Essay 306 - HMB

A)Non surgical treatment options include.

 Correction of anemia  by iron supplements,given orally or parenterally.This will improve her symptoms of anemia but will not be a definitive treatment for excessive bleeding.However She should be given iron supplement while awaiting for definitive treatment.

Tranexamic acid ,500mg  tid,given orally during menstruation can reduce blood loss by 40-50%.side effects include gastrointestinal disturbances i.e nausea, vomiting and diarrhea. Disturbance in color vision may warrant discontinuation of treatment.

NSAIDS-mefenamic acid  taken during menstruation can reduce blood loss by 25%.Associated with GI side effects but less severe than Tranexamic acid.It is helpful if bleeding is associated with dysmenorrheal.

COCP-very effective and cheap, can reduce blood loss by 50%. However for BMI 45,it is

UKMEC 3,hence it will not be a suitable option for her.

Progesterone-Nrethisterone  should be taken in high doses 5mg tid, from D5-25 to be effective. Can reduce blood loss by 60%Compliance will be an issue.

DMPA injections can reduce blood loss and even cause amenorrhea, but irregular bleeding pattern is an important side effect. She should be counseled about this.

GnRh analogues are very effective, can reduce blood loss effectively 60-100% by causing ammenorrhea.But it causes menopausal symptoms and loss of bone mineral density.It can be used for 6months ,while definitive treatment by surgery is planned.

LNG IUS  can be advised for her,if she desires contraception also and intends to use for more than a year.It is effective in reducing blood loss by 60% at 6m and 80-90%,at 1yr.

She should be given written information and her wishes should be considered in making a choice.

B)Surgical challenges with this obese woman  can be reduced by adequate preparation and couselling.

Route of hysterectomy-she should be counseled that vaginal route is associated with less morbidity.If abdominal route is the option,  laparoscopy is preferred as it is  associated with lesser morbidity than laparotomy.

General anesthesia  is associated with difficult intubation due to obesity.Hence regional anesthesia is preferred .

Difficulties in access may be overcome by taking bony land marks such as anterior superior iliac spine and xiphisternum for incision as cutaneous land marks are not reliable due to overhanging pannus.Panniculectomy may be done with the help of cosmetic surgeons ,but it increases operative time and morbidity.Laparoscopic entry can be made by open method  or at palmar`s point .

Risk of hemorrhage and difficulty in securing hemostasis  pose a problem as access to pelvis is challenging.Subtotal hysterectomy is acceptable in such situation if she has normal smear history.Flexible illuminators ,which can provide good light and long instruments can be used.

Wound complications,-Incision in midline has lesser risk of  infection than incision under the pannus.Risk of infection can be minimized by giving prophylactic antibiotics before skin incision.Apropriate preop aseptic technique ,Chlorhexidine is preferred to alcohol.Excessive use of cautery is avoided as it leaves dead tissue prone to infection.

Mass closure technique using delayed absorbable suture .without undue tension,and closure of scarpa`s fascia reduces the incidence of fascial breakdown.

Risk of VTE can be reduced by giving subcutaneous heparin.regional anesthesia,TED stockings and intermittent calf compression during surgery.Postoperatively early mobilization and good hydration is important.

(A)

No treatment is an option if heavy periods does not interfere too much with normal life . However , blood tests should be performed every so often to check for anaemia and iron tablets prescribed if anaemia detected .

Levonoregestrel intrauterine system  is an effective method ( most women will have lighter periods or amenorrhea within 3-6 months of its insertion) .It is a contraceptive method ( licensed for 5 years ) and so suitable for women who require long term contraception .Although expensive , it is cost-effective if used for more than one year .common side effects of this treatment include irregular bleeding that may last over 6 months and progestogenic side effects ( e.g acne ,breast tenderness and headache ) which , if present , are usually mild and transient .

Tranexemic acid is oral tablets taken for 3-5 days each period and reduces blood loss by 50% .It is not a contraceptive and has no effect on future fertility . Side effects include nasuea and bloating 

Nonsteroidal anti-inflammatory drugs reduces menstrual blood loss by third and also reduces period pain .It is not a contraceptive and does not affect future fertility . side effects include GIT upset , but less severe than tranexemic acid.

Combined oral contraceptives reduces menstrual blood loss by 50% . It is a reliable contraceptive and  also makes cycles more regular and lighter .However , it should be avoided in women with BMI  35 or more due to increased risk of thrombosis .

norethisterone tablet can be effective if given from day 5 to 25 of the cycle . it is not a contraceptive , but may prevent ovulation .side effects include bloating , breast tenderness and mood changes .

depot medroxypregesterone acetate is a contraceptive method that effectively reduces menstrual blood loss ( amenorrhea is common ) . there may be a delay in return of fertility for 1-2 years after stopping it . side effects include irregular bleeding and progestogenic  effects such as bloating and breast tenderness .

