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MRCOG PART 2 SBAs and EMQs

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Essay 197

Posted by Sreekala S.
The most probable diagnosis is an intra abdominal bleed following the abdominal hysterectomy. Airway should be checked and kept patent. Breathing should be ensured by administering oxygen with a face mask. Two large bore IV cannulae should be sited and blood taken for FBC, coagulation profile, U&E and crossmatch 6 units of blood. IV fluids should be commenced as fast as possible.Oxygen saturation should be checked with the pulsoximeter.
She should be examined for any abdominal distension and pallor which suggest an intra abdominal bleed. Porters and the blood bank have to be alerted as this is an emergency. The on call consultant, OT staff and anaesthetist should be alerted as there is a possibility of going to the OT for a laparotomy. The patient and the family should be explained the need for a blood transfusion and that she may be taken to the OT if her BP is not being maintained inspite of the fluids and blood transfusion.
Group specific blood is preferable to O negative blood , but in case of an emergency, O negative blood can be transfused. Blood transfusion should be started as soon as the blood is available. BP and Pulse should be continuously be monitored.
She should be taken to the OT for an emergency laparotomy if she continues to deteriorate. Haemostasis should be secured. BP, Pulse and urine output should be carefully monitored. A CVP line may be required to monitor the fluids. Post operatively, the patient should be explained of the events. More blood transfusions may be required postoperatively depending on the Hb result. Antibiotics should be given. Thromboprophylaxis should be given in the form of LMWH and TED stockings as there is a high risk of thrombo embolism. An incident form should be filled up.
Posted by adnan S.
The management of this patient starts with the resuscitation ,airway is checked ,oxygen should be given by fascial mask.Call for help from consultant,aneasthetist,porter blood bank.Two wide bore canulas are inserted blood is taken for FBC,U&E ,LFT,cross match 4-6 units of blood .It is necessary to replace volume lost using using crystalloids and blood transfusion ,CVP line may be needed to monitor fluid replacement.Renal perfusion will improve with correction of intravascular volume .If still oliguria persist renal physician should be involved After blood transfusion and fluid replacement still her pulse ,BP are not improving there might be stillongoing internal bleeding that need to be dealt.The decision whether or not to re-explore should be taken at senior level.The sooner re-exploration takes place ,the better chance there will be of identifying bleeding vessel .If the decision is taken for re-exploration informed consent is obtained and patients relatives should be informed of the decision of re-exploration. Post- operative patient is monitored in HDU .Pulse BP ,urine out-put is monitored,heamoglobin should be checked blood transfusion is given accordingly. .Thromboprophylaxis is considerd with LMWH,along with adequate hydration thromboembolic deterrent stocking and early mobilization.Prophylactic antibiotics should be given,Incident form should be filled..

