Hysteroscopy II: Complications and Troubleshooting
/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)