Gynae surgery, DAPT and anticoagulant

43yo lady for EUA, D&C, and Mirena.

Background

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.

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

Discussion

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?

Plan:

Perioperative Talk