Hysteroscopy complications

A. Prof. Dr Aisha Mohamed El-Bareg

MBBS, DGO, MMedSci (ART,Nottingham University-

UK), ABOG, (MD), PhD (Manchester University-UK)

Consultant Obstetrician & Gynecologist

With subspecialty in Endoscopic Surgery, Reproductive

& Stem Cell Medicine

Al-Amal Hospital for Obstetrics & Gynaecology,Infertility

Treatments and Genetic Research

Faculty of Medicine , Misurata University /Libya

Auditing of our complication

& Learning from some ones

else’s complication

however good the car

with its safety features

and however good the

road, the driver still has

to drive carefully to

complete the journey

safely.

Perforation

Bleeding

Fluid overload

Infection

Hematometra

Hysteroscopic Complications

Incidence

McGurgan et al., 2015

2.7% to 3.8% of all hysteroscopies.

A multicenter study in the Netherlands.

0.13% - diagnostic hysteroscopy.

0.96% - operative hysteroscopy.

Highest rate of complications seen with

hysteroscopic adhesiolysis (4.5%).

Propst AM, et al. Obstet Gynecol 2008

Jansen FW, et al. Obstet Gynecol 2007

Hulka JF, et al. J Am Assoc Gynecol Laparosc 2005

Incidence

Complications have reduced significantly over

the years:

Improved equipment.

Better understanding of the risk factors.

Proper training and better experience of the

operating surgeons.

Operative Hysteroscopy

• Operative Hysteroscopy is not for the novice,

but should be an extension of basic skill learnt

at diagnostic hysteroscopy.

• It is recommended by one author that unless

you have done 500 diagnostic hysteroscopy,

you should not venture operative hysteroscopy.

Peri-operative Complications

Patient positioning.

vasovagal attack (pain)

Anesthesia complications

Access to the endometrial cavity:

Cervical trauma, false passage.

Uterine perforation.

Intraoperative bleeding.

Thermal injury, air or gas emboli

Fluid overload.

Post-operative complications

EARLY

Infection.

Post-operative bleeding.

LATE – sequale

Persistent complain.

Intrauterine adhesions, hematometria.

Uterine rupture during pregnancy.

Patient Positioning

• Lithotomy position

• Modified lithotomy

position – Ideal

position

• Moderate hip

flexion with limited

abduction and

external rotation.

Incorrect Patient Positioning:

Nerve injuries

Back injuries

Damage to soft tissue

(Compartment syndrome)

Deep venous thrombosis (DVT)

Nerve injury

Sciatic nerve

Femoral neuropathy

• Excessive hip flexion,

abduction, ext hip

rotation extreme

angulation of FEMORAL

nerve- compression inj.

• Temporary – needs

intensive physical therapy

to resolve

Nerve injury

Sciatic nerve injury : At sciatic notch

Nerve injury

Common peroneal injury

• At neck of fibula – foot drop/ lower lateral

paraesthesia.

Brachial plexus

Brachial plexus injury may result from

incorrectly placed shoulder restraints or from

leaving the patient's arm abducted on an arm

board. A non-slip mattress is preferable to

restraints that compress the patient's

shoulders. Injury can result from 15 minutes in

a faulty position

erve injuryN

The anaesthetized patient is defenseless

against traction injury to the lumbar spine.

The legs should always be lifted

simultaneously and kept together until they are

at the appropriate height when they should be

abducted gently and placed in the supports.

They should never be over-abducted as this

can lead to damage to the sacro-iliac joints.

Back injuries.

Pressure on the muscle of an osteofascial

compartment-- ischemia + reperfusion inj.

Sequelae:

Rhabdomyolysis

Permanent disability

Events facilitating it:

Leg holders

Pneumatic compression stockings

Any direct pressure

Compartment syndrome in the lower legs

Risk reduction & Management

Ideal lithotomy position- moderate flexion

with limited abduction and external rotation.

Avoid pressure on prone areas.

Avoid leaning on the thigh of the patient.

Early identification and management

Vasovagal attack

Proper evaluation to role out preexisting heart

disease.

Instillation of LA in cervical canal may reduce

incidence.

Routine administration of intracervical or

paracervical LA is not indicated.

