This document provides information on performing hysteroscopies, including indications, contraindications, equipment, procedures, and complications. It discusses the parts of the hysteroscope, distention media options and their properties, inflow and outflow management, pre- and post-operative care, the procedure steps, and ways to prevent and manage potential complications such as perforation, fluid overload, and gas embolism. Hysteroscopy is described as a generally safe procedure but certain complications are potentially life-threatening, with an overall low complication rate of around 0.22%.

1. DR ARSLA MEMON
KING FAHAD MEDICAL CITY

2.  INTRODUCTION
 INDICATION AND CONTRAINDICATION
 PARTS OF HYSTEROSCOPE
 DISTENTION MEDIA N TYPES
 INFLOW AND OUTFLOW
 PRE AND POST OP CARE
 PROCEDURE
 COMPLICATION (PREVENTION AND
MANAGEMENT)

3.  A hysteroscopy is a telescope that is inserted
into the uterus via the vagina and cervix to
visualize the endometrial cavity, as well as
the tubal ostia, endocervical canal, cervix,
and vagina

4.  Abnormal premenopausal or postmenopausal
uterine bleeding
 Endometrial thickening or polyps
 Submucosal, and some intramural, fibroids
 Intrauterine adhesions
 Müllerian anomalies (eg, uterine septum)
 Retained intrauterine contraceptives or other
foreign bodies
 Retained products of conception
 Desire for sterilization
 Endocervical lesions

5.  Viable intrauterine pregnancy
 Active pelvic infection (including genital
herpes infection .
 cervical or uterine cancer
 Hysteroscopy cannot assess myometrial
disease, tubal pathology, or the external
uterine contour.
 Additional procedures (eg, laparoscopy or
hysterosalpingography) are necessary.

6.  Excessive uterine bleeding may limit
visualization during hysteroscopy, but it is
not a contraindication
 Medical comorbidities (eg, coronary heart
disease, bleeding diathesis) are also potential
contraindications .
 However, since this is a minimally invasive
procedure, it is rarely contraindicated in few
women

7.  The rigid hysteroscope includes an outer
sheath which surrounds channels for the
telescope, inflow and outflow, and operative
instruments.

8.  Sheath ODs range from 3.1 to 10 mm.
Smaller OD hysteroscope cause less pain and
decrease the need for mechanical dilation.
 Even reducing the sheath size from 5 to 3.3
mm can improve patient comfort.
 The working length of a hysteroscope
measures from the eyepiece to the distal tip,
and range from 160 to 302 mm.
 A longer working element permits the
hysteroscopist to be further away from the pt.

9.  Most hysteroscopes are rigid, but narrow
caliber scopes (<5 mm) may also be semi-
rigid or flexible,cause more intraoperative
pain, but offer better optical quality and are
less costly.
 Flexible hysteroscopy is especially useful for
in women with an irregularly shaped uterus,
as the distal tip can be deflected upward or
downward (eg, for tubal cannulation or lysis
of adhesions near the tubal ostia

10.  A uterine distending medium is used to allow
a global view of the endometrial cavity.
 Carbon dioxide and low viscosity fluids are
the most frequently used distending media.
 Each medium has advantages and
disadvantages, including specific safety
concerns.

11. Allows clear visualization
 Nonconductive (to avoid electrocautery-
related injury)
 Inexpensive
 Nontoxic
 Hypoallergenic
 Non-hemolytic
 Isoosmolar
 Rapidly cleared from the body

12.  Liquid
 electrolyes- NS +RL
 nonelectrolyte -manittol , sorbitol ,
glycine
 hyskon
 Gases - co2

13.  The choice of fluid type depends upon
procedure and equipment (ie, monopolar or
bipolar energy source).

14. The electrolyte-containing media include
normal saline and lactated Ringer's solution and
cannot be used with monopolar electrocautery
because they conduct electric current (but can
be used with mechanical, laser, or bipolar
energy).
 The electrolyte-poor solutions are 5 percent
dextrose, 1.5 percent glycine, 3 percent
sorbitol and 5 percent mannitol, and are used
with monopolar energy systems.

15.  The electrolyte-poor fluids that are used
most commonly for hysteroscopy are: 1.5
percent glycine, 3 percent sorbitol, 5 percent
mannitol.
 All the electrolyte-poor fluids used in
hysteroscopy can lead to hyponatremia if a
large volume is absorbed.
 Mannitol differs from the others because it is
isoosmolar, but is not commonly used
because it is not available in the 3 L bags
typically used for hysteroscopy

16.  Inflow and monitoring are controlled by the
hysteroscope and the fluid inflow system.
 Automated systems have advantages over
manual set-ups Continually measure fluid
deficit and provide automated alerts
 Measure and titrate intrauterine fluid
pressure.
 automated pump systems should be set to
give audible alerts at each 250 mL of fluid
deficit

17.  Lowest pressure should be use that allows
optimal visualization.
 typically, intrauterine pressure ranges from
70 to 80 mmHg.
 Higher pressures (up to 100 mmHg) may be
required with intrauterine bleeding, blood
clots, or debris; a uterine wall that is less
compliant; or a uterus that is large and/or
has intramural fibroids.

