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CMECNE

Hysteroscopy Guidelines

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. List the contraindications to hysteroscopy
2. Identify and manage complications that may arise with hysteroscopy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Feb 19 2019 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Hysteroscopy can be performed either in the operating room or the office.  When planning a hysteroscopic procedure, the joint ACOG/AAGL 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
  • Optimize visualization
    • Perform during follicular phase of cycle, after menses | Secretory phase may mimic polyps : Irregular menses may be scheduled at any time
    • Actively bleeding “may not undergo the procedure” due to decreased visibility
    • Pretreatment with progestins or combined OCP may further optimize visualization by thinning the endometrial lining
  • Antibiotic prophylaxis not recommended
  • Pain management
    • Multiple pharmacologic approaches described, but evidence insufficient to recommend any particular analgesic regimen | No regimen has been shown to be superior to placebo
      • NSAIDS | Topical anesthetic | Acetaminophen | Benzodiazepines (anti-anxiety medications) | Opiates | Intracervical and/or paracervical block
    • Non-pharmacologic
      • <5 mm diameter hysteroscopes | Flexible hysteroscopes | Vaginoscopic approach
  • Cervical Ripening
    • “Insufficient evidence to recommend routine cervical ripening before diagnostic or operative hyseteroscopy”
      • Consider if risk of cervical stenosis or increased procedural pain
    • Misoprostol (off label)
      • 200–400 micrograms oral or intravaginal the night before surgery (12 hours prior to procedure)
      • Postmenopause: 25 micrograms vaginal estrogen 14 days prior to procedure plus misoprostol 12 hours prior to procedure
    • Osmotic dilators
      • Data to support use | Requires additional office visit | Must be removed if procedure is cancelled
    • Vasoconstrictors (epinephrine or vasopresessin)
      • Potential benefits: Less bleeding | Reduce fluid absorption | Improve potency of local anesthesia | Reduce force needed to dilate cervix
      • Risks (rare): Bradycardia | Hypotention or increased BP | Cardiac arrest
      • No evidence for optimal dose
      • One regimen cited in literature (see ‘Learn More – Primary Sources’ below): 20 mL dilute vasopressin solution (4U of 0.05 U/mL in 80 mL normal saline)

Location

  • Office hysteroscopy
    • Diagnostic or minor operative
    • Should be considered for the treatment of endometrial polyps
  • Operating room hysteroscopy
    • Use for patients with
      • Cervical stenosis
      • Medical comorbidities (e.g., cardiopulmonary disease)
      • Significant uterine pathology
      • High levels of anxiety
      • Previously failed or not tolerated office hysteroscopy

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

Vasovagal 

  • Signs and symptoms
    • Hypotention | Bradycardia
    • Sweating | Pallor | Loss of conciousness |  Nausea and vomiting
  • Management
    • Assess: Vitals | Airway, Breathing, Circulation
    • Place patient in Trendelenberg or raise legs
    • If bradycardia does not resolve
      • Atropine: Single dose 0.5 mg IV q3 to 5 minutes (total dose 3 mg)

Fluid Overload and Hyponatremia 

  • Prevention
    • Strictly monitor both IV hydration and hysteroscopic fluid deficit
    • Electrolyte poor fluids maximal deficit: 1000 mL (in healthy individuals)
      • Consider stopping procedure at 750 mL deficit
    • Electrolyte-containing fluids maximal deficit: 2500 mL (in healthy individuals)
      • Consider stopping procedure at 2000 mL 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 | Avoid repetitive instrument insertions | Limit intrauterine pressure
  • Worrisome symptoms include
    • Dyspnea | Chest pain | Decreased O2 saturation | ‘mill wheel’ heart murmur | Hypotension | Cardiac arrhythmia (e.g., tachycardia/bradycardia)
  • Management
    • Terminate procedure
    • Deflate uterine cavity
    • Eliminate sources of fluid and gas
    • Position in left lateral decubitus with Trendelenburg position (Durnat’s maneuver)

Learn More – Primary Sources:

ACOG Committee Opinion 800: The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology

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.)

The Effect of Dilute Vasopressin Solution on the Force Needed for Cervical Dilatation: A Randomized Controlled Trial

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Perform Hysteroscopy or Endometrial Biopsy First for Uterine Bleeding?
How Well Does Sonohysterography Match Up Against the Gold Standard of Hysteroscopy?
Endometrial Polyps – Do They Always Need To Be Removed?
Is Tamoxifen a Risk Factor for Endometrial Cancer in Women with Endometrial Polyps?
Endometrial Hyperplasia – Current Nomenclature and Treatment

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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