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Complications in hysteroscopy: Prevention, treatment and legal risk
Abstract
Fortunately, gynecologists are enthusiastically embracing diagnostic and operative hysteroscopy as a means to evaluate women with menstrual disorders, infertility, post-menopausal bleeding, recurrent pregnancy loss, and for ultrasound images. In general, operative hysteroscopy is a safe procedure, is easily learned, and has excellent surgical outcomes. As more obstetricians/gynecologists perform hysteroscopy, they must remain cognizant about the salient complications. The recognition of complications and prompt intervention will prevent adverse sequelae as well as minimizing undesirable patient outcomes and reducing legal risks.
Hysteroscopy remains a relatively safe procedure. Diagnostic hysteroscopy has the fewest risks, followed by operative hysteroscopic adhesiolysis, metroplasty, and myomectomy. Fluid management is critical for intraoperative safety. Meticulous detail should be paid to fluid management, and consultation sought with a critical care specialist when fluid overload or hyponatremia is suspected. Lingering pain, fever, or pelvic discomfort after surgery requires prompt evaluation. Women becoming pregnant after operative hysteroscopic procedures need careful antepartum and intrapartum care. Special attention to unusual pain complaints during pregnancy or with fetal distress in labor need prompt intervention.
The preoperative use of misoprostol or laminara decreases the risk of uterine perforation. Expert preoperative evaluation is essential in determining the surgical skill and expertise needed, surgical time, and the likelihood of completing the operative procedure. Overall, complications in operative hysteroscopy are infrequent and are usually easy to manage. This knowledge should help physicians perform more procedures.
... Uterine perforation is the most frequent type of complication associated with hysteroscopy, with the reported rates varying between 0,12 and 3% [30]. A number of individual factors increase the risk of uterine perforation, including menopause, nulliparity, an extremely anteverted or retroverted uterus, history of a previous cervical procedure that can result in a stenosed cervical canal, intrauterine synechiae, use of gonadotropin-releasing hormone agonists and operator inexperience [5,31]. ...
... High viscosity dextran 70 has fallen out of use due to its safety profile (i.e. risk of anaphylactic reactions) and potential to damage operative instruments due to crystallization [31]. In recent years, with the development of bipolar electrosurgical equipment and mechanical instruments, professional organizations have started recommending the use of isotonic media over hypotonic media due to a better safety profile [45,46]. ...
... Complications associated with infection after an operative hysteroscope are rare events and the incidence ranges from 0.3% to 1,6% [74]. These include urinary tract infections, endometritis, pyometra and pelvic inflammatory disease [31]. ...
Operative hysteroscopy is a minimally invasive gynaecological procedure and is considered the gold standard for the treatment of intracavitary uterine pathology. Over the last decades, with the development of new surgical instruments, the popularity of this technique has increased with gynaecologists across the world. However, this minimally invasive technique can be associated with rare but serious complications that can lead to severe morbidity and, if not treated adequately in some cases, ultimately lead to mortality. Any gynaecologist using this procedure should not only train in the operative technique but should also acquire knowledge on what type of complications may arise whilst performing an operative hysteroscopy. The following chapter explores the diagnosis of complications associated with the operative hysteroscopy and management options.
... 2,4-9 As a consequence, significant stenosis may result in the obstruction of menstrual flow, inadequate cervical assessment during colposcopy, unsuccessful gynecological procedures and potential implications with fertility. 1,4,10,11 Furthermore cervical stenosis has been reported, alongside pain, as the most frequent reason for failed hysteroscopy. 3 Two main methods of cervical dilatation have been described in the literature, especially in the context of labor. ...
... 20,21 Mechanical dilatation is often required prior to operative hysteroscopies, with crucial navigation of the internal os to allow successful insertion of surgical instruments. 11 Mathew and Mohan, however recognized outpatient cervical dilatation as the first line management for cervical stenosis, with general or regional anesthesia reserved for those who cannot tolerate under a local anesthetic. 22 In a retrospective study of over 10 000 women undergoing outpatient hysteroscopies, stenosis of the cervix was managed successfully with minimal discomfort in 98.5% of patients. ...
... There has been discussion into the safety of rigid cervical dilatation, with reports of cervical tears, uterine perforation and the creation of a false cervical passage. 11,27 Arsenijevic et al. reported greater cervical tissue damage using Hegar dilators versus balloon dilatation. 15 The use of prostaglandins to pharmacologically prime the cervix has also been described to reduce the risk of laceration by decreasing the instrumental force required. ...
