Hysteroscopic Complications Case File

Hysteroscopic Complications Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 35

A 62-year-old G1P1 menopausal woman with a 6-month history of postmenopausal bleeding is undergoing hysteroscopy. She states that, on many occasions, her undergarments are blood tinged. She denies any nausea, vomiting, or abdominal pain. She has been menopausal for 5 years. Her past medical history is significant for type 2 diabetes for 10 years and is controlled with an oral hypoglycemic agent daily. Socially, she runs 3 miles, two times a week. A pelvic examination was noncontributory, without masses. A transvaginal ultrasound reveals a small uterus, with an 8-mm endometrial stripe; normal ovaries. An endometrial biopsy was negative for hyperplasia and carcinoma.

Prior to inserting the hysteroscope, the cervical canal is dilated with the Hegar dilators. She undergoes a dilation and curettage (D&C) with an operative hysteroscopy which reveals an endometrial polyp. The 30-degree hysteroscope is placed through a 10-mm outer sheath and glycine 1.5% is used as the distention medium. Upon entering the uterine cavity, the endocervix, the anterior and posterior walls, and the tubal ostia are all visualized. The endometrium appears pale, and a fundal endometrial polyp is visualized. The polyp extends into the endometrial cavity, while its broad base remains attached to the fundus, closer to the right tubal ostia. Grasping forceps are used in an attempt to provide adequate visualization of the base of the polyp, in its entirety. The loop resectoscope is used to resect the polyp at the base. Forty-five minutes after the start of the procedure, the nurse announces that there is a 900-cc fluid deficit. The polyp is only partially resected. The procedure continues, and the loop electrode is placed anterior to the base of the polyp and the resection continues. After several passes with the resectoscope, there is noted to be an immediate loss in intrauterine pressure to 30 mm Hg.

➤ What is the intraoperative diagnosis?

➤ What are the risk factors associated with this intraoperative diagnosis?

➤ What is the next step in managing this patient?

ANSWERS TO CASE 35:

Hysteroscopic Complications

Summary: This is a 62-year-old woman with postmenopausal bleeding for 6 months. An operative hysteroscopy revealed an endometrial polyp as the etiology for her bleeding. During the surgery to resect the polyp, adequate visualization was difficult to obtain in order to resect the polyp. However, the resection began, under poor visualization and a uterine perforation occurred. Of note, at the time of the perforation, there was a fluid deficit approaching 1 L.

➤ Intraoperative diagnosis (points of injury): Uterine perforation is a complication of hysteroscopy. The uterus is at the greatest risk of being damaged in two instances: (1) at the time of cervical dilation or entry into the uterus and (2) thermal injury secondary to use of electrical current. Of special note, the uterine wall is very thin near both tubal ostia. Care must be taken when using the loop resectoscope in this area.

➤ Risk factors associated with intraoperative diagnosis: An unrecognized injury to the uterine wall may result in trauma to the intra-abdominal organs, or the pelvic vessels. Complications during operative hysteroscopy can occur during one of the following instances: (1) intraoperatively, (2) immediately postoperatively, or (3) as a late complication.

➤ Next step: A good surgeon prepares the patient preoperatively for the indicated procedure. All risks, benefits, and possible complications should be discussed during the preoperative counseling session. A discussion has to occur to understand that if a complication occurs, the procedure has to be discontinued. In this patient, the intraoperative diagnosis was a uterine perforation. An immediate loss of intrauterine pressure is noted at the time of perforation secondary to the loop resectoscope, which signals the diagnosis of a uterine perforation. The next step is to discontinue the hysteroscopy and evaluate the extent of damage done to the uterus, via laparoscopy.

ANALYSIS

Objectives

1. Know the different categories of hysteroscopic complications and be able to recognize them.
2. Be familiar with the advantages and disadvantages of each distending medium used during hysteroscopy.
3. Understand that there are legal risks associated with hysteroscopic complications.
4. Know the six most common gynecologic procedures that are associated with a higher incidence of complications.

Considerations

This is a 62-year-old G1P1 woman with postmenopausal bleeding who undergoes an operative hysteroscopy for removal of the endometrial polyp (Figure 35–1). Hysteroscopy is a quick, minimally invasive diagnostic and therapeutic procedure. Hysteroscopic surgery decreases morbidity and adds to a speedy recovery, but this advantage is minimal if complications occur. The experience of the surgeon is a strong predictor of complications. A preoperative workup revealed there to be an organic cause of the bleeding. The differential diagnosis for postmenopausal bleeding is numerous. The most common cause is atrophy of the endometrium. Other diagnoses that cause postmenopausal bleeding include endometrial hyperplasia, endometrial polyp, and endometrial carcinoma. There should be some prerequisites in place to minimize the risk of hysteroscopic complications: (1) There has to be accurate visualization of the uterine cavity and the lesion in its entirety. (2) Bleeding should be kept to a minimal because it impairs vision. (3) Laparoscopy may be used simultaneously, in some instances, to increase the safety of the procedure. (4) Accurate balancing of fluid intake and output must occur.

