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Cutting the Risk of Hysteroscopic Complications

Cutting the Risk of Hysteroscopic Complications

OBGMANAGEMENT COVER ARTICLE LINDA D. BRADLEY, MD

Hysteroscopy will uncover numerous intracavitary lesions, such as submucous fibroids, polyps, endometrial , and . Gynecologists need to possess the expertise and skill to resect focal lesions or perform directed .

Cutting the risk of hysteroscopic complications

Proper selection and treatment of patients and prompt intervention minimize complications and legal risks of this effective, underutilized procedure.

he state of the art can be simply put: ablation rather than abandon the procedure is underutilized. Most altogether. This is not as unusual as it might Tstudies consistently demonstrate the appear: In US Food and Drug Administra- safety and efficacy of operative hysteroscopy, tion trials, there was a staggering 10% to 22% as well as high patient satisfaction. malfunction of global ablation technology.1 It is a valuable tool in the evaluation and treatment of , recurrent Safe, easily learned loss, and abnormal and postmenopausal uter- lthough gynecologists are beginning to ine , and is useful when saline infu- Aembrace this modality, many sion sonography findings are equivocal. avoid it because of inadequate training or Further, if a global ablation device fails, exaggerated fears of complications. In reality, the surgeon can convert to hysteroscopic hysteroscopy is one of the safest and most

44 OBG MANAGEMENT • January 2004 easily acquired surgical skills in gynecology. tions occurred in the 13,600 procedures. The For example, in a prospective evaluation of greatest risk of complications occurred with 13,600 diagnostic and operative hysteroscop- adhesiolysis (4.48%), followed by endometri- ic procedures performed at 63 hospitals in the al resection (0.81%), myomectomy (0.75%), Netherlands—which involved both estab- and polypectomy (0.38%). lished surgeons and residents—Jansen et al2 found an astonishingly low complication rate Cervical entry of 0.28%, with no deaths. requires special attention Proper selection and treatment of patients lmost half of the complications in the and prompt intervention minimize complica- AJansen study were related to cervical entry, tions as well as legal risks. Surgical misadven- so caution and, perhaps, preoperative cervical tures and lawsuits occur with delayed interven- ripening are advised. Many premenopausal tion, failure to recognize or risky con- subjects were given GnRH analogues, which ditions, and inadequate preventive maneuvers. may render the more resistant to dila- Overall, emphasis on safety is vital to suc- tion. Complications associated with a stenotic cess, and thorough awareness of potential cervix include a cervical tear, creation of a false complications is just as important. cervical passage, and uterine perforation. Cervical ripening may help prevent Three types of complications uterine perforation. The most common Complications fall into 3 categories (TABLE): complication, occurring in 14.2 cases per thou- • Procedure-related sand, is uterine perforation.2 The risk of this is • Media-related highest in postpartum procedures, followed by • Postoperative procedures in postmenopausal, then peri- menopausal, women. Patients with endometri- PROCEDURE-RELATED COMPLICATIONS al cancer also have a higher rate of perforation. Complication rates Risk factors for uterine perforation include: n a retrospective investigation, Propst et al3 • nulliparity Idetermined the rate of complications associ- • ated with specific hysteroscopic procedures. • use of GnRH agonists Demographic data and medical histories were • prior cone collected for 925 women who had operative • markedly retroverted hysteroscopy in 1995 and 1996. The overall • undue force CONTINUED complication rate was 2.7%. Myomectomy and resection of uterine septa carried the greatest odds of complications; polypectomy and KEY POINTS had the lowest. ■ Preoperative treatment with a gonadotropin- Preoperative treatment with a gonadotropin- releasing hormone agonist increases the odds of releasing hormone (GnRH) agonist increased operative complications by a factor of 4 to 7. the odds of complications by a factor of 4 to 7. Women under age 50 were more likely to expe- ■ Preoperative cervical ripening reduced the need for rience complications than those over 50. , minimized cervical complications, and reduced operative time. In the study by Jansen et al,2 38 complica-

■ CO2 should never be used for operative hystero- ■ Dr. Bradley is director of hysteroscopic services, section of gen- scopic procedures because of the high risk of CO eral gynecology, Cleveland Clinic Foundation, Cleveland, Ohio. 2 embolism. She also serves on the OBG MANAGEMENT Board of Editors.