GnRH analouge produces amenorrhea . it can be used if other methods failed or contraindicated and can also be used before surgical treatment of fibroids . its use is associated with menopausal symtoms ( e.g hot flushes , night sweats ) and if used long term (> 6 months ) ,  ' add back ' therapy with oestrogen containing compound is needed

(B)

With morbid obesity , there are anaesthetic problems e.g difficult cannulation and difficult intubation .Therefore , early anaesthetic assessment is recommended and regional anaesthesia is encouraged as it is associated with lower morbidity compared to general anaesthesia .However , an experineced anaesthetist should perform regional anaesthesia as it may be difficult.

There are problems with lifting and moving the patient . Therefore , early communication with theatre staff is recommended so that trained personnel able to deal with such cases and suitable equibments (e.g electronically operated beds and theatre tables with safe working loads and with lateral transfer and width extension facilities ) can be arranged .

Intraoperatively , there is problem with positioning the incision due to displacement of the umblicus . Therefore , bony landmarks such as pubis , anterior superior iliac spine and xephesternum has to be considered to decide where to perform the incision .  Midline incision in morbidly obese women give an easier access .if laparoscopy to be performed , open ( Hasson ) technique or entry at the palmers point is recommended .

There is increased risk of wound infection in morbidly obese women . Measures to reduce this risk include careful cleaning under the pannus and in the groin region and avoiding incision below the pannus as such wound is associated with increased risk of infection because of the anaerobic moist enviornment of the subpannicular pannus . the use of antibiotic before skin incision also reduces risk of wound infection .

Access to the pelvis is difficult and this may lead to intraoperative complications such as organ damage . Goos assisstance , retraction , the use of flexible illumination and long instruments are helpful to overcome this problem .

Panniculectomy can give a wider access to the pelvic field , but requires a plastic surgeon and significantly prolong operation time .

There is difficulty with haemostasis , particularly when removing the cervix and suturing the vaginal vault . For this reason , subtotal hysterectomy is an acceptable option if there is no malignancy and cervical smear history is normal .vaginal hysterectomy is another option associated with lower morbidity compared to total abdominal hyterectomy .

There is increased risk of wound dehiscence . Measures to overcome this problem include good haemostasis ( but avoid excessive cautery) , mass closure technique with delayed absorbable sutures and closure of superfacial fascia .

There is increased risk of venous thromboembolism . To reduce this risk , stop oestrogen -containing contraceptives ( if used ) four weeks before the operation . use appropriate sized antithrombotic stocking and intermittent pneumatic compression devices .low molecular weight heparin   should be used  postoperatively ( unless there is risk of bleeding ) and continued througout hospital stay and for 7 days after surgery ( 4 weeks in case of malignancy ) . early mobilisation and adequate hydration are advised .

Non hormonal pharmaceutical treatments like tranexamic acid 1g TDS for 4 days at menses and mefanemic acid 500mg TDS are cost effective, simple measures that are suitable for women wishing to concieve or where hormonal methods are not appropriate. Additionally tranexamic acid, an NSAID will provide effective analgesia is dysmenhorrea coexists. Side effects include diarrhoea and vomiting, and mefanemic acid users may experience rash and headache. NSAIDs are unsuitable for asthma sufferers or with peptic ulcer disease. Iron therapy will also help alleviate symptoms of anaemia.

Levonogestral IUS is cost effective if given for at least 1 year. Although considered more invasive, provides effective contraception and is effective in up to 80%. It is associated with less prementrual type side effects (breast tenderness, irritability) that other progestogen only options. Problematic spotting for up to be 4 months should be discussed.

High dose progestogens such as norethisterone 5mg TDS for days 5 till day 26 or DMPA are effective. Irregular bleeding is associated with DMPA but effective contraception is also implemented.

Other forms of ovarian suppression include danazol and gestrinone. Both can cause virilising effects such as hair loss, acne, and irreversible voice deepening. Neither provides effectiove contraception which is required owing to the virilising effects on a developing female fetus.

GnRH anologues are useful if an immediate, albeit short term solution is required. Associated with bone thinning and menopausal symptoms it is not licenced for long term use.

B.

Preoperative counselling and advice regarding weight loss and alternatives should be given with supporting written information.

Preoperative anaesthetic assessment is essential due to the additional risks and difficulties in obese patients; failed intubation, difficulty ventilating and the advantages of regional anaesthesia (spinal, epidural)  in post operative recovery. Regional techniques can be especially difficult in obese patients.

The appropriate route of surgery should be chosen for this patient. Minimal access routes (vaginal hysterectomy, LAVH, Total Laparoscopic hysterectomy) provide quicker recover time and reduces risk of infection and thrombosis, however may be technically difficult and pose addtional dangers (diffciult ventilation). Laparotomy, using bony landmarks, provides better access but increases operating time and thus risks of infection, thrombosis.

Additional thought should be given to the location of the incision in respect of the abdominal pannus. avoiding incision in the subpannicular fold reduces the risk of infection. An experienced surgeon should operate to reduce operating time and blood loss. Interrupted, non dissolvable sutures allow foreign material to be removed from the wound at 10 days.