Local anesthesia related:

Allergic reactions

Cardiovascular complications

Awareness and avoiding:

Fluid overload

Electrolyte disturbance

Anesthesia complications

Cervical laceration

False passage

Perforation

Bleeding

Injury to genital tract

Cervical Lacerations

Due to:

Excessive traction on cervix by tenaculum.

When cervix is forcefully dilated.

Predisposing factors:

Nulliparity, Menopause, Cervical hypoplasia

Diagnosis:

Dilatation itself can also cause bleeding from

the cervix.

Diagnosis is usually easy and immediate.

TT:

• Bleeding is less: expectant.

• Sutures can be placed if necessary.

Prevention:

Preoperative preparation of cervix with

prostaglandin gel or vaginal misoprostol(200

microgms) kept 2 h prior to surgery.

Cervical Lacerations

If cervical stenosis is encountered, and

misoprostol have not been used or were

ineffective:

Deep intra cervical injection of dilute vasopressin at 4

and 8 o’clock on the cervix): reduces the force

required for cervical dilation.

In cases of previous access failure, adhesions or

synechiae in the canal frequently exist:

Use of mechanical scissors passed through the

operating channel to divide the adhesions under

direct vision.

A false passage…

If muscle fibers are visible and the tubal ostia

are not, assume the passage is false.

Slowly remove the hysteroscopy and identify

the true cavity for confirmation.

Discontinue the procedure— even if no

perforation is detected—to prevent distention

fluid from being absorbed into the circulation

through the injury.

To Avoid Creating A False Passage…

Dilate the cervix with slow, steady pressure and

stop as soon as the internal os opens; do not

attempt to push the dilator to the uterine

fundus.

Often the external os opens, but the internal os

cannot be dilated. The extra 1 to 2 mm

necessary to accommodate the 27- French

resectoscope, Rather than exert more force and

risk perforation or laceration

To Avoid Creating A False Passage…

Simply turn on the resectoscope’s inflow with

the outflow shut off, and let the fluid pressure

dilate the cervix.

Always insert the hysteroscope or

resectoscope under direct vision rather than

use an obturator.

Keep the “dark circle” in the center of the field

and slowly advance the hysteroscope toward it

until the cavity is reached

Uterine perforation

The incidence of perforation was 14 per 1,000.

It was even higher during resection of lateral

and fundal adhesions: 2 to 3 per 100.

Although perforation is more common with

thermal energy sources, it may occur

mechanically with dilators or when scissors

are used to resect a uterine septum,

synechiae, or polyps.

Uterine Perforation

Predisposing factors:

• acute ante or retroversion of uterus

• cervical stenosis, uterine synechiae

• endometrial malignancy

• uterine malformation.

Recognition of perforation:

• Loss of uterine distension.

• Rapid increasing in fluid deficit.

• Intestinal loops or omentum is seen.

Management:

1.Procedure should be stopped immediately.

2.If perforation is of small caliber and is not

caused by electric current : Expectant tt,

observed for signs of hge

3.Tachycardia and hypotension indicates

ongoing hge:

Uterine Perforation

Laparoscopy: stop bleeding by endocoag-

ulation or sutures.

Laparotomy if adjacent organs injury

Broad spectrum antibiotics

Hysteroscopy can be repeated after 6 weeks

Uterine Perforation

Prevention:

Pelvic examination to determine uterine, size,

position.

Stop when Pink myometrium becomes visible.

Resection to be done till both ostia seen

simultaneously.

Laparoscopic guidance or USG guidance.

Uterine Perforation

Prevention

Activate the foot pedal only

when the electrode is moving

toward the operator, not the

fundus.

Never activate the device

during a forward movement.

Use roller-ball based

device at the cornu.

Uterine Perforation

Intra-op/Post-op bleeding

Most common complications:

Cervical laceration, Perforation.

Myoma or endometrial resection.

Depends on the form of energy used for

resection. With loop and roller ball or loop

alone the incidence is 2.57% and 3.53%

respectively whereas with laser or roller ball it

is 1.17% and 0.97% (Maresh 1996).

op bleeding-op/Post-Intra

Management:

Clear the field by opening the outflow channel.

Increase the distension pressure above the

mean arterial pressure (100mmHg) which

compresses the uterine wall sufficiently to stop

the bleeding.

