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MRCOG Part 2, MRCOG II

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Forum >> ESSAY 246 - VTE
ESSAY 246 - VTE Posted by Paul T.
Mon Aug 13, 2007 12:28 pm
A 50 year old woman has been admitted for an abdominal hysterectomy because of a large fibroid uterus. (a) How would you assess her risk of venous thrombo-embolic disease? [8 marks]. (b) Which measures can be taken to minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery? [12 marks].
Posted by Natalia  N.
Tue Aug 14, 2007 12:30 am
(a) This woman has following moderate risk factors of venour thrombo-embolism, e.g. age more than 40 and major abdominal surgery. I will take detailed history to explore other risk factors of VTE, in particular past medical history of thromboembolic episodes (DVT, strokes, pulmonary embolism), history of heart disease or heart surgery (valve replacement), malignancy, diabetes. I would enquire about any concurrent sytemic illnesses, e.g. infections increase risk of VTE as well as connective tissue disease, chronic illnesses. I will ask if she or her family have thrombophilia, wich is a high risk factor for VTE. I will ask about any previous surgery or prolonged immobilization and it was associated with DVT. Prolonged immobilization prior to current surgery is high risk factor for VTE. I wll check her reproductive history, e.g. pregnancies and deliveries and any association with DVT. I will check of she takes any medications, which increase risk of VTE (HRT) or any medications that decrease risk of VTE (aspirin, clopidogrel, warfarin, heparin, low molecular weight heparin). I will ask if she smokes as it increases risk of VTE.
I will check her BMI as obesity is a risk factor of VTE. I will aslo check if she has any varicose veins which predispose to development of VTE.

(b). Appropriate surgical procedure which is as short as possible and the least invasive procedure (e.g. vaginal hysterectomy instead of abdominal hysterectomy, minimal access surgery should be performed if technically possible). This will shorten postoperative immobilization and posteoperative hospital stay. Patients position should be carefuly checked prior to procedure to avoid any pressure points which could lead to interference with normal circulation, and, therefore, predispose to VTE.
Women should be encouraged to cease smoking and to loose weight if necessary.
HRT and COCP should stopped 4 weeks prior to surgery.
Women should be well hydrated in pre- and postoperative period as dehydration predisposes to VTE.
All women with moderate risk factors of VTE (major surgery > 30 mins, age > 40, obesity with BMI >25, gross varicose veins, intercurrent infection, COCP, HRT) should have calf compressors during the surgery and should use TEDS stockings in post-operative period until they resume their normal activity. Women at high risk of VTE ( 3 or more of moderate risk factors, personal history of VTE, immobilisation for > 4 days prior to major surgery, surgery for malignancy) in addition to TEDS stockings and calf compressors should be given anticoagulation during peri-operative period until full mobilisation or discharge. Unfractioned heparin is used in dose 5000 IU subcutaneously, twice a day, with the first dose given 2 hours pre-operatively. It should be used 3 times a day in cases of surgery for malignancy. Heparin decreases risk of VTE by 50%, but increases risk of heamorrhage twofold. Low molecular weight heparin (enoxaparin) is given once daily, which is more convinient. It has less risk of heamorrhage, and is contraindicated in renal failure.
Posted by Radhika A.
Tue Aug 14, 2007 06:47 am

a)Since her age is more than 40 yrs, she already has a moderate risk factor.I would like to take a detailed history to assess her risk status. I would like to verify if she has had any thromboembolic episosdes in the past following delivery or any other previous surgery,if she is a smoker, any reason for reduced physical activity, if she is on OCPs/ HRT , if she has any other associated medical disease e.g.diabetes,if there is family history of thrombophilias. I would like to examine her specifically with respect to her weight and BMI (which, if it is more than 25 is a risk factor), varicose veins. Thesed are moderate risk factors. Presence of 3 or more of these factors puts her at high risk for thromboembolism.
b) The various steps to reduce the risk are encouragement to lose weight preopertively in case her BMI is high & stop smoking. Hormonal preparations should be stopped at least 4weeks pre-operatively.One should explore methods of reducing the operative time - vaginal hysterectomy is preferable where possible. She should be kept well hydrated during the intraoperative period and also encouraged to mobilise early in the postoperative period. Patients with moderate and high risk factors should be started on heparin or Low molecular weight heparin preoperatively. Heparin should be given at least 2 hours before surgery - this reduces the chances of VTE by half but doubles chances of hemorrhage and would hematoma.This should be continues till she mobilises postoperatively or till discharge. Heparin needs to be given at least twice daily while LMWH has the advantage of once daily dosage. When used for short duration heparin is associated with only occasinal side-effects like transient thrombocytopenia.TED stockings could also be used since these have found to be beneficial in benign conditions. thromboembolism.
Posted by Saad A.
Tue Aug 14, 2007 12:39 pm
VTE is the commonest cause of maternal mortality and morbidity. Risk assessment is needed to be done to prevent VTE. The risk assessment involves taking detailed history which include personal/family history of VTE,thrombophilia ,history of thrombophilia in family, history of immobility for more than 4 days, and moderate risk factors more than three. If history of thrombophilia is present then thrombophilia screening is needed. Moderate risk factors are assessed by obtaining history of intermittent illness,varicose veins, parity>4, immobility ,infection and obseity(80Kg). Low risk factors donot have any factors present. Then she is also enquired about contraception, HRT and contraindication to HRT. Drug history of any anti coagulant being taken. Her examination is carried out including BMI(>30 is independent risk factor for VTE). The risk factors are asessed to decrease risk of VTE during surgery.
b. To minimise the risk during surgery assessment is done to identify the risk factor. Anaesthetic review should be taken and if the patient is taking anti-coagulation haemotologist review should be taken to adjust dose for surgery . TED should be advised before surgery . Heparin prophylaxis 2 hours pre-operatively is given.
Intra-operatively fastidious haemostasis is needed. Drain should be placed during surgery to prevent haematoma as there is risk of haemorrhage with fibriod surgery. Interrupted sutures should be applied to reduce the risk of haemotoma formation.
Post operatively if the patient is low risk then early mobilisation and good hydration is advised. TED stocking will be provided.
If the patient is moderate risk then heparin prophylaxis with hydration therapy ,Early moblisation and TED stockings are provided.
In case of high risk/very high risk heparin thromboprophylaxis and management in ITU in consultation with haematologist is carried out. TED stocking and early mobilisation is advised.
Posted by Zarkoth A.
Tue Aug 14, 2007 03:55 pm
a) I would first take a thorough history trying to identify risk factors for VTE. Any comorbidities (e.g. diabetes, Ca) should be noted as they increase the risk. The same is true for thrombophilias or personal/family history of VTE. The patient\'s age is a risk factor by itself; medications (like COCP, HRT) may also increase the risk and appropriate questions should be asked.
On examination, the BMI should be noted. The patient\'s hydration and mobility capacity should be assessed since all of the above are risk factors for VTE. I would also check for varicose veins as they too increase the risk. If there are any doubts about the risk assessment, I would ask for haematologist\'s involvement.
b) Preoperatively, thorough history should be taken and examination undertaken to identify risk factors for VTE. The operation should be planned appropriately and tailored to patient\'s need with the aim of minimising operation time and speeding up recovery (laparoscopy generally superior to laparotomy and regional anaesthesia superior to GA); anaesthetic involvement may therefore be beneficial. The patient\'s health should be optimised if there are relevant issues (losing weight, improving hydration and mobility, stopping COCP)
Care should be taken to apply TED stockings and commence heparin treatment to minimise VTE risks. During operation, a Pfannenstiel incision should be preferred (unless midline incision necessary) as it is associated with quicker recovery. Blood loss should be kept to a minimum and haemostasis should be meticulous. Operation time should be as short as possible.
Postoperatively, administration of heparin should be continued until patient fully mobile and ready to be discharged (TEDS should be applied all this time). Physiotherapist\'s involvement will be beneficial to encourage early mobilisation. The patient should be kept well hydrated.
Posted by Misbah W.
Tue Aug 14, 2007 07:09 pm
This woman should be assessed thoroughly for risk factors, keeping in mind her age and major surgery .Her family history and personal history of past VTE will catagorise her high risk for VTE. A detail medical history for major concurrent diseases like recent myocardial infarction, Bowel inflammatory diseases, sickle cell, nephrotic syndrome etc, as well as immobility of more than 4 days should be taken into consideration. She should be enquired about drugs with special emphasis on contraceptive use. Her examination should include checking weight ,BMI, gross varicose veins and current infection[fever ,tachycardia].After assessment patients risk status should be discussed with her and documented including any plan for prophylactic measures and drug therapy. This plan should cover time frame of such measures.
B]? A pre-operative assessment of risk factors categorization of patient into high, medium and low grade will help to decide about preventive measure. She should be advise on weight control ,smoking if necessary and use of non-hormonal method of contraception at least 4weeks before surgery. Any medical condition should be well controlled. Women should be treated for current infection .She should be advised for TED stockings. In high risk case a plan for when to start and stop prophylactic heparin should be discussed and documented.
Intraoperative measure should include use calf compression/stimulation devices, keeping patient well hydrated, reducing blood loss, measure to decrease operative time and prophylactic antibiotics.