This risk of venous thromboembolism needs to be indicually assessed in this patient. high risk patients can be given LMWH 2 hrs before surgery then a prophylactic, weight adjusted dose 12hrly following the procedure.  Mechanical VTE prophylaxis in the form of graduated compression stockings post operatively and intermittent calf compression during surgery should be implemented.

Surgical site infection should be minimised by administration of a suitable antibiotic prior to the skin incision. immaculate scrub technique, preparation of the skin with a suitable antiseptic with time to dry aswell as patient education regarding wound hygiene and social factors (smoking cessation, nutritional status). MRSA carriers should be identified in the pre-op assessment by routine screening (nasal and groin swabs)

Post operatively, mobilisation should be encouraged and discharge planned. This is encouraged by minimal or early removal of drains and catheters. Discharge planning in agreement with the patient allows the patient to be an active particapant in the process.

Practical considerations to the patients weight to be considered. Risk assessment should be undertaken preoperatively, ensuring suitable equipement is available to ensure safe patient handling and all staff are trained in manual handling.

a)Non surgical treatment options.Need to  treat anaemia.This improves quality of life ,but does not treat the heavy bleed.Combined oral contraceptive pills is well tolerated ,and advantageous if contraception also required.Not advisable,if she is,obese bmi-45, hypertensive,smoker or has h/o dvt,migraine.In this case not advisable for COCP.It reduces blood loss by 50%.periods are not painful and inexpensive treatment..But in this case not advisable due to BMI -45.Nonsteroidalantiinflammatory drugs (mefenemic acid),antifibrinolytic agents(tranexemic acid)..

Lesser blood loss with tranexemic acid.Blood loss reduced by 50%.Side effects are irritation of git,intracranial thrombosis,central venous stasis,retinopathy .NSAID have better side effects than tranexemic acid,better analgesia too.

.Cyclical  progestogens are useful if given from 5th day to 25th day,of cycle.Reduces blood loss significantly.Disadvantage is bloating,mood change effects on skin.Not a contraceptive.Depo progesterone induces amenorrhoea and effective contraceptive.Side effects irregular bleed,weight gain.Delay in return to normal fertility once  discontinued.

Levonorgestrel releasing intrauterine system reduces blood loss by 80% in 3 months and95% in one yr.Effective contraceptive.Cost effective if used more than a year

Gnrh analogues produce amenorrhoea.Cause menopausal symptoms and loss of bone density if used > 6 months.May be used  a few weeks prior to surgery.

b)surgical challenges and ways to overcome.Anesthetist ,preferrably senior as obesity poses difficulty in case of intubation,also for epidural,difficulty in accessing the epiduralspace,due to fat.

Due to pannus,cutaneous landmarks are unreliable.Hence for incision for laproscopy or laprotomy use bony landmarks of ant. superior illiac spine and xiphisternum..Enter at palmers point.Consider vag. hysterectomy,if previous vaginal delivery.If not,according to wideness of pubic arch,and descent of uterus will decide if fit for vag. hysterectomy.

hemorrhage and visceral injury.Risks increase due to difficult access,especially in pelvis.subtotal hysterectomy or vaginal hysterectomy are less morbid,and easier .

Wound complications.Wound infections, hematoma and dehiscence..Use antiseptic chlorhexidine,for clensing pre op.Midline incision has better exposure.

Use mass closure with delayed absorbable suture,and close scarpas fascia to reduce superficial dehiscence.

Venous thrombo embolism,regional anesthesia has less risks.Heparin thromboprophylaxis,TED stockings,intermittent calf compression,good hydration and early mobilisation.

Non-Surgical treatment options include Tranexamic acid which is an antifibrinolytic agent and decreases blood loss by about 50%, however, has gastrointestinal side effects like nausea acid diarrhea. Non – steroidal anti-inflammatory agents like mefanamic acid  which again have above mentioned gastrointestinal side effects and also increased chances of peptic ulceration if used prolonged periods. Combined oral contraception is very effective in bringing down the amount of blood loss but are contraindicated in women with a BMI >40 Kg/m² as there is increased chances of venous thromboembolism. Therefore, is not suitable for this patient. Progesterone like norethisterone, medroxy progesterone also bring down blood loss but are associated with weight gain and associated with lipid profile changes which may suitable for her. Danazol is a testosterone derivative produces ammenorhoea however is associated androgenic side effects including lipid profile changes, weight gain, acne and menopausal symptoms ,therefore, would be unsuitable for her also. It cannot be given long term as causes voice changes and hirsuitism. GnRH analogues are also used but have disadvantage of causing osteoporosis and postmenopausal hot flushes and cannot be given more than 6 months, if given for a longer period then  add back therapy should be given. Obese women already have vitamin D deficiency therefore may not be suitable. Mirena, is the best  option as systemic side effects of progesterone are not there and produces ammenorhoea in 90% by the end of first year, irregular bleeding may be a problem in first year.