Then the bleeding vessels can be coagulated

with a 3mm ball electrode.

if the distension pressure is relaxed at the end

of the procedure, the bleeding continue:

hemostasisTo achieve

1) Insert a Foley balloon into the uterine cavity,

inflate 30-50 mL (or more for a larger cavity) of

fluid into the balloon, and observe the patient.

The balloon left for 6-12hrs.

2) Pack the uterus.

1/2-inch–gauge packing that has been soaked

in a dilute vasopressin solution.

(20 U [1 mL] in 60 mL Normal Saline).

If fails---------------

In very rare cases when the bleeding is arterial

and is not controlled by the above techniques

the procedure is abandoned:

Vital sign monitoring

UAE/ Hysterectomy

Benefits of Vasopressin

Before balloon tamponade or Packing the

uterus, Inject very dilute vasopressin :

(4 U [0.2 mL] in 60 mL normal saline)

directly into the cervix 2 cm deep,

at the 4 and 8 o’clock positions.

43

Gas

CO2

Liquid

HMW

32% Dextran

LMW

Distension Media

Non electrolyte

• 1.5% Glycine

• 3% Sorbitol

• 5% Mannitol

• 5% Dextrose

Electrolyte

• Normal saline

• Ringer lactate

Low molecular weight (LMW) fluids

low viscosity

1. Electrolyte-free

1.5% Glycine

3% Sorbitol

5 % Mannitol

5% glucose

Used in diagnostic hysteroscopy.

Used in operative hysteroscopy using

mechanical or monopolar resectoscope.

1.5 % Glycine

Simple amino acid that is mixed in water &

supplied in 1/2, 1,3 liters bags:

Non electrolytic

Hypo-osmolar (200mOsm/L)

Non hemolytic

Non Immunogenic

Low molecular weight (LMW) fluids

low viscosity

Intravascular absorption syndrome

Occurs with electrolytes free medium (Glycine

1.5%).

More in premenopausal women

Female sex steriods – inhibits Na-K+/

ATPase pump thus water and sodium not

thrown out of cells.

GnRH agonists inhibits such hormones

action – may prevent this complication to

occur.

• For diagnostic and simple procedure:

Rare

• For operative procedures:

• Glycine can gain access to the systemic

circulation if the integrity of the uterine

vasculature is breached

• In the extreme:

• Fluid overload & electrolyte disturbances


Electrolyte disturbance:

• Hypervolemia

• Severe hyponatremia

• Decreased osmolarity.

Hazards:

• Right heart failure

• Pulmonary and cerebral edema

• Death.

Rate:0.2-2%


Mechanism and CP

Rapid intravascular absorption of glycine

through exposed venous sinuses:

Dilutional hyponatremia

Acute fluid overload

High blood pressure, reflex bradycardia.

Cerebral odema, pulmonary oedema.

This is followed by Hypotension, nausea,

vomiting, headache, visual disturbance,

agitation, confusion and lethargy.


Glycine is metabolized into

1. Amonia: higher concentration in the brain

decreases the visual acuity.

Glyoxylic acid: form oxalate.

Glycine is contraindicated in patients with

renal impairments.


The severity depends on:

Amount of fluid absorbed

Number of vascular apertures,

Duration of procedure

Flow pressure

It can present intra or postoperatively.


Women’s brain deficient in such

mechanisms.

Circulatory absorption creates a gradient between blood and the brain

cells

Can be overcome by pumping cations out of the cell into

blood

CEREBRAL EDEMA

BRAIN

CELLS

VESSEL

Na/K ATPase

Serum

Na (mEq/L)

Associated signs and

symptoms

135-142 Normal serum Na

130-135

Mild hyponatremia-

apprehension,disorientation,nausea,v

omiting,irritability,twitching,shortness

of breath

125-130

Mild to moderate hyponatremia

Dilute urine ,moist mucous memb,

moist skin, pitting oedema ,polyuria ,

pulm.rales

<120

Severe hyponatremia

Hyponatremic encephalopathy, CHF,

lethargy, confusion ,twitching, focal

weakness, convulsions, death.

<115

Possible brainstem herniation,

grandmal seizures, coma, resp.arrest,

mortality up to85%

Treatment

Nil

Oxygen

Frosemide 40-

60mg IV

0.9% normal

saline

Ventilator

support

Frusemide IV

1mg/kg 4-6hrly

3% hypertonic

saline

Preoperative prevention

GnRHa:

Decreases volume of systemically absorbed

distension media.