Post ?operative patient should be kept well hydrated with fluid and transfused if required .All measure should be taken for early mobilization of patient. She should continue with use of TED-stockings. Reassessment for prophylactic heparin should be done.
Posted by Shahla  K.
Tue Aug 14, 2007 07:57 pm
Venous thromboembolism is a risk to gynaecological surgery,estimated risk around 20% in average surgeries there fore it is very important to assign risk and start prophylaxis at time of surgery.
High risk women include personal or family history of venous thromboembolism known thrombophilic.
presence of malignant disease or women with 3 or more moderate risks
.Moderate risks are, age more then 40year ,obesity(BMI >35),varicose vein ,presence of certain medical disorder also increase risks for example presence of cardiac disease ,polycythemia,sickle cell anemia ,intercurrant infection, and surgery more then 30 minute..In her social history smoking ,prolong immobility (long haul flight )illicit drug should be consider.

b)Her risk of VTE can be minimize by her assessment in clinic by advising her to reduce her weight ,avoid immobility ,quit smoking, if she is still using low dose combine oral contraceptive pills, she should stop using at least a month before surgery, ,where as HRT doesn’t need to be stop,reloxifen should be discontinue a week before surgery.Infection should be treated.
she has been planned for abdominal hysterectomy due to large fibroid ,Vaginal rout associate with less incidence of VTE . fibroid can be shrink by using GnRH,and vaginal hysterectomy can be possible ,
In high risk situation where she is having throbophilia,personal or family history of VTE then haematologist ,anaesthetist should be involve in her operative care.

Upon admission reassessment done .
Good hydration avoid dehydration with thromoembolic deterant stocking can prevent VTE ,It should wear preoperatively till discharge .it has limited value.
Low molecular weight heparin in started 12 hour before surgery and continue postoperativly till discharge.
Surgery should be quick, avoid bleeding by active haemostasis,
Post operative ensure good analgesia ,hydration and early mobility is very important. To avoid VTE.
Measures to avoid infections by antibiotics .
Keeping high index of suspicion to any calf pain or chest pain ,start therapeutic heparin before objective diagnosis can be made.

Posted by Natalie P C.
Tue Aug 14, 2007 10:01 pm
Essay
A
This woman already has some risk factors being age over 35 and major pelvic surgery. I would take a history looking for other risk factors. Weight >80 Kg or raised BMI >30 has a higher risk. Smokers and heavy alcohol drinking. Current illness or infection especially inflammatory conditions like inflammatory bowel disease or conditions like nephritic syndrome or polycythaemia where there is a hypercoaguable state increase risk. If she has a very sedentary lifestyle. Diabetes , hpertention, chronic renal failure or hepatic disease and other ill health.

A personal history of venous thromboembolism and if it was provoked or not is important. A non-provoked VTE is associated with a higher risk of an undiagnosed thrombophilia. A diagnosed thrombophilia either acquired (antiphospholipid syndrome ) or inherited (higher risk ones being homozygous Factor V Leiden, antithrombin II or combinations). A family history of thromboembolism or thrombophilias is also important. Drug history like use of HRT or raloxifene as an increased risk. Varicose veins are also associated. Immobility example in a wheelchair bound patient or recent immobilised fracture.

B
Preoperative measure would include weight loss and increasing her fitness to improve her post op recovery. Management of intercurent illnesses is important but may not eradicate risk example quiescent inflammatory bowel disease, ensuring no infections present. Graduated compression stocking used intraop and post op improve venous drainage and reduce risk. Postponement of the operation until the woman is in the best possible health to proceed. Liaison with other health professionals who manage her other illnesses to optimise her health pre-op. Stopping possible offending medications like HRT 1 week previously can reduce risk. Prophylactic low molecular weight heparin given postoperatively for 3-5 days reduces the risk further. Care during the operation to avoid excessive trauma to the tissues and pelvic veins. Admission pro-op with enough time to stabilise conditions like diabetes.

Other measures include measures to increase the chance of early mobilisation. Choice of incision (transverse better than midline), vaginal surgery versus abdominal, and regional or local anaesthesia over general. Keeping the patient well hydrated intra and post op. Avoiding infection in the wound or chest would reduce the risk and this can be done by ensuring good haemostasis, avoiding aspiration, chest physiotherapy if needed and overall good surveillance to detect and treat infection early.

Posted by Valerie T.
Tue Aug 14, 2007 10:14 pm
a) A detailed history should be taken to identify any risk factors for venous thromboembolism. General risk factors such as age should be considered. A woman over the age of 40 is at at increased risk of developing thromboembolism. Smoking would increase the risk, particularly if she smokes more than 15 cigarettes per day. The use of hormone replacement therapy with cobined estrogen and progestogen would also increase her risk of venous thromboembolism. A history of clinical conditions such as the presence of cardiac disease, inflammatory diseases or nephrotic syndrome should be determined. These conditions would also increase the risk of thromboembolism.
Inherent major risk factors should be determined for example a personal history of thrombophilias such as protein C deficiency, protein S deficiency or Factor V Leiden which would lead to an increased risk of thromboembolism. A past history of thromboembolism or stroke would also increase her risk of repeat thromboembolism. I would also enquire about her family history of thrombophilias or venous thromboembolism. This would increase her risk but also it would indicate that there may be a heriditary thrombophilia and the patient may need further investigations prior to surgery to determine whtehre she also has a thrombophilia.

Physical examination can also contibute to the assessment of risk. The body mass index should be calculated from the weight and height. A value of more than 30kg/m2 would increase the risk of venous thromboembolism. An increased is also associated with the presence of varicose veins.

Hysterectomy is also a major operation. The indication is uterine fibroids and this means that the operation will be long, there may be heavy blood loss and she will be in hospitals for a few days. These factors will also increase her risk of thromboembolism.

