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.

How to minimize risks

Avoid coaxial gas cooling tips associated with Nd:YAG crystal lasers
Avoid a steep Trendelenburg position
Keep cervix covered with sponge or dilator when operative hysteroscope is removed to minimize air embolism
Deaerate the equipment prior to surgery Use a low-pressure hysteroscopic CO₂ insufflator
Carefully monitor the patient
Be highly suspicious when vital signs are unstable

POSTOPERATIVE COMPLICATIONS

Some complications of hysteroscopy may not become clinically evident for months or even years. The most common complications of hysteroscopic endometrial ablation include pregnancy, postablation tubal sterilization syndrome, new or worsening dysmenorrhea, hematometra, endometrial cancer, and failure to completely treat symptoms.

Patients scheduled for hysteroscopy must be informed of potential delayed risks of the procedure. In addition, all reproductive-aged women should be advised that pregnancy is possible after endometrial ablation or operative removal of an intracavitary mass; thus, contraception is crucial. The endometrial tissue is resilient and may regenerate after ablation.

Hematometra: Avoid cervical canal

Hematometra is an infrequent late complication of operative hysteroscopy. If menstruating women or those taking hormone replacement therapy experience cyclic or chronic lower pelvic pain after surgery, scarring or narrowing of the endometrial cavity may be the cause. Approximately 1% to 2% of women who undergo operative hysteroscopy experience this phenomenon. Most cases can be treated with cervical dilation alone.

Since the cervical canal contains no endometrial glands, there is no need to treat this area in women undergoing endometrial ablation. In fact, avoiding this area during treatment is a critical component of successful surgery.

Tubal sterilization syndrome possible after endometrial ablation

Consider this syndrome when a patient undergoing endometrial ablation complains of crampy, cyclic, unilateral or bilateral pelvic pain, possibly accompanied by vaginal spotting. Sometimes a unilateral mass can be palpated, but more commonly tenderness is elicited on pelvic examination.

Ultrasound may demonstrate fluid near the cornual region. Laparoscopy confirms the diagnosis by visualizing a swollen, edematous proximal fallopian tube. Salpingectomy may confirm hematosalpinx, chronic or acute inflammation, or hemosiderin deposits.

Treatment includes bilateral cornual resection and reablation of proximal endometrium, or hysterectomy.¹⁴

Pregnancy complications

Endometrial ablation is not to be regarded as a method of contraception. Patients needing birth control should consider concurrent tubal ligation or other reliable methods after this procedure.

The frequency of pregnancy after endometrial ablation ranges from 0.2% to 1.6%, though this data may represent underreporting. Pregnancy outcomes have been dismal in women conceiving after endometrial ablation. Complications include preterm labor, premature delivery, intrauterine growth retardation, prenatal death, postpartum hemorrhage, and placentation problems such as placenta accreta, increta, or percreta, as well as placental abruption.¹⁵

Uterine dehiscence and sacculation and extremely thin myometrium have been reported after uterine adhesiolysis, uterine perforation during operative hysteroscopy, and with myoma resections. A high index of suspicion is vital when a gravida presents with pelvic pain, decreased fetal movement, vaginal bleeding, or abnormal uterine masses detected ultrasonographically.

Signs of uterine rupture. Pregnancyrelated complications of operative hysteroscopy can be dramatic and fatal if not recognized quickly, as in the case of uterine rupture. Kerimis et al¹⁶ describe uterine rupture in a term pregnancy after hysteroscopic resection of a uterine septum. Severe fetal distress, maternal shoulder pain, and abdominal pain led to an emergency cesarean section. Intraoperative findings included a 7-cm tear from left cornua to right cornua. The original metroplasty, performed with cutting diathermy and laparoscopy, was not accompanied by complications or perforation.

Patients who experience intraoperative complications during metroplasty or deep resection of intramural fibroids should be informed of the risk of uterine rupture so they may consider elective cesarean. Regardless of the mode of delivery, prompt attention is vital if fetal distress is suspected.

Postablation warning signs

Patients undergoing endometrial ablation generally have a quick postoperative return to activity, minimal need for postoperative pain medication, and limited complaints. Beware of patients who make frequent postoperative phone calls and have escalating requirements for pain medication. While bowel and bladder injuries are infrequent—as is postoperative endometritis—these must be vigilantly considered and evaluated when patients complain of persistent pain, fever, and general malaise. Office evaluation is necessary, including thorough abdominal and pelvic examinations. Laboratory testing should include electrolytes, complete blood count, sedimentation rate, ultrasound, and a flat plate of the abdomen (kidneys, ureter, and bladder; upright) may be required. Sometimes a computed tomography scan of the pelvis/abdomen may be needed if perforation with bowel or bladder injury is suspected.

Hysteroscopic fibroid removal may be necessary after UAE

Uterine artery embolization (UAE) is gaining popularity for the treatment of symptomatic uterine fibroids. Transcatheter embolization of the uterine artery leads to occlusion of the fibroid, ischemic shrinkage of the fibroid, and shrinkage of residual myometrial tissue. Fibroids may migrate weeks to months after the procedure as the myometrium contracts and the treated fibroid degenerates, leading to delayed discharge, passage of necrotic fibroids, cramps, and heavy bleeding if the fibroid migrates to a submucosal location. Hysteroscopic removal is an obvious option.