■ Ultrasound guidance may improve outcomes in

January 2004 • OBG MANAGEMENT 45 selected hysteroscopic procedures. Modern operative hysteroscopes often perforation. Do not proceed if abnormal require dilation of the cervix to a number 8- uterine morphology is detected. If uterine 10 Hegar dilator. Navigation of the internal perforation occurs, injury to bladder and os is critical before operative instruments can bowel is possible when electrical energy is be inserted and the surgical procedure per- applied to a uterine wall compromised by formed. In the past, use of preoperative lam- prior . Strict visualization of uterine inaria was recommended to soften the anatomy is critical in this population so that cervix, except in women with marked cervi- bowel or bladder burns can be avoided. cal stenosis and iodine . Preoperative cervical softening still should be considered MEDIA-RELATED COMPLICATIONS in high-risk patients. otorious complications and several Vaginal or oral for cervical Nrecent lawsuits have stemmed from fluid ripening prior to operative hysteroscopy was overload. A common element has been the evaluated in a randomized trial.4 Researchers ’s lack of awareness of how rapidly found a reduced need for cervical dilation, a complications can arise, and what signs and minimum of cervical complications, and symptoms are specific to the fluid used. reduced operative time in study patients com- pared with controls. Monitor fluids vigilantly When 400 µg oral misoprostol is given 12 perative hysteroscopy must be performed and 24 hours before surgery, it also softens the Oin a fluid medium. The type of fluid cervix and eases dilation.5 Although miso- depends on the surgeon’s preference and the prostol has several bothersome side effects instrument utilized, but any fluid can be (such as lower and slight associated with complications. Fluid choices ), few if any prevent its use. with monopolar instruments include glycine Signs of perforation. Patients who sustain 1.5%, a mixture of 3% and uterine perforation with subsequent intraperi- 0.54%, and mannitol 5%. These are frequent- toneal bleeding often complain of pain in the ly used with the continuous-flow resecto- abdomen and shoulder, and experience hemo- scope. Bipolar operative hysteroscopy can be dynamic instability. A quick sonographic sur- performed using saline. vey of the abdomen will demonstrate free The solution to media-related complica- intraperitoneal fluid. (It is rare for much tions is basic: vigilant monitoring of fluids. A intraperitoneal fluid to accumulate by cavalier attitude, poor fluid documentation, transtubal regurgitation during operative hys- and failure to respond to complications can teroscopy, despite the quantity of fluid used.) lead to trouble. If fluid overload occurs, If perforation is suspected, or comanagement and consultation with an is necessary to clarify the cause of intensive care specialist is advised. pain, unstable vital signs, or free fluid visual- ized by ultrasound.6 Distention media Exercise extra care and precautions in mong the options for distention media in women who have had a prior cesarean sec- Aoperative and diagnostic hysteroscopy are tion, myomectomy, or uterine perforation. high-viscosity 70 and low-viscosity flu- Complete visualization of uterine landmarks ids such as hypotonic, electrolyte-free and iso- is necessary during operative hysteroscopy to tonic, electrolyte-containing solutions. The exclude uterine dehiscence, sacculation, and popularity of dextran 70 is waning, however. perforation. Prior uterine surgery may cause While it is immiscible with blood, significant myometrial weakness and lead to possible complications have been reported.

46 OBG MANAGEMENT • January 2004 Cutting the risk of hysteroscopic complications

TABLE Complications associated with hysteroscopy

TYPES OF SPECIFIC COMPLICATIONS COMPLICATIONS AVOIDANCE STRATEGY

Procedure-related Bowel and bladder injury Visualize and inspect endometrial cavity. Cervical laceration Yellow tissue is likely associated with bowel injury. or trauma Indentations and sacculation may be associated Hemorrhage with myometrial weakness and possible bowel or Inability to dilate bladder injury. Observe uterine morphology in the cervix patients with prior cesarean, myomectomy, or Uterine perforation known uterine perforation.

