It is always good practice to discuss, and include in the consent, any possible additional procedures that may be required during the intended operation. Generally, any additional surgical treatment which has not previously been discussed with the woman should not be performed, even if this means a second operation (Royal College of Obstetricians and Gynaecologists 2008a). One must not exceed the scope of authority given by the woman, except in a life-threatening emergency. There are three different situations where an additional procedure may be necessary during the course of an elective surgery. Firstly, when a minor pathology related to the patient’s symptoms is detected such as endometriosis or adhesions in women undergoing laparoscopy for pelvic pain or infertility. In this situation, treatment can be performed if the patient has been made aware of this possibility and has consented for additional minor treatment. The second situation arises when a more complex disease is detected such as a pelvic mass, suspicious looking ovary, severe endometriosis or severe adhesions. Surgery in these situations should be deferred to a second operation after adequate counselling of the patient. In particular, oophorectomy for unexpected disease detected at surgery should not normally be performed without previous consent. The third situation involves intraoperative complications such as injury to the bowel or urinary tract that could lead to serious consequences if left untreated. Corrective surgery must proceed in these cases, and full explanation should be given as soon as practical following surgery.

Who should obtain the consent?

It is the responsibility of the clinician undertaking the surgical procedure to obtain consent. However, if this is not possible, it may be delegated to another doctor who is adequately trained and has sufficient knowledge of the procedure to be performed (General Medical Council 2008). The consent, however, remains the responsibility of the surgeon performing the operation. The clinician obtaining the consent should see the patient on her own first, for at least part of the consultation. She should then be allowed the company of a trusted friend or relative for support if she wishes. If consent is taken on the day of surgery, enough time should be allowed for discussion (Royal College of Obstetricians and Gynaecologists 2008a).

Additional consents

• Fertility treatment using assisted reproduction technology (e.g. oocyte retrieval under general anaesthetic) requires specific consent forms according to the regulations set by the Human Fertilisation and Embryology Authority.

• If images or video records are going to be taken during surgery, consent should be obtained for this and the use specified; for example, for teaching or educational purposes (Royal College of Obstetricians and Gynaecologists 2008a).

• Consent for the presence of medical students during consultations and in the operating theatre as an observer or assistant should be obtained. If the medical student has consent for vaginal examination while the woman is anaesthetized, this should be in writing.

• It is not required to have consent for taking tissue samples unless it is intended for research purposes. Women should be advised that blocks or slides of tissue taken for histological examination might be kept as part of the medical record whilst the rest of the sample is destroyed.

Duration of consent

The consent will remain valid indefinitely unless withdrawn. However, if new information is available between the consent and the procedure (e.g. new evidence of risk or new treatment options), the doctor should inform the patient and reconfirm the consent. It is also wise to refresh the consent form if there is a significant amount of time between consent and the intervention (Department of Health 2001).

Consent of special groups of patients

Jehovah’s Witnesses

Jehovah’s Witnesses are an Adventist sect of Christianity founded in the USA in the late 19th Century. They believe that accepting a blood transfusion, even autologous blood transfusions in which one’s own blood is stored for later transfusion, is a sin. This includes red blood cells, white blood cells, platelets and plasma. Jehovah’s Witnesses are aware of the possible risk to life in refusing blood transfusion and they take full responsibility for this. It is important to respect their wishes and to consider alternative measures to blood transfusion. There are special consent forms for Jehovah’s Witnesses’ refusal of blood products, stating clearly that this may result in the death of the patient. They also specify what blood fractions they might accept (e.g. interferons, interleukins, albumin, clotting factors or erythropoietin) as well as any blood salvage procedures, such as cell saver that recycles and cleans blood from a patient and redirects it to the patient’s body. More information can be found on the official website of Jehovah’s Witnesses (www.watchtower.org).

Adults without capacity

The Mental Capacity Act 2005

Clinicians should work on the assumption that every adult has the capacity to make decisions about her care. The patient should only be regarded as lacking capacity if she is considered unable to comprehend and retain information in order to make a decision after all practical steps to help her do so have been taken without success. A woman is entitled to make a decision based on her own religious beliefs or values as long as she understands what is entailed in her decision, even if it is the clinician’s belief that this is not in her best interests. Likewise, a woman should not be thought to lack capacity because she has previously made an unwise decision. The capacity of people with a learning disability, mental illness or apparent inability to communicate should not be underestimated. Capacity may also be temporarily affected by factors such as confusion, pain, fatigue, medication or shock.

