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MRCOG PART 2 SBAs and EMQs

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ans essay 352

ans essay 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

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