Media-related Anaphylaxis Alert to type of fluid being used, discuss Cardiovascular collapse known fluid concerns, and ask anesthesia to promptly

Cerebral edema report a change in vital signs, including CO2, difficulty Congestive ventilating patient, or arrhythmias. Strict monitoring Fluid overload of fluid intake, output by automated system. Gas and air embolism Hyponatremic hyper- volemia

Postoperative Adhesions Consider sounding cervix at 2- to 4-week post- operative visit to decrease risk of cervical synechiae Delayed diagnosis and . of Consider and endometrial ablation in (new or worsening) in patients who need contraception, or advise strict Failure to treat use of contraception by patient or partner to decrease significant symptoms risk of pregnancy. Hematometra Myometrial thinning Pregnancy testing in patients with pregnancy Postablation tubal symptoms. sterilization syndrome Pregnancy complications Consider magnetic resonance imaging to exclude • Intrauterine growth if persistent postoperative pain. retardation • Placentation problems, eg, Consider preoperative cervical cultures for women accreta with suspected sexually transmitted disease or • Postpartum hemorrhage high risk factors. Do not operate in women with • Preterm labor prodromal or herpes infection. • Premature delivery • Uterine rupture • Uterine dehiscence or sacculation Synechiae Tubal sterilzation syndrome Unrecognized bowel, bladder or major blood vessel injury

CONTINUED

January 2004 • OBG MANAGEMENT 47 Signs of anaphylactic reactions to dex- Isotonic, electrolyte-containing solutions. tran 70 include acute hypotension, hypoxia, Mannitol 5% is electrolyte poor but isotonic, pulmonary edema, fluid overload, fulminant creating less risk for hypo-osmolality. , and . The surgeon However, dilutional (ie, low must operate quickly, minimize endometrial sodium levels) can still occur. trauma, use continuous pulse oximetry, and Advantages of bipolar instruments. To obtain a preoperative panel. minimize complications from hypotonic, elec- Dextran 70 also can ruin operative hys- trolyte-free solutions, manufacturers devel- teroscopes if they are not cleaned promptly oped operative hysteroscopes that can function and thoroughly after use. in a bipolar environment. Bipolar instruments Hypotonic, electrolyte-free solutions. can operate in isotonic, physiologic, elec- With hypotonic, electrolyte-free solutions such trolyte-containing media. Hyponatremia and as glycine 1.5%, early recognition of possible hypo-osmolality cannot occur with normal complications, including hyponatremic hyper- saline or Ringer’s lactate, but fluid overload volemia, is vital. For example, when glycine can. (Fluid overload with saline can cause pul- and sorbitol are metabolized, free water accu- monary edema and congestive heart failure.) mulates and the body attempts to achieve How much fluid will be absorbed? The homeostasis through compensatory mecha- answer depends on factors including surface nisms such as osmosis, which moves free water area of the surgical field, duration of surgery, into extracellular and intracellular spaces. This opened venous channels, type of irrigation can lead to increased free water in the brain, fluid used, and pressure of the delivery system. resulting in , rising intracranial Modern gynecologic suites employ fluid irriga- pressure, and cellular necrosis. tion systems that continuously measure input The cerebral cation pump normally and output, with alarms that signal a predeter- pumps osmotically active cations into the mined fluid deficit. The alarm indicates the extracellular space, thereby minimizing need to halt the procedure and quickly evalu- cerebral edema. However, this pump is ate the patient. Careful attention to the recom- inhibited by , so the compensatory mendations of Loffer et al8 would lead to fewer mechanism is diminished. complications from fluid mismanagement. Classic clinical features of hyponatremic hypervolemia include apprehension, confu- Appropriate use of CO2 sion, fatigue, headache, mental agitation, nau- High risk of embolism with CO2 in sea, visual disturbances (including blindness), operative procedures. Although diagnostic vomiting, and weakness. These complications hysteroscopic procedures often are performed are more readily apparent when regional anes- with carbon dioxide (CO2), operative proce- thesia is used rather than general anesthesia. dures never should be. The reason: the high If hyponatremic hypervolemia goes risk of CO2 embolism that occurs with open unrecognized, bradycardia and hyperten- venous channels and vascular . sion can ensue, followed rapidly by cerebral The choice between CO2 and fluid medium and pulmonary edema and cardiovascular col- for diagnostic hysteroscopy often is determined lapse. In addition, glycine 1.5% is metabolized by physician preference and the presence of to glycolic acid and ammonia. Free ammonia uterine bleeding. Many gynecologists prefer is associated with central nervous system disor- CO2 for its optical clarity and patient comfort ders. Recognition and prompt treatment by an during .9 intensivist may prevent permanent neurologic Purge tubing of room air before each pro- 7 sequelae, death, and lawsuits. cedure. Embolic complications with CO2