            These women are at increased risk of having comorbid conditions like diabetes and hypertension therefore increased risk of surgical and anaesthesia related problems. Appropriated size OT tables, BP cuffs would be required and shifting these patients may be difficult. Incision site may be difficult to delineate as they have a big panniculus. Laparoscopic Hysterectomy may be difficult as entry might be difficult and appropriately sized laparoscopic instruments would be required. Exposure at laparatomy may be difficult because of panniculus hanging down and obstructing vision. Post-operative, wound infection and dehisence be increased and thrombo- embolism risk is also increased. Therefore appropriately sized BP cuffs, OT tables and shifting trolleys should be there. Laparoscopy is better than laprotomy however, may require long instruments and good experienced operator. Antibiotics and thromboprophylaxis is an absolute must.

a)

Nonsurgical treatment options for the heavy menstrual bleeding includes Levonorgestrel intrauterine devise (Mirena) which is first choice of treatment, and other pharmacological agents. Benefits of Mirena coil include long acting method i.e. lasts for 5 years, additional contraceptive benefit, and absence of systemic side effects. It is a preferred option for the women desiring to preserve the uterus and future fertility. Although, after Mirena coil insertion, 6-8 months period is expected for its benefits to become evident and it is recommended to wait atleast 6 months before switching to next options. Also some women may omplain continuous irregular pv bleeding/spotting, headache and breast tenderness.

Other options include combined oral contraceptive pills , which provides not only relief from heavy bleeding, but also regularises the menstrual cycles. These pills also protect against endometrial, ovarian & colorectal cancers. In view of risk of developing venous thromboembolism, its use in obese women is restricted, as with the given case.

Other nonhormonal options include NSAIDS and tranexamic acid. These help reduce the symtoms of bleeding & pain associated and improve the quality of life. The problem with these include gastritis and prolonged use is not recommended in fear of NSAIDS induced nephropathy.

Gonadotrophin releasing hormone analogues (GnRH) like Zoladex (Goserline 3.6 mg) injections do reduce the bleeding significantly. It also has added advantage to treat associated fibroid or adenomyosis or endometriosis. It needs to be taken as monthly injections. But if taken for more than 4 months, there is need of addback therapy with HRT to prevent the bone loss. Major disadvantage of it is menopausal symptoms and recurrence of symptoms shortly after discontinuation.

Use of danazol, ethamsylate, herbal medicines and acupuncture therapy are not recommended.

b)As this women is willing for hysterectomy, all the options like abdominal / vaginal or laparoscopic route should be discussed with her including the benefits & risks.

Major difficulty in her case would be due to her morbid obesity. There is difficulty anticipated for anaesthesia either for intubation if GA or finding a proper plane for spinal anaesthesia. There is intraoperative risk of cardio-respiratory compramise. Also there is high risk of development of venous thromboembolism. VTE assessmnent should be done for any other risk factors. Whatever the route of surgery is chosen, it is a challenging for surgeons due to difficult access. There is signifiant risk of surgical complications like tissue injuries, wound infection/hematoma, bleeding, emphysema, and increased morbidity & mortality.

These complications can be overcome by some of the preventive measures like, weight reduction prior to surgery, direct involvement of consultant anaesthetist & consultant gynecologist in decision making and during the procedure. Laparoscopic approach is found to be safest for the patient. Adequate counselling and consenting should be done for alternate procedures in the event of complications. Preop work up should include FBC, RFT & group & save. Anti DVT stockings, LMWH thromboprophylaxis, adequate hydration and early ambulation these are key things to prevent thromboembolism. Antibiotics prophylaxis and suturing of subcuticular layer of fat is recommended if fat thickness > 2cm.

If needed, postoperative management can be carried out in HDU/ITU set up. Post-operative debriefing and follow up should be arranged to see for delayed complications.

a)

Tranexamic acid is an anti-fibrinolytic that can be given orally reduces menstrual blood flow by 50%. However, with oral preparations, dosage may need to be adjusted in obesity and compliance with oral dosing is required. Non-steroidal anti-inflammatory drugs can reduce menstrual blood loss by approximately 30%, and is als effective in relieving coexistent dysmenorrhoea. NSAIDs have to be used with caution in patients with gastric problems as these may cause gastritis and gastric ulcers. Combined oral contraceptive pills  are effective in reducing menstrual blood loss and can also act as contraception. They carry a risk of venous thromboembolic events and stroke. Combined oral contraceptive pills are contraindicated in morbid obesity and should not be used in this patient. Oral progestogens such as norethisterone may be given orally on D5-26 of the menstrual cycle and are effective. Progestogen only injections such as depoprovera can be given as 3-monthly injections and is useful as long-acting contraception. However, these progesterone-only methods cause weight gain which is an undesirable side effect in this morbidly obese patient. Depoprovera can also cause irregular vaginal bleeding which may be unacceptable to the patient. Levonorgestrel intrauterine system is effective in reducing menstrual blood loss, with amenorrhoea in 65% of patients after 1 year of use. The risk of systemic progestogenic side effects such as headaches, weight gain and acne is also lower with the levonorgestrel intrauterine system compared to other progestogen-only methods. There is however a risk of irregular bleeding in the first 6 months of use. Gonadotrophin releasing hormone analogues  may be considered but these are associated with menopausal symptoms of hot flushes, mood swings and loss of bone mineral density especially with use of more than 6 months. Endometrial ablation is an effective procedure which can be done under local anaesthesia, avoiding risks of general anaesthesia. It is not suitable if the patient is keen for future fertility. There is a risk of uterine perforation, hemorrhage and infection. The procedure may be difficult to perform in a morbidly obese patient due to constraints in access and positioning. 

