Hysteroscopy II: Complications and Troubleshooting

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Here’s the RoshReview Question of the Week!

A 45-year-old woman in the postoperative recovery unit develops dyspnea. Her serum sodium is 130 mEq/L. Which of the following was the most likely distending medium used during her hysteroscopic monopolar fibroid resection?

Check out the answer and enter the QE QBank Giveaway at the links above!

Why do we do hysteroscopy?

  • Diagnostic

    • AUB

    • Infertility

    • Structural anomalies

  • Operative

    • IUD removal

    • Polyps

    • Fibroids

    • Septums

    • Intrauterine adhesions and Ashermans

    • Endometrial ablation

    • C/section scar (isthmocele) excision

    • C/section scar or cervical ectopics

    • Tubal cannulation

Complications of Hysteroscopy -check out ACOG CO 800!

  • Perforation

    • Most common complication - range 0.12-1.61%

    • Risk factors

      • Blind insertion of instruments

      • Cervical stenosis

      • Anatomic distortion - fibroids, adhesions, myometrial thinning, extreme anteversion or retroversion)

    • High index of suspicion

    • Decrease risk by using ultrasound or laparoscopic guidance

    • With dilation or with scope (unlikely)

      • Low risk of subsequent complications

    • During instrumentation

      • Increased risk of injury to extra-uterine structures

      • Requires evaluation - laparoscopy +/- laparotomy 

  • Fluid Overload

    • Rare - 0.2%

    • Risk factors - resection of large or deep lesions, high pressure setting

    • As reviewed in prior episode

      • Limit fluid deficit to 1000mL for electrolyte-free hypotonic media, 2500mL for electrolyte-rich isotonic media

      • Use fluid management systems, Designated individual to monitor fluid deficit, decreased deficit limits for patients with comorbidities

      • Other preventive measures

        • GnRH agonists (pre-op)

        • Intracervical vasopressin injection

        • Planning for staged procedures

    • Management

      • Stop procedure

      • Assess hemodynamic, neurologic, respiratory, CV status

      • Check labs - serum electrolytes, osmolality

      • Consider loop diuretic (Furosemide)

      • Consider hypertonic saline

  • Hemorrhage

    • 0.03-0.61%

    • Risk factors - cervical laceration, uterine perforation, cavitary lesion resections

    • Management will depend on site and severity of bleeding

      • Suture, electrocautery, intrauterine foley balloon, UAE, hysterectomy

    • Prevention

      • Dilute vasopression injection

  • Cervical laceration

    • Prevention

      • Ensure good bite with tenaculum

  • Air embolism

    • 0.03-0.09%

    • Risk factors - repetitive reintroduction of instruments through the cervix, not purging air from tubing

    • Signs/symptoms

      • If awake - chest pain, SOB 

      • If under anesthesia - decreased end-tidal CO2, hypotension, tachycardia

      • Mill-wheel murmur on physical exam

    • Management

      • Terminate procedure - deflate cavity

      • Place patient in left lateral decubitus and trendelenburg to move air bubble away from RV outflow tract

  • Infection

    • 0.01-1.42% (includes intrauterine infection (endometritis) and UTIs)

    • Risk is low enough that antibiotic prophylaxis not routinely warranted

  • Vasovagal reaction

    • Typically due to cervical dilation

    • Stop procedure, assess ABCs, raise legs/Trendelenburg

    • Can consider atropine if needed for bradycardia

Troubleshooting Hystersocopy

  • Cervical stenosis

    • Misoprostol (200-400mcg vaginally 12-24 hrs pre-procedure)

    • Vasopressin

    • Small dilators (lacrimal duct dilators), ultrasound guidance

  • Sudden increase in fluid deficit

    • Consider perforation

    • Ensure all outflow is being collected appropriately

  • Reaching fluid deficit limit

    • Staged procedures (particularly Type 2 fibroids)

Hysteroscopy: The Basics, feat. Andrey Dolinko, MD

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Today we’re joined for a first part of a two-part talk on hysteroscopy with special guest, Dr. Andrey Dolinko! Andrey was our co-resident at Brown and is currently a second-year fellow in reproductive endocrinology and infertility at the University of Pennsylvania.

What is hysteroscopy?

  • Ancient Greek hustérā, “the womb” & Skopéō - to see 

  • History (Rudic-Biljic-Erski et al 2019)

    • First developed in mid-19th century

      • Pantaleoni performed hysteroscopy on a 60yo woman to diagnose an endometrial polyp and treated it with silver nitrate. Used cystoscope developed by Desormeaux that used series of concave mirrors and light source

    • Early 20th century

      • Carbon dioxide used as first distention medium in 1925

      • 1926 - two-channel hysteroscopy (introduction and suction of distention media)

      • 1927 - operative channel introduced

      • 1928 - irrigation system

      • 1930s - fixed optic systems and fluid delivery systems

    • Second half of 20th century

      • Fiberoptic cable added to hysteroscope in 1965 (cold xenon light)

      • Operative hysteroscopy and use of different distention media takes off in 1970s

      • Videoendoscopy started in 1982

      • 1996 - Bettocchi office hysteroscope

      • 1990s - resectoscopes, first monopolar and then bipolar

    • 21st century

      • Morcellators - i.e., MyoSure

How does hysteroscopy work?

  • Contraindications

    • Pregnancy

    • Cervicitis

    • Active PID

    • Comorbidities that may be exacerbated by intravascular volume expansion

  • Timing

    • Reproductive-aged women: proliferative phase CD5-12, ideally not during active bleeding

    • Exclude pregnancy!

    • Post-menopausal-aged women: any time

  • Positioning

    • Dorsal lithotomy position

    • Avoid steep trendelenburg because risk of air embolism

      • Causes negative pressure in pelvic veins

  • Patient prep

    • Vaginal prep w/4% chlorhexidine gluconate soap or providone-iodine

  • Antibiotics

    • not indicated

  • Anesthesia (ranges)

    • None

    • Can do PO/IM/IV NSAIDs, benzos

    • Paracervical blocks

    • Regional anesthesia

    • IV sedation

    • General LMA

    • GETA

  • Vaginal instruments

    • Speculums and retractors

    • Tenaculum

    • Dilators

    • Curettes

  • Hysteroscope

    • Hysteroscope components

      • Scope

        • Eyepiece

        • Barrell

        • Objective lens

          • 0 to 70 degrees (typically 0 or 30)

      • Inner sheath w/inflow

      • Outer sheath w/outflow for operative scopes

      • Light source

        • Most-commonly Xenon or LED these days

      • Camera-head and video monitor

    • Diagnostic

      • Flexible

      • Rigid

    • Operative

      • Rigid operative scope

      • Scopes to be used with hysteroscopic tissue removal systems

      • Resectoscopes

    • Distention media

      • Fluid choice

        • Historical

          • Gas - CO2

          • High-viscosity 32% Dextra (Hyscon)

        • Current

          • Low viscosity

            • Electrolyte-rich

              • Saline

              • LR (rarely)

            • Electrolyte-poor

              • 5% Mannitol

              • 3% Sorbitol

              • 1.5% Glycine

      • Fluid deficit

        • A reflection of potnetial systemic fluid absorption

          • Surgical disruption of endometrium and myometrium provides direct access to sinus/vessels

            • If intrauterine pressure greater than vascular pressure → intravasation -> a fluid bolus!

        • Where else may the fluid be going?

          • Out the tubes

          • Out the vagina

          • Onto the floor

    • Fluid management systems help to determine deficit

      • Simple

        • Gravity

        • Pressure bag

      • Automated systems

        • Can set fluid deficits for automatic calculation

        • Uterine pressure setting