This lady will be considered low risk if her only risk factors are age over 40 and major operation lasting more than 30 mins. Moderate risk if there is also the presence of a medical disorder. High risk if she also has a history of venous thromboembolism or a thrombophilia.

b) A preoperative assessment by the anaesthesist and discussion with the gynaecology team to determine the level of risk. A multidisciplinary approach is needed to minimize risk in this lady. The level of risk will also determine the dose and duration of prophylactic heparin.
Blood loss should be minimized during the operation to prevent hypovolaemia. This can lead to a thromboembolic event. Mechanical thromboprphylaxis should be done in theatre and during the operation.
Postoperatively, the patient should be encouraged to mobilise. Prolonged mobility increases the chance of thromboembolism. A fluid input output chart should be maintained to ensure that the patient does not become dehydrated or hypovolaemic. Both conditions can lead to thromboembolism. Antiembolism graduated compression stockings should be worn to reduce venous stasis. Daily subcutaneous injections of Low molecular weight heparin should be given prophylactically to prevent thromboembolism.
Posted by Malar R.
Wed Aug 15, 2007 12:32 am
A 50 year old woman has been admitted for an abdominal hysterectomy because of a large fibroid uterus. (a) How would you assess her risk of venous thrombo-embolic disease? [8 marks]. (b) Which measures can be taken to minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery? [12 marks].

Her BMI should be known.Enquiry should be made about her smoking habits pre operatively.Her past medical history and family history should be assessed specifically for personal history of thromboembolism and thrombophilia.She should also be checked for severe varicose veins.The combined contraceptive pill intake should be known as it increases her risk after major surgery.Her general fitness and mobility should be assessed as post operative immobility will increase her risk.
The length of the operation and the extent of surgery will also determine her risk of thromboembolism.

Patients must be advised to lose weight prior to elective surgery to reach a BMI of less than 30 if possible.They should also stop smoking pre operatively.The combined oral contraceptive pill must be stopped 4 weeks before major surgery and an alternative contraception advised.
The patients should have flowtron boots intraoperatively and kept well hydrated intra and post operatively.TED stockings should be worn post operatively and early mobilisation encouraged , with the help of a physiotherapist if possible.Patients at high risk of thromboembolism should be given prophylactic heparin, preferably low molecular weight heparin, the day before surgery and post operatively.
Patients at very high risk of thromboembolism and listed for elective surgery may be considered for alternative treatment if available.
Posted by Idris O.
Wed Aug 15, 2007 05:57 am
a) The high risk factors I would look for in this woman include the presence of 3 or more moderate risk factors, personal history of VTE or a family history of thrombophilia.
The moderate risk factors include age of 50 years and having major pelvic surgery and operation more likely to last > 30mins. Others would include the presence of co-morbidity like heart disease, inflammatory bowel disease or nephrotic syndrome. History of smoking also important. The finding of a BMI >30 and the presence of varicose veins.
Low risk patients are women with no additional risk factors.

b) The measures would include a pre-op assessment to correct anemia before surgery. This encourages wound healing and promotes rapid post operative recovery. Co-morbid situations are also treated before surgery. I would ensure that high risk patients are reviewed by the anaesthetist ( to plan appropriate method of pain relief) and the haematologist to assess for the risk of thromboprophylaxis and offer treatment. Patients would be appropriately selected for the type of surgery in relation to risk of VTE ie the mirena coil may be better than TCRF in high risk parients. I would review the need to swap warfarin for heparin with the haematologist before operation. Heparin would be stopped 12-24h before surgery.
I would advice life style modification to stop smoking and alcohol. I would also offer dietary advice and exercise to reduce BMI.
Intra operative measures include avoiding prolonged operation and the use of pneumatic compression stockings. I would ensure good surgical technique, meticulous haemostasis and the use of drains in high risk patients.
Post operatively, I would ensure correction of anemia and adequate hydration . I would encourage chest physiotherapy and early mobilization.The patient would be offered TEDS and thromboprophylaxis after the operation. Patients would be closely monitored for symptons and signs of leg and chest symptons and appropriate treatment offered.
Low risk patients would be offered early mobilisation, good hydration and TEDS. The moderate risk patients are offered TEDS, pre-op heparin 2h pre-op then 12h and high risk patients are offered TEDS with heparin 12h pre-op then 8h. Low molecular weight heparin like enoxaparin or tinzaparin has advantage of only daily dosage( heparin used 8-12h). The LMWH are as effective and probably safer than the unfractionated. The thromboprophylaxis are usually administered at a site away from the proposed surgery and continued till 5days or untill fully ambulant. The side effects include thrombocytopaenia and an increased risk of bleeding ( wound haematoma). The alternatives to heparin have limited usefulness and include IV dextran but this interferes with crossmatching of blood or warfarin requires close monitoring .
Posted by Mohammad H.
Wed Aug 15, 2007 02:06 pm
50 year old woman has been admitted for an abdominal hysterectomy because of a large

fibroid uterus. (a) How would you assess her risk of venous thrombo-embolic disease? [8

marks]. (b) Which measures can be taken to minimise the risk of venous thrombo-embolism in

women undergoing gynaecological surgery? [12 marks].

a- I will take history about risk factors for venous thrombo-embolism (VTE ) that include multiparity,smoking,use of combined oral contraceptive pills (cocps)and hormone replacement therapy(HRT).History of thrombophilia, systemic lupus erythematosus(SLE) , inflammatory bowel disorders(IBD) or urinary tract infection increses the risk of VTE.Immobile patients or
patients with prolonged bed rest(more than 4 days )also at incresedt risk of VTE.
Assessment of patient\'s BMI as obese patients are at more risk for VTE.
FBC to detect anemia and leucocytosis .Thrombophilia screenis not routinely used to assess patients undergoing hysrectomy but onlyshould be offered to patients with previous history or family history of VTE and in patients with bostetric history suggestive of thrombophilic disorders.