Dilute Vasopressin:

Immediate before cervical dilatation

8 ml (0.1U/ml)injected deeply about 4 and 8

o’clock in the cervix.

Before using the resectoscope

Baseline serum electrolyte levels should be

measured.

Women with cardiopulmonary disease should

be evaluated carefully for shifts in fluid volume.

Operating at the lowest effective IU pressure

(50–80 mm Hg), always trying to keep this at

less than the mean arterial pressure

Intra-operative Fluid Media Management

Completing the procedure as quickly as

possible.

Measurement of fluid inflow and outflow in a

closed system: precise calculation of the

absorbed volume.

Bulk vaporizing electrodes: reduced systemic

absorption compared with the resection loops

{greater degree of electrocoagulation: collateral

vessel sealing}.

Intra-operative Fluid Media Management

Deficit should b calculated frequently:

If the deficit reaches a predetermined limit

(depending on the patient’s baseline status,

could be 750–1500 ml)

serum electrolytes are measured.

Furosemide: IV, 10-40 mg, depending on

renal function.

Termination of procedure:

Serum sodium decrease to < 125 mEq/L,

Deficit: 1500 to 2000 ml for glycine

For saline double

Normal saline (0.9% NaCl)

Safest, widespread availability.

Low operative cost

Physiological disposal by peritoneal absorption.

Excessive vascular absorption fluid overload

pulmonary odema.

NOT SUITABLE FOR MONOPOLAR SYSTEM : good

conductor of electrons.

Distention medium delivery system

Air or Gas Embolism

The risk of gas embolism is the primary

complication associated with the use of carbon

dioxide as the distention medium.

Carbon dioxide is a soluble gas, so these

emboli generally resolve rapidly.

In contrast, room air emboli are more likely to

be fatal.

Gas Embolus

Faulty methods

Use of laparoscopic insufflator to infuse CO2

in uterus.

Diagnosis:

Tachycardia , desaturation & Hypotension

Cog-wheel murmur (10% cases) –

disappearance once the hysteroscopy stops

Rapid fall in expired CO2.

Precautions to prevent embolism

Avoid Trendelenburg positioning.

Remove last dilator just before inserting the

resectoscope. Minimize cervical trauma.

Limit repeated removal-reinsertion of the

resectoscope.

Maintaining intrauterine pressures below 100

mm Hg and flow rates below 100 mL/min .

OT assistant must keep a watch on fluid bottle

and inform surgeon before changing it to

prevent entry of air bubble into the uterus.

Vaporizing myomas eliminates the need to

remove fibroid chips.

Intracervical injection of vasopressin may

block gas from entering circulation.

Precautions to prevent embolism

Management

DURANT Maneuver – left lateral with head

low position with tredelenberg position

100% oxygen

CVC insertion or direct needle in right atrium

to remove the air

May require CPR.

Late onset complications

1. Infection

Avoid hysteroscopy in gross cervical infection,

uterine infection & salpingitis.

Role of antibiotics controversial.

Supportive studies in cases with RHD, CHD.

Suspected chronic endometritis

Submucous myomas procedure

Imbedded IUDs.

ACOG guidelines do not recommend routine prophylactic

antibiotics for hysteroscopy.

2. Vaginal Discharge,

Vaginal discharge is common after any ablative

procedure and is usually self limiting.

3. Hematometria

If obstruction of the internal OS secondary to

adhesion due to hysteroscopic surgery.

Isthmus region and cervical canal should be

avoided during resection.


3. Adhesion Formation

Intrauterine adhesions are common especially

after myomectomy when two fibroids are

situated on opposing uterine walls.

After lysis of IU adhesion, excessive endomet-

rial resection.

Prevention:

Cyclical hormone tablest to facilitate the

growth of the endometrium\

Insertion of IUCD


Conclusion

Hysteroscopic surgery

Safe and effective

Specific risks due to the distension media

and surgical technologies used.

Most new technologies avoid the use of

nonionic distension media and hence many

of the complications of fluid overload.

Conclusion

To minimize the risk of complication.

1.Appropriate case selection

2.Recognition of the learning phase.

3.Patient and surgical team preparation.

4.knowledge of distension media used

5.Knowledge of hysteroscopic equipment used

Hysteroscopy complications

Health & Medicine