43-year-old lady for Hysteroscopy/D&C

Background:

• Asthma and upper airway dysfunction – stable disease, well-controlled with inhaled therapies and regular respiratory review
• Cannabis smoker – daily

Issues

• Abnormal uterine bleeding – menorrhagia for 3/52 each month, using 6+ pads per day
• Bleeding significantly affecting QoL; unable to work, take children swimming.
• Fe-deficiency, no anaemia. 3 monthly iron infusions.
• Positive bleeding history – epistaxis x2 per week. Gum bleeding when brushes teeth.
• International Society of Thrombosis and Haemostasis (ISTH) Bleeding score = 4 

• Normal range is <4 in adult males, <6 in adult females and ❤ in children

Discussion

Preoperative interventions required?

• Discussed with haematology registrar, unusual pathology results; Factor VIII levels and antigens supra-normal indicating vWD unlikely
• Normal Full Blood Count, APTT slightly raised at 39
• Interestingly, lupus anticoagulant and fibrinogen were raised which would indicate a propensity for clotting rather than bleeding
• Urgent Haematology appointment organised – unlikely to occur preoperatively. Public outpatient system under pressure at present
• Consensus that it would be reasonable to proceed with above procedure

Surgical Options

• Discussed with Gynaecology Fellow, agreed it is important to address bleeding while awaiting further haematology review
• Options for Mirena will be presented to patient as a short-term management

Plan: 

• Proceed to surgery
• Haematology review pending