments, ensuring a dgree of head down tilt of the operating table and ensuring good lighting will facilitate the procedure.
Ans Posted by cLEMENT  F.
A 36 year old woman attends the gynaecology clinic because of heavy menstrual periods. She weighs 125kg with a BMI of 45 kg/m2. Following full assessment, no underlying cause has been identified. (a) Critically evaluate the non-surgical treatment options for this woman [10 marks]. (b) After counselling, she wishes to have a hysterectomy. Discuss the surgical challenges posed by hysterectomy in this woman and how these can be overcome [10 marks]. I investigate and treat iron deficiency anaemia by giving oral iron supplements. Her options of treatment will be determined by her fertility intentions and wishes and may include the following; No treatment: this may be suitable if the patient is satisfied that objective menstrual loss is normal and there is no associated anaemia. It avoids the risk of drug treatment and associated side effects. She will however require regular follow up by GP to rule out anaemia. Mefenamic acid: this is a nonsteroidal antiinflammatory drug that is associated with about 30% reduction in menstrual blood loss. There is a small associated risk of nausea and vomitting, and gastric irritation, which is reduced by taking it after meals. Tranexamic acid: this is an antifibrinolytic drug that reduces menstrual blood loss by 20 to 40 percent. There have been concerns about a theoretical risk of thromboembolic disease and caution must be exercised in patients at very high risk of VTE, such as this patient with morbid obesity, particularly if therte are additional risk factors. COCP: this is highly effective in reducing heavy menstrual blood loss.It also has the added benefit being an effective contraceptive and reducing the lifetime risk of ovarian cancer. However it is associated with an increased risk of VTE, breast cancer and is not suitable if the patient has migraines with aura, hypertensive and diabetic disease, smokers, and age more than 35. Depo Provera: This a depo progesterone that effectively reduces menstrual blood loss. It is suitable in most people with contraindications for COCP, reduces the risk of endometrial hyperplasia and cancer, and is an effective contraceptive. It however has the side effects including breast tenderness, unscheduled bleeding and weight gain. Implannon: This is a long acting progestogen implant that is effective contraception for 3 years. Many users have amenorrhoea and most others have reduced menstrual blood loss. It however has to be inserted and removed by trained personnel. Miraena IUS: This is a highly effective form of contraceptive associated with significant reduction in menstrual blood loss with patient satisfaction rates of about 90%. It is a progestogen impregnated intrauterine device that releases progestogen locally into the uterus to reduce endometrial thisckness. It is also effective agains endometriosis pain and some cases of adenomyosis and small fibroids. It however caries a risk of unscheduled bleeding, breast dicsomfort, acne and oily skin, and coil expulsion. GnRh analogues: this is injected monthly over a 3 to 6 month period and suppresses ovulatory activity and induces a temporary menopause through competitive inhibition of GnRh receptors.It is highly effective treatment for HMB. It however carries the risk of severe menopausal symtoms such as hot flushes, irritability mood disturbances and osteoporosis. Laparoscopic Hysterectomy; This may be technically difficult and special operating table may be required. There is a recognised high risk of entry related injury to abdominal organs. This risk may be reduced by using the Hasson's technique or entry through Palmer's point. Abdominal hysterrectomy: this may be technically difficult due to difficult access into a deep pelvis. These may be overcome by making a generous initial abdominal incision, getting additional help with retraction, and using an abdominal pack for bowels and a self retained retractor. The procedure may be made easier by doing a subtotal hysterectomy first and then removing the cervix finally. Vaginal hysterectomy: This may be technically difficult due to access restriction by the patients thighs. Using two extra assistants to hold retractors and other instruments, ensuring a dgree of head down tilt of the operating table and ensuring good lighting will facilitate the procedure.