Within the English legal system, no one is able to give consent to treatment of adults unable to give consent for themselves. The key principle in care of an incapable adult is that the treatment should be in their best interests. It is lawful to carry out a procedure that is in the best interests of the patient. One cannot sign the consent form on their behalf; rather, one should document in the medical notes why the patient cannot consent for the procedure and why it is in their best interests. This is not confined to the best medical interests; it is to preserve life, health or well-being of the patient. This also covers procedures such as washing and dressing.

It is good practice to involve those close to the patient in order to find out about the patient’s values and preferences prior to the loss of capacity. In addition, patients should be encouraged and supported, as far as they are able, to be involved in decisions about their care.

Certain procedures such as sterilization, management of menorrhagia and abortion do occasionally arise in women with severe learning disabilities who lack capacity to consent. They give special concern about the best interests and human rights of the person who lacks capacity. They can be referred to court if there is any doubt that the procedure is the most appropriate therapeutic recourse. The least invasive and reversible option should always be favoured (Department of Health 2001).

Children and young people

People aged 16 years and over are entitled to consent to their own medical treatment using the same criteria for competency as for adults. It is not legally necessary to obtain consent from the person with parental responsibility in addition.

Girls aged less than 16 years must be assessed as ‘Gillick competent’ to consent for their procedure. This is named after the case of Gillick vs West Norfolk and Wisbeth AHA 1986. Mrs Gillick challenged the lawfulness of Department of Health guidance that doctors could provide contraceptive advice and treatment to girls under the age of 16 years without parental consent or knowledge. The House of Lords held that a doctor could give contraceptive advice and treatment to a young person under the age of 16 years if:

• she had sufficient maturity and intelligence to understand the nature and implications of the proposed treatment;

• she could not be persuaded to tell her parents or to allow her doctor to tell them;

• she was very likely to begin or continue having sexual intercourse with or without contraceptive treatment;

• her physical or mental health was likely to suffer unless she received the advice or treatment; and

• the advice or treatment was in the young person’s best interests.

This case was specifically about contraceptive advice and treatment, but the case of Axon vs Secretary of State for Health (2006) makes it clear that the principles also apply to decisions about treatment and care for sexually transmitted infections and abortion. Thus, if a child is ‘Gillick competent’ and is able to give voluntary consent after receiving appropriate information, the consent is valid. It is not legally necessary to obtain agreement of an additional person with parental responsibility. It is, however, good practice to encourage them to inform their parents, unless it is clearly not in the child’s best interest to do so. It is important to ensure that the consent is voluntary and to be aware of undue influences by parents, carers or sexual partner.

Conversely, if a child assessed as ‘Gillick competent’ refuses treatment, the person with parental responsibility can over-rule this decision if it is in the best interests of the child. Consideration should be given to applying for a court ruling for this intervention. For parents to be in a position to over-rule a competent child’s refusal, they must be provided with sufficient information about the child’s condition. This may be in breach of confidence on the part of the doctor treating the child, but may be justifiable in view of the child’s best interests. The child should still be as involved as possible in making decisions about their care.

Finally, refusal of treatment by a competent child and persons with parental responsibility for a child can be over-ruled by a court if this is in the best interests of the child (Department of Health 2001).

Preoperative Assessment

The purpose of preoperative assessment is to achieve an accurate diagnosis and to assess the patient’s fitness for surgery (risk assessment).

Accurate diagnosis

A thorough clinical examination aided by specific investigations (as necessary) is essential in patients undergoing gynaecological surgery to confirm the diagnosis and to ensure correctness of the planned operation. Special attention should be paid to the extent and complexity of the disease, and the involvement of other organs. For example, patients with complex endometriosis should be assessed for possible involvement of the bowel, bladder or ureter with this disease. Patients undergoing pelvic surgery for stress incontinence should be considered for urodynamic studies if detrusor instability is suspected, if they have had previous surgery for stress incontinence or if they have substantial voiding dysfunction.