Figure 35–1. Endometrial polyps noted in the uterine cavity.

APPROACH TO

Hysteroscopic Complications

DEFINITIONS:

HYSTEROSCOPE: A telescope that transmits light and carries the image to the viewer’s eye. It contains the eyepiece, barrel, and lens.

DIAGNOSTIC HYSTEROSCOPY: A hysteroscope that is introduced into the endometrial cavity to detect intrauterine pathology, which aids in diagnosis. 

OPERATIVE HYSTEROSCOPY: A hysteroscope, which is placed through an operative sheath that allows the introduction of flexile instruments to perform intrauterine surgery.

SHEATH: A device that is fitted over the telescope, which allows infusion of distention media.

DISTENTION MEDIUM: Fluid used to separate the walls of the uterus in order to perform the intrauterine surgery.

CLINICAL APPROACH

History

Baggish first reported hysteroscopy in the United States in 1979. However, the first hysteroscope was developed in the early nineteenth century. In 1807, a hollow tube was invented to explore the natural human cavity.1 Today, hysteroscopes are used to aid in gynecologic diagnoses.

Instrumentation

The hysteroscope is placed in an 8- to 10-mm operative sheath, and a retractable hand piece is placed through the hysteroscope to perform electrosurgery within the uterine cavity. A variety of instruments may be used which include the monopolar loop electrodes, grasping forceps, biopsy forceps and scissors, and bipolar instruments, such as the VersaPoint (Gynecare Versapoint™ Bipolar Electrosurgery System). The surgeon should be aware of the type of angulation of the lens; in general, the 0-degree hysteroscope gives a more “straight-on” view, whereas the 30-degree hysteroscope allows for good visualization of the entire uterine cavity (Figure 35-2A and B).

Prior to the start of the procedure, the surgeon must select the type of distention media to be used. The distention medium flows through the operative sheath and it separates the anterior and posterior walls of the uterus. It also creates sufficient intrauterine pressure for the procedure. Complications occur in both diagnostic and operative hysteroscopic procedures. However, the reported complication rates are lowest with diagnostic procedures.1

Figure 35–2. Different types of hysteroscopes.The 0-degree hysteroscope (A) gives a “straight-on” view which has a limited field of vision, whereas the 30-degree hysteroscope (B) gives a wider view of the uterine cavity, so long as the operator is aware of the direction of the fore-oblique lens. (Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw- Hill, 2008:950.)

Intraoperative Complications

Uterine perforation is the most common complication reported to be associated with hysteroscopy.2,3 This complication commonly occurs during dilation of the cervix and if there is a lack of knowledge of the specific location of the uterine position. Perforation can also occur when the cervical os is stenotic and the uterus is small or sharply ante- or retroflexed. The likelihood of a perforation increases when the woman is nulliparous, menopausal, and has a history of a prior cone biopsy, and if undue force is placed while dilating. If cervical stenosis is encountered, there are pharmacologic methods used to aid in ripening.2 Vaginal misoprostol and laminaria tent can be used.3 Keep in mind that persons allergic to shellfish should not receive laminaria. Be mindful that, if there is a stenotic cervical os, a false passage can be created with the Hegar dilators, which too increases the risk of uterine rupture. Once the uterus is perforated, the procedure is immediately stopped and evaluation for trauma to intra-abdominal organs and/or pelvic vessels has to occur. After 6 weeks, the operative hysteroscopy may be rescheduled.2 Cervical mucosal lacerations can also occur from use of the tenaculum. Treatment consists of applying pressure, cautery, or suturing the cervix.

Complications can occur when measurements of inflow and outflow of distention media are inaccurately or incompletely recorded. The type of electrical unit used, such as monopolar or bipolar, will determine the type of distention media to choose. There are two types of low-viscosity fluids: hypotonic (electrolytepoor media) and isotonic (electrolyte-rich media). In general, monopolar instruments cannot be used in electrolyte rich media such as normal saline due to the possibility to electrical current conduction; thus, these instruments are usually restricted for electrolyte poor media. Glycine, sorbitol, and mannitol are examples of electrolyte-poor fluid media. These media are considered hypoosmolar and will decrease serum osmolality and serum sodium levels. The fluid overload that results from these media will increase the risk of pulmonary edema, cerebral edema, and death. Isotonic media, such as normal saline and lactated Ringer solutions, are electrolyte-rich media. Laser and bipolar electrical instruments are used with these media. The risk of fluid overload and hyponatremia is less, secondary to the isotonicity of these fluids.