b-Patient should be evaluated for the risk of VTE and categorised as low or high risk .The patient should be advised to stop smoking for weeks before the operation.Advice for weight
reduction pre-operatively in cases undergoing elective surgery. HRT should be discontinued pre-operatively but there is no need to discontinue COCPs.
Treatment of factors that incraese the risk of VTE as sepsis or infection ,controlling SLE and IBD and treatment of anaemia.
Prophylactic pre-operative anti-coagulant (unfractionated{uh} low molecular weight heaprin{LMWH}in high risk patients and to be started 2 hours pre-operatively.
Advice against surgery and give alternative medical treatment if available in patients unfit for surgery or till control of factors that increases VTE when possible .
Selection of procedures associated with less time and early recover is associated with less risk of VTE as laparoscopic procdures,vaginal hystrectomy compared to abdominal hystrectomy and subtotal compared to total hystrectomy.Regional anaesthesia is associated with less
less risk of VTE.
Intra-operatively :good haemostasis ,avoiding dehydration and use of pneumatic matress and prophylactic antibiotocs in prolonged procedures reduces the risk of VTE.
Early mobilization ,good hydration,treatment of any infection reduces post-operative VTE.
Post-operative prophylactic LMWH or UH in high risk patients.
Provide written informatin leaflets to the patient.
Posted by Sabahat S.
Wed Aug 15, 2007 09:08 pm
a) She being 50 yrs old & booked for a major surgery increases her thromboembolic(TE) risk. History should be taken about any personal or family history of thromboembolic events, which may prompt investigation for thrombophilias (inherited / acquired). If she smokes, her risk of thromboembolism is further increased. Any present history of using combined (estrogen + progestogen) contraception, puts her at a high risk of TE. In case she has started using HRT(risk increased 5 times), and specially if using raloxifene, her TE risk is further increased.
Her BMI should be checked, if more than 30kg/m2, is a thromboembolic risk. Any evidence of gross leg varicosities further enhances the risk. Presence of mobilization problems e g paraplegia, leg fracture increases her thromboembolic risk.
Any history of inflammatory bowel deseases, nephrotic syndrome, sickle cell desease, certain cardiac conditions,hypertention, further increase her thromboembolic risk.
B) Preoperatively, weight reduction & cessation of smoking should be encouraged. She should be jointly evaluated by anaesthetist, physician & haematologist in case she has a personal history of VTE or carries a homozygous or combined thrombophilia or antithrombin lll deficiency. Preoperative heparin/ aspirin could be started in such cases.
Estrogen containing contraception should be stopped 4 weeks preoperatively.There is no need to stop HRT pre-op routinely but Raloxifene needs to be stopped preoperatively(as it carries the same risk as estrogen containing contraception). Optimization of any inflammatory bowel deseases, diabetes,hypertention or systemic infections will help to reduce the risk. Preanaesthetic evaluation by the anaesthetist is important. Blood should be crossmatched & kept ready. Results of any thrombophilia studies or coagulation screen should be available to guide management. Prophylactic heparin (LMWH) 2 hrs preop, reduces the thromboembolic risk.
Intraoperative, she should be kept well hydrated. Graduated pneumatic compression stocking should be well fitted & used intraoperatively. Blood loss should be minimized. With a view to encourage early post op mobilization, epidural anaesthesia, lower transverse incision ( if feasible) or perhaps a vaginal hysterectomy ( after reduction of fibroid size with GnRHa pre op )can help. Tissue trauma & surgery time should be minimized. Venous compression/ stasis by retractors should be avoided.
Post op, early mobilization with TED stockings is encouraged. She should be kept well hydrated by maintaining an I / O chart. Prophylactic heparin can be started post operatively depending on the time of insertion / removal of epidural catheter. ( prophylactic LMWH can given 4 hrs after removal of catheter. Maintaining good analgesia helps early & full mobilization. Minimizing the duration of hospital stay may also be helpful.
Posted by Parveen  Q.
Thu Aug 16, 2007 05:41 am
Risk assessment is done to categorise her under either moderate, or high risk category. I will ask for any personal or family history of thrombophilia which places her under moderate risk. I will enquire about her obstetric history, as multiparity is a moderate risk factor. Any history of chronic illness like chronic inflammatory bowel disese, nephrotic syndrom is another moderate risk factor. Treatment history about steriods use, oral contraceptic pills or HRT will be enquired, as HRT need not be stopped before surgery, but OC pills has to be stopped 4weeks before surgery. Iwill note down her BMI as BMI more than 30 is a risk factor. She is 50years old, it places her under moderate risk. I will review her medical records to look for any investigation report of thrombophilia. High risk categorises patients with 3 0r more moderate risk factors, gynaecological surgery more than 30minutesi patients with the family history or personal history of DVT or sufferinf from immobilisation or paralysis.

Minimising the risk is under various levels. Starting with patient care, adequate preparation, correction of anaemia, treatment of any intercurrent infections and control of chronic illness . This needs multidisciplinary team involvement of gynaecologist, haemotologist and internal medicine physician. Giving GnRH analogue 3months before surgery, reduces the intraoperative blood loss, reduces the need for blood transfusion and thereby reduces the operation time. Patient should be given graduated compression stocking/anti embolic stockings and shown how to use them correctly .LMWT heparin should be started before surgery and continued for 5days or untill she is fully mobile. If patient is with prosthetic valves Iv heaprin or warfarin should be given. During opearation intermittent pneumatic compressions may be used in addition to graduated compression /anti embolic stockings. Per opearatively, securing haemostasis, and using drains to prevent collection of blood, to prevents sepsis. In the event of any untoward accidents like vessel, bowel or ureteric injury, timely consultation with senior gynaecologists and bowel surgeon, or urologist will reduce morbidity or mortality of timely intervention and reducing the re operation. NOn closure of peritoneum reduces operation time, in a obese patient mass closure technique prevents wound dehiscence. Post opeartively early mobilisation is encouraged. Whie in bed advise to elevate the leg. Intake output chart to ensure there is no dehydration.Patient has to wear gc/anti embolic stockings until return to mobility. SC heparin continued till she is fully mobile. Following up protocols, regular audit will further reduces the risk.
Posted by Paul T.
Thu Aug 16, 2007 10:31 am
(a) This woman has following moderate risk factors of venour thrombo-embolism, e.g. age more than 40 and major abdominal surgery (1) . I will take detailed history to explore other risk factors of VTE, in particular past medical history of thromboembolic episodes (DVT, strokes , pulmonary embolism) (1) , history of heart disease or heart surgery (valve replacement), malignancy, diabetes. I would enquire about any concurrent sytemic illnesses, e.g. infections increase risk of VTE as well as connective tissue disease, chronic illnesses . I will ask if she or her family have thrombophilia, wich is a high risk factor for VTE. I will ask about any previous surgery or prolonged immobilization and it was associated with DVT. Prolonged immobilization prior to current surgery is high risk factor for VTE (1) . I wll check her reproductive history, e.g. pregnancies and deliveries and any association with DVT. I will check of she takes any medications, which increase risk of VTE (HRT) or any medications that decrease risk of VTE (aspirin, clopidogrel, warfarin, heparin, low molecular weight heparin). I will ask if she smokes as it increases risk of VTE.
I will check her BMI as obesity is a risk factor of VTE. I will aslo check if she has any varicose veins which predispose to development of VTE (1)

It is not clear from your answer that you would readily recognise moderate / high risk patients. Risk assessment is best done using a proforma, making it easy to see how many / which risk factors she has. You have not stated that 3 or more moderate risk factors = high risk
.

