Hysteroscopy in DUB

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PAPER AT FIGO SOUTH AFRICA IN OCT 2009

Published in: Education, Health & Medicine

Hysteroscopy in DUB

  1. 1. HYSTEROSCOPY In DUB<br />Dr. Kawita Bapat<br />ONE DAY HYSTERECTOMY SPECIALIST<br />Bapat Hospital <br />INDORE <br />INDIA<br />
  2. 2. Dr. Kawita Bapat <br />Ms <br />Obgyn <br />Goldmedallist <br />Special interest in pelvic gyn surgery <br />One day hysterectomy <br />Hysteroscopy and colposcopy <br />First in Madhya Pradesh <br />To start menopausal counseling clinic <br />One day hysterectomy(MIVH)<br />Cervical cancer vaccination <br />Vice president of obgyn in Indore <br />Start website for obgyn in Indore <br />Diploma in computers <br />
  3. 3. HYSTEROSCOPY<br /> hysteroscopy has become an important tool in the armamentarium of the gynecologist, especially in the evaluation of DUB<br />
  4. 4. See and treat approach <br />Revolutionized <br />Cost <br />convenience <br />Accuracy <br />Acceptable<br />Current gold standard for endometrial evaluation <br />Alert the physician <br />Diagnostic hysteroscopy <br />
  5. 5. Unexplained DUB<br />(DUB) is one of the most common clinical problems in gynaecology<br />Small endometrial polyp<br /> Small cervical polyp<br /> Adhesion at cornual cones<br />Cornual polyp<br />Endometrial atrophy or hyperplasia<br />
  6. 6. HysteroscopyInstrumentation<br />Lockable cabinet<br />Telescope<br />Sheath system<br /> Hysteroscope<br /> Diagnostic<br /> Operative<br /> Resectoscope<br />Distention systems<br /> Gas insufflator<br /> Fluid delivery system<br />Light source and cable<br />Video cameras and monitors<br />
  7. 7. Hysteroscopes / Sheaths<br />Flexible (3-5 mm)<br />Adv. Minimal risk of trauma, ability to deflect the view manually<br />Disadv.Greater cost, inability to widen view or to magnify the image, inability to use the instrument<br />Rigid (4 mm) 0-30 degrees <br />Microhysteroscope (2.4-2.7 mm)<br />
  8. 8. Light Source<br />The optics of telescope 150 – W light source with flexible fiber optic cables<br /> Halogen or xenon types bulbs for video cameras and monitors<br />
  9. 9. Distention media<br />Normal saline , Ringer’s lactate<br />( Low-viscosity fluid)<br />Best with continuous flow, clear view, costly insufflators and pumps are unnecessary, bipolar procedures<br />Sorbitol, Glycine, Mannitol<br />( Low-viscosity fluid)<br />Monopolar procedures<br />
  10. 10. TIMING<br />It is preferable to perform hysteroscopy in the proliferative phase or immediately following a menstrual period.<br />
  11. 11. Hysteroscopy - Benefits<br />Direct visualization of any pathology<br /> No X-ray exposure<br /> Insertion under visualization decreases chance of perforation<br />
  12. 12. Indication hysteroscopy<br />Unexplained uterine bleeding<br />Suspected intra- uterine pathology(polyps, myomas, adhesions, foreign bodies)<br />
  13. 13. HysteroscopyContraindications<br />Active PID<br /> Active profuse uterine bleeding<br />Recent uterine perforation<br /> Pregnancy<br /> Cx Ca <br /> Cardiovascular or systemic diseases<br />
  14. 14. HysteroscopyComplications<br />Uterine perforation<br /> Hemorrhage<br /> Infection<br /> Hypervolemia<br /> Hyponatremic encephalopathy and cardiac asystole, arrhythmia<br /> Hypercarbia, acidosis, gas embolism<br />
  15. 15. OUTPATIENT HYSTEROSCOPY<br />Because of excellent drainage, the risk for infection with office hysteroscopy is exceedingly low. <br />( 0.1%-2.8%)<br />
  16. 16. OUTPATIENT HYSTEROSCOPY<br />The outpatient hysteroscopy failure rate is less than half (2%) with the mini-hysteroscope compared with the traditional 5 mm hysteroscope (5%).<br />De Angelis C Hum Reprod. 2003;18:2441-5.<br />
  17. 17. OUTPATIENT HYSTEROSCOPY<br />Office flexible minihysteroscopes (2.5 and 3.5 mm) can be successfully used in an office setting for gynecologic indications with high patient acceptance.<br />Ross JW. J Am Assoc GynecolLaparosc. 2000 ;7:221-6.<br />
  18. 18. OUTPATIENT HYSTEROSCOPY<br />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.<br />Perez-Medina T Int J Gynaecol Obstet. 2000 ;71:33-8.<br />
  19. 19. ANALGESIA ANESTHESIA<br />Pain, cramping, vagal reaction 10% <br /> Para cervical block<br />In severe problem;<br /> Atropine 0.1-0.2 mg IM with/without<br /> Ketorolac 30 mg IM<br /> IV sedation (rarely)<br />
  20. 20. TECHNIQUE<br />Analgesia-anesthesia-vaginal region cleaning, <br /> No speculum- no tenaculum <br />(Vaginoscopical approach)<br /> Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3: Supplement-S4.<br />Fluid distention media, continuous flow<br /> Endomat; irrigation pressure=75-100 mm Hg, Flow=200-350 ml/min; suction= (-) 0.25 bar<br /> 2.9 mm scopy (30o)<br /> Operating canal (1.6 mm) <br />(Operative office hysteroscopy)<br />
  21. 21. <ul><li>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.</li></li></ul><li>OUTPATIENT HYSTEROSCOPY<br />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.<br />
  22. 22. Immediate evaluation <br />Direct visualization <br /> endometrium and endocervix<br />Detect focal pathology <br />ADVANTAGES <br />
