The document discusses hysteroscopy, focusing on the types of distension media, their purposes, and associated risks, particularly fluid overload. It outlines the mechanisms of fluid absorption, monitoring techniques, complications, and management strategies, including pre-operative and intra-operative preventive measures. Additionally, the document emphasizes the importance of training and awareness for surgical teams to mitigate risks during procedures.

1. Introduction
Hysteroscopy is essential for diagnosing and treating intrauterine
pathologies.
This presentation covers:
- Types of distension media
- Complications and prevention
- Guidelines for safe practices.

2. Purpose of Distension Media
1. To achieve clear visualization of the uterine cavity.
2. Enables surgical access with minimal trauma.
3. Facilitates use of mechanical and electrosurgical instruments.

3. Types of Distension Media
1. Fluid media (isotonic and hypotonic solutions)
2. Carbon dioxide gas (limited to diagnostic procedures).

4. Comparison: Fluid vs. Gas
Fluid Media:
- Better visualization, continuous irrigation.
Gas Media:
- Risk of embolism, limited use in diagnostic hysteroscopy.

5. Hypotonic Solutions
Examples:
- Glycine 1.5%
- Sorbitol 3%
Advantages:
- Compatible with monopolar systems.
Disadvantages:
- Risk of hyponatremia and cerebral edema.

6. Isotonic Solutions
Examples:
- Normal saline
- Ringer's lactate
Advantages:
- Compatible with bipolar systems.
Disadvantages:
- Risk of hypervolemia and cardiac failure with large volumes.

7. Fluid Overload: Definition
1. Hypotonic solutions:
- Threshold: >1000 mL deficit.
2. Isotonic solutions:
- Threshold: >2500 mL deficit.
Women with renal of cardiac disease
1. Hypotonic solutions:
- Threshold: >750 mL deficit.
2. Isotonic solutions:
- Threshold: >1500 mL deficit.

8. Pathophysiology of Fluid
Absorption
1. Mechanisms:
- Retrograde passage through fallopian tubes.
- Systemic absorption through open blood vessels.
2. Risk factors:
- High intrauterine pressure
- Prolonged procedures.

9. Monitoring Fluid Deficit
1. Closed systems allow accurate measurement.
2. Automated systems monitor fluid deficit in real-time.
3. Manual systems require regular recalculation by a designated team
member.

10. Complications of Fluid
Overload
Cardiovascular:
- Pulmonary edema
- Hypertension
- Cardiac failure
Neurological:
- Cerebral edema
- Seizures
- Confusion and agitation.

11. Preventing Fluid Overload
1. Pre-operative:
- GnRH agonists to reduce fibroid size.
- Intracervical vasopressin to reduce systemic absorption.
2. Intra-operative:
- Maintain intrauterine pressure < mean arterial pressure.

12. Management of Complications
1. Asymptomatic cases:
- Fluid restriction
- Diuretics (e.g., frusemide).
2. Symptomatic cases:
- Hypertonic saline infusion
- Multidisciplinary ICU management.

13. Delivery Systems for
Distension Media
1. Gravity systems:
- Simple but less precise.
2. Pressure bags:
- Manual control with pressure cuffs.
3. Automated pumps:
- Accurate intrauterine pressure control.

14. Anesthesia Considerations
1. Local anesthesia with sedation minimizes fluid absorption.
2. General anesthesia increases the risk of fluid overload.

15. Key Thresholds for Fluid
Absorption
Healthy women:
- Hypotonic: Stop at 1000 mL deficit
- Isotonic: Stop at 2500 mL deficit
Comorbid patients:
- Hypotonic: Stop at 750 mL
- Isotonic: Stop at 1500 mL.

16. Air or Gas Embolism
Rare but serious complication:
- Sudden oxygen desaturation or cardiovascular collapse.
Prevention:
- Prime tubing to remove air bubbles.
- Avoid excessive intrauterine pressure.

17. Advances in Distension Media
1. Development of safer isotonic solutions.
2. Automated delivery systems for real-time monitoring.
3. Registry-based research for long-term data collection.

18. Training and Awareness
1. Educate surgeons on fluid absorption risks.
2. Conduct regular audits of fluid deficit management practices.
3. Introduce case-based learning sessions.

19. Real-World Case Study
Scenario: Managing fluid overload during a myomectomy.
Steps:
1. Identify early signs of overload.
2. Implement immediate fluid restriction.
3. Engage multidisciplinary care for severe cases.

20. Future Directions
1. Establish safe fluid deficit thresholds for prolonged procedures.
2. Encourage research on new distension media.
3. Promote collaboration among international hysteroscopic societies.

21. Hyponatremia: Immediate
Steps
1. Stop the procedure immediately if fluid deficit
exceeds the safe threshold.
2. Insert a urinary catheter for strict fluid balance
monitoring.
3. Obtain blood samples to assess:
- Serum sodium
- Potassium, calcium
- Osmolality, urea, and creatinine.
4. Administer oxygen if oxygen saturation drops.

22. Hyponatremia: Initial
Management
1. Asymptomatic or mild hyponatremia (Serum Sodium
>120 mmol/L):
- Restrict fluids to <1 L/day.
- Administer loop diuretics (e.g., frusemide).
2. Symptomatic or severe hyponatremia (Serum Sodium
<120 mmol/L):
- Administer 3% hypertonic saline infusion at 1-2
mmol/L/hour.
- Use a 100 mL bolus of 3% saline for acute symptomatic
cases, repeated as needed (up to 3 doses).

23. Hyponatremia: Ongoing Care
1. Monitor:
- Serum sodium levels every 2-4 hours.
- Neurological signs (e.g., confusion, agitation).
- Cardiac and pulmonary status with echocardiogram and chest X-ray if
needed.
2. Target increase in serum sodium:
- No more than 6-8 mmol/L in 24 hours to avoid osmotic
demyelination.
3. Multidisciplinary care:
- Intensivists, anesthetists, and physicians for severe cases.
- Ensure ICU availability for critically ill patients.