(b). Appropriate surgical procedure which is as short as possible and the least invasive procedure (e.g. vaginal hysterectomy instead of abdominal hysterectomy, minimal access surgery should be performed if technically possible) (1) . This will shorten postoperative immobilization and posteoperative hospital stay. Patients position should be carefuly checked prior to procedure to avoid any pressure points which could lead to interference with normal circulation, and, therefore, predispose to VTE.
Women should be encouraged to cease smoking and to loose weight if necessary (1) .
HRT and COCP should stopped 4 weeks prior to surgery COCP should be stopped but HRT should be continued but considered in risk assessment .
Women should be well hydrated (1) in pre- and postoperative period as dehydration predisposes to VTE.
All women with moderate risk factors of VTE (major surgery > 30 mins, age > 40, obesity with BMI >25, gross varicose veins, intercurrent infection, COCP, HRT) should have calf compressors during the surgery and should use TEDS stockings (1) in post-operative period until they resume their normal activity. Women at high risk of VTE ( 3 or more of moderate risk factors, personal history of VTE, immobilisation for > 4 days prior to major surgery, surgery for malignancy) in addition to TEDS stockings and calf compressors should be given anticoagulation during peri-operative period until full mobilisation or discharge. Unfractioned heparin is used in dose 5000 IU subcutaneously, twice a day, with the first dose given 2 hours pre-operatively This is treatment for MODERATE risk patients. See BNF . It should be used 3 times a day in cases of surgery for malignancy. Heparin decreases risk of VTE by 50%, but increases risk of heamorrhage twofold. Low molecular weight heparin (enoxaparin) is given once daily, which is more convinient. It has less risk of haemorrhage (1) , and is contraindicated in renal failure.
Posted by Paul T.
Thu Aug 16, 2007 10:47 am
a)Since her age is more than 40 yrs, she already has a moderate risk factor.I would like to take a detailed history to assess her risk status. I would like to verify if she has had any thromboembolic episosdes in the past following delivery or any other previous surgery,if she is a smoker, any reason for reduced physical activity, if she is on OCPs/ HRT , if she has any other associated medical disease e.g.diabetes (1) ,if there is family history of thrombophilias. I would like to examine her specifically with respect to her weight and BMI (which, if it is more than 25 is a risk factor obese = BMI >30 ), varicose veins. Thesed are moderate risk factors. Presence of 3 or more of these factors puts her at high risk for thromboembolism (1) Risk best assessed using proforma .
b) The various steps to reduce the risk are encouragement to lose weight preopertively in case her BMI is high & stop smoking (1) . Hormonal preparations should be stopped at least 4weeks pre-operatively does this include HRT, GnRH analogues ? ? .One should explore methods of reducing the operative time - vaginal hysterectomy is preferable where possible (1) . She should be kept well hydrated (1) ? post-op?? during the intraoperative period and also encouraged to mobilise early in the postoperative period (1) . Patients with moderate and high risk factors should be started on heparin or Low molecular weight heparin preoperatively. Heparin should be given at least 2 hours before surgery - this reduces the chances of VTE by half but doubles chances of hemorrhage and would hematoma (1) should moderate and high risk patients be treated the same? Does low molecular weight heparin increase the risk of haemorrhage / wound haematoma in the same way as unfractionated heparin?.This should be continues till she mobilises postoperatively or till discharge (1) . Heparin needs to be given at least twice daily while LMWH has the advantage of once daily dosage. When used for short duration heparin is associated with only occasinal side-effects like transient thrombocytopenia.TED stockings (1) could also be used since these have found to be beneficial in benign conditions. thromboembolism.
Posted by Paul T.
Thu Aug 16, 2007 01:00 pm
VTE is the commonest cause of maternal mortality and morbidity. Risk assessment is needed to be done to prevent VTE. The risk assessment involves taking detailed history which include personal/family history of VTE,thrombophilia ,history of thrombophilia in family, history of immobility for more than 4 days are these high risk factors? You have not stated so , and moderate risk factors more than three what does this mean? You should state that 3 or more moderate risk factors = high risk . If history of thrombophilia if she has a history of thrombophilia then she must have a thrombophilia??? is present then thrombophilia screening is needed. Moderate risk factors are assessed by obtaining history of intermittent illness, gross varicose veins, parity>4, immobility ,infection and obseity(80Kg) BMI is the relevant indicator . Low risk factors donot have any factors present ? meaning?? Low risk women. She is 50 and is undergoing surgery likely to take > 30 mins . Then she is also enquired about contraception, HRT and contraindication to HRT. Drug history of any anti coagulant being taken. Her examination is carried out including BMI(>30 is independent risk factor for VTE) (1) . The risk factors are asessed to decrease risk of VTE during surgery.
b. To minimise the risk during surgery assessment is done to identify the risk factor. Anaesthetic review should be taken and if the patient is taking anti-coagulation haemotologist review should be taken to adjust dose for surgery (1) manage very high risk patients in conjunction with haematologist & anaesthetist . TED stockings should be advised before surgery (1) . Heparin prophylaxis 2 hours pre-operatively is given to which group? Are moderate and high risk women treated the same? .
Intra-operatively fastidious haemostasis is needed. Drain should be placed during surgery to prevent haematoma as there is risk of haemorrhage with fibriod surgery. Interrupted sutures should be applied to reduce the risk of haemotoma formation.
Post operatively if the patient is low risk then early mobilisation and good hydration is advised. TED stocking will be provided.
If the patient is moderate risk then heparin prophylaxis with hydration therapy (1) ,Early moblisation (1) and TED stockings are provided.
In case of high risk/very high risk heparin thromboprophylaxis and management in ITU in consultation is high risk of VTE an indication for ITU management? High risk = 3 or more moderate risk factors. Would you admit a 50 year old undergoing abdominal hystsrectomy with a BMI of 32 to ITU?? (-1) with haematologist is carried out. TED stocking and early mobilisation is advised.
Posted by Paul T.
Thu Aug 16, 2007 09:08 pm
a) I would first take a thorough history trying to identify risk factors for VTE. Any comorbidities (e.g. diabetes, Ca) should be noted as they increase the risk. The same is true for thrombophilias or personal/family history of VTE are these moderate or high risk factors? . The patient\'s age is a risk factor by itself; medications (like COCP, HRT) may also increase the risk and appropriate questions should be asked.
On examination, the BMI should be noted. The patient\'s hydration and mobility capacity should be assessed since all of the above are risk factors for VTE. I would also check for varicose veins as they too increase the risk. If there are any doubts about the risk assessment, I would ask for haematologist\'s involvement. you have simply stated that factors increase risk but have not indicated which are MODERATE and which are HIGH risk factors. You have also not recognise that a woman with three or more moderate risk factors is high risk
b) Preoperatively, thorough history should be taken and examination undertaken to identify risk factors for VTE that was part (a) . The operation should be planned appropriately and tailored to patient\'s need with the aim of minimising operation time and speeding up recovery (laparoscopy generally superior to laparotomy and regional anaesthesia superior to GA) (1) ; anaesthetic involvement may therefore be beneficial. The patient\'s health should be optimised if there are relevant issues (losing weight, improving hydration and mobility, stopping COCP (1) )
Care should be taken to apply TED stockings (1) and commence heparin treatment you have not recognised that there are moderate and high risk patients who require different heparin regimens to minimise VTE risks. During operation, a Pfannenstiel incision should be preferred (unless midline incision necessary) as it is associated with quicker recovery. Blood loss should be kept to a minimum and haemostasis should be meticulous. Operation time should be as short as possible.
Postoperatively, administration of heparin should be continued until patient fully mobile (1) and ready to be discharged (TEDS should be applied all this time). Physiotherapist\'s involvement will be beneficial to encourage early mobilisation (1) . The patient should be kept well hydrated (1) .
Posted by Paul T.
Thu Aug 16, 2007 09:21 pm
This woman should be assessed thoroughly for risk factors, keeping in mind her age and major surgery .Her family history and personal history of past VTE will catagorise her high risk for VTE (1) . A detail medical history for major concurrent diseases like recent myocardial infarction, Bowel inflammatory diseases, sickle cell, nephrotic syndrome etc, as well as immobility of more than 4 days should be taken into consideration are these moderate or high risk factors? . She should be enquired about drugs with special emphasis on contraceptive use which type? Does POP increase risk of VTE? . Her examination should include checking weight , BMI what is the cut-off for BMI where this becomes a risk factor? , gross varicose veins and current infection[fever ,tachycardia].After assessment patients risk status should be discussed with her and documented including any plan for prophylactic measures and drug therapy. This plan should cover time frame of such measures you have not demonstrated that you know what are moderate or high risk factors or that at the end of your assessment, you will be able to class the woman as low, moderate or high risk .
B]? A pre-operative assessment of risk factors categorization of patient into high, medium and low How do you arrive at such categorisation? grade will help to decide about preventive measure. She should be advise on weight control (1) ,smoking if necessary and use of non-hormonal method of contraception at least 4weeks before surgery would you stop POP or implanon? . Any medical condition should be well controlled (1) . Women should be treated for current infection .She should be advised for TED stockings (1) . In high risk case a plan for when to start and stop prophylactic heparin should be discussed and documented when would you start and stop heparin? How does the examiner know that you know thois? .
Intraoperative measure should include use calf compression/stimulation devices, keeping patient well hydrated, reducing blood loss, measure to decrease operative time and prophylactic antibiotics.

