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Cutting the risk of hysteroscopic complications

OBG Manag. 2004 January;16(1):44-52

Proper selection and treatment of patients and prompt intervention minimize complications and legal risks of this effective, underutilized procedure.

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References

1. Gurtcheff SE, Sharp HT. Complications associated with global endometrial ablation: the utility of the MAUDE database. Obstet Gynecol. 2003;102:1278-1282.

2. Jansen FW, Vredevoogd CB, Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000;96:266-270.

3. Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol. 2000;96:517-520.

4. Preutthipan S, Herabutya Y. Vaginal misoprostol for cervical priming before operative hysteroscopy: a randomized controlled trial. Obstet Gynecol. 2000;96:890-894.

5. Thomas JA, Leyland N, Durand N, Windrim RD. The use of oral misoprostol as a cervical ripening agent in operative hysteroscopy: a double-blind, placebo-controlled trial. Am J Obstet Gynecol. 2002;186:876-879.

6. Stotz M, Lampart A, Kochli OR, Schneider M. Intraabdominal bleeding masked by hemodilution after hysteroscopy. Anesthesiology. 2000;93:569-570.

7. Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:347-366.

8. Loffer FD, Bradley LD, Brill AL, Brooks PG, Cooper JM. Hysteroscopic fluid monitoring guidelines. J Am Assoc Gynecol Laparosc. 2000;7:167-168.

9. Bradley LD, Widrich T. Flexible hysteroscopy: a state-of-the-art procedure for gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995;2:263-267.

10. Neis KJ, Brandner P, Lindemann HJ. Room air as a cause of gas embolism in diagnostic CO₂hysteroscopy. Zentralbl Gynakol. 2000;122:222-225.

11. Bradner P, Neis KJ, Ehmer C. The etiology, frequency, and prevention of gas embolism during CO₂hysteroscopy. J Am Assoc Gynecol Laparosc. 1999;6:421-428.

12. Munro MG, Weisberg M, Rubinstein E. Gas and air embolization during hysteroscopic electrosurgical vaporization: comparison of gas generation using bipolar and monopolar electrodes in an experimental model. J Am Assoc Gynecol Laparosc. 2001;8:488-494.

13. Murdoch JAC, Gan TJ. Anesthesia for hysteroscopy. Anesthesiol Clin North Am. 2001;1:125-140.

14. Cooper JM, Brady RM. Late complications of operative hysteroscopy. Obstet Gynecol Clin North Am. 2000;27:367-374.

15. Rogerson L, Gannon B, O’Donovan P. Outcome of pregnancy following endometrial ablation. J Gynecol Surg. 1997;13:155-160.

16. Kerimis P, Zolti M, Sinwany G, Mashiach S, Carp H. Uterine rupture after hysteroscopic resection of uterine septum. Fertil Steril. 2002;77:618-620.

17. De Iaco P, Golfieri R, Ghi T, Muzzupapa G, Ceccarini M, Bovicelli L. Uterine fistula induced by hysteroscopic resection of an embolized migrated fibroid: a rare complication after embolization of uterine fibroids. Fertil Steril. 2001;75:818-820.

18. Coccia ME, Becattini C, Bracco GL, et al. Intraoperative ultrasound guidance for operative hysteroscopy. J Reprod Med. 2000;45:413-418.

19. Brooks-Carter GN, Killackey MA, Neuwirth RS. Adenocarcinoma of the endometrium after endometrial ablation. Obstet Gynecol. 2000;96:836-837.

20. Cooper JM. Swimming lessons: check the water before jumping in. J Am Assoc Gynecol Laparosc. 1998;5:87-90.

21. Kudela M, Pilka R. Is there a real risk in patients with endometrial carcinoma undergoing diagnostic hysteroscopy (HSC)? Eur J Gynecol Oncol. 2001;22:342-344.

KEY POINTS

Preoperative treatment with a gonadotropinreleasing hormone agonist increases the odds of operative complications by a factor of 4 to 7.
Preoperative cervical ripening reduced the need for cervical dilation, minimized cervical complications, and reduced operative time.
CO₂ should never be used for operative hysteroscopic procedures because of the high risk of CO₂ embolism.
Ultrasound guidance may improve outcomes in selected hysteroscopic procedures.