Aim:
Cervical stenosis is traditionally managed by mechanical dilatation under general anesthesia (GA). We aimed to assess the safety, effectiveness, and patient acceptability of dilatation in the outpatient setting under local anesthesia (LA).
Methods:
Data were collected prospectively from all patients attending the outpatient department with cervical stenosis from March 20, 2015 to September 23, 2020. Mechanical dilatation of the cervix was performed using Hegar dilators under LA. Subsequent colposcopic assessment, cytology, histology, and management were recorded.
Results:
One hundred forty-nine cases were referred for cervical dilatation, 63 (43%) of which had complete stenosis. One hundred eighteen (79%) patients had previously undergone cervical procedures. Successful dilatation under LA was achieved in 119 (83%) patients; 5 (3%) declined (requesting GA), 6 (4%) did not tolerate speculum examination, and 19 (13%) had unsuccessful procedures. The median Hegar size used was 8 mm. Dilatation under LA was acceptable in 93% attempted procedures. Thirteen episodes of restenosis were recorded with no major adverse events. Younger age (p = 0.045) and severe (compared to complete) stenosis (p < 0.0001) were associated with procedure success, with improved results over time (p = 0.003). Successful dilatation permitted cervical assessment; eight patients required cervical excisions, two underwent hysterectomies, with one confirmed case of adenocarcinoma.
Conclusion:
Rigid cervical dilatation in the outpatient setting provides effective, instantaneous treatment for women who have failed cytological or colposcopic assessment. For the vast majority of women, the procedure was well tolerated and preferred to using GA. However, given that 1 in 10 women experienced restenosis, patients should be counseled about the possibility of requiring further management.
... Hysteroscopy is generally safe; however, rare complications such as bleeding, uterine perforation, fluid overload, pulmonary embolism, endometritis, and post-procedure adhesions can pose serious risks [2,[13][14][15][16]. ...
... This observation is in line with other studies where hysteroscopic perforation was highlighted as the predominant issue [7,15,36]. Nonetheless, it was higher than the figures reported in studies [16,35,[37][38][39], which ranged from 0.8 to 1.6%. The elevated likelihood of perforation could be linked to the frequent occurrence of multiple endometrial polyps and extensive intrauterine adhesions identified in most of our patients. ...
Background
Hysteroscopy is considered the standard for evaluating the uterine cavity. Limited data exists regarding hysteroscopy in Ethiopia. Therefore, the objective of the study was to describe the diagnostic and operative hysteroscopic procedures at St. Paul’s Hospital.
Methodology
A three-year retrospective descriptive study examined patients who underwent diagnostic and therapeutic hysteroscopy at the Center for Fertility and Reproductive Medicine, St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia, from June 2018 to June 2021. Descriptive statistics were employed to summarize the findings observed during the hysteroscopy procedures.
Result
A total of 328 patient records underwent review and analysis in the study. The mean participant age was 31.9 years (31.9 ± 5.1 years), with about 81.4% being nulliparous. Primary infertility (48.5%) was the leading indication for hysteroscopic evaluation, followed by secondary amenorrhea (18%), secondary infertility (17.4%), and abnormal uterine bleeding (8.8%). Concerning hysteroscopic procedures, 6.1% of participants exhibited no uterine cavity abnormalities. Primary hysteroscopy findings comprised intracavitary adhesions (48.2%), endometrial polyps (18%), and submucosal myomas (9%). Adhesiolysis stood out as the foremost surgical procedure, conducted in 48.2% of patients, followed by polypectomy in 20.7%, and fibroid removal in 9%. The complication rate was 2.4%, exclusively during operative hysteroscopy, with uterine perforation observed in six patients.
Conclusion
Our hysteroscopic evaluation was predominantly requested for primary infertility cases, with secondary amenorrhea, secondary infertility, and abnormal uterine bleeding also being commonly encountered indications. Adhesiolysis was the leading intervention during hysteroscopy, while uterine perforation was the main complication. The hysteroscopy procedures exhibited a strong safety profile, with few complications noted. Future studies should address factors affecting outcomes in diagnostic and operative hysteroscopy, and common factors linked to intrauterine adhesions.
