summary of distension media used in hysteroscopy for all practising gynecologists and those in training.

1. HYSTEROSCOPY
MEDIA

2. OBJECTIVES
Classification of media
Properties and use of the media
Media supply
Guidelines of using various media
Complications and management

3. INTRODUCTION
 Distension media mandatory to allow visualization in the
potential uterine cavity
 Excessive absorption likely with prolonged procedure or
where vessels within the myometrium opened e.gTCRE
and TCRF
 Operative procedures more risky
 Surgery could use cold scissors and graspers, mechanical
energy or electrosurgery.
 Normal plasma osmolality 280 mOsm/L

4. CLASSIFICATION
 Gas – carbon dioxide
 Liquid – high viscosity – dextran 32%, Hyskon
- low viscosity – iso-osmolar (electrolyte) – Normal saline 0.9% (285mOsm),
- Ringers lactate (279 mOsm)
- mannitol 5%, (274 mOsm) – non-electrolyte
- hypo-osmolar ( non electrolyte) – Glycine1.5%, (200 mOsm)
- sorbitol 3%, (165mOsm)
- dextrose 5%

5. IDEAL MEDIUM
Good view – even in blood staining
Readily available
Isotonic
Non-toxic
Hypoallergenic
Non-hemolytic
inexpensive
Allows operative work

6. CARBON
DIOXIDE
 Good for only diagnostic procedures, not for operative
work
 Poor vision in presence of blood
 Usual insufflator setting 110-120mmHg,flow rate 30-60ml/
min to maintain intracavitary pressure of 40-80 mmHG

7. GLYCINE 1.5%
HYPO-OSMOLAR,
HYPOTONIC
ELECTROLYTE FREE 200 MOSM/L

8. SORBITOL 3%
Hypotonic, electrolyte free, sugar
solution
165 mOsm/L
Added hyperglycemia and hypocalcemia

9. DEXTRAN 32%
High viscosity
Max infused volume
500 ml and 300 ml
in elderly and those
with compromise

10. FLUID SUPPLY
• 3-5 l bag at 90-100cm above the pelvis height
• Gives pressure approx. 70mmHg
Gravity flow
• Set to 80-120 mmHg
• Not advisable – keep the flow and pressure at
the inflow port constant and thus if the
pressure exceeds MAP - absorption
Fluid bag with compression cuff

11. FLUID SUPPLY
 Microprocessor controlled irrigation/ suction pumps
 Maintains constant IUP and adjusts flow according to
this
 Set the irrigation pressure to 50-80 mmHg – below or
at MAP
 Rate 200-400 ml/min
 Gives 30-40 mmHg IUP
 Suction 0.25 bar

12. VALVES
Cervical external os
Cervical internal os
Ostium – 75mmHg
Fimbrial end

13. SYSTEMIC FLUID
ABSORPTION
• Retrograde through tubes
• Through endometrium
• Opened vessels and sinuses during resection
How??
• High IUP - >75mmHg,fluid through the ostia
• Low MAP
• Depth of myometrial and endometrial penetration –
myomectomy,endometrial resection,metroplasty
• Duration of surgery
• Size of uterine cavity – larger surface area
When?

14. FLUID
OVERLOAD
 Fluid deficit of >1000ml when using hypotonic solution in
healthy reproductive age [C]
 >2500ml when using isotonic solution [GPP]
 750ml and 1500ml in elderly or women with comorbid
issues like CVs and renal issues.
 Incidence: <5% in operative cases,
 Depends on case mix and type of hysteroscopic
surgery done

15. SEVERITY &
NATURE OF
COMPLICATIONS
 Osmolality of fluids
 Hypotonic – neurologic (hyponatremia,cerebral edema,
neurologic impairment and seizures) and cardiovascular
( hypervolemia, pulmonary edema, heart failure)
 Isotonic - cardiovascular effects only
 Menopausal status – premenopausal higher risk of
neurologic complications due to suppressive effect of
estrogen on ATPase pump
 Cardiovascular and renal status

16. NEUROLOGIC
SYMPTOMS
Develop when sodium falls below 125mmol/L (
normal value 135-145 )
Headache, nausea, vomiting and weakness
Further drop – brain edema and increased ICP –
agitation, confusion, visual, blindness, headache
<120 - confusion, lethargy, seizures, coma,
arrythmias, bradycardia, resp. arrest

17. CARDIOVASCULAR
OVERLOAD
Pulmonary edema – low
SpO2, basal creps,
CCF – tissue edema and
poor tissue oxygenation,
pedal edema,

18. MANAGEMENT -
MULTIDISCIPLINARY
 Urinary cathether
 Fluid restriction
 Vitals, SpO2,
 UEC, calcium, Haemogram
 Loop diuretic – frusemide
 If hypervolemia – CXR, Echo
 i.v slow 3% hypertonic saline until sodium >125
 If sorbitol – insulin sliding scale, hypocalcemia – with 3g cal
gluconate over 10 min

19. MEDIUM
CHOICE
 Isotonic media safer than hypotonic as there is no
hyponatremia [A]
 Fluid deficit should still be closely monitored in either case
[GPP]
 For diagnostic cases – saline or Carbon dioxide can be
used
 For monopolar resectoscopes – use only hypotonic non-
electrolyte solutions
 Monopolar energy in Saline ?......... No effect
 Bipolar resectoscope – saline

20. SAFETY TIPS –
REDUCE FLUID
ABSORPTION
 Pre-op GnRH-a in premenopausal women before TCRF
[B]
 Intra-cervical injection of dilute vasopressin (8ml of
0.05U/ml) before dilatation of cervix
 Maintain IUP as low as possible to maintain adequate
visualization and keep below MAP [B]
 70-100 mmHg
 Pressure within venous sinuses in the myometrium
around 10-15mmHg
 Pressure and flow controlled pump system with correct
settings

21. MONITORING
FLUID DEFICIT
Closed systems more accurate for measuring the fluid output [GPP]
Use drapes that have a reservoir
Automated fluid management systems more accurate than manual.
Fluid volume infused – ( fluid from
outflow channel + leak through cervix +
into abdominal cavity )
Leak = on drape + on floor + in bucket
Done by one dedicated member of the team
Done at a minimum of 10 min intervals [GPP] and at end of every fluid bag.