Dextran 70 (Hyskon), another distention medium, is a very viscous, sticky solution that provides excellent visibility, but is a powerful plasma expander. Instruments need to be meticulously cleaned after being used with dextran; residual material can ruin the instrumentation. The major disadvantage is that the maximum volume to be used is 500 cc, because for every 100 cc absorbed, the plasma volume expands 850 cc.4

Carbon dioxide gas is the final medium that can be used during hysteroscopy, but should not generally be used with operative hysteroscopy. This medium is immiscible with blood and has a high risk of carbon dioxide embolism with operative procedures. Signs and symptoms of gas emboli include pulmonary hypertension, arrhythmia, hypercarbia, hypoxia, tachypnea, and systemic hypotension.

Immediate Postoperative Complications

All fluids used with operative hysteroscopy can be associated with complications. To avoid the fluid overload, accurate balancing of inflow and outflow of distention media is required. The surgeon and surgical team are responsible for calculating the difference between the amount of fluid infused and the amount of fluid expelled during the surgery. The difference, between the two, is defined as the fluid deficit. The deficit should be less than 1 L. If the deficit is greater than 1.5 L, surgery should generally be terminated immediately.5 This deficit can become absorbed rapidly and can cause fluid overload syndrome. Absorption or intravasation may occur via several mechanisms: (1) directly into vascular structures during surgical resection, (2) across the walls of the endometrium, and (3) via the fallopian tubes with absorption from the peritoneum.6 The first clinical sign of fluid overload is the rapid production of dilute urine. Besides addressing the fluid overload, the patient should be assessed for hyponatremia, which likewise should be treated. Correction can occur over the first 24 hours by raising the sodium levels 1 to 2 mEq/L/h.4 Keep the patient well oxygenated and use diuretics to manage the volume overload.

The best two means to prevent the fluid overload complication are to accurately measure the inflow and outflow of distention media and to control the intrauterine irrigation pressure that distends the uterus. Intrauterine pressures that are safe remain less than 100 mm Hg.

Hemorrhage, defined as greater than 500 cc, can occur during the procedure and immediately postoperatively.7 Remember, clear vision is required to adequately perform operative hysteroscopy. A few methods, used to control intrauterine bleeding, are irrigation of the uterine cavity, insertion of a Foley catheter balloon, or injection of vasopressin at the bleeding site, or intravenous oxytocin.4 These methods should not be considered if the hemorrhage is secondary to an intraoperative complication, such as uterine perforation or laceration of the surrounding pelvic vessels. In these circumstances, the operative hysteroscopy should be stopped immediately.

Infection is rare after operative hysteroscopy. Prophylactic antibiotics are not universally employed, and do not prevent infection.1 Infection is reported with an incidence of less than 2%.1 If an infection does occur, it may involve the urinary tract or endometrium. Risk factors that increase the likelihood include extensive endomyometrial destruction, multiple insertions with the hysteroscope, and lengthy procedures.2

Late Complications

This category of complications can occur months to years after an operative hysteroscopy. It has been reported that late complications are associated with intrauterine fertility surgeries or after an endometrial ablation for abnormal uterine bleeding.8 Intrauterine synechiae that result from the operative hysteroscopy can inhibit regular menstrual flow. Commonly recognized conditions that can occur late include development of a hematometra, a pregnancy-related endometrial cancer, or post-tubal sterilization syndrome. The majority of these complications occur after an endometrial ablation.

Prompt recognition of complications is a must. Patients may complain of a myriad of complaints, such as increasing pain, bleeding, and persistent nausea and vomiting, postoperatively. Remember, if the procedure was completely uncomplicated, a patient will not call the office repeatedly. A patient who repeatedly calls the office may be experiencing a late complication, which previously had been occult. An astute surgeon has to be prompt in the diagnosis and treatment of associated complications. Legal risks can increase if a surgeon maintains a cavalier attitude, fails to accurately document fluid balance, and fails to respond promptly to possible complaints of a complication.

Indications

Operative hysteroscopy allows for visualization of the endometrial cavity, and it uses a variety of electrical current to treat intrauterine pathology. Unlike diagnostic hysteroscopy that can be performed in an office setting under local anesthesia, operative hysteroscopy is performed in a surgical suite under general or regional anesthesia. There are a variety of angled tip lenses available on the hysteroscope. The two most common are 0- and 30 degree. A 0-degree hysteroscope gives a straightforward, panoramic view of the anterior and posterior walls of the uterus and the tubal ostia. It is very similar to normal vision. A 30-degree hysteroscope allows visualization of the fundus; however, in order to see the tubal ostia, the scope has to be turned to a 90-degree angle to view the tubal ostia.