... Furthermore, uterine septum resection by a hysterolaparoscopic approach is useful, with remarkable improvement in post-procedure pregnancy rates. This has many advantages, such as shorter operating and hospitalization periods, reduced risk of postoperative pelvic adhesions, low morbidity, and an increased rate of vaginal delivery [6,7]. ...
... The septate uterus has been noted to be the most common Mullerian duct abnormality and is involved in around 55% of the instances [5]. The occurrence of Mullerian duct anomalies is either sporadic or multi-factorial in nature, with extrauterine and intrauterine factors like hypoxia in pregnancy, medications like methotrexate, thalidomide, or diethylstilbestrol, ionizing radiation, and intrauterine viral infections documented as possible aetiologic agents [6]. There was no associated history linking the index patient with these causative agents. ...
Background: The septate uterus, which is the most common Mullerian duct anomaly, results from the abnormal fusion of the Mullerian duct during embryonic life, and it is usually associated with poor obstetric outcomes such as recurrent spontaneous abortions, subfertility, preterm labour, and reproductive failure. A large proportion of the patients that are affected remain asymptomatic owing to lack of indication for abdominal ultrasound before conception, and the problems are mainly detected after several pregnancy losses. The exact aetiology of the septate uterus is unknown but is caused by incomplete resorption of the uterovaginal septum after fusion of the Mullerian duct during embryogenesis. Case Presentation: We present a 32-year-old Para 0+3 woman referred to the radiology department for ultrasonography and hysterosalpingography (HSG) on account of recurrent miscarriage, which occurs within the first trimester of gestation. She has had three (3) consecutive miscarriages within the last 4 years, of pregnancies which were achieved spontaneously and were lost between the gestational ages of 9-12 weeks. She was investigated with ultrasonography, which demonstrated a bulky uterine appearance with two endometrial cavities that is connected to one cervical canal. Hysterosalpingography (HSG) showed a contrast-filled partly divided uterus with inter-cornual angles of 34º and intercornual distance of 1.92cm. The patient had hysteroscopic septum resection with a satisfactory outcome given addressing other medical problems that could militate against conception and has been on monthly follow-up. Conclusion: Radiological investigation of patients with recurrent miscarriages is indispensable for optimal evaluation to achieve accurate diagnosis and identify women whose problems are amenable to specialized treatments.
... [20] The preoperative use of misoprostol or laminaria decreases the risk of uterine perforation. [20,21] We found that less than 31 (25%) of 126 survey respondents dilated the cervix without cervical priming with misoprostol [ Figure 5]. Necessary precautions should be taken pre-and intra-operatively to avoid complications: preoperative thinning of the endometrium, continuous control of fluid balance, minimal intrauterine pressure, reduction of operating times, and concurrent use of ultrasound when cutting into the myometrium. ...
... Expert preoperative evaluation is essential in determining the surgical skill and expertise, needed surgical time, and the likelihood of completing the operative procedure. [21] Overall, complications in operative hysteroscopy are infrequent and are usually easy to manage. [ Figure 11: Timing of second look follow up after hysteroscopic myomectomy 28%, with fluid overload and uterine perforation being the most frequent complications occurring during hysteroscopic surgery. ...
... Of the 2680 cases, 4 cases of uterine perforation [11,12] were encountered, giving a complication rate of 0.15%. Two thousand six hundred and eighty patients underwent surgery, and only one patient (0.04%) complained of horizontal indurated reddish welt streaks post procedure [ Figure 6]. ...
... We have used this method successfully and to good effect, particularly in guiding us to avoid uterine perforations [12,13] during dilation of the cervix as well as in the therapeutic hysteroscopy surgery itself. We believe that this device facilitates efficient and safe therapeutic hysteroscopic surgeries and in monitoring dilatation and curettage procedures as well as other possible intrauterine surgeries [ Figure 7]. ...
Objectives: Conventionally, an assistant would be required to hold the ultrasound probe during therapeutic hysteroscopy. To manage without a skilled assistant, Lin developed a self-retaining hands-free probe method that can be used to hold an abdominal ultrasound probe. One can now perform ultrasound-guided hysteroscopic procedures single-handedly. The purpose of this study is to report the successful development of a method to keep an abdominal ultrasound probe self-retained without an assistant's help.
Materials and Methods: A technique derived from improvisation with available equipment.
