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