b)

A multidisciplinary team should be involved throughout the course of planning, executing and post-operative management of a hysterectomy in this morbidly obese patient. This includes an experienced gynaecologist, anaesthetist, operating theatre staff and tissue handling teams. Anaesthetic review preoperatively is vital in view of the increased risk of a difficult airway and difficult intubation and potential difficulties with intra- and post-operative monitoring. Invasive monitoring may be considered if obesity precludes accurate monitoring of blood pressure with the standard blood pressure cuffs. Obesity is often associated with comorbidities such as diabetes and hypertension and these should be optimised preoperatively. Difficulty with positioning and transferring in the operating theatre can be overcome by involving tissue handling teams and ensuring that adequate staff and equipment is available for transfers and positioning. Also ensure that an operating table suited to take the patient's weight is available. In view of increased anaesthetic risks, the operating time should be kept to the shortest possible, hence surgery should be performed by a senior experienced and skilled gynaecologist. Difficult surgical access at laparotomy due to excessive tissue folds and the risk of wound infection may be overcome by selecting a laparoscopic or vaginal route of hysterectomy. However laparoscopy is associated with increased airway pressures and potential difficulties in ventilation which should be avoided in this patient. Vaginal access may also be difficult in a morbidly obese patient. Suboptimal exposure of the surgical field can be overcome by adequate lighting, appropriate packing away of bowels, use of deep retractor blades and good surgical assistance. Increased depth of surgical field will necessitate the use of longer instruments. Risk of ureteric injury may be decreased by ensuring that both ureters are traced, or performing a subtotal hysterectomy. Risk of wound infection can be reduced by the use of prophylactic antibiotics, meticulous hemostasis, use of subcutaneous drains and closure of the skin with staples. An apronectomy can also be performed if the expertise is available. Intraabdominal drains can be left to aid postoperative monitoring of possible intraabdominal blood loss. Postoperative monitoring should be in a high dependency unit in view of the risk of obstructive sleep apnoea. There is an increased risk of deep vein thrombosis and the patient should be on TED stockings and pneumatic calf compressors intra- and postoperatively. Early ambulation should be encouraged. The increased risk of atelectasis and chest infections can be reduced by incentive spirometry and chest physiotherapy.

a)      Non surgical treatment option available depends on her desire to fertility and comorbidity such as hypertension, or family history of hereditary cancer. 

          Tranexemic acid reduce menorrhagia around 50% taken during heavy menses.  Side effect of tranexemic acid includes nausea, vomiting, diarrhea and disturbance in colour vision.  Non steriodal anti inflammatory drugs (NSAIDs) also reduce the menstrual bloos loss around 50% and  has benefits in whose with associated dysmenorrhea.  Gastritis, worsening asthma and peptic ulcers are its side effects.  They both do not have contraceptive properties. 

          Combines contraception pills regulate the cycle, improved HMB and also beneficial in those with dysmenorrhea.  However it is not suitable for her as her BMI is >35 as it increases the risk of thromboembolism.  Progestogens are infective in treating ovulatory dysfunction uterine bleeding however they are effect in high does such as  15-20mg per day for 3 out of 4weeks cycle.  Side effects include weight gain,, bloating, headaches and ache.  Injectable or implanted progestogen may cause bleeding to stop completely and it has contraception effect as same side effect profile like the oral progestogen. 

          Androgenic drugs such as danazol may be used but they have undesirable effects such as breast atrophy, voice changes and emasculating of the female fetus thus needing effective contraception.  GnRH analogues result in amenorrhea but is associated with menopausal symptoms and loss of bone minieral density.  It is given in IM or Subcutaneous monthly injection.  Due to loss of bone minieral density, it is recommended to use as short term for intractable menorrhagia or to suppress endometrium prior to transcervial rection of endometrium or to reduce the size of fibroid prior to myomectomy. 

Levonogestrel intrauterine system is associated with reduction in menstrual loss up to 80% although it can give rise to irregulate bleeding during the first 3-4 months afer insertion.   It has benefit of contraception. 

          B.  Operation in obese patient imposed high risk of bleeding, wound infection, thromboembolism, respiratory infection and manual handling of patient as well as anesthetic risk.

Preoperative patient should be counseled and encourage regarding weight loss which can be overcome with diet, exercise or bariatric surgery.  Delaying surgery can be done to achieve weight reduction to overcome the above risks. 

She should also be discussed regarding route of operation as vaginal hysterectomy.  It advantages includes absence of abdominal wound, less post-operative pain, faster mobilization and earlier discharge from hospital.  Laparascopic in obese patient need special skilled operator and it also imposed more risk on anesthesia although it has faster recovery and early ambulation and small scar thus reducing risk of thromboembolism and wound infection. 