Although the diagnosis is usually established during the initial consultations in the outpatient clinic, it is important to reassess the patient closer to or on the day of surgery to detect any changes in her gynaecological condition that may require alteration or even cancellation of the planned surgery. A common example of this is the disappearance of an ovarian cyst prior to ovarian cystectomy. Another example is the enlargement of a leiomyoma to an extent that may necessitate a change in the planned route of surgery. In these cases, a repeat preoperative pelvic ultrasound scan close to the day of surgery should be considered.

Risk assessment

One should start with a thorough assessment of the patient’s risk by way of a full medical and surgical history followed by general examination. This will determine which patients require further investigations. Routine preoperative testing of healthy individuals is of little benefit. Guidelines from the National Institute for Health and Clinical Excellence (2003) conclude that no routine laboratory testing or screening is necessary for preoperative evaluation unless there is a relevant clinical indication. Preoperative testing is a substantial drain on NHS resources, and substantial savings can be achieved by eliminating unnecessary investigations (Munro et al 1997). False-positive results may also cause unnecessary anxiety and result in additional investigations causing a delay in surgery. The indications and aims of common preoperative tests are shown in Table 7.2.

Table 7.2 Indications for preoperative tests

Respiratory

• Reduced functional residual capacity

• Airway closure and desaturation when supine

• Difficult intubation due to nuchal fat pad and deposition of fat into soft tissues of neck

• Increased acid reflux

• Sleep apnoea and obesity hypoventilation syndrome

Cardiac

• Hypertension

• Hyperlipidaemia

• Ischaemic heart disease

• Heart failure

Metabolic diseases

• Increased incidence of diabetes mellitus

• Complications of diabetes mellitus

• Cardiac and renal disease

• Autonomic dysfunction

Preoperative assessment is the key component in assessment and management of risk in the obese patient. All patients should have their height and weight measured and BMI calculated. Special attention should be paid to the patient’s exercise tolerance and comorbidities placing obese patients at increased risk such as cardiac, respiratory and metabolic disease. Consideration could also be given to the treatment of sleep apnoea if present. Preoperative assessment should ideally be performed in a multidisciplinary setting with ready access to imaging, laboratory and specialist services to minimize hospital visits. The patient’s size in itself may limit the quality of investigations ordered. The quality of electrocardiograms, chest X-rays and transthoracic echocardiograms is reduced and patients may not fit in the computed tomography or magnetic resonance imaging machine. Ideally, a consultant anaesthetist with an interest in the management of obese patients should be available.

In order to reduce perioperative risk for obese patients, one should ensure correct case selection by preoperative assessment. This can ensure correct allocation to day-case or inpatient lists, preoperative counselling for smoking cessation and dietary advice, as well as thromboprophylaxis.

An equipment suitable for the morbidly obese patient should be made available. Trolleys, beds and operating tables have a maximum weight-bearing load, usually around 150 kg. Equipment suitable for the morbidly obese patient can carry heavier loads, is wider and can sometimes have a ‘tilt-to-standing’ mode to reduce manual handling. One should also ensure that large gowns, compression stockings and blood pressure cuffs are available.

Obese patients are at significantly increased risk of venous and pulmonary thromboembolism. All obese patients should be considered for mechanical and pharmacological thromboprophylaxis. With full consideration of assessment and explanation of potential risks, the patient may wish to reconsider whether or not to proceed with surgery or to postpone it until weight reduction has been achieved.

Preoperative Preparation

Thromboprophylaxis

Venous thromboembolism (VTE) kills 25,000 people per year in England. This is more than breast cancer or road traffic accidents. The incidence of deep venous thrombosis (DVT) in gynaecological surgery with no prophylaxis is 16% and the incidence of symptomatic pulmonary embolism (PE) is 1%. VTE usually occurs 1–2 weeks following surgery. DVT is commonly asymptomatic but may result in sudden death from PE or long-term morbidity secondary to venous insufficiency and post-thrombotic syndrome (National Institute for Health and Clinical Excellence 2007).

In order to minimize the risk of VTE in patients undergoing surgery, each patient should be assessed carefully for individual risk factors. Box 7.1 details patient-related risk factors for VTE.

