What are the key considerations and protocols for minimizing complications during and after a hysteroscopy procedure?

Hysteroscopy: High-Yield Points for Quiz Competition

Critical Complications to Know

The most common serious complication of hysteroscopy is uterine perforation, followed by fluid overload complications, which are the most critical intraoperative concerns requiring meticulous monitoring. 1, 2

Major Complications (in order of importance):

• Fluid overload with electrolyte disturbances - occurs in <4% of cases but represents the most critical intraoperative problem requiring accurate fluid balance monitoring 2, 3
• Uterine perforation - most common serious complication; when recognized during operative hysteroscopy with monopolar or bipolar loop, the procedure must be stopped and laparoscopy performed to rule out bowel injury 1, 4
• Hemorrhage requiring transfusion 1
• Cervical laceration or tearing 1, 5
• Bowel or bladder injury 1
• False track formation 5
• Endomyometritis 6

Essential Pre-Procedure Protocols

Patient Positioning and Preparation:

• Elevate the exam table so patient maintains eye contact with clinician throughout the procedure to reduce anxiety and improve communication 1
• Ensure patient has eaten and drunk beforehand to prevent vasovagal reactions 1
• Pre-procedure NSAIDs are recommended for pain control (moderate evidence) 1

Cervical Preparation:

• Misoprostol for cervical ripening reduces mechanical dilatation needs (OR 0.08,95% CI 0.04-0.16) and decreases intraoperative complications (OR 0.37,95% CI 0.18-0.77) compared to placebo 5
• Routine misoprostol, vaginal estrogens, or GnRH agonist administration is NOT recommended before operative hysteroscopy 4
• No vaginal disinfection or antibiotic prophylaxis is needed for routine diagnostic hysteroscopy 4

Infection Prevention:

• Antibiotic prophylaxis is NOT routinely indicated for diagnostic or simple operative hysteroscopy 4
• Single-dose IV antibiotics within 60 minutes should be considered for complex operative cases, particularly when involving extensive resection 6

Critical Intraoperative Monitoring

Fluid Management (Most Critical):

• Purge all air from the system before starting to prevent air embolism 4
• Maintain distention pressure below mean arterial pressure and <120 mmHg 4
• Maximum fluid deficit thresholds:
  • Normal saline: 2000 mL maximum deficit 4
  • Hypotonic solutions (glycine, sorbitol): 1000 mL maximum deficit 4
• Monitor for dilutional hyponatremia and hypothermia - most commonly encountered fluid-related complications 3

Distending Media Complications:

• Carbon dioxide: risk of embolism 3
• Glycine/sorbitol: dilutional hyponatremia, hyperglycemia, volume expansion 3
• Dextran: pulmonary edema, renal failure, rare anaphylaxis 3
• Normal saline is preferred for operative hysteroscopy 4

Office vs. Operating Room Hysteroscopy

Office Hysteroscopy Technique (Vaginoscopy):

• Vaginoscopy should be the standard technique for outpatient diagnostic hysteroscopy 4
• Use miniature (≤3.5mm sheath) rigid hysteroscope 4
• Normal saline distension medium 4
• No anesthesia or conscious sedation routinely 4
• No cervical preparation required 4
• Pause after hysteroscope insertion to allow patient to indicate readiness to continue 1

Contraindications for Office Setting:

• High-risk cardiac patients should not undergo hysteroscopy in office settings 1
• Active pelvic infection is an absolute contraindication 2

Operative Hysteroscopy Specifics

For Submucosal Fibroids:

• Use electrosurgical wire loop or mechanical instruments for resection 1
• Risks include: uterine perforation, fluid overload, blood transfusion need, bowel/bladder injury, endomyometritis, need for reintervention 6
• Shorter hospitalization and faster return to activities compared to laparoscopic or open myomectomy 6

Complication Rates by Fibroid Type:

• Patients with significant intramural or subserosal fibroid burden with concomitant adenomyosis are less likely to experience symptom relief from hysteroscopic myomectomy 6

Post-Procedure Management

Immediate Recovery:

• Keep patient lying flat for 5 minutes with legs out of stirrups 6
• Gradually raise head of table in increments to prevent vasovagal reaction 6
• Provide acupressure on Large Intestine-4 (LI4) or Spleen-6 (SP6) for cramping 6

Pain Management:

• Multimodal, opioid-sparing analgesia should be standard 6
• NSAIDs: naproxen 440-550 mg every 12 hours OR ibuprofen 600-800 mg every 6-8 hours with food for first 24 hours 6

High-Yield Comparison Points

Hysteroscopic vs. Other Myomectomy Approaches:

• Equivalent symptom scores and quality of life at 2-3 months compared to laparoscopic/open approaches 6
• Shorter hospitalization than other surgical approaches 6
• Faster return to usual activities 6

Risk Factors for Complications:

• Inexperienced, unsupervised surgeon is most likely to encounter significant complications 2
• Almost 50% of hysteroscopic complications are related to difficulty with cervical entry 5

Special Populations

Postmenopausal Patients:

• Endometrial biopsy must be negative before proceeding with hysteroscopic myomectomy for bleeding 6
• Uterine sarcoma and endometrial cancer must be ruled out before any minimally invasive fibroid treatment 6
• Diagnostic or operative hysteroscopy is allowed when endometrial cancer is suspected 4

Fertility Considerations:

• Pregnancy is possible after hysteroscopic myomectomy - counsel all patients regardless of stated fertility desires 6
• Risk of intrauterine adhesions is a late complication that can affect fertility 7

Common Pitfalls to Avoid

• Ignoring patient distress signals - patient controls the procedure and can pause/stop at any time 1
• Inadequate fluid balance monitoring in operative cases leads to most critical complications 2
• Failure to perform laparoscopy when perforation is recognized during operative hysteroscopy with energy devices 4
• Using abdominal approach when vaginal/laparoscopic feasible - associated with longer recovery, more pain, higher infection risk 6