Obesity and postmenopausal bleeding in vaginal hysterectomy: successful anaesthetic management using fractional combined spinal–epidural anesthesia: A case report

Background: Postmenopausal Bleeding is a concerning gynecological symptom requiring prompt evaluation to exclude malignancy or significant uterine pathology. Obesity further complicates anesthetic management due to altered respiratory mechanics, increased cardiovascular workload, and technical challenges during neuraxial anesthesia.

Case Presentation: A 52-year-old female with a body mass index of 37.5 kg/m², gravida 5 para 3, presented with postmenopausal bleeding and was scheduled for Vaginal Hysterectomy. The patient also had hypertension and type 2 diabetes mellitus. After careful preoperative evaluation, she was classified as ASA Physical Status III. A fractional combined spinal–epidural (CSE) technique was administered using hyperbaric bupivacaine with nalbuphine followed by incremental dosing of bupivacaine with buprenorphine. Adequate sensory blockade was achieved with stable hemodynamics throughout surgery. Estimated blood loss was minimal and the postoperative course was uneventful.

Conclusion: Fractional combined spinal–epidural anesthesia offers controlled sympathetic blockade and stable perioperative hemodynamics in obese patients undergoing gynecological surgery. Careful titration of intrathecal drugs and vigilant monitoring contribute to favorable outcomes.