In case of abdominal hysterectomy, more assistances are needed for retraction to have adequate surgical view or it can be overcome by using omnitract which is fixed to operating table. 

Risk of thromboembolism (VTE) can be overcome by several measures such as TED stocking, pneumatic boots, early mobilization and adequate hydration and weight adjusted does of low molecular weight heparin.

Infection prophylaxis should be overcome by give antibiotic prior to skin incision, careful haemostasis.  Incision should be made to avoid not to be buried under the over hanging abdominal skin fold. 

Regional anaesthesia to general anesthesia (GA) provides excellence post operative pain and early mobilization thus reducing VTE risk as well as overcoming respiratory complication / infection from GA. 

Operation therater should be informed to be ready to have specialized operating table to be able to handle the weight, adequate size of BP cuffs, special equipment for transfer of heavy patients to avoid accident.

a) The treatment options include drugs and mirena. Drugs can be divided into hormonal and non-hormonal. Non-hormonal drugs include tranexamic acid and non-steroidal anti-inflammatory drugs(NSAIDs) like mefenamic acid. The advantage of tranexamic acid is less side effects and well tolerated by the pateint. There are no major side effects, only headache and gastro-intestinal disturbance. They are also more convenient as they only need to be taken on days of heavy menstrual flow. NSAIDs have more adverse effects, namely gastritis and nephrotoxicity, and is contraindicated in women with renal impairment. However, it is unlikely to cause renal impairment at the dosages used. The disadvantage of these 2 medications is that it causes less decrease in menstrual flow compared to mirena. Oral hormonal drugs include progesterone and oral contraceptive pills. The disadvantage is that it is inconvenient as they need to be taken everyday. Also, progesterone cause unpleasant side effects such as water retention, mood changes, weight gain and gastrointestinal disturbance, and is more often discontinued as a result. Oral contraceptive pills are unsuitable for this lady as they increase risk of thromboembolism, and she is already at high risk for it. Mirena is the first line treatment I would recommend for this patient. It is associated with the most reduction in menstrual flow. It is convenient as it does not need to be taken daily. Side effects include progestogenic side effects as mentioned above, but less than oral preparations as less progesterone is absorbed systematically. Some disadvantages include pain during insertion, infection, migration or dropping out, and uterine perforation during insertion. Also, as this lady is at risk of endometrial hyperplasia and cancer, Mirena will help to treat/prevent this condition.                                      b) She is at high risk of thromboembolism and wound infection post operation. Pre-operatively, I would take a full history including any pre-existing illness such as diabetes, hypertension and heart disease. I would screen for diabetes and hypertension, and do a chest Xray and ECG to look for occult heart disease. I would refer her to an anaesthetist as she may have problems with mode of anaesthesia and venous access. Regional anaesthesia is preferred but may not be possible for laparoscopic route. I would discuss route of hysterectomy. Either laparoscopy or vaginal route is preferred as it is associated with better post operative recovery. I would inform the OT in advance as she needs a bigger bed, more OT staff to transport her and a bigger BP cuff. I would give her chlorhexidine body wash to decrease skin microbial carriage. I would screen for MRSA carriage and treat accordingly. Intra-operatively, I would be careful when shaving the skin to avoid lacerations and abrasions. I would clean the skin properly to avoid infection. I would put her on calf compressors to prevent venous thromboembolism (VTE). I would give her prophylactic antibiotics before skin incision. I would ensure careful haemostasis to prevent haematoma as this would predispose to infection. I would close her subcutaneous layer and consider a subcutaneous drain to prevent seroma. Post operatively I would start VTE prophylaxis, usually low-molecular weight heparin. I would transfer her to high dependency as she is at risk of obstructive sleep apnea. I would encourage early ambulation for VTE prophylaxis and avoid atelectasis and chest infection. I would start her on chest physiotherapy. 

A. Menorrhagia is likely to be associated with anaemia. Detection with blood tests and treatment with simple measures like diet and iron supplementation done will improve the clinical symptoms of anaemia though not a definite treatment.

Non steroidal anti inflammatory drugs like Mefanamic Acid are useful first line treatment as they reduce menstrual blood loss up to 20% and have useful analgesic properties. Side effect profile [ nausea, gastritis, GIT upset} is better than Tranexemic Acid, an  Anti fibrinolytic agent also used as it reduces  menstrual blood loss up to 50%.It  has  GI side effects like nausea,vomiting,diarrhoea. Intracranial thrombosis may occur and treatment to be discontinued if associated with visual disturbances { retinopathy.}

Combined oral contraceptive pill is particularly useful if contraception required. It reduces menstrual blood loss up to 50%, regulates menstrual cycle with less dysmenorrhoea besides being relatively inexpensive. However they are UKMEC 3 for a woman with BMI > 35 as increased risk of venous thromboembolism and stroke.

Levonorgestral releasing intrauterine system MIRENA, reduces menstrual blood loss up to 75% after three months and 95%after 1year. Cost effective option if contraception required and used for > than one year with return of fertility once removed. However there is  risk of irregular  bleeding in first three months and occasional progestogenic side effects. The insertion maybe uncomfortable or painful in some women.

