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MRCOG PART 2 SBAs and EMQs

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EMQ1502
SBA2115
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Essay 352 marked answers

kshama u Posted by Kshama U.

 

The patient has abnormal uterine bleeding without any identifiable cause, i. e. Dysfunctional uterine bleeding. She should be offered the non-surgical treatment option which are the first line treatment for dysfunctional uterine bleeding. She should be offered information about various treatment options, which include NSAIDS like Mefenamic acid, Antifibrinolytics such as Tranexamic acid which are the non-hormonal medications. The hormonal treatment options include combined oral contraceptive pills, progestogens which include oral as well as Injectable progestogens , Mirena – levonorgestrel intrauterine system and GnRh analogues.

NSAIDS (Mefenamic acid) & Tranexamic acid are time line treatment. They reduce the menstrual blood loss & generally well treated. Tranexamic acid decreases by 50%

Combined oral contraceptives are first line hormonal therapy, but have increased risk of VTE associated with obesity. They reduce menstrual blood loss by 50%. Progesterone cyclical (leuteal phase) were given previously are not recommended now. They are associated with irregular bleeding.

Mirena coil is very effective in treatment of DUB, it reduces HBL by 90-95%. It is associated with minimal systemic side effects. It may be associated with irregular bleeding for initial 3-6 months, which then settles down.

GnRh analogues can be used in patients while waiting for surgery for correction of anemia or weight loss, but are not a preferred option.

Patient should be offered evidence based information about the treatment options & allowed to make an informed decision.

As the patient wishes to undergo a hysterectomy, she should be offered information about the risk associated with surgery such as risks of anaesthesia, increased risk of hemorrhage, infection, morbidity & wound dehiscence . She is at a greater risk of VTE due to her obesity.

Anesthesia risk is more due to difficult intubation, difficulty in regional anesthesia due to obesity.

Pre-operative preparation has to be done & she is advised to stop smoking. If patient is taking OC pills they had to be stopped. Pre-operative weight loss & correction of anemia is advisable.

Route of surgery should be decided depending on the expertise & equipments available. Vaginal route may be preferred as it is associated with less post operative morbidity but inspection of adnexa can be difficult . It requires surgical expertise in a case with no descent.

Laparoscopic surgery is now a days preferred in obese patients with appropriate expertise as it is associated with less post operative pain, morbidity & early mobilization. Entry into the peritoneum can be difficult, can be overcome by inserting Verre's needle perpendicular to the abdominal wall. Visiports can be used

Abdominal hysterectomy is less preferred as it has increased risk of wound dehiscence. Prophylactic antibiotics should be given.

Pelvic surgery in obese patients have increased risk of VTE. Graduated elastic compression stockings should be recommended during surgery & post operative. LMWH Prophylaxis should be started. Maintenance of hydration & early mobilization & physiotherapy are encouraged.

 

Essay Posted by Samira  K.

a-This lady is suffering from abnormal uterine bleeding of endometrial origin .Nonsurgical treatment options are first of all Weight reduction to decrease her hyperestrogenic state which might lead to endometrial hyperplasia.Mirena as a first line of treatment.This lady is obese and combined oral contraceptive pills are not recommended for her due to high risk of venous thromboembolism.Oral progesterone also can increase her weight as its side effect but local progesterone in the form of Mirena is best for her.It decreases blood loss 605 after 3 months and 90% OR COMPLETE AMENORRHEA AFTER 9 MONTHS.It can cause irregular vaginal bleeding for the 1st 3-6months and patient should be informed.It will work as contraception as well if she desire.There can be technical problems in insertion due to obesity and if there is insertion can be done under analgesia/anaesthesia.The other alternative for this lady is oral mefanamic acid or trenaxemic acid during mensturation.both can decrese blood loss by 40%.They can be used separately or together.There are usually no side effects from them except some nausea from trenaxemic acid

b-Hysterectomy is a major operation and there are special surgical challenges for this obese lady and she should be conselled regarding them.Spinal and even general anaesthesia is difficult needle insertion and intubation respectively .She should be referred to anaesthesia before surgery so that they can plan ahead.Apart from bladder,bowl,vascular injury anb hemorrhage risk like any women going for hysterectomy this lady can have some special problems because of her weight.Like need of special bed and staff that can transfer her to OR room safely.Due to abdominal fat exposure will be difficult but special equipment and competent assisstant can make life easy.She will require mass closure of rectus sheath as there is risk of dehisence and hernia later on.Surgery will take longer time then usal and there is risk of DVT which can be reduced by using inytaoperative leg stockings and post operative prophylactic heparin(low molecular weight.Vaginal hystectomy will avoid problems of wound dehisence and wound infection and can be quicker with early postoperative recovery ,so it should be offered.Her risks of infection can be avoided by prophylactic antibiotics,

No role of endometrial ablation? Posted by Mythli B.

Dear Dr.Paul,

Should we not discuss endometrial ablation in this patient?