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MRCOG PART 2 SBAs and EMQs

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EMQ1470
SBA2076
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assay364

assay364 Posted by huaida A.

 

A healthy 39 year old woman has undergone laparotomy and myomectomy because of uterine fibroids. Her pre-operative Hb was 11.3 g/dl and the estimated blood loss was 700 ml. You are asked to see her because she has only passed 40 ml of urine over 4h post-operatively. (a) List the most important causes of oliguria in this woman [2 marks]. (b) Based on these causes, discuss your initial assessment [6 marks]. Two hours later, laboratory results show normal renal function and Hb of 6.8 g/dl and haematocrit of 0.24. Discuss your management [12 marks].

     A/   Oligurea in this patient may be due to internal bleeding   that reduces the renal blood flow and hence the glumerular filtration rate resulting in oligourea.

 Ureteric injury or ligation is an other possible causes specially if there is parasitic fibroid in the broad ligament  or if there is distorted anatomy.

bladder injury with leakage of urine intra peritonealy is an other possible cause. 

B/I would inquire about abdominal pain radiating to shoulder tip which indicate diaphragmatic irritation by internal bleeding.Also I would ask about  loin pain which may point to presence of hydronephrosis.

I would assess the general condition of the patient looking for evidence of hypovoleamia , so would assess her bp, PR,pallor,oxygen saturation

I would examine the abdomen  for,distension,tenderness and rebound tenderness  which may point to presence of internal bleeding.

also would examine the loins area looking for tenderness.

Then would invistigate the patient ,re test the Hb , RFT , perform U/S of the abdomen  looking for free fluid ,as well as u/s for renal system .

c/

It is clearly that this is is internal bleeding so the pateint should informed with the possible cause 

consent of re openning  and possibility of hysterectomy if bleeding not stop should be discusesed with patient 

the senior obstetrician should be called as well as the anasthetist and haematologist

The patent should transfused with cross matched  blood  and further blood  should be prepared for the laprotomy

intra operatively  bleeding should be secured, a drain should be inserted

The pt at risk of wound dehesciness so the abdomen should closed in mass suture.

The pt also at risk of infection so should covered with postoperative antibiotic.

Thromboprohylaxsis should be given after the risk of further bleeding subsided

incidence form for risk managment  is of paramount important