This document discusses complications that can occur during and after hysteroscopy procedures. It begins by stating that the overall complication rate is around 2% according to studies. It then discusses specific direct complications like cervical injury, uterine perforation, hemorrhage, infection, and thermal damage. Indirect complications include reactions to anesthesia or distention media. The document provides details on managing three main complications - uterine perforation, hemorrhage, and injury to other organs like the bowel or bladder. It emphasizes the importance of proper training, experience, instruments and use of distention media like CO2 to reduce complications.

1. Dealing with Complication of
Hysteroscopy
Dato DR ARUKU NAIDU
MD(UKM), FRCOG(LONDON), CU(JCU), AM
CONSULTANT O& G, UROGYNAECOLOGIST
Hosp Raja Permaisuri Bainun,
Sessional consultant Ipoh Specialist Hosp,
Honorary lecturer HUKM, Perak Med College
aruku-naidu.blogspot.com

2. Complication of Hysteroscopy
• Complication rate 2% ( Assoc. Gynaecologic
Laparoscopists, AAGL, 1993)
• Prospective randomize trial by Jansen et. Al,
13,600 procedures, Netherland
Diagnostic hysteroscopy: 0.13%
Operative hysteroscopy: 0.95%

3. Complication of hysteroscopy
(directly related )
• Cervical injury
• Uterine perforation
• Haemorrhage
• Infection
• Injury to bladder, bowel and blood vessels
• Thermal damage by electrical current

4. • Medical complications resulting from reactions
to drugs or anesthetic agents
- anaphylaxis
• Complications due to distending media
– CO2 : Acidosis, Arrhythmia, Embolism
– Dextran : Anaphylaxis, Pulmonary oedema
– NS: Pulmonary oedema, hyponatraemia
– Dextose : Pulmonary oedema, hypoglycaemia
Complication of hysteroscopy
( Indirect)

5. • Accidental perforation of the uterus is the
most common complication
• generally diagnosed by direct visualization
 suspected in cases of unexplained rapid increase
in the fluid deficit, uncontrolled hemorrhage, and
hemodynamic instability
1. UTERINE PERFORATION

6. UTERINE PERFORATION
• Can occur during:
– Cervical dilatation
– Surgery
– Retrieval of tissue
• Action:
– Observation
– Laparoscopy
– Laparotomy

7. Hemostatic uterus perforation
 By uterine sound, cervical dilator, hysteroscope, or blunt
instrument
 may be managed conservatively: scan to exclude
haemorrhage, antibiotics, iv oxytocin
Consider Laparoscopy/ Laparotomy if:
 Perforations through the posterior or lateral uterus
 sharp or electrocautery instruments
- In view of potential for injury to the pelvic viscera or vasculature
UTERINE PERFORATION

8. 2. Haemorrhage
May be encountered during or after hysteroscopy.
Exclude uterine perforation 1st
Mild bleeding is typically self-limited and generally
does not require intervention
Electrocautery may be used to coagulate small vessels
If conservative approached failed:
 Foley catheter or intrauterine balloon can be inserted into the
cavity and inflated to tamponade the hemorrhage
 Packing of uterus with roller gauze +/- vasopressin
 IV oxytocin, inj vasopressin paracervical
 Rarely embolisation, ligation or hysterctomy

9. 3. Injury to viscus/organs
 Bowel
 Bladder
 Omentum
 Lateral uterine wall ( Haematoma)
Can be detected immediately or post-op
Direct visualization with hysteroscopy
Presence of abd pain, fever, leucocytosis, pertonitis
after surgery= injury till proven other vice

10. Injury to viscus/organs
Bowel
The emanation of foul smelling gas through
pneumoperitoneal needle is a helpful diagnostic
sign
Minilaparotomy and repair of perforation
Laparoscopically, perforation may be sutured using
laparoscopic stapler
Colostomy

11. Injury to viscus/organs
Bladder
Diagnosis: appearance of blood and gas on
Foley’s catheter bag
Check cystoscopy….
Place an indwelling catheter for 7-10 days
Prophylaxis antibiotic
If defect is larger, repaired by a figure of 8 suture
through muscularis of bladder and second suture
to close peritoneum

12. Complication due to
Distending Media
1.Fluid Overload
2.Gases embolism ( Co2, Air)

13. Fluid overload may be
due to:
• Intravasation
• Transtubal loss
• Uterine perforation
1
2
3
1. Fluid Overload
Fluid overload may cause pulmonary edema
 Mostly occur in cases with excessive intravasation of
isotonic fluids

14. Mechanism of fluid overload
Uterine cavity- a potential space
Minimum pressure
• 30 mmHg to separate uterine walls
• 45-80 mmHg to expand uterine
cavity, rarely >100 mmHg
MAP ~ 100 mmHg

15. Fluid Overload ( 0.2%)
Electrolyte free distension media can cause rapid and
profound hyponatremia if absorbed in large quantities.
• Abrupt changes in the serum sodium level may cause
– altered mental status
– Seizures
– Coma
– Death
Action:
 If Na< 125, correct with Intravenous 3% sodium chloride
 furosemide should be used to achieve the appropriate
amount of diuresis.

16. FLUID MONITORING DURING
HYSTEROSCOPY
Inflow/outflow charts
Adjust intrauterine pressure
Measurement of serum Na+
Measurement of plasma osmolality
CVP measurement
Patient weight

17. 2. CO2 Embolism
Symptoms of embolism
• A sudden decrease in PCO2, especially when
accompanied by a decrease in blood pressure
• A decrease in oxygen saturation
• Arrhythmias, tachycardia, Cardiovascular collapse
• Sustained hypotension not explained by
hypovolemia alone
• Electrocardiography changes

18. Electrocardiographic changes
 Bradycardia or tachycardia,
 Premature ventricular contractions
 Heart block
 ST-segment depression
ECG Monitoring

19. If suspected gas embolism (CO2):
• Rapid identification, stop procedure
• Prevention of further gas entrainment by
closing the point of air entry.
• give 100% oxygen
• Put the patient in a reverse
trendelenburg position
• The Durant maneuver- With this
maneuver the patient is placed on
the left side while using Trendelenburg
position

20. The complication are extremely rare if the correct
insufflator is used.
The hysteroflator delivers CO2 at a rate of not more
than 100ml per minute whereas the laparoflator
can deliver 1-6 litres in the same time
A laparoflater should NEVER be used for
hysteroscopy.
Prevention of gas embolism

21. Monitoring During Operating
Hysteroscopy
Standard monitoring
• pulse oximetry,
• 3-lead electrocardiography,
• blood pressure measurements
• PCO2 monitoring
• standard ventilatory monitoring.
• Strict inflow / out flow chart

22. Post operative complications
 Secondary haemorrhage, rare, haemataoma
 Infection ( 1-2%)= fever & pelvic pain with 72
hrs after hysteroscopy
 Thermal injuries(Adjacent organs)
presence of abd pain, fever, leucocytosis,
pertonitis after surgery= injury till proven
other vice

23. Conclusion
• Current hysteroscopic surgery is safe
• BUT complications are related to experience
of surgeons
• Proper instruments essential to reduce
complications
• Right distention media & right energy source
essential
• Proper training essential get good outcome &
reduce complications

24. THANK YOU