18.  A higher intrauterine pressure may result in
increased absorption or extravasation of the
distending medium.
 if a higher pressure is used, the fluid deficit
should be monitored closely, the procedure
should be performed as quickly as possible,
and the pressure should be lowered if the
higher pressure is no longer needed.

19.  To avoid hypothermia during longer
procedures fluid distending media should be
warmed to room temperature at a minimum.
 hypothermia may potentiate the risk of
acidemia and cardiac arrhythmias .

20.  Carbon dioxide is the only gaseous medium
used in hysteroscopy.
 It provides a clear field of view, is rapidly
absorbed, and has a long history of safety in
tubal patency testing .
 it is also widely available and makes cleaning
of instruments easy.
 best suited for diagnostic rather than
operative hysteroscopy, since gas bubbles
form in association with intrauterine bleeding
and impair visualization .

21.  Women should be counseled about
alternative diagnostic or treatment
approaches,success and possible
complications.
 Patients should be informed of possible need
to abandon or to stop a procedure due to
fluid overload.
 patients should consent to a possible
laparoscopy or laparotomy if it becomes
necessary to rule out visceral or vascular
injury.

22. full medical history is taken
A complete pelvic and general physical
examination, with particular attention to the
size and mobility of the uterus and the patency
of the cervix.
Pregnancy testing is performed;
cervical cultures are appropriate if cervicitis is
suspected

23.  proliferative phase is best.
 secretory phase- the thick endometrium can
mimic endometrial polyps and lead to
inaccurate diagnoses.
 Menstruation- blood may interfere with
visualization.
 irregular bleeding- the ideal time for the
procedure is unpredictable.
 For postmenopausal women, hysteroscopy
may be performed at any time.

24.  hysteroscopes (≤5 mm) typically do not
require cervical dilation.
 If possible, mechanical cervical dilation
should be avoided since it can be painful.
 prostaglandin (eg, misoprostol) may be
sufficient.
 The vaginal route may be more effective than
oral.
 optimal dose has not been established, but
usually 200 to 400 mcg.

25.  Antibiotics are not routinely administered
during hysteroscopy for prevention of
surgical site infection or endocarditis since
posthysteroscopy infection occurs in less
than 1 percent of women.

26.  Anesthesia may be needed to improve patient
comfort during hysteroscopy.
 Parts of the procedure that are potentially
painful include placement of a tenaculum on
the cervix, dilation of the cervix, insertion of
the hysteroscope, uterine distension, and
uterine biopsy.
 Pre-procedure nonsteroidal antiinflammatory
drugs reduce postoperative, but not
intraoperative, pain,

27.  Foley urethral catheter is not necessary
unless intensive monitoring of urine output is
necessary (eg, prolonged procedure,
excessive fluid absorption, or need to
diuresis patient).

28.  dorsal lithotomy position,
 placement of speculum, use of tenaculum or
mechanical dilation as needed.
 The cervix should not be dilated beyond the
size of the hysteroscope,
 Insert the hysteroscope through the cervical
os under direct endoscopic vision and remove
the speculum.

29.  The vaginoscopic, or "no touch," technique is
performed without a speculum or tenaculum
and without anesthesia
 Women with cervical stenosis are not
candidates for this approach.
 significant decrease in operative pain

30.  Once the hysteroscope is within the
endometrial cavity, the uterine cavity is
distended,inspected, including the tubal ostia
and any pathology.

31.  1 to 3 percent of benign or malignant
endometrial lesions are missed on
hysteroscopy
 To avoid missing uterine pathology,
endometrial sampling (hysteroscopic biopsies
or blind sampling) should be performed in
patients with global endometrial pathology or
with persistent bleeding and no hysteroscopic
findings.

32.  There are several reasons for failure.
 in the office setting,
 pain,
 cervical stenosis,
 and poor visualization
 excessive fluid absorption or uterine
perforation

33.  the overall rate of failure was 3.6 percent,
and was similar in ambulatory and
hospitalized patients and pre- and
postmenopausal women .

34.  When dilation of the cervix is difficult, a
flexible hysteroscope may be passed more
easily.
 If a small dilator cannot be easily inserted,
hysteroscopy can be performed under
ultrasound guidance to confirm correct
passage of the dilator into the endometrial
cavity and make sure a false passage is not
created.

35.  Extreme uterine retroversion or anteversion may
be congenital or may be due to pelvic adhesions
limit the ability to introduce the hysteroscope.
 Traction with a tenaculum on the anterior lip of
the cervix.
 use of a flexible hysteroscope may be helpful.
 malposition may increase the risk of uterine
perforation.
 When the uterus is severely angulated, the tubal
ostia must be visualized to confirm that the
entire uterine cavity has been evaluated

36.  Once the cervix has been dilated, it is
unusual to have difficulty instilling a
distention medium.
 If this difficulty is encountered, it is likely that
there is an obstruction in the uterine cavity
(eg, synechiae, malignancy).