48 OBG MANAGEMENT • January 2004 Cutting the risk of hysteroscopic complications

Cancer concerns: When is the best option?

ne of the greatest concerns about endome- should raise suspicion. These patients require full Otrial ablation is that diagnosis of endometrial visualization of the endometrium. cancer will be delayed because the endometrial Heightened risk during perimenopause cavity has been obliterated. Vilos19 recently Newer ablation techniques that utilize global reviewed the salient characteristics and findings make it paramount that perimenopausal in women treated by endometrial ablation who women undergo scrupulous evaluation. Until subsequently developed endometrial cancer. A much more information is available, endometrial review of the individual cases revealed that most ablation should be avoided in patients with of these patients had numerous risk factors for , particularly with atypia. endometrial cancer. While some gynecologists may be persuaded to Review risk factors, chronic conditions consider endometrial ablation as a minimally Many patients with abnormal bleeding also have invasive procedure compared to hysterectomy, risk factors for endometrial cancer, as well as the risk of delayed diagnosis of endometrial can- medical conditions that increase the likelihood of cer is of paramount concern. The treatment of morbidity with surgery, such as , hyper- choice for these patients remains medical thera- tension, , and advanced age. In these py with oral and, possibly, long- cases, hysterectomy may be a better option than term use of a -releasing intrauter- endometrial ablation. It would be far better to ine system. If this fails, hysterectomy is advis- have such high-risk patients cleared for hysterec- able. As Cooper20 aptly states, “Conservative, tomy than to chance their becoming an endome- nonextirpative procedures offer no life raft” trial-ablation “statistic.” If endometrial ablation is compared with hysterectomy, which covers performed in these cases, we prevent the egress many missed diagnoses. of blood, foster development of synechiae, ren- No risk of spreading cancer cells der difficult or impossible Some gynecologists have worried about the risk and, potentially, “bury” endometrial cells deeper of disseminating endometrial cancer cells during within the —all of which contribute hysteroscopy. However, Kudela and Pilka21 stud- to a delayed and “upstaged” diagnosis of ied the true risk in women undergoing blind dila- endometrial cancer. tion and curettage and hysteroscopy performed Patients at risk of endometrial cancer should with a fluid medium. Cul-de-sac aspiration prior undergo a scrupulous and unambiguous work-up to instrumentation and at the conclusion of the and evaluation. Indeterminate endometrial echo procedure demonstrated no increased risk of and office evaluation that generates biopsy sam- positive cytology. They are continuing a Phase II ples designated as “insufficient for diagnosis,” trial comparing outcomes of both groups over “no endometrial tissue seen,” or “” 5 years.

have been recorded with use of the neodymi- procedure. It is critical to purge the entire um: yttrium aluminum garnet (Nd:YAG) tubal system with CO2 prior to instrumenta- laser and during operative procedures. Less tion, since up to 40 cm3 of room air may be well known are the adverse sequelae that can insufflated into a patient when 200 cm of con- 10 occur with room air prior to beginning the nective tubing with a 0.5-cm lumen is used. CONTINUED