Results: The hands-free ultrasound probe was used successfully in 2680 cases needing therapeutic hysteroscopy management for various endometrial pathologies. We only encountered one case of latex allergy, which serves as a reminder to ask about latex allergy before the procedure. Upon notification, the handle can be improvised to a latex-free solution. Compression indentation marks were of negligible concern as they resolved spontaneously within 1–2 h postsurgery. We have used this method successfully and to good effect, particularly in guiding us to avoid uterine perforations during dilation of the cervix as well as during the therapeutic hysteroscopy surgery itself. This device facilitates efficient and safe therapeutic hysteroscopic surgeries. In addition, this method encourages the reuse and recycling of plastic water bottles.
Conclusion: The usage of Lin's self-retaining ultrasound probe method is practical, cheap, and not dependent on an assistant's participation during procedures.
... Hysteroscopy is one of the most important diagnostic methods in gynecology. In order to identify intrauterine lesions, it is the gold standard [6]. It offers a more comprehensive examination of the surface of the endometrium. ...
... Misoprostol, a prostaglandin analog, helps contract uterine smooth muscles and dilate the cervix. However, it may also induce side effects [6,7]. When preparing for hysteroscopy, it is crucial to consider the use of drugs with minimal side effects and optimal performance. ...
Background
Hysteroscopy is a valuable surgical technique, but some complications are related to cervical dilatation. Sublingual trinitroglycerin (TNG) is a vasodilator that can facilitate cervical dilation. In our study, we compared its effectiveness to that of misoprostol.
Methods
This randomized controlled trial study was conducted on 199 women of reproductive age who were referred to Rasoul Akram Hospital. Patients were randomly divided into two groups: TNG and misoprostol. Next, they were examined for clinical and practical indicators of cervical preparation. The data was analyzed using SPSS software.
Results
Demographic characteristics exhibited no significant differences between the groups. The mean size of the largest dilator inserted without resistance showed not statistically significant difference between the TNG and misoprostol groups (6.26 ± 1.95 vs. 6.57 ± 2.05; p = 0.20). Side effects were reported in 66 (33.2%) of the women studied. The misoprostol group experienced a significantly higher rate of side effects (53.7%) compared to the TNG group (14.4%; p < 0.001). The most frequently observed side effect in the TNG group was headache, which occurred at a statistically significantly higher rate than in the misoprostol group (p = 0.04). On the other hand, uterine bleeding before hysteroscopy was significantly lower in the TNG group compared to the misoprostol group (p < 0.001).
Conclusions
There was no statistically significant difference in the mean size of the largest dilator inserted without resistance between the TNG and misoprostol groups. Additionally, TNG experienced significantly fewer side effects than sublingual misoprostol group, with headache being the most prominent side effect. Sublingual TNG can be used to improve cervical preparation before hysteroscopy.
Clinical Trial Registration
The study has been registered on https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20191123045476N4 (registration number: IRCT20191123045476N4).
... Postmenopausal status is a risk factor for cervical stenosis 2 . When the cervix is stenosed, there is an increased risk of false passage, cervix dilatation failure, cervical laceration, and uterine perforation 3 . A false passage, if not identified, will most likely lead to uterine perforation and its associated complications. ...
OBJECTIVE
Intraoperative complications of hysteroscopy, such as the creation of a false passage, cervix dilatation failure, and uterine perforation, may require suspension of the procedure. Some patients refuse a new procedure, which delays the diagnosis of a possible serious uterine pathology. For this reason, it is essential to develop strategies to increase the success rate of hysteroscopy. Some authors suggest preoperative use of topical estrogen for postmenopausal patients. This strategy is common in clinical practice, but studies demonstrating its effectiveness are scarce. The aim of this study was to evaluate the effect of cervical preparation with promestriene on the incidence of complications in postmenopausal women undergoing surgical hysteroscopy.
METHODS
This is a double-blind clinical trial involving 37 postmenopausal patients undergoing surgical hysteroscopy. Participants used promestriene or placebo vaginally daily for 2 weeks and then twice a week for another 2 weeks until surgery.
RESULTS
There were 2 out of 14 (14.3%) participants with complications in the promestriene group and 4 out of 23 (17.4%) participants in the placebo group (p=0.593). The complications were difficult cervical dilation, cervical laceration, and vaginal laceration.
CONCLUSION
Cervical preparation with promestriene did not reduce intraoperative complications in postmenopausal patients undergoing surgical hysteroscopy.
