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Hysteroscopy in DUB

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PAPER AT FIGO SOUTH AFRICA IN OCT 2009

PAPER AT FIGO SOUTH AFRICA IN OCT 2009

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Hysteroscopy in DUB Hysteroscopy in DUB Presentation Transcript

  • HYSTEROSCOPY In DUB
    Dr. Kawita Bapat
    ONE DAY HYSTERECTOMY SPECIALIST
    Bapat Hospital
    INDORE
    INDIA
  • Dr. Kawita Bapat
    Ms
    Obgyn
    Goldmedallist
    Special interest in pelvic gyn surgery
    One day hysterectomy
    Hysteroscopy and colposcopy
    First in Madhya Pradesh
    To start menopausal counseling clinic
    One day hysterectomy(MIVH)
    Cervical cancer vaccination
    Vice president of obgyn in Indore
    Start website for obgyn in Indore
    Diploma in computers
  • HYSTEROSCOPY
    hysteroscopy has become an important tool in the armamentarium of the gynecologist, especially in the evaluation of DUB
  • See and treat approach
    Revolutionized
    Cost
    convenience
    Accuracy
    Acceptable
    Current gold standard for endometrial evaluation
    Alert the physician
    Diagnostic hysteroscopy
  • Unexplained DUB
    (DUB) is one of the most common clinical problems in gynaecology
    Small endometrial polyp
    Small cervical polyp
    Adhesion at cornual cones
    Cornual polyp
    Endometrial atrophy or hyperplasia
  • HysteroscopyInstrumentation
    Lockable cabinet
    Telescope
    Sheath system
    Hysteroscope
    Diagnostic
    Operative
    Resectoscope
    Distention systems
    Gas insufflator
    Fluid delivery system
    Light source and cable
    Video cameras and monitors
  • Hysteroscopes / Sheaths
    Flexible (3-5 mm)
    Adv. Minimal risk of trauma, ability to deflect the view manually
    Disadv.Greater cost, inability to widen view or to magnify the image, inability to use the instrument
    Rigid (4 mm) 0-30 degrees
    Microhysteroscope (2.4-2.7 mm)
  • Light Source
    The optics of telescope 150 – W light source with flexible fiber optic cables
    Halogen or xenon types bulbs for video cameras and monitors
  • Distention media
    Normal saline , Ringer’s lactate
    ( Low-viscosity fluid)
    Best with continuous flow, clear view, costly insufflators and pumps are unnecessary, bipolar procedures
    Sorbitol, Glycine, Mannitol
    ( Low-viscosity fluid)
    Monopolar procedures
  • TIMING
    It is preferable to perform hysteroscopy in the proliferative phase or immediately following a menstrual period.
  • Hysteroscopy - Benefits
    Direct visualization of any pathology
    No X-ray exposure
    Insertion under visualization decreases chance of perforation
  • Indication hysteroscopy
    Unexplained uterine bleeding
    Suspected intra- uterine pathology(polyps, myomas, adhesions, foreign bodies)
  • HysteroscopyContraindications
    Active PID
    Active profuse uterine bleeding
    Recent uterine perforation
    Pregnancy
    Cx Ca
    Cardiovascular or systemic diseases
  • HysteroscopyComplications
    Uterine perforation
    Hemorrhage
    Infection
    Hypervolemia
    Hyponatremic encephalopathy and cardiac asystole, arrhythmia
    Hypercarbia, acidosis, gas embolism
  • OUTPATIENT HYSTEROSCOPY
    Because of excellent drainage, the risk for infection with office hysteroscopy is exceedingly low.
    ( 0.1%-2.8%)
  • OUTPATIENT HYSTEROSCOPY
    The outpatient hysteroscopy failure rate is less than half (2%) with the mini-hysteroscope compared with the traditional 5 mm hysteroscope (5%).
    De Angelis C Hum Reprod. 2003;18:2441-5.
  • OUTPATIENT HYSTEROSCOPY
    Office flexible minihysteroscopes (2.5 and 3.5 mm) can be successfully used in an office setting for gynecologic indications with high patient acceptance.
    Ross JW. J Am Assoc GynecolLaparosc. 2000 ;7:221-6.
  • OUTPATIENT HYSTEROSCOPY
    Saline diagnostic hysteroscopy offers at least all the advantages of the CO2 hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed.
    Perez-Medina T Int J Gynaecol Obstet. 2000 ;71:33-8.
  • ANALGESIA ANESTHESIA
    Pain, cramping, vagal reaction 10%
    Para cervical block
    In severe problem;
    Atropine 0.1-0.2 mg IM with/without
    Ketorolac 30 mg IM
    IV sedation (rarely)
  • TECHNIQUE
    Analgesia-anesthesia-vaginal region cleaning,
    No speculum- no tenaculum
    (Vaginoscopical approach)
    Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3: Supplement-S4.
    Fluid distention media, continuous flow
    Endomat; irrigation pressure=75-100 mm Hg, Flow=200-350 ml/min; suction= (-) 0.25 bar
    2.9 mm scopy (30o)
    Operating canal (1.6 mm)
    (Operative office hysteroscopy)
    • Abstract Study objective We perform hysteroscopy in 78 women for the diagnosis and treatment of pathologic changes in the uterine cavity of women with dysfunctional uterine bleeding age above 45 . All hysteroscopies were successfully carried out and the therapeutic results were excellent. Design Retrospective study. Setting BAPAT hospital INDORE MP. INDIA , department of obstetrics and gynaecologyPatient 78 married women who underwent hysteroscopy on the condition of age more than 45 for DUB . Interventions Hysteroscopy was used for the diagnosis and treatment of pathological changes in the uterine cavity of women Measurements and main results All 78 hysteroscopies were successfully carried out , and the therapeutic results were excellent.