Box 7.1 Patient-related risk factors for VTE

• Age >60 years

• Obesity (BMI >30 kg/m²)

• Personal or family history of VTE

• Pregnancy or puerperium

• Use of oral contraceptives or hormone replacement therapy

• Varicose veins with associated phlebitis

• Thrombophilia including:

– factor V Leiden

– prothrombin mutation (G20210A, 5’UTR)

– deficiencies of protein C, protein S and antithrombin

• Antiphospholipid syndrome

• Severe infection

• Acute medical illness

• Active cancer or cancer treatment

• Active heart or respiratory failure

• Behçet’s disease

• Central venous catheter in situ

• Continuous travel of more than 3 h approximately 4 weeks before or after surgery

• Immobility (e.g. paralysis or limb in plaster)

• Inflammatory bowel disease (e.g. Crohn’s disease or ulcerative colitis)

• Nephrotic syndrome

• Recent myocardial infarction or stroke

Patients should be given verbal and written information on the risks of VTE and the effectiveness of prophylaxis before surgery. Patients on the combined oral contraceptive pill (COCP) who are undergoing major surgery with subsequent immobilization should be advised to stop the COCP 4 weeks prior to their operation.

Ample hydration and early mobilization

All patients should be given general advice before surgery to help decrease the risk of VTE, including ample hydration and early mobilization. In patients with restricted mobility, leg exercises by physiotherapy should be arranged. Although studies have shown smoking to be a risk factor for VTE in the general population, it does not appear to be so in patients undergoing surgery.

The National Institute for Health and Clinical Excellence (2007) has recommended thromboprophylaxis regimens for gynaecological surgery. Mechanical prophylaxis should be used in all patients with no risk factors for VTE. Pharmacological prophylaxis should be considered in the presence of any risk factors for VTE.

Mechanical prophylaxis

Mechanical prophylaxis includes compression stockings, intermittent pneumatic compression, electrical stimulation and foot impulse devices. There is no difference in the effectiveness of different types of mechanical prophylaxis. They appear to have a similar effect whether used alone or in conjunction with a pharmacological method. All patients should be offered thigh-length graduated compression stockings unless contraindicated (e.g. in peripheral arterial disease and diabetic neuropathy). They should be shown how to wear the stockings correctly and should be monitored and assisted as necessary. The stockings should be equivalent to Sigel profile (i.e. 18 mmHg at the ankle, 14 mmHg mid calf and 8 mmHg on the upper thigh). Knee stockings may be used instead of thigh-length stocking if there are fit or compliance issues. Patients should be encouraged to wear the stockings from the time of admission until they return to their normal mobility, as immobility is a risk factor for VTE. Intermittent pneumatic compression or foot impulse devices may be used as alternatives or in addition to graduated compression/antiembolism stockings while patients are in hospital.

Pharmacological prophylaxis

Pharmacological prophylaxis should be considered in patients undergoing surgery in the presence of any additional risk factors, as summarized in Box 7.1. Low-molecular-weight heparin (LMWH) should be offered in preference to unfractionated heparin. Fondaparinux can be offered as an alternative, within its licensed indications.

Heparin is composed of a mix of mucopolysaccharides of differing chain length and molecular size, hence the term ‘unfractionated heparin’. It produces its major anticoagulant effect by binding to antithrombin (AT) and coagulation enzyme, thereby inactivating thrombin and activated factor X (Xa). For inhibition of thrombin, heparin must bind to both the coagulation enzyme and AT, whereas binding to the enzyme is not required for inhibition of factor Xa. LMWH is derived from heparin by chemical or enzymatic depolymerization to yield fragments approximately one-third the size of heparin. Compared with unfractionated heparin, LMWH has reduced ability to inactivate thrombin, but almost the same ability to inactivate factor Xa. The smaller fragments of LMWH cannot bind simultaneously to AT and coagulation enzyme, hence its inability to inhibit thrombin.

The main advantage of LMWH is its reduced binding to plasma proteins and cells, resulting in a more predictable dose–response relationship, a longer plasma half-life and a lower risk of thrombocytopenia and osteopenia compared with unfractionated heparin. Both decrease the risk of DVT and PE but increase the risk of bleeding.

Fondaparinux is a synthetic pentasaccharide based on the AT binding region of heparin in the body. Hence it is a catalyst for AT inhibition of factor Xa. However, it does not inhibit thrombin directly, because this requires a minimum of 13 additional saccharide units which are present in unfractionated heparin and LMWH. It is therefore a specific, indirect inhibitor of factor Xa through its potentiation of AT. Like LMWH, it is administered subcutaneously on a once-daily dosing regimen. It is more effective than LMWH at reducing the risk of DVT, but has not been shown to reduce the risk of PE and is associated with larger bleeds.