Posted by Aroosha B.
The scenario goes with the primary haemorrhage which might be significant to derange the vital signs and urinary output.
Management should start with explaining the diagnosis to the patient and her relatives if present while starting resuscitative measures which include I/V access with 2 widebore cannulae and facial oxygen by mask. At the same time , blood should be drawn for FBC , coagulation profile , RFT and urgent cross-matching of atleast 4 units of blood.
Call for senior consultant gynecologist on call , consultant anesthetist , haemotologist and inform blood bank and operating theatre for an urgent laparotomy.
Examination of patient may show distention but may be negative if bleeding is retroperitoneal . Little weight should be placed on a small suction drain which often becomes blocked . Vaginal bleeding should be noted as she can bleed from a vault bleeder .
When massive blood loss occurs a consumptive coagulopathy may develop and it is important therefore to monitor coagulation status repeatedly and blood and blood products replaced according to the results and advice of haemotologist. Volume replacement initially should be with crystalloids and if more than 1000ml of fluid required , colloid replacement is recommended until blood becomes available in order to maintain renal perfusion . Hypothermia should be avoided as it will worsen coagulation abnormalities.
If the patient is bleeding vaginally from the vault , it is worth examining vaginally under anaesthesia to identify a bleeding point which can be sutured from below . If relaparotomy required it is done through the previous incision . Clot should be removed gently to avoid provoking more bleeding and they should be included in the blood loss assessment . The operation site should be explored carefully and all pedicles should be examined even if bleeding site has been identified as there can be multiple bleeding sites . Ureters should be identified carefully to avoid injury . Hot packs will decrease general oose and help identify active bleeding sites . When bleeding site cannot be identified and still she is bleeding internal iliac ligation should be done by a person who is expert in this procedure so as to avoid injury to underline iliac vein . If it proves impossible to achieve homeostasis the omentun may be brought into the pelvis and several large packs placed firmly over it to gain haemostasis by pressure. Abdomen is then closed over the packs while the tapes are brought together through the wound . The packs can be removed after 24-48 hours under GA. Post operatively patient should be shifted to high dependency units for observation of vital signs and urinary output and shifted toward when stable. Broad spectrum I/V antibiotics are prescribed to avoid infectious morbidity. Thromboprofilaxis is needed due to increased risk of thromboambolism due to massive haemorrhage prolonged surgery. Blood transfusion is given according to her HB level followed by haematinics when oral . The procedure should be explained to the patient by the surgeon when she is stable and incident form is filled up.
Posted by Freha Z.
The first priority in this case would be to institute basic resuscitation techniques. The airway and breathing should be checked. Oxygen should be administered and intravenous access should be obtained by two wide bore cannulas. Rapid Volume replacement is indicated with colloids initially and then cross matched or even group specific or O negative blood. Baseline blood tests should be checked and four units of blood arranged. Seniors should be informed about the patients condition.
Further management of patient depends on the diagnosis of problem. Examination should include examination of wound and dressing and signs of intra-abdominal bleeding which is most likely cause of hypovolemic shock in this condition. Multidisciplinary approach should be sought. Anaesthetic opinion should be taken. After seeking senior opinion and examination for possible haemorrhage patient should be prepared for re-exploration of abdomen.Relatives should be informed about the condition and counselled for need of re-exploration. After surgery postoperative management should be in high dependency unit.
Second differential might be pulmonary embolism which can be ruled out on examination and chest x-ray if suspected.
Posted by Ismatara B.
Dear Sir,
This is my first attempt. Please check. Thank you.
Here the most probable cause of this clinical scenario is intra abdominal bleeding after operation and the patient needs immediate help, as this is an emergency. I will delegate someone to call for help from consultant, anaeshesist, SHO, nursing staff, porter, OT staff and haematologist and ensure quicker response and all the required help for her management. At the same time, the operating theatre, blood bank and laboratory should be alerted to ensure quick response for the patient.
I would start immediate resuscitation of the patient by approaching airway, breathing and circulation. Adequate oxygenation, maintenance of breathing and volume replacement is important to prevent serious morbidity and even mortality due to cerebral and peripheral tissue hypoxia.Oxygen supply and intubation is necessary if no spontaneous breathing.Two large bore (14G-16G) IV cannula should be sited and blood sent for FBC, crossmatching (4-6 units of blood) and baseline coagulation screening. Volume replacement be started immediately with crystalloid, colloids and group specific blood, if not available then O-negative blood can be transfused.to maintain renal perfusion.If still oliguria renal physician should be involved. Incertion of CVP line, catheterization and FBC will dictate amount of fluid intake output and and blood that need to be given.Oxygen saturation should be checked by pulse oxymeter as there is chance of tissue hypoxia.Coagulation profile to correct coagulopathy if needed.
She should be examined for any symptoms of intra abdominal blood loss ( pallor, abdominal distention) and her pulse BP should be monitored to detect any improvement. If there is still no improvement,here intra abdominal bleeding may be the most possible cause of shock, decision about reexploration should be taken with the help of consultant.When decision about reexploration is taken, the patient should be informed. If not possible, next of kin should be given a brief explanation to prevent misunderstanding and informed consent is obtained. Reexploration should be done by an experienced gynaecologist. During the procedure, the operation site should be explored carefully by observing all pedicle, if any oozing, it should be secured.
After surgeryt, the patient should be monitored in HDU. Her vital sign (Pulse, BP, Temp., Respiratory rate) and urine output should be checked.Hb level should be checked and blood will be transfused if needed.
Thromboprophylaxis in the form of adequate fluid, early mobilizatoin,TED stockings, LMWH, according to risk factors to prevent thromboembolic events. Antibiotics should be given to prevent infection. Analgesia is to be given to reduce pain.The patient should be informed in details about the procedure when she is stable and an incident form should be filled up to avoid litigation.