Post ?operative patient should be kept well hydrated (1) with fluid and transfused if required .All measure should be taken for early mobilization (1) of patient. She should continue with use of TED-stockings. Reassessment for prophylactic heparin should be done.
Posted by Paul T.
Thu Aug 16, 2007 09:35 pm
Venous thromboembolism is a risk to gynaecological surgery,estimated risk around 20% in average surgeries does this refer to symptomatic / clinically evident VTE? there fore it is very important to assign risk and start prophylaxis at time of surgery.
High risk women include personal or family history of venous thromboembolism known thrombophilic (1) .
presence of malignant disease the woman in question has a fibroid or women with 3 or more moderate risks
.Moderate risks are, age more then 40year, obesity(BMI >35),varicose vein ,presence of certain medical disorder (1) do not write a list also increase risks for example presence of cardiac disease ,polycythemia,sickle cell anemia ,intercurrant infection (1) , and surgery more then 30 minute you should recognise that an abdominal hysterectomy would take more than 30 mins ..In her social history smoking ,prolong immobility (long haul flight ) this is not prolonged immobility illicit drug should be consider.

b)Her risk of VTE can be minimize by her assessment in clinic by advising her to reduce her weight (1) ,avoid immobility ,quit smoking, if she is still using low dose combine oral contraceptive pills, she should stop using at least a month before surgery (1) , ,where as HRT doesn?t need to be stop,reloxifen should be discontinue a week before surgery.Infection should be treated (1) .
she has been planned for abdominal hysterectomy due to large fibroid ,Vaginal rout associate with less incidence of VTE (1) . fibroid can be shrink by using GnRH,and vaginal hysterectomy can be possible ,
In high risk situation where she is having throbophilia,personal or family history of VTE then haematologist ,anaesthetist should be involve in her operative care (1) .

Upon admission reassessment done .
Good hydration avoid dehydration with thromoembolic deterant stocking can prevent VTE (1) poor English , It should wear preoperatively till discharge .it has limited value ? meaning .
Low molecular weight heparin in started 12 hour before surgery and continue postoperativly till discharge is this for all, moderate or high risk women?? .
Surgery should be quick, avoid bleeding by active haemostasis,
Post operative ensure good analgesia ,hydration (1) and early mobility (1) is very important. To avoid VTE.
Measures to avoid infections by antibiotics .
Keeping high index of suspicion to any calf pain or chest pain ,start therapeutic heparin before objective diagnosis can be made.
Posted by Zarkoth A.
Thu Aug 16, 2007 10:23 pm
Dr Paul, could you please guide us about where the guidelines for moderate/high risk patients for VTE in gynaecology can be found? It seems that some of us (including myself) failed to identify this salient point.
Posted by Paul T.
Fri Aug 17, 2007 01:55 am
A
This woman already has some risk factors being age over 35 and major pelvic surgery. I would take a history looking for other risk factors. Weight >80 Kg or raised BMI >30 BMI is the relevant factor, not weight has a higher risk. Smokers and heavy alcohol drinking. Current illness or infection especially inflammatory conditions like inflammatory bowel disease or conditions like nephritic syndrome or polycythaemia where there is a hypercoaguable state increase risk. If she has a very sedentary lifestyle. Diabetes , hpertention, chronic renal failure or hepatic disease and other ill health are these moderate or high risk factors? .

A personal history of venous thromboembolism and if it was provoked or not is important what does important mean? Is it a moderate or high risk factor? . A non-provoked VTE is associated with a higher risk of an undiagnosed thrombophilia. A diagnosed thrombophilia either acquired (antiphospholipid syndrome ) or inherited (higher risk ones being homozygous Factor V Leiden, antithrombin II or combinations) ? this is not a sentence . A family history of thromboembolism or thrombophilias is also important this is a high risk factor . Drug history like use of HRT or raloxifene as an increased risk. Varicose veins are also associated. Immobility example in a wheelchair bound patient or recent immobilised fracture.
It needs to be clear that after your assessment, you would be able to categorise her as low, moderate or high risk. To do this, you must know what constitutes high risk (personal or Family Hx of VTE, thrombophilia, 3 or more moderate risk factors) and what constitutes moderate risk (age >40, BMI > 30, current illness, gross varicose veins?

B
Preoperative measure would include weight loss (1) and increasing her fitness to improve her post op recovery. Management of intercurent illnesses (1) is important but may not eradicate risk example quiescent inflammatory bowel disease, ensuring no infections present. Graduated compression stocking used intraop and post op improve venous drainage and reduce risk (1) . Postponement of the operation until the woman is in the best possible health to proceed. Liaison with other health professionals who manage her other illnesses to optimise her health pre-op. Stopping possible offending medications like HRT 1 week previously can reduce risk HRT does not need to be stopped but should be considered in risk assessment . Prophylactic low molecular weight heparin given postoperatively for 3-5 days NO ? should be given pre-op (2-12h depending on risk) and continued until fully mobile reduces the risk further. Care during the operation to avoid excessive trauma to the tissues and pelvic veins. Admission pro-op with enough time to stabilise conditions like diabetes.

Other measures include measures to increase the chance of early mobilisation (1) . Choice of incision (transverse better than midline), vaginal surgery versus abdominal, and regional or local anaesthesia over general (1) . Keeping the patient well hydrated intra and post op (1) . Avoiding infection in the wound or chest would reduce the risk and this can be done by ensuring good haemostasis, avoiding aspiration, chest physiotherapy if needed and overall good surveillance to detect and treat infection early.
Posted by Paul T.
Fri Aug 17, 2007 02:10 am
a) A detailed history should be taken to identify any risk factors for venous thromboembolism. General risk factors such as age should be considered. A woman over the age of 40 is at at increased risk of developing thromboembolism. Smoking would increase the risk , particularly if she smokes more than 15 cigarettes per day. The use of hormone replacement therapy with cobined estrogen and progestogen would also increase her risk of venous thromboembolism. A history of clinical conditions such as the presence of cardiac disease, inflammatory diseases or nephrotic syndrome should be determined. These conditions would also increase the risk of thromboembolism.
Inherent major risk factors should be determined for example a personal history of thrombophilias such as protein C deficiency, protein S deficiency or Factor V Leiden which would lead to an increased risk of thromboembolism. A past history of thromboembolism or stroke would also increase her risk of repeat thromboembolism. I would also enquire about her family history of thrombophilias or venous thromboembolism. This would increase her risk but also it would indicate that there may be a heriditary thrombophilia and the patient may need further investigations prior to surgery to determine whtehre she also has a thrombophilia. The factors you have discussed ?increase risk? and you have given smoking the same relevance as previous VTE. You need to indicate which are high risk factors (previous / family Hx of VTE, thrombophilia, 3 or more moderate risk factors) and which are moderate risk factors (age > 40, BMI > 30, current illness, gross varicose veins?). Using a proforma, you would then be able to categorise her as low, moderate or high risk and manage her accordingly

Physical examination can also contibute to the assessment of risk. The body mass index should be calculated from the weight and height. A value of more than 30kg/m2 would increase the risk of venous thromboembolism. An increased is also associated with the presence of varicose veins.