The timing of administering the LMWH should be planned carefully if regional anaesthesia is being employed, with a view to reducing the risk of haematoma formation. Regional anaesthesia should be used where appropriate as this decreases the risk of VTE compared with general anaesthesia. The available evidence is limited regarding whether LMWH can be safely given before surgery or if it should be delayed until after surgery.

Antibiotic prophylaxis

Surgical infections include infections of surgical wounds or tissues involved in the operation, occurring within 30 days of surgery. They prolong hospital stay and are an important outcome measure for surgical procedures. Surgical infections are caused by direct contact from surgical instruments or hands, from air contaminated with bacteria or by the patient’s endogenous flora of the operation site. Additional risk factors for surgical site infections are shown in Table 7.4. The most causative organisms are Staphylococcus aureus, Streptococcus pyogenes and enterococci.

Table 7.4 Risk factors for surgical site infections

Patient related	Operation related
Extremes of age	Length of operation
Poor nutritional state	Skin antisepsis
Obesity	Preoperative skin shaving
Diabetes mellitus	Inadequate sterilization of equipment
Smoking	Poor surgical technique and tissue handling
Coexisting infection
Bacterial colonization (e.g. methicillin-resistant Staphylococcus aureus)
Immunosuppression
Prolonged hospital stay

The goal of prophylactic antibiotics is to reduce the total number of bacteria contaminating the operative site and to inhibit their growth. This can be achieved by maintaining adequate tissue levels of antibiotics for the duration of the operation. Reduction of the contaminating bacteria allows the patient’s natural defence mechanisms to eradicate the remaining organisms. In addition to prophylactic antibiotics, surgeons should remember that meticulous surgical techniques are also crucial in preventing infections.

The main drawback of using prophylactic antibiotics is increasing the prevalence of antibiotic-resistant bacteria that can predispose to infections such as Clostridium difficile. The prevalence of antibiotic resistance is related to the proportion of the population receiving antibiotics and the total antibiotic exposure. Antibiotic prophylaxis use should therefore be restricted to procedures where there is proven benefit.

Prophylactic antibiotics should ideally be given intravenously at anaesthetic induction or no more than 30 min before. This should ensure the maximum blood concentration at the time of skin incision and entry to the genitourinary tract when blood contamination occurs. If given too early, antibiotics could increase the resistance among colonizing organisms. On the other hand, late administration of prophylactic antibiotics will reduce their efficacy, especially if given more than 3 h after the start of the procedure. A single-dose prophylactic antibiotic is effective. Multiple doses may be necessary when surgery is prolonged and where there is a major blood loss of more than 1.5 l requiring fluid resuscitation, which results in reduction of the antibiotic concentration. Prolonged use of prophylactic antibiotics for more than 24 h should be avoided as it could result in an increase in resistant organisms (Scottish Intercollegiate Guidelines Network 2008).

A system of classification for operative wounds based on the degree of microbial contamination was developed by the US National Research Council group in 1964 (Berard and Gandon 1964, Culver et al 1991). Four wound classes with an increasing risk of surgical site infection were described: clean, clean-contaminated, contaminated and dirty (Table 7.5). Most gynaecological procedures fall into the ‘clean-contaminated’ category. Hence, prophylactic antibiotics are highly recommended for certain procedures. However, the final decision rests with the surgeon who should assess the risks and benefits for that patient. There is good research evidence supporting the use of prophylactic antibiotics for vaginal and abdominal hysterectomy with a significant reduction in the incidence of febrile morbidity, pelvic infection and wound infection.

Table 7.5 Wound classification and risk of infection

Classification	Description	Infective risk
Clean	• Uninfected operative wound • No acute inflammation • No entry to genitourinary, alimentary or respiratory tracts • No break in aseptic technique

<2% Clean-contaminated

• Opening to genitourinary, alimentary or respiratory tracts but no significant spillage of contents

• No evidence of infection or major break in aseptic technique

<10% Contaminated

• Opening to internal organs with inflammation or spillage of contents

• Major break in aseptic technique

15–20% Dirty

• Purulent inflammation present

• Intraperitoneal abscess formation or visceral perforation

40%

Methicillin-resistant S. aureus (MRSA) may be a risk factor for surgical site infection. Those known to be carriers should receive MRSA eradication therapy prior to surgery, and most units now screen patients before surgery.