Posted by Remi A.
This is likely to be a case of intraabdominal bleeding following a major surgery,and urgent management is required to reduce morbidity and mortality.

Urgent multidisciplinary help should be sought-Senior Gynaecologist,Anaesthestist,Haematologist,and the operating theatre staff should be notify of possible need for laparotomy.

Assessment should be done for a patent airway,breathing[oxygen bshould be administered by facemask if necessary] and iv access[if not already in place] with two wide bore needle.
Blood should be taken for FBC,urea and electrolytes,LFTS,Coagulation screen,and Xmatch 4-6 units of blood.Blood products like Fresh Frozen plasma,platelets,Fibronegen may also be required,as they may be needed along the way.Urgency of need should be communicated to the Haematologist.
Resustitation with crystalloid,colloid,Rh -ve blood,or Xmatch blood[if available] should commence immediately.
There should be continous monitoring of Pulse,Blood pressure,Oxygen saturation,and hourly input and output chart.A central venous pressure line may be necessary.
If there is no improvement with resustitative measures,Consent should be taken for Laparotomy.
At laparotomy,bleeding points should be identified,and haemostasis secured.Measures to reduce risk of intraabdominal adhesions like gentle tissue handling,minimising the use of diathermy,Good haemostasis, appropriate use of antibiotics ,and peritoneal wash out should be employed.
There should be continous monitoring of the Pulse,B/P,Oxygen saturation,and urinary output intra and post operativelyThis may be better achieved post operatively in High dependency unit.
Post op FBC should be done and transfuse as appropriate.
The reason for surgery and operation findings should be explain as soon as possible.
Thromboprophylaxis in form of LMW HEPARIN should be given.
Proper documentation and filling of an incident form is important for Good practice,audit and Risk management.
Follow-up apointment should be arranged and the General practitioner should be informed.
Posted by Sarwat F.
This patient is most likely having secondary haemorrhage. This is a gynae emergency. Management will include stabilization of patients condition and relaparotomy to secure haemostasis. Patient will most likely already have an intravenous access, so fluid replacement with colloids and crystalloids initially. As this is an elective procedure blood must have been group and held so 2 units blood will be ordered. Blood tests like full blood count, urea and electrolytes, coagulation studies are done. I will inform my consultant as well as consultant anaesthetist and theatres to arrange emergency laparotomy. Patient and her relatives will be counseled and informed consent taken. Repeat laparotomy will be carried out preferably by the senior person available. Patient will have a repeat general anaesthesia, abdomen will be opened through previous incision, source of haemorrhage will be identified and secured. Peritoneal cavity will be cleaned and anterior abdominal wall will be closed. Risk assessment is done for venous thromboembolism and thromboprophylaxis provided with heparin if needed. Ted stockings are provided. Postoperatively strict monitoring will be done. Blood pressure, pulse, temperature, input, output will be monitored every 15 min for 1 hour then hourly for 4 hours then 4 hourly. Broad spectrum antibiotics like cefuroxime and metronidazole will be given for 5 to 7 days. Blood tests will be reviewed and will be repeated in 4 to 6 hours time. Incident report form will be filled.
Posted by Vinayak B.
This is an emergency situation where immediate action to be taken as patient is in hypovolemic stage may be due to intraabdominal leak, or inappropriate fluid/blood replacement in intraoperative and post operative period due to under estimation of blood loss.