Cyclical Progestogens like Norethisterone  causes reduction of blood loss upto 60% when used from D5-D25 , though short term use is ineffective .Side effects like fluid retention, breast pain, acne , mood changes are known. It does not provide contraception.  Depot Medroxy progesterone is an effective contraception that induces amenorrhoea. Side effects include irregular bleeding, weight gain, bloating and delay in return of fertility on discontinuation.GnRH agonists maybe used to effectively reduce menstrual blood loss to 60-100%.but have menopausal side effects like hot flushes, night sweats .Risk of loss of bone mineral density if used for more than 6 months and Add back therapy with HRT needed. They are used preoperatively to reduce the size of fibroids as monthly injections { unacceptable to some}.Danazol is an androgenic preparation that reduces blood loss by 50% but has serious side effects {weight gain ,breast atrophy, irreversible deepening of voice}.

Treatment will depend on her fertility wishes, co morbidities and compliance. Written information should be provided.

B.Morbidly obese women have increased risk of surgical complications and technical difficulties.Multidisciplinary team including senior anaesthetist,physician,gynaecologist and trained theatre staff is essential to avoid increase morbidity in such women. Detailed counselling and assessment of co morbidities {Hypertension, Diabetes Mellitus,  ,Ischemic heart disease } is done  in the preoperative period for a good surgical outcome. Counsel regarding the benefits and risks of laparoscopic, abdominal or vaginal surgical routes. Preoperative risk assessment for VTE undertaken considering the increased risk of venous thromboembolism. Appropriate sized antithromboembolic stockings and intermittent pneumatic compression devices recommended. Low molecular weight heparin started 2hours preoperatively, continued throughout hospital stay until one week post surgery. Theatre staff needs to be communicated early, arrange electronically operated beds, trolley, equipment and “obesity packs”. Staff should have manual handling training .Choice of anaesthesia rests with the senior anaesthetist with expertise in handling difficult canulation, intubation and accurate blood pressure monitoring.

Morbid obesity is a relative contraindication for Laparoscopic surgery but with  experienced surgeon using Hassan’s open technique or Palmer point entry has fewer wound infections, early mobilisation and less postoperative ileus risk. Blood will be grouped and cross matched to take care of intraoperative bleeding.

Vaginal route has reduced morbidity but again difficult access in obese women though women with previous vaginal births are good candidates.Intraoperatively, Abdominal Hysterectomy has the problem with incision placement due to overhanging pannus so bony landmarks will be referred .Increase risk of wound infection needs adequate wound antisepsis with chlorhexidine-alcohol under the pannus and groin area. Antibiotics are administered before incision to reduce wound infection.Panniculectomy with the help of Plastic surgeons is an option but increases the operative time and morbidity. Midline vertical incision gives better access to pelvis though transverse incision higher on the abdominal wall gives advantage of better healing with lesser risk of hernia postoperatively. Adequate exposure to avoid visceral injury and haemostasis is a surgical challenge but overcome with good assistance, retraction of pannus, flexible lighting and use of long instruments. Subtotal hysterectomy is an option {as reduced risk of bleeding or ureteric injury} in non malignant cases with history of normal cervical smear.  Good haemostasis and mass closure using delayed absorbable sutures will reduce wound breakdown along with use of Surgical site drains  and  superficial fascia closure.

Postoperatively, monitoring is done in High dependency Unit with good nursing care. Adequate analgesia and hydration maintained .Early mobilisation encouraged, chest physiotherapy offered to reduce chest infections, continue low molecular weight heparin {adjusted for weight] for one week .Early feeding is advised and follow up arranged.

A) Mirena intrauterine system is the first choice if usage is beyond 12 months duration to reduce menstrual loss. It also provide effective contraception as pregnanacy is high risk for her. Insertion may be difficult due to her BMI. Mirena is associated with irregular bloss loss with subseqent amenorrhoea and requires a change every 5 yeras. Oral tranexemic acid reduces blood loss by 50% but is associated with nausea and gastric symptoms. Non steroidal anti inflammatory agents reduces blood loss by 25% and is especially useful if she has concurrent dysmenorrhoea. It may be used in combination ith oral Tranexemic acid. Side effects include worsening gastritis.Oral pregestogens such as Norethisterone and provera taken 10-15 days per cycle is effctive but is associated with progestogenic sude effects such as breast tenderness and weight gain. IM Depo Provera 150 mg every 3 months reduces blood loss and confers contraceptive effect. However it is assciated with irregular periods and preogestogenic side effects. IM Gonadotrophin analogue is effective in causing cessation of periods. However its use is limited to 6 months duration, is expansive and associated with menopausal symptoms.