Hysterectomy is also a major operation. The indication is uterine fibroids and this means that the operation will be long, there may be heavy blood loss and she will be in hospitals for a few days. These factors will also increase her risk of thromboembolism.

This lady will be considered low risk if her only risk factors are age over 40 and major operation lasting more than 30 mins NO ? age over 40 = moderate risk factor, as is surgery lasting over 30 mins. So she has 2 moderate risk factors at least . Moderate risk if there is also the presence of a medical disorder. High risk if she also has a history of venous thromboembolism or a thrombophilia (1) .

b) A preoperative assessment by the anaesthesist and discussion with the gynaecology team to determine the level of risk. A multidisciplinary approach is needed to minimize risk in this lady. The level of risk will also determine the dose and duration of prophylactic heparin.
Blood loss should be minimized during the operation to prevent hypovolaemia. This can lead to a thromboembolic event. Mechanical thromboprphylaxis should be done in theatre and during the operation what does this mean? .
Postoperatively, the patient should be encouraged to mobilise . Prolonged im mobility increases the chance of thromboembolism. A fluid input output chart should be maintained to ensure that the patient does not become dehydrated preventing dehydration does not = keeping her well hydrated or hypovolaemic. Both conditions can lead to thromboembolism. Antiembolism graduated compression stockings should be worn to reduce venous stasis should be applied pre-op . Daily subcutaneous injections of Low molecular weight heparin should be given prophylactically to prevent thromboembolism should be administered 2-12h pre-op depending on risk .
Posted by Paul T.
Fri Aug 17, 2007 02:20 am
Her BMI should be known.Enquiry should be made about her smoking habits pre operatively.Her past medical history and family history should be assessed specifically for personal history of thromboembolism and thrombophilia.She should also be checked for severe varicose veins.The combined contraceptive pill intake should be known as it increases her risk after major surgery.Her general fitness and mobility should be assessed as post operative immobility will increase her risk.
The length of the operation and the extent of surgery will also determine her risk of thromboembolism. you have not indicated which are high / moderate risk factors. High risk factors = personal / FHx of VTE, thrombophilia, 3 or more moderate risk factors (age > 40, BMI > 30, intercurrent illness, gross vv?). At the end of your assessment, you should be in a position to categorise her as low, moderate or high risk and manage her accordingly

Patients must be advised to lose weight (1) prior to elective surgery to reach a BMI of less than 30 if possible.They should also stop smoking pre operatively.The combined oral contraceptive pill must be stopped 4 weeks (1) before major surgery and an alternative contraception advised.
The patients should have flowtron boots intraoperatively and kept well hydrated intra and post operatively (1) .TED stockings (1) should be worn post operatively and early mobilisation encouraged (1) , with the help of a physiotherapist if possible. Patients at high risk moderate and high risk patients need heparin of thromboembolism should be given prophylactic heparin, preferably low molecular weight heparin, the day before surgery (1) and post operatively.
Patients at very high risk of thromboembolism and listed for elective surgery may be considered for alternative treatment if available.
Posted by Paul T.
Fri Aug 17, 2007 10:08 am
a) The high risk factors I would look for in this woman include the presence of 3 or more moderate risk factors (1) , personal history of VTE or a family history of thrombophilia (1) .
The moderate risk factors include age of 50 years and having major pelvic surgery and operation more likely to last > 30mins. (1) Others would include the presence of co-morbidity like heart disease, inflammatory bowel disease or nephrotic syndrome (1) . History of smoking also important. The finding of a BMI >30 (1) and the presence of varicose veins.
Low risk patients are women with no additional risk factors (1) .

b) The measures would include a pre-op assessment to correct anemia before surgery. This encourages wound healing and promotes rapid post operative recovery. Co-morbid situations are also treated before surgery (1) . I would ensure that high risk patients are reviewed by the anaesthetist ( to plan appropriate method of pain relief) and the haematologist (1) to assess for the risk of thromboprophylaxis and offer treatment. Patients would be appropriately selected for the type of surgery (1) in relation to risk of VTE ie the mirena coil may be better than TCRF in high risk parients. I would review the need to swap warfarin for heparin with the haematologist before operation. Heparin would be stopped 12-24h before surgery.
I would advice life style modification to stop smoking and alcohol. I would also offer dietary advice and exercise to reduce BMI (1) .
Intra operative measures include avoiding prolonged operation and the use of pneumatic compression stockings (1) . I would ensure good surgical technique, meticulous haemostasis and the use of drains in high risk patients.
Post operatively, I would ensure correction of anemia and adequate hydration (1) . I would encourage chest physiotherapy and early mobilization (1) .The patient would be offered TEDS and thromboprophylaxis should be started 2-12h pre-op depending on risk after the operation. Patients would be closely monitored for symptons and signs of leg and chest symptons and appropriate treatment offered.
Low risk patients would be offered early mobilisation, good hydration and TEDS. The moderate risk patients are offered TEDS, pre-op heparin 2h (1) pre-op then 12h and high risk patients are offered TEDS with heparin 12h (1) pre-op then 8h. Low molecular weight heparin like enoxaparin or tinzaparin has advantage of only daily dosage( heparin used 8-12h). The LMWH are as effective and probably safer why? Reduced risk of bleeding than the unfractionated. The thromboprophylaxis are usually administered at a site away from the proposed surgery and continued till 5days or untill fully ambulant (1) . The side effects include thrombocytopaenia and an increased risk of bleeding ( wound haematoma). The alternatives to heparin have limited usefulness and include IV dextran but this interferes with crossmatching of blood or warfarin requires close monitoring .

Excellent answer
Posted by Paul T.
Fri Aug 17, 2007 10:16 am
a- I will take history about risk factors for venous thrombo-embolism (VTE ) that include multiparity,smoking,use of combined oral contraceptive pills (cocps)and hormone replacement therapy(HRT).History of thrombophilia, systemic lupus erythematosus(SLE) , inflammatory bowel disorders(IBD) or urinary tract infection increses the risk of VTE.Immobile patients or
patients with prolonged bed rest(more than 4 days )also at incresedt risk of VTE.
Assessment of patient\'s BMI as obese patients are at more risk for VTE.
FBC to detect anemia and leucocytosis .Thrombophilia screenis not routinely used to assess patients undergoing hysrectomy but onlyshould be offered to patients with previous history or family history of VTE and in patients with bostetric history suggestive of thrombophilic disorders.

you have not indicated which of these are moderate or high risk factors. You will therefore not be able to categorise the woman as low, moderate or high risk



b-Patient should be evaluated for the risk of VTE and categorised as low or high risk HOW? This is what (a) was about .The patient should be advised to stop smoking for weeks before the operation.Advice for weight
reduction (1) pre-operatively in cases undergoing elective surgery. HRT should be discontinued pre-operatively but there is no need to discontinue COCPs ??? COCP must be stopped but HRT should not. Once you make such a major error, your answer cannot pass (-2) .
Treatment of factors that incraese the risk of VTE as sepsis or infection ,controlling SLE and IBD (1) and treatment of anaemia.
Prophylactic pre-operative anti-coagulant (unfractionated{uh} low molecular weight heaprin{LMWH}in high risk patients and to be started 2 hours pre-operatively NO ? this is the regimen for moderate risk women .
Advice against surgery and give alternative medical treatment if available in patients unfit for surgery or till control of factors that increases VTE when possible .
Selection of procedures associated with less time and early recover is associated with less risk of VTE as laparoscopic procdures,vaginal hystrectomy compared to abdominal hystrectomy and subtotal compared to total hystrectomy.Regional anaesthesia is associated with less
less risk of VTE (1) .
Intra-operatively :good haemostasis ,avoiding dehydration and use of pneumatic matress how does this reduce VTE risk? and prophylactic antibiotocs in prolonged procedures reduces the risk of VTE.
Early mobilization (1) ,good hydration (1) ,treatment of any infection reduces post-operative VTE.
Post-operative prophylactic LMWH or UH in high risk patients.
Provide written informatin leaflets to the patient.