  23. 23. Need of expensive equipments <br />Skillful <br />Cost <br />But with in comparison it is cost effective <br />Disadvantage<br />
  24. 24. Simple <br />Decrease patient anxiety<br />Adequate instructions<br />Informed consent <br />Clear explaination to patient <br />Knowledgeable assistant <br />Appropriate instruments <br />Technique <br />
  25. 25. No vaginal speculum <br />No tantalum <br />No cervical dilatation<br /> Instrument <br />Semi rigid hysteroscop 4-5 mm <br />Instruments Grasp, cut, biopsy, vaporize or coagulate <br />TECHNIQUE <br />
  26. 26. Bimanual examination <br /> Position <br /> Size <br />Shape <br />Characteristic of cervix <br />Consistency position <br />Transvaginal sonography <br />
  27. 27. Clean vagina <br />No systemic sedatives <br />Gentle advance of scope through cervical canal <br />Uterine distension pressure exerted by two connected by 3 lit bag of saline situated 1 mt above the level of vagina <br />Pressure 70 mm of HG <br />Procedure <br />
  28. 28. <ul><li>Slowly
  29. 29. Systematically
  30. 30. Small micro cavity by liquid
  31. 31. Endo cervical canal
  32. 32. Internal cervical os
  33. 33. Allow panoramic view of uterine cavity
  34. 34. Uterotubal cornu
  35. 35. Tubal Ostia
  36. 36. Explain patient </li></ul>Examination <br />
  37. 37. Simple <br />Expeditious <br />Comfortable <br />Full value for <br />decreasing expense <br />decreasing Inconvenience <br />
  38. 38. Out patient <br />Good optical properties<br />Little time <br />Excellent success rate <br />Less pain <br />Greater patient satisfaction <br />Lower risk of vasovagal<br />Rigid hysrteroscope <br />
  39. 39. Minimize patient discomfort <br />Inconvenience <br />Reduce complication <br />Optimize safety <br />Clinical outcomes <br />
  40. 40. Abnormal uterine bleeding <br />Peri menopausal females <br />Age between 45 to 50 <br />Persistent abnormal bleeding <br />Normal sonography in 90% of cases <br />No history of pregnancy or menopause <br />Regular previous menstrual cycles <br />Irregular menstrual bleeding <br />Inclusion criteria <br />
  41. 41. <ul><li>Direct visualization of uterine cavity
  42. 42. Suspected intrauterine pathology
  43. 43. Opportunity to obtain selected biopsies of abnormal or suspicious area of endometrium
  44. 44. Suction aspiration in every case </li></li></ul><li>Materials and Methods<br />This clinical trial study was carried out in Bapat hospital INDORE INDIA <br /> during March 21, 2007 to March 20, 2008<br />All cases of abnormal uterine bleeding<br />After history and clinical examinations<br />All underwent transvaginalsonography<br />
  45. 45. Targeted biopsy <br /> Suspicious areas of endometrium<br />Enhances evalution of architectural distorson<br />Visual exploration <br />Additional benefit<br />
  46. 46. It is most important to insure prevention of complications and their recognition, and their management, if they occur.<br />Complication may occur due to<br />Instrumental procedure<br />Distension media.<br />Inadequate visualization<br />Anesthetic agent<br />
  47. 47. Data from <br />patients' histories<br />clinical examinations<br />transavaginal sonography<br /> hysteroscopy <br /> pathologic results<br /> gathered and analyzed<br /> For analyzing, statistical description methods such as distribution frequency tables and calculation values for sensitivity, specificity and predictive value were used<br />
  48. 48. Hystroscopy in different age groups<br />
  49. 49. Hysteroscopicand pathologic results<br />
  50. 50. ectocervix<br />endocervical canal <br />internal os<br />
  51. 51. OUTPATIENT HYSTEROSCOPY<br />Hysteroscopy done as out patient procedure in patients of DUB, has low complication rate, high requirement and adds little equipment & cost. <br /> Positive hysteroscopic findings were found in many cases (21.8 %) despite having normal TVS and no suggestive history of uterine lesion.<br />
  52. 52. HYSTEROSCOPY<br />
  53. 53. OUTPATIENT HYSTEROSCOPY<br />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.<br />
  54. 54. Conclusion<br /><ul><li>Out of 78 (100%) with AUB 70 patients (90% )with normal transvaginalsonographcally
  55. 55. 17 patients (21.8%) were abnormal hysteroscopically
  56. 56. Cervical canal polyps may be missed by transvaginal sonography
  57. 57. but diagnosed by hysteroscopy</li></ul>In patients with AUB and normal TVS, hysteroscopy can be used as the second step.<br />
  58. 58. <ul><li>Therefore, hysteroscopy is one of the best methods to detect the polyps for this area.
  59. 59. According to high conformity between the hysteroscopy and pathology, diagnostic ability of hysteroscopy was higher than transvaginal sonography. </li></ul>Conclusion<br />
  60. 60. Conclusion<br /><ul><li>Therefore, it is recommended that patient with abnormal uterine bleeding whose transvaginal</li></ul> sonography is normal, hysteroscopy is considered<br />to be as the second step.<br />
  61. 61. Sufficiently advanced technology is indistinguishable from magic<br />Thank you<br />One Day hysterectomy<br />

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