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Complications in Hysteroscopy

Author   Reviewed by
Mansi Medhekar   Sanket Pisat
Dr. Mansi Medhekar   Dr. Sanket Pisat
MS,DNB, Diploma in Gyn Endoscopy (Germany),
Consultant Obst. & Gyn.
   

In Hysteroscopy, as in all invasive techniques, there is a risk of complications. Over the years the complication rates have been decreasing. This has been demonstrated by improvements in the equipment and the experience of surgeons. In two multicentric interviews of the AAGL performed by Hulka the severe complication rate decreased from 1 %to 0.2% in 3 years. Complication rates can be reduced if series of precautions are taken before, during and after the procedure. Here we will be discussing the different types of complications arising from diagnostic and surgical hysteroscopy, as well as preventive measures.

Cervical Tear

This usually occurs due to excessive traction with vulsellum or tenaculum. Nulliparity, menopause and treatment with GnRH analogues are predisposing factors. Diagnosis is usually easy and immediate. If the cervix does not bleed, treatment is expectant. Otherwise, a stitch with reabsorbable material may be applied.

Prevention:

Handle the vulsellum or tenaculum carefully.

Practice a vaginoscopy if possible.

In case of expected difficulty, prepare the cervix with vaginal misoprostol 200 mcg 2-4 hrs before the procedure.

Uterine perforation

Perforation can occur during dilatation, insertion of hysteroscope or while performing a procedure. It is more common in myomectomy, septal resection and adhesiolysis. Incidence is 1-9%. Uterine perforation is particularly important as it can cause damage to a major blood vessel, bladder, ureters or intestine. Uterine perforation is suspected when the intestine, omentum or bladder are visible through the lens, or when proper distention is not achieved or there is high consumption of the medium. The procedure should be discontinued immediately. Small perforations caused by a dilator or hysteroscope will need only expectant management. Large perforations or those caused by an electrical instrument may need further examination by laparoscopy or laparotomy. Hysteroscopy may be repeated after 6 weeks under ultrasound guidance.

fig_01

Prevention:

Negotiation of cervix and internal os under vision and gentle insertion of the hysteroscope.

Make sure the direction of uterus by performing a EUA at the start of surgery.

Do not attempt any procedure till vision is optimum.

Do not activate an energy device while thrusting or forward movement. Activate only in return phase of energy device.

Simultaneous laparoscopy helps in early recognition of a perforation but is not to be routinely performed with all hysteroscopic cases.

Since 30 degree hysteroscope is commonly used during diagnostic as well as operative hysteroscopy it is important to stress on the entry technique. Correct technique will not only ensure that the procedure is smooth but also prevent perforation and creation of false passage. The following figure clarifies the difference between bad placement and good placement. The cervical os as visualized through the hysteroscope should always be at 6’0 clock position at all times.

fig_02

Correct technique will prevent perforation at the time of entry

Bleeding

The most common complication inherent to hysteroscopic procedures is intraoperative and post-operative bleeding. It can be managed by aspirating the blood followed by increasing the intrauterine pressure so that it exceeds arterial pressure and compresses the wall to stop bleeding. The bleeder can then be coagulated with 3mm ball electrode if needed. The counter pressure with medium should then be relaxed. If bleeding continues, inserting an intrauterine balloon and inflating it stops the bleeding. The balloon is then removed after 6-8 hrs . Delayed post-operative bleeding is most commonly associated with endometrial slough (after ablation), chronic endometritis or spontaneous expulsion of intra-myometrial portion of previously resected submucous myoma. Bleeding clotting studies should be obtained in case of late postoperative bleeding.

