CLINICAL ACTIONS:

Hysteroscopy can be performed either in the operating room or the office.  When planning a hysteroscopic procedure, ACOG recommendations include the following

• Preoperative consultation
  • Discuss risks/ benefits/ alternatives
  • Review medical history
  • Exclude pregnancy if appropriate
• If cervical stenosis is present
  • Consider misoprostol (off label) 200-400 mcg buccal/ sublingual/ intravaginal the night before surgery
• Perform during follicular phase of cycle
• Antibiotic prophylaxis not recommended
• Procedure facilitation and pain management for office hysteroscopy may include
  • Misoprostol (off label) 200–400 micrograms oral or intravaginal the night before surgery
    • Evidence from non-hysteroscopy procedures that buccal or sublingual may be preferable
  • Pre-op NSAIDS
  • Anti-anxiety medications
  • <5 mm diameter hysteroscopes
  • Flexible hysteroscopes
  • Dedicated office staff

Location

• Office hysteroscopy
  • Diagnostic or minor operative
• Operating room hysteroscopy
  • Use for patients with
    • Cervical stenosis
    • Medical comorbidities
    • Significant uterine pathology
    • High levels of anxiety

Contraindications

• Known pregnancy
• Active herpetic infection
• Genital tract infection
• Known advanced stage cervical/ uterine malignancy

Distention Medium

CO₂ gas

• Clear view of cavity and easy equipment maintenance
• Limit flow to 100 mL/min
• Maintain intrauterine pressure to <100 mm Hg
• Use hysteroscopic (not laparoscopic) insufflator

Electrolyte poor fluids

• Glycine 1.5% | Sorbitol 3% |Mannitol 5%
• Use for
  • Operative hysteroscopy
  • Monopolar devices
  • Radio-frequency energy devices
• Caution: Excessive absorption associated with
  • Hyponatremia | Decreased serum osmolality | Hyperammonemia
  • Can lead to seizures and mortality
  • Note: Mannitol 5% is iso-osmolar and while may cause hyponatremia, should not decrease serum osmolality

Electrolyte-containing fluids

• Normal saline | Lactated Ringer’s solution
• Use for
  • Diagnostic cases
  • Laser | Bipolar | Mechanical energy
• Less risk of hyponatremia/ decreased osmolality

SYNOPSIS:

Polyps, synechiae, Mullerian abnormalities, leiomyomata and retained foreign bodies can often be diagnosed and treated successfully with hysteroscopy.  Visualization of the endometrial cavity allows biopsy of abnormal areas and can optimize the diagnosis of hyperplasia or malignancy

KEY POINTS:

Complications

Fluid Overload and Hyponatremia 

• Prevention
  • Strictly monitor both IV hydration and hysteroscopic fluid deficit
  • Electrolyte poor fluids maximal deficit: 1000 mL (in healthy individuals)
  • Electrolyte-containing fluids maximal deficit: 2500 mL (in healthy individuals)
    • Electrolyte solution: Consider stopping procedure at 2000 cc deficit
    • Consider lower thresholds for elderly, cardiovascular or renal comorbidity or when laboratory services/ acute care options are limited 
•  Management
  • Hypertonic saline solution and diuretics (e.g., furosemide)
  • Increase serum sodium levels by 1–2 mEq/L/h
  • Caution: Do not increase by more than 12 mEq/L in the first 24 hours
  • Transfer to an urgent care facility and further consultation may be required

Hemorrhage

• Management
  • Apply electrosurgical coagulation if bleeding sites identified
  • Inject vasopressin into the cervix
  • Use Foley catheter balloon tamponade or manual uterine compression
  • Surgical approach as a last resort includes
    • Laparoscopic suturing of perforation
    • Hysterectomy
    • Uterine artery embolization

Uterine Perforation

• Prevention
  • Perform careful pelvic exam prior to hysteroscopy
  • Use ultrasound guidance as needed
  • If flexible hysteroscope available, insertion may be performed prior to using dilators
• Management
  • Midline perforation is seldom morbid unless laser or electrosurgery is used
  • Lateral perforations carry risk for retroperitoneal hematomas
  • Discontinue hysteroscopy if perforation occurs
  • Consider laparoscopy to
    • Identify any bowel/ bladder injury
    • Check for hematomas

Air/CO2 Embolization

• Prevention
  • Purge and flush air from tubing prior to procedure and whenever bags are changed
• Worrisome symptoms include
  • Dyspnea | Chest pain | Decreased O2 saturation | ‘mill wheel’ heart murmur | Hypotension | Cardiac arrhythmia (e.g., tachycardia/bradycardia)
• Management
  • Position in left lateral decubitus with head 5% down
  • Aspirate air from the right ventricle using cardiocentesis or catheterization of jugular vein

Learn More – Primary Sources:

ACOG Technology Assessment 13: Hysteroscopy

AAGL Practice Report: Practice Guidelines for the Management of Hysteroscopic Distending Media: (Replaces Hysteroscopic Fluid Monitoring Guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.)

Mini Review: Art of Hysteroscopy

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