37.  Bleeding can impair visualization either
directly or, if carbon dioxide is used for
distension, bleeding may cause gas bubbles
to form.
 The gas bubbles can be cleared by switching
to a fluid medium.

38.  postoperative cramping or light bleeding
0rvaginal discomfort.
 Carbon dioxide distension can cause referred
shoulder pain, but this typically resolves
within 15 minutes.
 Acetaminophen or nonsteroidal
antiinflammatory drugs are usually adequate
for postoperative pain.
 The patient may resume most normal
activities within 24 hours .
 a follow-up visit 2_3weeks.

39.  generally safe procedure , complication
are rare, but some are potentially life
threatening,overall complication rate of 0.22
percent .(adhesiolysis)
 1 perforation of the uterus (0.12 percent),
2 fluid overload (0.06 percent),
 3 intraoperative hemorrhage (0.03 percent),
 4 bladder or bowel injury (0.02 percent), and
5 endomyometritis (0.01 percent

40. The operative procedure with the highest
frequency of complications was intrauterine
adhesiolysis

41. .Chance is less during diagnostic hysteroscopy
(eg, 0.1 versus 1.0 percent with operative
hysteroscopy].
 occur during mechanical cervical dilation or
insertion of the hysteroscope.
 instrument passes beyond depth of the
uterine fundus,
 there is sudden loss of visualization, when
omentum or bowel or peritone.
 sudden increase in the fluid deficit.

42. Bowel or bladder injury are rare, but may occur
in association with uterine perforation or as a
result of use of electrical current..
 Cervical lacerations can occur, particularly in
women with cervical stenosis.
 Lacerations that are large or are bleeding
require sutures

43.  rare, occurring in 0.06 to 0.2 percent of
operative hysteroscopy procedures].
 vary according to the patient and the medium
use as patient's ability to adapt to fluid
overload varies with age and comorbid
conditions.

44.  Absorption of large volumes of electrolyte-
poor fluid may result in acute decompensated
heart failure, pulmonary edema, dilutional
anemia
 hyponatremia, hypoosmolality,
hyperammonemia, hyperglycemia, acidosis
 Neurologic sequelae – slurred speech, visual
disturbances, hypersomnia, confusion,
seizures, coma

45.  During hysteroscopy, absorption is increased
when venous sinuses are exposed (eg, during
myomectomy).
 minimal fluid extravasates through the
Fallopian tubes; history of prior sterilization
does not alter total absorption].
 Hyponatremia is a particular risk with
electrolyte-poor fluids

46.  Use isoosmolar, electrolyte fluids whenever
possible
 Monitor fluid deficit closely and halt the
procedure and evaluate for fluid-related
complications at absorption thresholds
 Maintain intrauterine fluid pressure at or 70
to 80 mmHg.
 Limit surgical time to <1 hour

47.  — Serious complications of electrolyte-poor
fluid overload have been reported at a fluid
deficit of 500 to 1000 mL and are more likely
to occur in patients with comorbidities (eg,
heart disease).

48.  For nonconductive, electrolyte-poor fluids,
the procedure should be terminated when
1000 mL has been absorbed and the patient
evaluated for hyponatremia.

49.  Embolism (air or carbon dioxide) can occur
with any hysteroscopic technique and can
cause cardiovascular collapse.

50.  Keep the patient in flat or reverse Trendelenburg
position
 Avoid use of nitrous oxide for anesthesia (this
may enlarge air bubbles)
 Purge air from all tubing prior to insertion into
the uterus
 Maintain intrauterine pressure at <100 mmHg
 Limit removal and re-introduction of the
hysteroscope (this may force air or gas into the
uterus)
 Remove intrauterine gas bubbles (ideally with a
continuous outflow system)
 Limiting the distension fluid deficit.

51.  Dyspnea is the most common symptom;
 . A fall in a patient's end-tidal carbon dioxide
pressure,
 If gas embolism is suspected, the procedure
should be terminated immediately.
 Supportive care (eg, the use of mechanical
ventilation, vasopressors, volume
resuscitation as indicated) is the cornerstone
of management,

52.  Potential sources of intraoperative bleeding
include operative sites, uterine perforation, and
cervical laceration.
 Bleeding from cervical lacerations that is
recognized at surgery can be controlled using
electrocautery or sutures.
 Bleeding from a specific site within the uterine
cavity, with no suspicion of uterine perforation,
can be controlled with electrosurgery is most
cases.
 Women with diffuse bleeding should be evaluated
for coagulopathy.

53.  If coagulation testing is normal and diffuse
bleeding continues, it can be treated by
placing a Foley catheter in the uterine cavity
and then distending the bulb with 15 to 30
mL of water

54.  infection after operative hysteroscopy is low.
postoperative incidences of 0.1 to 0.9 % for
endometritis
 0.6 percent for urinary tract infections

55. Thankyou