B) Hysterectomy in this patient is high risk both surgically and from anesthetic aspect. Preoperatively, anaesthetic assessment is required as difficult intubation and ventilation is anticipated. Epidural and spinal anesthesia is also difficult due to difficult palpation of bony structures and thick fat pad at the back. Appropiate operative bed is needed to accomodate her body weight. More number of assistants needed to move patient. Pre operative thromboprophylaxis with weight-adjusted low molecular weight heparin given to reduce risk of venous thromboembolism. Last dose to be given more than 12 hours before surgery. Patient placed on automated calve compression to reduce risk of VTE intraoperatively. Prophylactic broad spectrum antibiotics to reduce risk of wound infection be given before skin incision. Operative field cleaned with povidone iodine especially below panniculus to reduce risk of wound infection and breakdown. Intraoperatively, incision made below fold between pannuculus and abdominal skin to prevent wound infection. Sugery is expected to be chalenging due to thick abdominal wall and prolapsing bowel, fat and soft tissue. Usage of self retaining retractors to reduce burden on assistants. A consultant gynaecologist needs to perform the surgery with adequately trained assistants. Blood loss may be increased and patient would need to be crossed matched preoperatively. Meticulous handling of soft tissue, and closing of subcutaneous fat if more than 2cm to reduce wound infection. Post operatively medical thromboprophylaxis needs to be continued and is given 4 hours after renoval of spinal needle. Appropiate wound care to reduce risk of wound infection.

(a) Nonsurgical treatment includes hormonal and non-hormonal medical treatments. Non-hormonal oral medications include tranexamic acid, which can decrease blood flow by 50%, with minimal side effects. Oral nonsteroidal anti-inflammatories(NSAIDs) can decrease blood flow by at least 20%, with concurrent pain relief if dysmenorrhoea present. Side effects are mainly gastrointestinal, and are not advisable in a history of gastritis or renal impairment. These two are good due to usage only during menses, but relief is temporary and not as effective in reducing flow compared to hormonal methods.

Hormonal methods can be oral progestogens, which are taken cyclically with greater reduction in menses flow. However, associated side effects include weight gain (which may be unacceptable especially to an obese patient), bloatedness, nausea, breast tenderness. Almost daily intake of medications may be troublesome resulting in noncompliance with breakthrough bleeding. Intramuscular progestogens such as DMPA can also be used for menorrhagia, but also have similar side effects and weight gain. Irregular bleeding can be a major problem for discontinuation. Each injection only lasts 3 months, and may be painful for some. Comparatively, the first line treatment for heavy menstrual bleeding is levonorgestrel-intrauterine devices (LNG-IUD). They show the greatest reduction in blood flow up to 80%, lasting 4 years, erradicating the need for oral medications and eliminating non-compliance. It is cost-effective, and can easily be inserted and removed in an outpatient setting, with additional contraceptive benefits in reproductive age group women. Side effects however include irregular beeding in the first 6 months, resulting in discontinuation; translocation or missing threads resulting in need for surgical retrieval; IUD dropping out. Systemic progestogenic side effects however are milder compared to oral progestogens. Insertion may be painful especially if virgo intacta, and there is risk of infection in the first 3 weeks post-insertion.

(b) Patient has class 3 obesity, which can be associated with metabolic syndrome including diabetes mellitus, hypertension, hyperlipidemia and cardiovascular disease, the presence of which will increase the risks of cardiovascular events under anaesthesia and intraoperatively, limiting the length of anaesthesia and surgery. There is greater risk of venous thromboembolic events (VTE), and pre-operative low molecular weight heparin (LMWH) can be given pre- and post-operatively, with use of calf compressors intraoperatively and TED stockings postoperatively. Anaesthetic risks for surgery include difficult intubation and regional anaesthesia, with difficulty in ventilation, which can also limit operating time. If laparoscopy is used, ventilation difficulties can limit insufflation pressure, decreaseing visibility and operation space, with resultant increase in dificulty of surgery and risks of visceral injury. Equipment has  to be tailored for the patient's size and weight, and operating tables and transfer trolleys supporting adequate weight must be made available beforehand. Adequate assistants are required for safe transfer and moving of patient. Mode of surgery such as laparoscopy may decrease risk of wound infection with earlier mobilisation and recovery, but limitations include the need for long ports and instruments and adequately skilled surgeons. Length of surgery may be increased if these are not available. In open surgery, incision should avoid the pannus to minimize wound infection, and midline incisions provide better exposure. Adequate retraction is needed with extra assistants and deep retractors. Self-maintaining retractors such as Alexis can decrease the need of extra assistants and minimize wound infection. Rectus sheath closure requires delayed absorbable stures with increased tensile strength such as PDS, to decrease risk of dehisence or burst abdomen. Subcutaneous layers must be adequately closed under minimal tension. Skin closure should be under less tension, difficulty may be encountered in apposition. Staples to skin might be beneficial in this instance. Postoperatively, obstructive sleep apnea is possible and patient should be moniotred overnight in a high dependency ward. Adequate thromboprophylaxis is required as mentioned. Wound infection risks are increased due to poor nutrition, inadequate skin opposition or concurrent diabetes mellitus. Preoperative broad spectrum antibiotics are needed.

Can anyone direct me to get answer for past paper (mrcog part 2) from 1997 to 2001?

Thanks!