How to clear a postmenopausal patient with abnormal vaginal bleeding, hypertension, atrial fibrillation, and insomnia for a dilation and curettage (D&C) procedure?

From the Guidelines

To clear a postmenopausal patient with abnormal vaginal bleeding, hypertension, atrial fibrillation, and insomnia for a dilation and curettage (D&C) procedure, a comprehensive preoperative evaluation is necessary, prioritizing the management of her atrial fibrillation and hypertension to minimize perioperative risks. Begin with a complete history and physical examination, focusing on the severity and control of her hypertension and atrial fibrillation, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. Order basic laboratory tests including complete blood count, comprehensive metabolic panel, coagulation studies (PT/INR, PTT), and ECG.

Management of Anticoagulation

If the patient is on anticoagulants for atrial fibrillation (such as warfarin, apixaban, or rivaroxaban), these should be temporarily discontinued before surgery according to specific guidelines, typically warfarin 5 days prior, apixaban/rivaroxaban 48 hours prior, as suggested by the perioperative management of antithrombotic therapy guidelines 1. Consider bridging with low molecular weight heparin if the patient has high thromboembolic risk, taking into account the patient's individual risk factors and the type of surgery, as noted in the American College of Chest Physicians clinical practice guideline 1.

Management of Hypertension and Other Conditions

Blood pressure medications should be continued perioperatively, with the possible exception of ACE inhibitors and ARBs, which may be held the morning of surgery, based on the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1. For insomnia medications, benzodiazepines can generally be continued, but discuss with anesthesia if the patient takes other sedative-hypnotics. Cardiac clearance may be necessary depending on the severity of her cardiac conditions, potentially including an echocardiogram to assess cardiac function, as part of a comprehensive approach to manage her comorbidities and minimize perioperative risks.

Preoperative Preparation

The patient should fast for at least 6 hours before the procedure, and any chronic medications approved for continuation should be taken with a small sip of water. This approach is in line with general preoperative guidelines and ensures the patient's safety during the procedure. By following these steps and considering the latest guidelines, including those from the European Society of Cardiology 1 and the American College of Chest Physicians 1, the patient can be adequately prepared for the D&C procedure, minimizing risks associated with her comorbid conditions.

From the Research

Patient Assessment and Clearance for D&C Procedure

To advise the patient, the following factors should be considered:

• The patient's history of abnormal postmenopausal vaginal bleeding, which is the primary reason for the scheduled D&C procedure
• The presence of comorbidities, including hypertension, atrial fibrillation, and insomnia, which may impact the patient's surgical risk and management plan 2, 3, 4
• The need for thorough preoperative evaluation, including a history and physical exam, review of medications, and evaluation of major organ systems, to identify potential surgical risks and complications 3, 5

Preoperative Evaluation and Testing

The preoperative evaluation should be driven by the patient's history and physical examination, as well as the risk of the surgical procedure 5. The following tests may be considered:

• Electrocardiogram (ECG) to evaluate the patient's cardiac status, given the history of atrial fibrillation 2, 6
• Blood work, including a full blood count, to assess the patient's overall health and identify potential bleeding risks 6
• Review of the patient's medication list, including anticoagulants and antihypertensives, to ensure safe management during the perioperative period 2, 4

Management of Comorbidities

The patient's comorbidities should be managed appropriately to minimize perioperative risks:

• Hypertension should be controlled to reduce the risk of cardiovascular complications 2
• Atrial fibrillation should be managed with anticoagulation therapy, if indicated, to reduce the risk of stroke 2, 4
• Insomnia should be addressed to ensure the patient is well-rested and able to tolerate the surgical procedure

Clearance for D&C Procedure

Based on the patient's evaluation and management of comorbidities, clearance for the D&C procedure can be determined. The patient's primary care physician and surgical team should communicate effectively to ensure that all necessary precautions are taken to minimize perioperative risks and promote uncomplicated recovery 3, 5.