See excellent answer above
Posted by Paul T.
Fri Aug 17, 2007 10:22 am
a) She being 50 yrs old & booked for a major surgery increases her thromboembolic(TE) risk. History should be taken about any personal or family history of thromboembolic events, which may prompt investigation for thrombophilias (inherited / acquired). If she smokes, her risk of thromboembolism is further increased. Any present history of using combined (estrogen + progestogen) contraception, puts her at a high risk of TE. In case she has started using HRT(risk increased 5 times), and specially if using raloxifene, her TE risk is further increased.
Her BMI should be checked, if more than 30kg/m2, is a thromboembolic risk. Any evidence of gross leg varicosities further enhances the risk. Presence of mobilization problems e g paraplegia, leg fracture increases her thromboembolic risk.
Any history of inflammatory bowel deseases, nephrotic syndrome, sickle cell desease, certain cardiac conditions,hypertention, further increase her thromboembolic risk.

How would you categorise her as low, moderate or high risk? You have not indicated which are high or moderate risk factors. See excellent answer above
B) Preoperatively, weight reduction (1) & cessation of smoking should be encouraged. She should be jointly evaluated by anaesthetist, physician & haematologist in case she has a personal history of VTE or carries a homozygous or combined thrombophilia or antithrombin lll deficiency (1) . Preoperative heparin/ aspirin could be started in such cases.
Estrogen containing contraception should be stopped 4 weeks preoperatively (1) .There is no need to stop HRT pre-op routinely but Raloxifene needs to be stopped preoperatively(as it carries the same risk as estrogen containing contraception). Optimization of any inflammatory bowel deseases, diabetes,hypertention or systemic infections will help to reduce the risk (1) . Preanaesthetic evaluation by the anaesthetist is important. Blood should be crossmatched & kept ready. Results of any thrombophilia studies or coagulation screen should be available to guide management. Prophylactic heparin (LMWH) 2 hrs preop, reduces the thromboembolic risk do you use the same regimen for all patients? 2h pre-op for moderate risk, 12h for high risk .
Intraoperative, she should be kept well hydrated (1) . Graduated pneumatic compression stocking (1) should be well fitted & used intraoperatively. Blood loss should be minimized. With a view to encourage early post op mobilization (1) , epidural anaesthesia, lower transverse incision ( if feasible) or perhaps a vaginal hysterectomy ( after reduction of fibroid size with GnRHa pre op )can help (1) . Tissue trauma & surgery time should be minimized. Venous compression/ stasis by retractors should be avoided.
Post op, early mobilization with TED stockings is encouraged. She should be kept well hydrated by maintaining an I / O chart. Prophylactic heparin can be started post operatively depending on the time of insertion / removal of epidural catheter. ( prophylactic LMWH can given 4 hrs after removal of catheter. Maintaining good analgesia helps early & full mobilization. Minimizing the duration of hospital stay may also be helpful.
Posted by Paul T.
Fri Aug 17, 2007 10:30 am
Risk assessment is done to categorise her under either moderate, or high risk category. I will ask for any personal or family history of thrombophilia which places her under moderate risk NO ? high risk . I will enquire about her obstetric history, as multiparity is a moderate risk factor. Any history of chronic illness like chronic inflammatory bowel disese, nephrotic syndrom is another moderate risk factor (1) . Treatment history about steriods use, oral contraceptic pills or HRT will be enquired, as HRT need not be stopped before surgery, but OC pills has to be stopped 4weeks before surgery (1) . Iwill note down her BMI as BMI more than 30 is a moderate risk factor. She is 50years old, it places her under moderate risk (1) . I will review her medical records to look for any investigation report of thrombophilia. High risk categorises patients with 3 0r more moderate risk factors (1) , gynaecological surgery more than 30minutesi moderate risk patients with the family history or personal history of DVT or sufferinf from immobilisation or paralysis.
You have confused some moderate & high risk factors
Minimising the risk is under various levels. Starting with patient care, adequate preparation, correction of anaemia, treatment of any intercurrent infections and control of chronic illness (1) . This needs multidisciplinary team involvement of gynaecologist, haemotologist and internal medicine physician. Giving GnRH analogue 3months before surgery, reduces the intraoperative blood loss, reduces the need for blood transfusion and thereby reduces the operation time. Patient should be given graduated compression stocking/anti embolic stockings (1) and shown how to use them correctly . LMWT heparin should be started before surgery how many h or days before? and continued for 5days or untill she is fully mobile (1) . If patient is with prosthetic valves Iv heaprin or warfarin would you use warfarin peri-operatively? (-1) should be given. During opearation intermittent pneumatic compressions may be used in addition to graduated compression /anti embolic stockings. Per opearatively, securing haemostasis, and using drains to prevent collection of blood, to prevents sepsis. In the event of any untoward accidents like vessel, bowel or ureteric injury, timely consultation with senior gynaecologists and bowel surgeon, or urologist will reduce morbidity or mortality of timely intervention and reducing the re operation. NOn closure of peritoneum reduces operation time, in a obese patient mass closure technique prevents wound dehiscence. Post opeartively early mobilisation (1) is encouraged. Whie in bed advise to elevate the leg. Intake output chart to ensure there is no dehydration keep well hydrated .Patient has to wear gc/anti embolic stockings until return to mobility. SC heparin continued till she is fully mobile. Following up protocols, regular audit will further reduces the risk.

See excellent answer above
Posted by Paul T.
Mon Aug 20, 2007 03:23 pm
a good candidate should

(a)

? Know that her risk is best assessed using a proforma (1)

? Know what constitutes high risk factors: Family / personal Hx of VTE, thrombophilia, long term immobilisation / paralysis; three or more moderate risk factors (2)

? Know other moderate risk factors (4) :

1) Age > 40 years
2) Obesity
3) Gross varicose veins
4) Immobility prior to surgery
5) Current infection
6) Major current illness
7) COCP or HRT

? Know that she is at least at moderate ? high risk of VTE (age, operation lasting > 30 mins) (1)

(b)

? Pre-operative weight reduction, stopping smoking and treatment of medical conditions (2)

? Stopping COCP (1)

? Thrombophilia screen in women with personal / family Hx of VTE to enable better assessment of risk (1)

? Using a less invasive route if possible ? for instance, vaginal instead of abdominal hysterectomy (1)

? Pre-operative heparin 2h pre-op in moderate risk patients or 12h pre-op in high risk patients (2)

? Know that heparin should be continued until fully mobile / discharge (1)

? Know the role of low molecular weight heparin in reducing risk of haemorrhage (1)

? Know that very high risk patients should be managed in conjunction with a haematologist (1)

? Know the value of TED stockings (1)

? Early mobilisation (1)

? Good hydration (1)