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