O&G SAQs · Perioperative care
Perioperative VTE prophylaxis — structured SAQ (15 marks)
FRANZCOG-format structured SAQ with per-part marking rubric.
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FRANZCOGMRCOGABOG
Prompt
A 66-year-old woman with BMI 38 kg/m² and ovarian cancer will undergo open cytoreductive surgery. Renal function and platelets are normal. An epidural is planned. (a) Assess her VTE and bleeding risk. (3 marks) (b) Prescribe mechanical prophylaxis. (3 marks) (c) Prescribe pharmacological prophylaxis and duration. (5 marks) (d) On day two she develops active intra-abdominal bleeding. Modify the plan. (4 marks)
How this SAQ is marked
Write short labelled points. A drug answer needs agent, dose, route, timing and rationale. A pathway answer needs an escalation or deviation trigger. [1]
Reveal model answer and mark schemeShowHide
(a) Risk assessment — 3 marks
- High VTE risk: active cancer, age, obesity, open major pelvic surgery and expected reduced mobility.
- Assess previous VTE/thrombophilia, oestrogen, mobility and additional comorbidity.
- Assess bleeding, platelets, renal function and the drug-specific neuraxial timing plan.
(b) Mechanical prophylaxis — 3 marks
- Correctly sized IPC applied before or at induction.
- Confirm pump is connected and cycling; inspect skin.
- Continue until mobile, including while pharmacological prophylaxis is temporarily unsafe.
(c) Pharmacological prophylaxis — 5 marks
- Use LMWH when haemostasis and epidural timing permit.
- ENOXACAN II: enoxaparin 40 mg SC once daily after open abdominal or pelvic cancer surgery.
- HIGHLOW neuraxial interval: at least 12 hours after low-dose LMWH and at least 24 hours after intermediate-dose LMWH; agree the plan with anaesthesia.
- Four weeks of LMWH (ENOXACAN II 12.0 versus 4.8 percent VTE); gynaecology discharge packs often run 28 days.
- At discharge prescribe, teach injection technique, document stop date and safety net.
(d) Active bleeding — 4 marks
- Hold LMWH and resuscitate/control the bleeding source.
- Continue IPC if safe.
- Document reason, owner and planned reassessment time.
- Restart pharmacological prophylaxis when haemostasis and neuraxial considerations permit.
References6ShowHide
- [1]American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232 Obstet Gynecol, 2021.PMID 34259490
- [2]Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer N Engl J Med, 2002.PMID 11919306
- [3]Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014 J Clin Oncol, 2015.PMID 25605844
- [4]Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, 2008.PMID 18574271
- [5]Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest, 2012.PMID 22315263
- [6]Bistervels IM, Wiegers HMG, Áinle FN, et al. Onset of labor and use of analgesia in women using thromboprophylaxis with 2 doses of low-molecular-weight heparin: insights from the Highlow study J Thromb Haemost, 2023.PMID 36695396