News for Your Practice

Cutting the risk of hysteroscopic complications

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

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.

Purge tubing of room air before each procedure. Embolic complications with CO₂ have been recorded with use of the neodymium: yttrium aluminum garnet (Nd:YAG) laser and during operative procedures. Less well known are the adverse sequelae that can occur with room air prior to beginning the procedure. It is critical to purge the entire tubal system with CO₂ prior to instrumentation, since up to 40 cm³ of room air may be insufflated into a patient when 200 cm of connective tubing with a 0.5-cm lumen is used.¹⁰ Wait for several minutes before starting the procedure so that the whole system is purged.

Cancer concerns: When is hysterectomy the best option?

One of the greatest concerns about endometrial ablation is that diagnosis of endometrial cancer will be delayed because the endometrial cavity has been obliterated. Vilos¹⁹ recently reviewed the salient characteristics and findings in women treated by endometrial ablation who subsequently developed endometrial cancer. A review of the individual cases revealed that most of these patients had numerous risk factors for endometrial cancer.

Review risk factors, chronic conditions

Many patients with abnormal bleeding also have risk factors for endometrial cancer, as well as medical conditions that increase the likelihood of morbidity with surgery, such as obesity, hypertension, diabetes, and advanced age. In these cases, hysterectomy may be a better option than endometrial ablation. It would be far better to have such high-risk patients cleared for hysterectomy than to chance their becoming an endometrial-ablation “statistic.” If endometrial ablation is performed in these cases, we prevent the egress of blood, foster development of synechiae, render endometrial biopsy difficult or impossible and, potentially, “bury” endometrial cells deeper within the myometrium—all of which contribute to a delayed and “upstaged” diagnosis of endometrial cancer.

Patients at risk of endometrial cancer should undergo a scrupulous and unambiguous work-up and evaluation. Indeterminate endometrial echo and office evaluation that generates biopsy samples designated as “insufficient for diagnosis,” “no endometrial tissue seen,” or “atrophy” should raise suspicion. These patients require full visualization of the endometrium.

Heightened risk during perimenopause

Newer ablation techniques that utilize global therapy make it paramount that perimenopausal women undergo scrupulous evaluation. Until much more information is available, endometrial ablation should be avoided in patients with endometrial hyperplasia, particularly with atypia. While some gynecologists may be persuaded to consider endometrial ablation as a minimally invasive procedure compared to hysterectomy, the risk of delayed diagnosis of endometrial cancer is of paramount concern. The treatment of choice for these patients remains medical therapy with oral progesterone and, possibly, longterm use of a levonorgestrel-releasing intrauterine system. If this fails, hysterectomy is advisable. As Cooper²⁰ aptly states, “Conservative, nonextirpative procedures offer no life raft” compared with hysterectomy, which covers many missed diagnoses.

No risk of spreading cancer cells

Some gynecologists have worried about the risk of disseminating endometrial cancer cells during hysteroscopy. However, Kudela and Pilka²¹ studied the true risk in women undergoing blind dilation and curettage and hysteroscopy performed with a fluid medium. Cul-de-sac aspiration prior to instrumentation and at the conclusion of the procedure demonstrated no increased risk of positive cytology. They are continuing a Phase II trial comparing outcomes of both groups over 5 years.

Advantages of CO₂in diagnostic hysteroscopy. Although any number of gaseous solutions could be used during diagnostic hysteroscopy, CO2is the most ideal due to its solubility in blood, the rapidity with which it is dissolved, and the large quantities (1 L/min or more) that would be necessary to cause a fatality. (A hysteroinsufflator utilizing 100 mL/min or less is used for diagnostic hysteroscopes.) When Bradner et al¹¹ reviewed the incidence of severe nonfatal embolism in 3,932 diagnostic hysteroscopic procedures using CO2, the risk of subclinical embolic events was 0.51%; 0.03% of patients experienced severe events. When special precautions were taken to deaerate the supply tubing and instruments, no events occurred in the next 1,000 cases. Thus, it is possible that ambient air trapped in tubing—rather than CO2—could be the culprit in gas emboli.

6 most common symptoms of venous or air emboli. Anesthesiologists and gynecologists must be vigilant to prevent venous or air emboli. Munro et al¹² succinctly outline the 6 most common symptoms:

pulmonary hypertension
hypercarbia
hypoxia
arrhythmias
tachypnea
systemic hypotension

Morbidity and mortality can be prevented when these symptoms are quickly recognized and promptly treated.¹³

Beware of a drop in end-tidal CO₂. The most common sign of impending cardiovascular collapse is a sudden decrease in end-tidal CO₂, when the right cardiac outflow tract is obstructed by CO₂, which leads to arterial oxygen (O₂) desaturation. If such a decrease is suspected, stop the procedure immediately and administer 100% O₂. (Also stop nitrous oxide, if used.) Turn the patient to the left lateral decubitis position and use a central venous catheter to aspirate gas, if necessary. Cardiac massage and a precordial thump may dislodge CO₂; unfortunately, high false-positive rates of pre-cordial Doppler make its use impractical.