January 2004 • OBG MANAGEMENT 49 Wait for several minutes before starting the to aspirate gas, if necessary. Cardiac massage procedure so that the whole system is purged. and a precordial thump may dislodge CO2; Advantages of CO2 in diagnostic unfortunately, high false-positive rates of pre- hysteroscopy. Although any number of cordial Doppler make its use impractical. gaseous solutions could be used during diag- nostic hysteroscopy, CO2 is the most ideal due How to minimize risks to its solubility in blood, the rapidity with • Avoid coaxial gas cooling tips associated which it is dissolved, and the large quantities with Nd:YAG crystal lasers (1 L/min or more) that would be necessary to • Avoid a steep Trendelenburg position cause a fatality. (A hysteroinsufflator utilizing • Keep cervix covered with sponge or dilator 100 mL/min or less is used for diagnostic hys- when operative hysteroscope is removed to teroscopes.) When Bradner et al11 reviewed the minimize air embolism incidence of severe nonfatal embolism in • Deaerate the equipment prior to surgery 3,932 diagnostic hysteroscopic procedures • Use a low-pressure hysteroscopic CO2 using CO2, the risk of subclinical embolic insufflator events was 0.51%; 0.03% of patients experi- • Carefully monitor the patient enced severe events. When special precautions • Be highly suspicious when vital signs are were taken to deaerate the supply tubing and unstable instruments, no events occurred in the next 1,000 cases. Thus, it is possible that ambient POSTOPERATIVE COMPLICATIONS air trapped in tubing—rather than CO2— ome complications of hysteroscopy may could be the culprit in gas emboli. Snot become clinically evident for months 6 most common symptoms of venous or or even years. The most common complica- air emboli. Anesthesiologists and gynecolo- tions of hysteroscopic endometrial ablation gists must be vigilant to prevent venous or air include pregnancy, postablation tubal sterili- emboli. Munro et al12 succinctly outline the 6 zation syndrome, new or worsening dysmen- most common symptoms: orrhea, hematometra, endometrial cancer, • pulmonary hypertension and failure to completely treat symptoms. • hypercarbia Patients scheduled for hysteroscopy must • hypoxia be informed of potential delayed risks of the • arrhythmias procedure. In addition, all reproductive-aged • tachypnea women should be advised that pregnancy is • systemic hypotension possible after endometrial ablation or operative Morbidity and mortality can be prevented removal of an intracavitary mass; thus, contra- when these symptoms are quickly recognized ception is crucial. The endometrial tissue is and promptly treated.13 resilient and may regenerate after ablation. Beware of a drop in end-tidal CO2. The most common sign of impending cardiovascu- Hematometra: Avoid lar collapse is a sudden decrease in end-tidal ematometra is an infrequent late compli- CO2, when the right cardiac outflow tract is Hcation of operative hysteroscopy. If men- obstructed by CO2, which leads to arterial oxy- struating women or those taking hormone gen (O2) desaturation. If such a decrease is sus- replacement therapy experience cyclic or pected, stop the procedure immediately and chronic lower after surgery, scar- administer 100% O2. (Also stop nitrous oxide, if ring or narrowing of the endometrial cavity used.) Turn the patient to the left lateral decu- may be the cause. Approximately 1% to 2% of bitis position and use a central venous catheter women who undergo operative hysteroscopy

