Hysteroscopy

Hysteroscopy is the direct visualization of the uterine cavity using a rigid or flexible fiberoptic instrument. Hysteroscopy can be done as an office procedure under intravenous sedation or in an operating room under general anesthesia, spinal or epidural anesthesia, or intravenous sedation. Hysteroscopy is done for both diagnostic and therapeutic purposes. The most common indication for hysteroscopy is abnormal vaginal bleeding. Other indications include uterine leiomyomata, intrauterine adhesions, proximal tubal obstruction, removal of intrauterine devices, müllerian anomalies, and infertility evaluation. Therapeutic applications include directed biopsies, removal of small myomata, and endometrial ablation for menorrhagia. Complications of hysteroscopy occur in approximately 2 percent of cases and include fluid overload, uterine perforation with possible damage to intraabdominal organs, infection, toxic shock syndrome, anesthesia reaction, postoperative bleeding, and embolism.7

Fluid overload is rare but can occur from absorption of electrolyte and nonelectrolyte solutions during lengthy procedures. The entry of dextran into the circulation can lead to pulmonary edema and disseminated intravascular coagulation. For this reason, no more than 500 mL dextran should be used during a procedure. A lack of recovery of distention medium in excess of 1000 mL also places the patient at risk for fluid overload. If fluid overload is suspected, hyponatremia should be anticipated. A rapid decrease in the serum sodium level can result in generalized cerebral edema, seizures, and death.

Uterine perforation is a relatively common complication. A midline uterine perforation generally does not have significant sequelae. A lateral perforation may lacerate uterine vessels and cause substantial bleeding. Most often, the perforation is noted at the time of surgery, and a laparoscopy is done to investigate for bleeding and/or damage to bowel or bladder. If the complication is not noted at the time of surgery, the patient may present with peritoneal signs if the bowel has been injured or pain and/or bleeding if the vessels were lacerated.

Infection is very rare and most commonly occurs in patients with concurrent genital tract infections. Endometritis or even toxic shock can result.

Postoperative bleeding may be uterine or cervical in origin. Cervical lacerations may be caused by forceful dilation or tears from the tenaculum. Uterine bleeding can result from resection procedures. After hemodynamic stabilization of the patient, the gynecologist can place a Foley or balloon catheter into the uterine cavity and fill it with approximately 10 to 15 mL of water or saline solution. One technique is to remove one-half the fluid from the balloon after 1 h and the other half after 2 h. If bleeding remains stopped, the patient can usually be discharged. If bleeding persists, the patient should be admitted. The catheter is reinflated and left overnight, or occasionally reeploration is required.

Embolism is the most feared complication of using CO2 gas as a distention medium. The risks of such an occurrence are low when the principles of low flow and low pressure are followed.

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