Symptoms which indicate that a hysteroscopy should be performed are abnormal uterine bleeding, infertility, or postmenopausal bleeding. Contraindications for performing the procedure, include pregnancy, infection, and endometrial carcinoma. Complications related to operative hysteroscopy are directly associated with the type of surgical procedure being performed. The six most common procedures, performed via the hysteroscope, are myomectomy septum resection, adhesiolysis, D&C with hysteroscopy, endometrial ablation, and polypectomy (Figure 35–3).7 While polypectomy and endometrial ablations have lower rates of complications, myomectomy, adhesiolysis, and resections of a uterine septa are associated with higher complication rates.

Rates of Injury

Complications are more likely to occur with operative rather than diagnostic hysteroscopy.1 Accurate vision is the first step in order to minimize the complication risk. The time required to perform the procedure is directly

Figure 35–3. A submucous myoma is noted by hysteroscopy. This fibroid can be resected hysteroscopically.

associated with the risk of complications. It was reported that out of 925 patients, myomectomy had the highest percentage of complications (10%), compared to a polypectomy, which has the lowest rate (0.4%).7 In another study, 38 complications occurred after 13,000 procedures. The complication rate for diagnostic hysteroscopy is 0.4% as compared to 0.95% of operative hysteroscopy.1

Comprehension Questions

35.1 A 25-year-old woman is undergoing hysteroscopic resection of submucous uterine fibroids. The surgeon is using 1.5% glycine solution as a distention medium. After 40 minutes of the procedure, the nurse informs the surgeon that there is a 500-mL fluid deficit. What is your next step?

A. Stop the procedure at this time.

B. Continue the procedure and carefully monitor fluid deficit.

C. Switch the fluid media to normal saline.

D. Give the patient furosemide and then continue the procedure.

35.2 The surgeon is using electrosurgery in a hysteroscopic procedure. Normal saline is used as a distention medium. Which of the following is the most accurate statement?

A. Normal saline should not be used with electrosurgery due to the possibility of conduction of electricity.

B. Normal saline may be used with a bipolar cautery device such as VersaPoint.

C. Normal saline has a greater risk of volume overload than dextran solution.

D. Normal saline is not often used as a distention medium due to the danger of hypernatremia, and instead half-normal saline is recommended.

ANSWERS

35.1 B. Until the fluid deficit with glycine or sorbitol reaches 1000 mL, the procedure can continue.

35.2 B. Normal saline is a commonly used distention medium, and is less likely to lead to fluid overload or DIC as compared to dextran, although these complications can occur. A bipolar device may be used with normal saline, and because the electrical current flows between the electrodes, it is safe to use with saline.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ The hysteroscope contains the eyepiece, barrel, and lens (Level B).

➤ Accurate and clear visualization of the uterine lesions is the key to decreasing the risk of intraoperative complications (Level B).

➤ Uterine perforation is the most common complication associated with operative hysteroscopy (Level A).

➤ Pharmacologic agents, such as vaginal misoprostol and laminaria, may be used to ripen the cervical os prior to an operative hysteroscopy. This decreases the risk of uterine perforation (Level B).

➤ Each distention medium has its own advantages and disadvantages (Level A).

➤ Accurate balancing of fluid inflow and outflow will decrease the risk of the fluid overload and hyponatremia complication (Level B).

➤ Procedures which have longer operative times have a higher incidence of complications, such as myomectomy, adhesiolysis, and resection of a uterine septum (Level B).

➤ Once an intraoperative complication occurs, the hysteroscopy is immediately terminated (Level B).

➤ Late complications may occur months to years after an operative hysteroscopy (Level B).

REFERENCES

1. Julian TM. Hysteroscopic complications. J Low Genit Tract Dis. 2002;6(1):39-47. 

2. Bradley LD. Complications in hysteroscopy: prevention, treatment, and legal risk. Curr Opin Obstet Gynecol. 2002;14:409-415. 

3. Shveiky D, Rojansky N, Revel A, Benshushan A, Laufer N, Shushan A. Complications of hysteroscopic surgery: “beyond the learning curve.” J Minim Invasive Gynecol. 2007;14:218-222. 

4. ACOG Technical Assessment. Hysteroscopy. August 2005;4:350-353. 

5. Konig M, Meyer A, Aydeniz B, Kurek R, Wallwiener D. Hysteroscopic surgery— complications and their prevention. Contrib Gynecol Obstet. 2000;20:161-170. 

6. Hsieh MH, Chen TL, Lin YH, Chang CC, Lin CS, Lee YW. Acute pulmonary edema from unrecognized high irrigation pressure in hysteroscopy: a report of two cases. J Clin Anesth. 2009;20:614-617. 

7. Propst AM, Lieberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol. October 2000;96(4):517-520. 

8. Cooper JM, Brady RM. Late complications of operative hysteroscopy. Obstet Gynecol Clin North Am. June 2000;27(2):367-374. 

9. Jansen FW, Vredevoogd CB, Ulzen KV, Hermans J, Trimbos B, Trimbos-Kemper TCM. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. August 2000;96(2):266-270.

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