50 OBG MANAGEMENT • January 2004 Cutting the risk of hysteroscopic complications experience this phenomenon. Most cases can reported after uterine adhesiolysis, uterine be treated with cervical dilation alone. perforation during operative hysteroscopy, Since the cervical canal contains no and with myoma resections. A high index of endometrial glands, there is no need to treat this suspicion is vital when a gravida presents area in women undergoing endometrial abla- with pelvic pain, decreased fetal movement, tion. In fact, avoiding this area during treatment vaginal bleeding, or abnormal uterine masses is a critical component of successful surgery. detected ultrasonographically. Signs of uterine rupture. Pregnancy- Tubal sterilization syndrome related complications of operative hys- possible after endometrial ablation teroscopy can be dramatic and fatal if not rec- onsider this syndrome when a patient ognized quickly, as in the case of uterine rup- Cundergoing endometrial ablation com- ture. Kerimis et al16 describe uterine rupture plains of crampy, cyclic, unilateral or bilateral in a term pregnancy after hysteroscopic resec- pelvic pain, possibly accompanied by vaginal tion of a . Severe fetal distress, spotting. Sometimes a unilateral mass can be maternal shoulder pain, and abdominal pain palpated, but more commonly tenderness is led to an emergency cesarean section. elicited on . Intraoperative findings included a 7-cm tear Ultrasound may demonstrate fluid near from left cornua to right cornua. The original the cornual region. Laparoscopy confirms the metroplasty, performed with cutting diagnosis by visualizing a swollen, edematous diathermy and laparoscopy, was not accom- proximal . may panied by complications or perforation. confirm , chronic or acute Patients who experience intraoperative inflammation, or hemosiderin deposits. complications during metroplasty or deep Treatment includes bilateral cornual resec- resection of intramural fibroids should be tion and reablation of proximal endometri- informed of the risk of uterine rupture so um, or hysterectomy.14 they may consider elective cesarean. Regardless of the mode of delivery, prompt Pregnancy complications attention is vital if fetal distress is suspected. Endometrial ablation is not to be regarded as a method of contraception. Patients need- Postablation warning signs ing should consider concurrent atients undergoing endometrial ablation or other reliable methods after Pgenerally have a quick postoperative return this procedure. to activity, minimal need for postoperative pain The frequency of pregnancy after medication, and limited complaints. Beware of endometrial ablation ranges from 0.2% to patients who make frequent postoperative 1.6%, though this data may represent under- phone calls and have escalating requirements reporting. Pregnancy outcomes have been dis- for pain medication. While bowel and bladder mal in women conceiving after endometrial injuries are infrequent—as is postoperative ablation. Complications include preterm labor, endometritis—these must be vigilantly consid- premature delivery, intrauterine growth retar- ered and evaluated when patients complain of dation, prenatal death, postpartum hemor- persistent pain, fever, and general malaise. rhage, and placentation problems such as pla- Office evaluation is necessary, including thor- centa accreta, increta, or percreta, as well as ough abdominal and pelvic examinations. placental abruption.15 Laboratory testing should include electrolytes, Uterine dehiscence and sacculation and complete blood count, sedimentation rate, ultra- extremely thin myometrium have been sound, and a flat plate of the abdomen (kidneys,