The state of the art can be simply put: Hysteroscopy is underutilized. Most studies consistently demonstrate the safety and efficacy of operative hysteroscopy, as well as high patient satisfaction.

It is a valuable tool in the evaluation and treatment of infertility, recurrent pregnancy loss, and abnormal and postmenopausal uterine bleeding, and is useful when saline infusion sonography findings are equivocal.

Further, if a global ablation device fails, the surgeon can convert to hysteroscopic ablation rather than abandon the procedure altogether. This is not as unusual as it might appear: In US Food and Drug Administration trials, there was a staggering 10% to 22% malfunction of global ablation technology.¹

Safe, easily learned

Although gynecologists are beginning to embrace this modality, many physicians avoid it because of inadequate training or exaggerated fears of complications. In reality, hysteroscopy is one of the safest and most easily acquired surgical skills in gynecology. For example, in a prospective evaluation of 13,600 diagnostic and operative hysteroscopic procedures performed at 63 hospitals in the Netherlands—which involved both established surgeons and residents—Jansen et al² found an astonishingly low complication rate of 0.28%, with no deaths.

Proper selection and treatment of patients and prompt intervention minimize complications as well as legal risks. Surgical misadventures and lawsuits occur with delayed intervention, failure to recognize pathology or risky conditions, and inadequate preventive maneuvers.

Overall, emphasis on safety is vital to success, and thorough awareness of potential complications is just as important.

Three types of complications

Complications fall into 3 categories (TABLE):

Procedure-related
Media-related
Postoperative

PROCEDURE-RELATED COMPLICATIONS

Complication rates

In a retrospective investigation, Propst et al³ determined the rate of complications associated with specific hysteroscopic procedures. Demographic data and medical histories were collected for 925 women who had operative hysteroscopy in 1995 and 1996. The overall complication rate was 2.7%. Myomectomy and resection of uterine septa carried the greatest odds of complications; polypectomy and endometrial ablation had the lowest. Preoperative treatment with a gonadotropinreleasing hormone (GnRH) agonist increased the odds of complications by a factor of 4 to 7. Women under age 50 were more likely to experience complications than those over 50.

In the study by Jansen et al,² 38 complica-tions occurred in the 13,600 procedures. The greatest risk of complications occurred with adhesiolysis (4.48%), followed by endometrial resection (0.81%), myomectomy (0.75%), and polypectomy (0.38%).

Cervical entry requires special attention

Almost half of the complications in the Jansen study were related to cervical entry, so caution and, perhaps, preoperative cervical ripening are advised. Many premenopausal subjects were given GnRH analogues, which may render the cervix more resistant to dilation. Complications associated with a stenotic cervix include a cervical tear, creation of a false cervical passage, and uterine perforation.

Cervical ripening may help prevent uterine perforation. The most common complication, occurring in 14.2 cases per thousand, is uterine perforation.² The risk of this is highest in postpartum procedures, followed by procedures in postmenopausal, then perimenopausal, women. Patients with endometrial cancer also have a higher rate of perforation.

Risk factors for uterine perforation include:

nulliparity
menopause
use of GnRH agonists
prior cone biopsy
markedly retroverted uterus
undue force

Modern operative hysteroscopes often require dilation of the cervix to a number 8-10 Hegar dilator. Navigation of the internal os is critical before operative instruments can be inserted and the surgical procedure performed. In the past, use of preoperative laminaria was recommended to soften the cervix, except in women with marked cervical stenosis and iodine allergy. Preoperative cervical softening still should be considered in high-risk patients.

Vaginal or oral misoprostol for cervical ripening prior to operative hysteroscopy was evaluated in a randomized trial.⁴ Researchers found a reduced need for cervical dilation, a minimum of cervical complications, and reduced operative time in study patients compared with controls.

When 400 μg oral misoprostol is given 12 and 24 hours before surgery, it also softens the cervix and eases dilation.⁵ Although misoprostol has several bothersome side effects (such as lower abdominal pain and slight vaginal bleeding), few if any prevent its use.

Signs of perforation. Patients who sustain uterine perforation with subsequent intraperitoneal bleeding often complain of pain in the abdomen and shoulder, and experience hemodynamic instability. A quick sonographic survey of the abdomen will demonstrate free intraperitoneal fluid. (It is rare for much intraperitoneal fluid to accumulate by transtubal regurgitation during operative hysteroscopy, despite the quantity of fluid used.)