Urine and respiratory infection

Prophylactic antibiotics are not recommended for the sole prevention of respiratory or urinary tract infections. Although meta-analyses do show a significant reduction in the incidence of urinary tract infection, the results for respiratory tract infection are equivocal. Patients at higher risk of a urinary tract infection (e.g. elderly women and those with indwelling catheters) are more likely to develop bacterial resistance and C. difficile due to prophylactic antibiotics (Scottish Intercollegiate Guidelines Network 2008).

Antibiotic prophylaxis against infective endocarditis

Infective endocarditis is a rare condition affecting less than one in 10,000 cases, but with significant morbidity and mortality of up to 20% (National Institute for Health and Clinical Excellence 2008). It is inflammation of the myocardium, which occurs following bacteraemia in a patient with a predisposing cardiac condition. Pathogens are likely to be commensal organisms, the most common being Streptococcus viridans, S. aureus and enterococci (Gould et al 2006). Up to 75% of cases of infective endocarditis occur without a preceding interventional or dental procedure to account for bacteraemia. Furthermore, there is no consistent association between having an interventional procedure and infective endocarditis. Antibiotic prophylaxis has been shown to reduce the incidence of bacteraemia following an interventional procedure, but does not eliminate it (Bhattacharya et al 1995). The clinical effectiveness of prophylactic antibiotics remains to be proven.

There is not enough evidence in the literature to show an increased risk of infective endocarditis in women undergoing genitourinary procedures. The large number of gynaecological procedures undertaken would mean that the risks of antibiotic prophylaxis against infective endocarditis (e.g. anaphylaxis and bacterial resistance) might outweigh the benefit. The British Society for Antimicrobial Chemotherapy states that there are no good epidemiological data on the impact of bacteraemia from non-dental procedures on the risk of developing infective endocarditis (Gould et al 2006). Likewise, the current guidelines of the National Institute for Health and Clinical Excellence (2008) suggest that antibiotic prophylaxis is not recommended for people undergoing genitourinary tract procedures.

Weight loss

As discussed above, obesity is a major risk factor and is associated with an increase in the incidence of most surgical complications in gynaecological patients. In addition, obesity increases the technical difficulty and prolongs surgery. Obese women should therefore be strongly encouraged to reduce their weight before their planned surgery. However, preoperative weight loss must be controlled and preferably supervised as obese patients often have poor nutritional status, despite their excess weight. A very low calorie diet can be dangerous and may cause cardiac arrhythmias or even sudden death. Women who have undergone bariatric surgery could develop malabsorption. A supervised exercise programme may be best to help with weight loss, exercise tolerance and glucose tolerance (Association of Anaesthetists of Great Britain and Ireland 2007).

Smoking cessation

Smokers have a substantially increased risk of intra- and postoperative complications. They are three to six times more likely to have intraoperative pulmonary complications and postoperative wound infections. Preoperative assessment is a good opportunity to offer smoking cessation intervention, as the patient may be more motivated. This approach has been shown to be effective in reducing preoperative smoking. However, whether or not smoking cessation of such short duration would lead to decreased operative complication rates remains to be determined (Møller and Villebro 2005).

Bowel preparation

Bowel preparation may be considered before gynaecological operations in patients with complex pelvic diseases involving the bowel, such as severe endometriosis, extensive adhesions or malignancy. In such cases, bowel preparation may be necessary if bowel surgery is anticipated or to provide better access for the surgeon. However, a large randomized trial investigating the value of preoperative bowel preparation in patients undergoing bowel resection and anastomosis showed no significant difference in the rate of anastomosis breakdown in women who received mechanical bowel preparation compared with those who did not (Contant et al 2007). However, patients experiencing anastomotic breakdown were less likely to develop an abscess if they had bowel preparation.

Bowel preparation has not been shown to improve the view of the operating field during laparoscopy. Furthermore, it may add to the patient’s inconvenience and discomfort during her preoperative hospital stay (Muzzi et al 2006, Lijoi et al 2009).

