Gynae surgery, DAPT and anticoagulant

43yo lady for EUA, D&C, and Mirena. 


  • Abnormal uterine bleeding – over last 4 years. Menorrhagia and irregular bleeding. Hb 142. Fe studies borderline. Normal endometrial Pipelle biopsy.
  • Radical vulvectomy 2020 – malignant undifferentiated neuroendocrine tumour. Margins included. For radiotherapy as per last Gynae-oncology MDT.
  • Asthma/COPD – Current smoker
  • Complex PTSD and chronic pain syndrome – known to Dr Chris Hayes
  • Increased BMI
  • Immobility – walks with 4WW or uses wheelchair due to above issues.


  • IHD – multiple myocardial infarctions, last in 2018. DAPT. No regular cardiology follow-up.
  • LV thrombus 2018 – anticoagulated with warfarin.
  • IDDM – previously very poor glycaemic control. Recent HbA1c 7.1%. regular endocrine review.
  • PVD – multiple lower limb surgeries. Prolonged admission in 2020 with femoral endarterectomy/fem-pop bypass, fasciotomies, and multiple angiographic procedures.
  • Gynae were unaware of DAPT and Warfarin


Correct procedure for this patient?

  • AUB and urinary incontinence are main issues for patient. 
  • Doesn’t want a Mirena as has had one previously; menorrhagia was worse and Mirena expelled itself. 
  • Patient thought she was having an endometrial ablation
  • Discussed above issues with surgical team. They organised to review her again in clinic and revisit her surgical options.

Management of anticoagulation and DAPT

  • Haematology review during last admission documented ‘unidentified prothrombotic state.’
  • No outpatient Haematology review arranged on discharge, no pathology on system.
  • A firm plan should be in place for management of anticoagulation and antiplatelet therapy perioperatively. 
  • Discuss with the cardiologist next week at MDT 
  • Is her triple therapy appropriate anyway? Could she just be on a NOAC?


  • Postpone surgery for 4 weeks 
  • Discuss at cardiology MDT
  • Re-review with gynae team organised
  • Referred to haematologist for investigation and advise on anticoagulation/DAPT