  • OUTPATIENT HYSTEROSCOPY
    It is no more acceptable for a gynecologist to insert a sharp curette into a uterine cavity blindly to discover and remove suspected pathology than it is for an orthopedist to insert a curette into a knee joint blindly.
  • Immediate evaluation
    Direct visualization
    endometrium and endocervix
    Detect focal pathology
    ADVANTAGES
  • Need of expensive equipments
    Skillful
    Cost
    But with in comparison it is cost effective
    Disadvantage
  • Simple
    Decrease patient anxiety
    Adequate instructions
    Informed consent
    Clear explaination to patient
    Knowledgeable assistant
    Appropriate instruments
    Technique
  • No vaginal speculum
    No tantalum
    No cervical dilatation
    Instrument
    Semi rigid hysteroscop 4-5 mm
    Instruments Grasp, cut, biopsy, vaporize or coagulate
    TECHNIQUE
  • Bimanual examination
    Position
    Size
    Shape
    Characteristic of cervix
    Consistency position
    Transvaginal sonography
  • Clean vagina
    No systemic sedatives
    Gentle advance of scope through cervical canal
    Uterine distension pressure exerted by two connected by 3 lit bag of saline situated 1 mt above the level of vagina
    Pressure 70 mm of HG
    Procedure
    • Slowly
    • Systematically
    • Small micro cavity by liquid
    • Endo cervical canal
    • Internal cervical os
    • Allow panoramic view of uterine cavity
    • Uterotubal cornu
    • Tubal Ostia
    • Explain patient
    Examination
  • Simple
    Expeditious
    Comfortable
    Full value for
    decreasing expense
    decreasing Inconvenience
  • Out patient
    Good optical properties
    Little time
    Excellent success rate
    Less pain
    Greater patient satisfaction
    Lower risk of vasovagal
    Rigid hysrteroscope
  • Minimize patient discomfort
    Inconvenience
    Reduce complication
    Optimize safety
    Clinical outcomes
  • Abnormal uterine bleeding
    Peri menopausal females
    Age between 45 to 50
    Persistent abnormal bleeding
    Normal sonography in 90% of cases
    No history of pregnancy or menopause
    Regular previous menstrual cycles
    Irregular menstrual bleeding
    Inclusion criteria
    • Direct visualization of uterine cavity
    • Suspected intrauterine pathology
    • Opportunity to obtain selected biopsies of abnormal or suspicious area of endometrium
    • Suction aspiration in every case
  • Materials and Methods
    This clinical trial study was carried out in Bapat hospital INDORE INDIA
    during March 21, 2007 to March 20, 2008
    All cases of abnormal uterine bleeding
    After history and clinical examinations
    All underwent transvaginalsonography
  • Targeted biopsy
    Suspicious areas of endometrium
    Enhances evalution of architectural distorson
    Visual exploration
    Additional benefit
  • It is most important to insure prevention of complications and their recognition, and their management, if they occur.
    Complication may occur due to
    Instrumental procedure
    Distension media.
    Inadequate visualization
    Anesthetic agent
  • Data from
    patients' histories
    clinical examinations
    transavaginal sonography
    hysteroscopy
    pathologic results
    gathered and analyzed
    For analyzing, statistical description methods such as distribution frequency tables and calculation values for sensitivity, specificity and predictive value were used
  • Hystroscopy in different age groups
  • Hysteroscopicand pathologic results
  • ectocervix
    endocervical canal 
    internal os
  • OUTPATIENT HYSTEROSCOPY
    Hysteroscopy done as out patient procedure in patients of DUB, has low complication rate, high requirement and adds little equipment & cost.
    Positive hysteroscopic findings were found in many cases (21.8 %) despite having normal TVS and no suggestive history of uterine lesion.
  • HYSTEROSCOPY
  • OUTPATIENT HYSTEROSCOPY
    It is no more acceptable for a gynecologist to insert a sharp curette into a uterine cavity blindly to discover and remove suspected pathology than it is for an orthopedist to insert a curette into a knee joint blindly.
  • Conclusion
    • Out of 78 (100%) with AUB 70 patients (90% )with normal transvaginalsonographcally
    • 17 patients (21.8%) were abnormal hysteroscopically
    • Cervical canal polyps may be missed by transvaginal sonography
    • but diagnosed by hysteroscopy
    In patients with AUB and normal TVS, hysteroscopy can be used as the second step.
    • Therefore, hysteroscopy is one of the best methods to detect the polyps for this area.
    • According to high conformity between the hysteroscopy and pathology, diagnostic ability of hysteroscopy was higher than transvaginal sonography.
    Conclusion
  • Conclusion
    • Therefore, it is recommended that patient with abnormal uterine bleeding whose transvaginal
    sonography is normal, hysteroscopy is considered
    to be as the second step.
  • Sufficiently advanced technology is indistinguishable from magic
    Thank you
    One Day hysterectomy