OBGMANAGEMENT COVER ARTICLE LINDA D. BRADLEY, MD Hysteroscopy will uncover numerous intracavitary lesions, such as submucous fibroids, polyps, endometrial hyperplasia, and cancer. Gynecologists need to possess the expertise and skill to resect focal lesions or perform directed biopsies. 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 Hysteroscopy 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 infertility, recurrent pregnancy Safe, easily learned loss, and abnormal and postmenopausal uter- lthough gynecologists are beginning to ine bleeding, and is useful when saline infu- Aembrace this modality, many physicians 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 pathology or risky con- subjects were given GnRH analogues, which ditions, and inadequate preventive maneuvers. may render the cervix 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- • menopause ated with specific hysteroscopic procedures. • use of GnRH agonists Demographic data and medical histories were • prior cone biopsy collected for 925 women who had operative • markedly retroverted uterus 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 endometrial ablation 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. cervical dilation, 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 surgery. 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 allergy. Preoperative cervical softening still should be considered MEDIA-RELATED COMPLICATIONS in high-risk patients. otorious complications and several Vaginal or oral misoprostol 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 physician’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 abdominal pain and slight associated with complications. Fluid choices vaginal bleeding), few if any prevent its use. with monopolar instruments include glycine Signs of perforation. Patients who sustain 1.5%, a mixture of sorbitol 3% and mannitol 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, laparoscopy or comanagement and consultation with an laparotomy 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 dextran 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 anesthesia 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 heart failure ventilating patient, or