January 2004 • OBG MANAGEMENT 51 Cutting the risk of hysteroscopic complications

ureter, and bladder; upright) may be required. Ultrasound guidance made it possible to Sometimes a computed tomography scan of the extend the resection beyond the limit conven- /abdomen may be needed if perforation tionally defined by hysteroscopy; none of the with bowel or bladder injury is suspected. patients in the ultrasound group required reintervention. Among controls, a second Hysteroscopic fibroid removal operation was necessary in 4 cases. may be necessary after UAE Investigators concluded that a wider resection terine artery embolization (UAE) is gain- (10 to 15 mm distance from the external sur- Uing popularity for the treatment of symp- face of the uterus) of fibroids was achieved tomatic uterine fibroids. Transcatheter using ultrasound guidance. ■ embolization of the uterine artery leads to REFERENCES occlusion of the fibroid, ischemic shrinkage of 1. Gurtcheff SE, Sharp HT. Complications associated with global endometrial abla- the fibroid, and shrinkage of residual myome- tion: the utility of the MAUDE database. Obstet Gynecol. 2003;102:1278-1282. 2. Jansen FW, Vredevoogd CB, Ulzen K, et al. Complications of hysteroscopy: a trial tissue. Fibroids may migrate weeks to prospective, multicenter study. Obstet Gynecol. 2000;96:266-270. months after the procedure as the myometri- 3. Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hystero- scopic surgery: predicting patients at risk. Obstet Gynecol. 2000;96:517-520. um contracts and the treated fibroid degener- 4. Preutthipan S, Herabutya Y. Vaginal misoprostol for cervical priming before oper- ates, leading to delayed discharge, passage of ative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2000;96:890-894. 5. Thomas JA, Leyland N, Durand N, Windrim RD. The use of oral misoprostol as necrotic fibroids, cramps, and heavy bleeding if a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-con- the fibroid migrates to a submucosal location. trolled trial. Am J Obstet Gynecol. 2002;186:876-879. 6. Stotz M, Lampart A, Kochli OR, Schneider M. Intraabdominal bleeding masked Hysteroscopic removal is an obvious option. by hemodilution after hysteroscopy. . 2000;93:569-570. 17 Recently, De Iaco et al reported the devel- 7. Cooper JM, Brady RM. Intraoperative and early postoperative complications of opment of a uterine fistula and discontinuity of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:347-366. 8. Loffer FD, Bradley LD, Brill AL, Brooks PG, Cooper JM. Hysteroscopic fluid the myometrium after hysteroscopic resection monitoring guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168. of an embolized migrated fibroid. They specu- 9. Bradley LD, Widrich T. Flexible hysteroscopy: a state-of-the-art procedure for gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995;2:263-267. lated this was due to the development of an 10. Neis KJ, Brandner P, Lindemann HJ. Room air as a cause of gas embolism in diag- avascular myometrium after UAE. The patient nostic CO2 hysteroscopy. Zentralbl Gynakol. 2000;122:222-225. 11. Bradner P, Neis KJ, Ehmer C. The etiology, frequency, and prevention of gas was asymptomatic, but routine diagnostic hys- embolism during CO2 hysteroscopy. J Am Assoc Gynecol Laparosc. 1999;6:421-428. teroscopy revealed a 2-cm discontinuity of the 12. Munro MG, Weisberg M, Rubinstein E. Gas and air embolization during hystero- scopic electrosurgical vaporization: comparison of gas generation using bipolar uterine wall at the site of the previous resecto- and monopolar electrodes in an experimental model. J Am Assoc Gynecol Laparosc. scopic myomectomy. The myometrium was 2001;8:488-494. 13. Murdoch JAC, Gan TJ. Anesthesia for hysteroscopy. Anesthesiol Clin North Am. white and less than the full thickness. 2001;1:125-140. 14. Cooper JM, Brady RM. Late complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:367-374. Ultrasound guidance 15. Rogerson L, Gannon B, O’Donovan P. Outcome of pregnancy following endome- improves outcomes trial ablation. J Gynecol Surg. 1997;13:155-160. 18 16. Kerimis P, Zolti M, Sinwany G, Mashiach S, Carp H. Uterine rupture after hys- occia et al described the benefits of intraop- teroscopic resection of uterine septum. Fertil Steril. 2002;77:618-620. Cerative ultrasound guidance during operative 17. De Iaco P, Golfieri R, Ghi T, Muzzupapa G, Ceccarini M, Bovicelli L. Uterine fis- tula induced by hysteroscopic resection of an embolized migrated fibroid: a rare hysteroscopy in fibroid treatment and uterine sep- complication after embolization of uterine fibroids. Fertil Steril. 2001;75:818-820. tum removal. Prospective evaluation of 81 18. Coccia ME, Becattini C, Bracco GL, et al. Intraoperative ultrasound guidance for patients involved an experienced ultrasonograph- operative hysteroscopy. J Reprod Med. 2000;45:413-418. 19. Brooks-Carter GN, Killackey MA, Neuwirth RS. of the er who mapped the limits of treatment. Patients endometrium after endometrial ablation. Obstet Gynecol. 2000;96:836-837. 20. Cooper JM. Swimming lessons: check the water before jumping in. J Am Assoc were compared to 45 historical controls who had Gynecol Laparosc. 1998;5:87-90. been similarly treated with laparoscopic monitor- 21. Kudela M, Pilka R. Is there a real risk in patients with endometrial ing. Satisfactory outcomes included relief of men- undergoing diagnostic hysteroscopy (HSC)? Eur J Gynecol Oncol. 2001;22:342-344. orrhagia, complete resection of fibroids (including full resection of intramural fibroids), and thor- Dr. Bradley reports that she serves as a consultant to Karl Storz, ACMI, ough metroplasty of uterine septum. Olympus, and Gynecare, and as a lecturer for Novacept.

52 OBG MANAGEMENT • January 2004

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