Intravenous access with two wide bore canula to replace the loss initially with crystalooids and then by blood . blood send for investigations fbc, renal function test, coagulation profile .Which will help in assessing blood loss, need for transfusion and renal function status. 4/5 blood units arranged to replace blood loss . . oxygen given with facial mask..consultant, senior anesthetists ot staff informed . In put output monitored with cvp line which helps to avoid overreplacement of fluid and pulmonary oedema Exploratory laparotomy needed to stop intraabdominal bleed. If patient s condition doesn?t improve after adequate fluid replacement.before proceeding for definitive laparotomy possibility of vaginal bleeding due to vault bleeding excluded.

Condition is explained to patient and relatives . and consent obtained. Senior person should be available during surgery as difficulty in achieving hemostasis during surgery .may need internal iliac ligation .chances of ureteric trauma while securing bleeders. Help from urologist should be taken if suspected ureteric injury during operation.post op period patient should be monitored in high dependency unit. Pulse , bp urine out put monitored frequently with cvp line. Thrmoboprophylaxis instituted if complete hemostasis achieved. Blood transfusion given as per estimated blood loss . Hematologist input needed if coagulation profile is deranged . Incident report written as to cover risk management .

Explaination with detail notes given to patient before discharge.

Posted by SWATI M.
This woman is in hypovolemic shock with decreasing urinary output.She needs resuscitation urgently , followed by identification and management of cause for the same to avoid its consequences such as acute renal failure ,irreversible shock ,DIC , multi - organ failure and death.

Oxygen should be given to maintain oxygen carrying capacity.Call for help from ward nurses , SHO , anaesthesia registrar.Crystalloids should be given fast and start another wide bore IV line to give fluid challenge.Inform blood bank for need and urgency of BT and she may have cross matched blood ready and also serum saved at blood bank.

The causes of her condition could be inadequate replacement of fluid lost or bleeding ? intra-abdominal / per vaginal.
To determine the cause history and clinical examination needs to be undertaken.
History should be obtained in regards to amount of IV fluids infused post ?op , time of last top up dose of epidural analgesia (if using it as a post-op analgesia) , shoulder tip pain , abdominal pain, distension , any PV bleeding.Find out if she has any objections to blood transfusion and amount of BT received if any.
On examination look for pallor , abdominal distension , guarding , rigidity ,rebound tenderness.Look for amount of blood loss if she has PV bleeding.
Explain condition to the woman and family members and measures undertaken.
She will respond to fluid challenge if cause is inadequately replaced fluids with improvement of vitals and increase in UOP and examination will show soft non distended abdomen and no PV bleeding.
Monitor vitals every 15 min and UOP per hour , assign one nurse for it.BT should be given if woman has no objection and has not been replaced adequately before.
If bleeding is suspected on examination as a cause of her condition , inform consultant gynaecologist , consultant anaesthetist ,haematologist as she needs laparotomy .Collect blood for FBC , coagulation studies , serum electrolytes , urea and creatinine and request for cross matching of 4 units of blood.
Consultant should undertake the laparotomy.Identify the source of bleeding and haemostasis should be achieved by additional stitches at bleeding vessels taking care to avoid injury to surrounding structures such as ureters.
Adequate replacement of fluids and blood in important and monitor her in ICU / HDU for 24 -48 hours or till she improves.Involve physician in her care and renal physician if develops ARF.
Explain reasons and findings of lapaotomy to the woman and her family and also keep them informed at all times about her condition .
Proper documention is important for the medico-legal purposes.Fill an incident form. Continue appropriate thromboprophylaxis post ? op.
Recheck Hb 24 hours later .At discharge prescribe iron if anaemic.Give letter to GP and arrange follow up appointment at 4 ? 6 weeks.