Complications associated with distention media

The mission of the distention medium is to expand the uterine cavity, and cleanse the cavity of blood and tissue remains to ensure optimal vision. The ideal fluid is transparent, isosmotic, non-conducive, non-metabolizable, non-hemolytic, non-toxic, sterile and inexpensive. Presently the media used are normal saline and glycine. Fluid overload occur in 0.6-2% of cases. Myomectomy, uterine septum resection, extensive lysis of adhesions, and prolonged operative times increase the risk of clinically significant fluid overload and hyponatremia,

Although commonly used liquid distending media do not cause hemolysis, their excess absorption can result in hyponatremia and hypo-osmolality. This in turn can cause what is described as the TURP (transurethral resection of prostate) syndrome. It is characterized by hyponatremia, hypo-osmolality, nausea, vomiting, pulmonary edema and neurologic symptoms including muscular twitching, grand mal seizures, and coma. When recognized promptly and treated properly, most patients with TURP syndrome recover without sequelae. On the other hand, convulsions, respiratory arrest, and permanent brain damage were associated with an average delay of 16 hours before therapy was given.

Prevention of Fluid Overload:

The prevention of complications from distending media revolves around two principles:

Avoiding excess fluid absorption

Prompt recognition and proper treatment of overload should it occur.

Fluid is delivered to the resectoscope by means of gravity or by pump. The lowest intrauterine pressure necessary to provide a clear field of view should be used to decrease the rate of absorption of the medium. Fluid absorption increases significantly when intrauterine pressure exceeds mean arterial pressure (MAP).

Accurate measurement of intake and output remains the mainstay of preventing excess absorption.

A Foley catheter should be placed in the bladder to monitor urine output in any case considered at risk for excess fluid absorption, or if excess absorption is suspected. One person in the operating room should be assigned the responsibility of measuring intake and output and informing the surgeon and anesthesiologist of the measurements. Intake and output should be reported after each container of fluid is used, and at a minimum of every 10 minutes. Consideration should be given to use of an instrument that continuously monitors fluid balance.

If 500 to 1000 ml (less if the patient is medically compromised) is believed to be absorbed, the following should be undertaken: (1) the procedure should be suspended until fluid status is ascertained, (2) a Foley catheter should be placed, if not already in place; (3) consideration should be given to sending serum for immediate measurement of electrolytes; and (4) consideration should be given to rapid conclusion of the operative procedure as appropriate, as once fluid absorption is started it can progress rapidly.

If greater than 1500 ml is absorbed or serum sodium is less than 125 mmol/L, the procedure should be terminated as rapidly as reasonable. Patients with a serum sodium level below 120 mmol/L should be considered for treatment in a critical care setting, especially if a hypotonic distending medium was used.

Late complications

Depending on the extent of the procedure performed, additional, late complications may occur with operative hysteroscopic procedures. Uterine septum resection and myomectomy have been implicated in postoperative intrauterine adhesion formation and uterine rupture in subsequent pregnancies. Although rare, postoperative endometritis may be treated with broad-spectrum antibiotics in the hospital setting if necessary.

Although minimally invasive, hysteroscopic procedures are associated with specific complications. It is therefore prudent to take an informed consent with all the risks pertaining to the surgery noted clearly to avoid medicolegal issues.

References

  1. Hulka JF, Peterson HB, Phillips JM, Surrey MW.Opertaive Hysteroscopy. American Association of Gynaecologic Laparoscopists 1991 membership survey. J. Reprod Med 1993; 38:572-3.
  2. Jansen FW, Vredevoogd CB, van ULzen K. Compliactions of Hysteroscopy: a prospective multicentric study. Obstet and Gynecol 2000;96(2):266-70.
  3. Arieff AI: Hyponatremia associated with permanent brain damage. Adv. Intern Med 32:325-344. 1987.
  4. Garry R, Hasham F, Kokri MS, et al: The effect of pressure on fluid absorption during endometrial ablation. J Gynecol Surg 8:1-10, 1992
  5. Shirk GJ, Gimpelson RJ: Control of intrauterine fluid pressure during operative hysteroscopy. J Am Assoc Gynecol Laparosc 1:229-233, 1994
  6. Vulgaropulos SP, Haley LC, Hulka JF: Intrauterine pressure and fluid absorption during continuous flow hysteroscopy. Am J Obstet Gynecol 167(2):386-390. 1992

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