Additional medications prior to gynaecological surgery

Gonadotrophin-releasing hormone analogues

Gonadotrophin-releasing hormone (GnRH) analogues can be used before fibroid surgery and endometrial ablation. GnRH analogues taken for 3–4 months prior to fibroid surgery (myomectomy or hysterectomy) have been shown to decrease uterine and fibroid size, and to improve menhorrhagia after surgery; and to reduce intraoperative blood loss, thereby improving pre- and postoperative haemoglobin levels. In reducing the fibroid size, GnRH analogues can also decrease the rate of vertical abdominal incisions, and reduce the operating time and hospital stay. However, these benefits of GnRH analogues should be balanced against their associated side-effects such as menopausal symptoms (Lethaby et al 2002).

GnRH analogues may also be of value in women undergoing endometrial ablation or resection to help thin out the endometrium. An alternative approach is to perform the procedure shortly after cessation of menstruation when the endometrium is at its thinnest. GnRH analogues are associated with shorter surgery time and increased rate of postoperative amenorrhoea with endometrial resection. However, this benefit does not seem to last in the long term and does not extend to second-generation ablation treatments (Sowter et al 2002)

Misoprostol

Misoprostol is the most commonly used cervical priming agent worldwide. The most common use is in first-trimester abortion or for surgical management of miscarriage. It is effective in cervical softening and dilatation before surgery. However, there is not enough evidence to conclude that misoprostol is necessary to reduce complications such as cervical laceration. An alternative is Laminaria, although this requires administration to the endocervix via a speculum. Misoprostol can be administered vaginally and sublingually with similar effect, although the sublingual route has more side-effects. It can also be given orally but needs to be administered up to 12 h before surgery (Allen and Goldberg 2007).

Pre-existing medications

Anticoagulants

Patients already on prophylactic anticoagulants due to a previous VTE should stop treatment 5 days before surgery. Heparin and oral anticoagulants should be restarted soon after surgery. If possible, surgery should be postponed beyond 3 months of the previous event. If surgery cannot be delayed, oral agents should be converted to intravenous heparin and should continue following surgery until oral agents can be restarted. Vena caval filters should be considered if the patient has had a VTE within the past month and anticoagulation is contraindicated.

Hypoglycaemic agents

Patients whose diabetes is controlled by diet alone do not usually need any special preoperative measures, providing that dietary control is adequate.

Patients on oral hypoglyacemic agents should discontinue their medication on the day of surgery. Blood glucose should be monitored and, if the levels increase above 13 mmol/l, small doses of soluble insulin could be given. After surgery, metformin therapy should be temporarily suspended (except in minor procedures not associated with restricted intake of food and fluids) until the patient’s oral intake has resumed. This is important to reduce the risk of lactic acidosis.

Patients undergoing major surgery requiring prolonged postoperative fasting should be put on an approved protocol of intravenous insulin and glucose infusion before surgery. The dose is determined by regular blood glucose testing. Following surgery, patients can resume their regular treatment when they have resumed their oral intake.

One should utilize the expertise of the multidisciplinary diabetes team and the experience of the patient herself in maintaining tight glucose control.

Oral contraception

Hormonal methods of contraception are used in 29% of women of reproductive age in the UK, with 18% using the COCP. The background risk of VTE is five per 100,000 women per year. This is increased by a factor of three in users of second-generation COCPs (containing levonorgestrel or norethisterone) and by a factor of five in users of third-generation COCPs (containing desogestrel or gestodene). The absolute risk remains low with an incidence of 15–25 VTE per 100,000. This risk is increased in the first 4 months of use and falls to levels of non-users within 3 months. There is no evidence that progestogen-only pills increase the risk of VTE.

The Royal College of Obstetricians and Gynaecologists advises that the COCP should ideally be discontinued at least 4 weeks prior to major surgery where immobilization is expected. Discontinuation of the COCP has been shown to reduce the postoperative VTE rate from 1% to 0.5%. This small absolute risk reduction must be balanced against the risks of discontinuing an effective contraception with the risk of unplanned pregnancy (Royal College of Obstetricians and Gynaecologists 2004a). Table 7.6 shows the World Health Organization’s recommendations for contraceptive use in surgery.

Table 7.6 World Health Organization eligibility criteria for contraceptive use in surgery

Contraceptive	Type of surgery	Recommendation
Combined oral contraceptive pill	Minor surgery	Unrestricted use
	Major surgery without immobilization	Benefits outweighs risk
	Major surgery with prolonged immobilization	Unacceptable risk
Progestogen-only pill	All surgery	Benefits outweigh risk