Posted by Kishor S.
The findings suggest that the patient is in hypovolemic shock. Prompt resuscitation is needed along with identification and management of the cause to prevent irreversible shock, acute renal shut down and DIC.
Oxygen should be given to maintain oxygen saturation and iv fluid should be given fast. If the drip is not running, another wide bore IV line will be started. Ward nurses, SHO and those involved in her post operative care will be alerted.
The possible causes to be kept in mind are inadequate fluid replacement or bleeding (internal or vaginal). Post operative fluid replacement should be reviewed to see the adequacy of fluid/blood in the light of intra operative bleeding and duration of surgery.
Presence of pallor of conjunctiva and tongue would suggest anaemia or blood loss. External bleeding at the site of incision and per vaginum should be looked for. It may be difficult to diagnose internal bleeding though it might be suggested by abdominal and shoulder tip pain and abdominal distension with guarding (may also present in normal post op period). However, a soft non tender flat abdomen would likely rule out the possibility of internal bleed.
Pulse and BP should be monitored every 15 minutes along with hourly urine output. She will respond to fluid challenge if cause is inadequate fluid replacement with improvement in pulse, BP and increase in urine output.
In case she does not respond and bleeding is suspected, she will require exploration. Blood will be sent for FBC, coagulation studies, serum electrolytes, urea and creatinine and cross matching of at least 2 units of blood (Blood bank may have cross matched blood ready and also serum saved). Consultant will be informed and necessary procedure should be done by him or under his direct guidance. External vaginal bleeding can be controlled by applying stitch, if the bleeder can be identified under GA. In case of internal bleed re-laparotomy has to be done, bleeders identified and ligated. While catching the retracted bleeding vessels care should be taken to avoid injury to ureter/bowel.
Post operative she should be monitored in HDU and adequate replacement of fluid/blood is to be ensured. Appropriate thromboprophylaxis post ? op will be instituted. Hb should be rechecked after 24 hours and further transfusion of blood may be required depending on the report. Otherwise, iron should be prescribed during discharge to take care of anaemia, if present. A follow up appointment will be given 6 weeks.
Proper documentation is important for the medico-legal purposes. If there is exploration, incident form is to be filled in.
Patient and family members should be informed at every stage along with the measures undertaken.
Posted by OJO AJIBADE  .
The most likely diagnosis is hypovolemic shock likely due to intra-abdominal bleeding.This is a common complication of a major surgical procedure like this .Due to her deteriorating clinical condition;I will inform senior colleagues;consultant obstetrician and anaestehitics.Adequate attention will be paid to rescucitating her by given her oxygen by face mask;ensuring she is breathing adequately(check oxygen saturation with pulse oximeter);2 wide bore cannula(size14/16G) will be inserted and blood taken for full blood count(FBC)-to determine her recent Heamoglobin;urea &electrolytes for renal status and liver function test and coagulation screen.I will put up crystalloid solutin eg normal saline or hartmans solution. Urgent transfusion of xmatched 2 units of blood may be necessary if condition deteriorates rapidly or in case of delay with 2 units of O RH -ve blood.
I will quickly reveiew her operation note to check the type of hysterectomy she had.Subtotal carry less morbidity than Total.General examinationwill reveal pallor ;level of dehydration will be assessed;wound will be inspected and vagina exam.will be performed to exclude local source of bleeding that can be treated.
If intrabadominal bleeding is suspected;she will have to be taken back to the theatre for exploratory laparomy.She will be informred and consent taken;consulatant gynaecologist and anaesthetics as well as theartre staffs will be informed.
In the theartre ;the abdominalwound will be reopened and the bleeding points will be located and prompt heamostasis ensured.Intraoperative antibiotics eg augmentin/metrionidazole will be given if these has not be given before. This will be continued post-operatively.
If there is injury to major blood vessels;bladder or ureters or bowel;approprite specialist will be informed and called in eg vascular surgeon etc.
Abdominal wound will be closed in layers and drain left in situ, She will be monitered post-operatively in HDU. Vital signs will be monitored every 15 mins till stable.Input/output chart (ensure adequate fluid balance.
Heparin thromboprophylasis will given as per protocols and incident form will be completed and risk managers informed.Her GP will be notified.
She will be followed up in the clinical 6 weeks post-operatively and histology report will be discussed.
** sorry for answering late **.
Posted by OJO AJIBADE  .
Sorry for answering late.
Would you Please correct if you do not mind.
Thanks.