... Our research outcomes were comparable to those of several other reports [44,46,47], where hysteroscopic perforation was the most common complication, as well as Indian research with a 2.7% complication rate. However, it was higher than the prior studies, ranging from 0.8 to 1.6% [48][49][50][51]. This may be accounted for by the fact that the majority of our patients had severe intrauterine adhesions, which raised the possibility of perforation. ...
Background
Asherman syndrome is one of the endometrial factors that influence a woman’s reproductive capacity. However, in our context, it needs to be well-documented. This study aimed to evaluate the clinical characteristics and hysteroscopic treatment outcomes of Asherman syndrome.
Method
A retrospective follow-up study from January 1, 2019, to December 31, 2022, was conducted on cases of Asherman syndrome after hysteroscopic adhesiolysis at St.Paul’s Hospital in Addis Ababa, Ethiopia. Clinical data were collected via telephone survey and checklist. Epidata-4.2 and SPSS-26 were employed for data entry and analysis, respectively.
Result
A total of 177 study participants were included in the final analysis. The mean patient age was 31 years (range: 21–39) at the initial presentation, and 32.3 years (range: 22–40) during the phone interview. The majority of the patients (97.7%) had infertility, followed by menstrual abnormalities (73.5%). Among them, nearly half (47.5%) had severe, 38.4% had moderate, and 14.1% had mild Asherman syndrome. The review identified no factor for 51.4% of the participants. Endometrial tuberculosis affected 42 patients (23.7%). It was also the most frequent factor in both moderate and severe cases of Asherman syndrome. Only 14.7% of patients reported menstrual correction. Overall, 11% of women conceived. Nine patients miscarried, three delivered viable babies, and six were still pregnant. The overall rate of adhesion reformation was 36.2%. Four individuals had complications (3 uterine perforations and one fluid overload) making a complication rate of 2.3%.
Conclusion
Our study revealed that severe forms of Asherman syndrome, which are marked by amenorrhea and infertility, were more common, leading to incredibly low rates of conception and the resumption of regular menstruation, as well as high recurrence rates. A high index of suspicion for Asherman syndrome, quick and sensitive diagnostic testing, and the development of a special algorithm to identify endometrial tuberculosis are therefore essential. Future multi-centered studies should focus on adhesion preventive techniques.
... (16) Although complications of cRS procedures are rare ranging between 0.22% to 0.28 % the mHTR systems were developed in an attempt to overcome the limits of traditional hysteroscopic procedures. (17) In two systematic reviews of 650 patients and 498 patients respectively with fibroids or polyps there was no statistically significant difference in the rate of operative and postoperative complications between mHTR and cRS (18,19). Therefore, prior to initiating the surgical procedure, all hysteroscopic equipment should be connected to light sources, suction, fluid irrigation and the blade to the control unit and vacuum source. ...
... If the patient is under anesthesia, an air embolism should be suspected if there is a drop in EtCO2 pressure or hypotension, or if hemodynamic abnormalities that resemble tachycardia are present. In the literature, very few cases of clinically severe gas embolism events are linked to hysteroscopic procedures [5,6]. Various risk factors are depicted in Table 1. ...
Compared to operative hysteroscopy, diagnostic hysteroscopy rarely leads to issues. However, one very uncommon yet potentially fatal complication is air embolism, with an incidence rate of three in 17,000 cases. This report describes an unexpected complication discovered during diagnostic hysteroscopy surgery. In the course of routine infertility testing, a 29-year-old woman underwent a diagnostic hysteroscopy under general anesthesia. Intraoperatively, her end-tidal carbon dioxide (EtCO2) levels decreased, oxygen saturation dropped, and heart rate increased, leading the anesthesiologists and critical care team to terminate the procedure and manage her further. Subsequent transesophageal echocardiography confirmed the diagnosis of air embolism. She was managed with 100% oxygen and inotropes and cardiopulmonary resuscitation but despite aggressive medical interventions, her condition did not improve, and she unfortunately passed away. To diagnose, prevent, and manage the potentially devastating consequences associated with diagnostic hysteroscopy, gynecologists and surgical teams must maintain vigilance. The focus should be on proper patient selection, optimal surgical techniques, and the use of high-quality equipment to mitigate the risk of air embolism.
... Thus, timely treatment must be taken (Cholkeri-Singh and Sasaki, 2016). For patients with pregnancy needs, a second pregnancy after hysteroscopic surgery increases the risk of preterm birth, intrauterine growth delay, and prenatal death (Bradley, 2002). ...
Intrauterine adhesion (IUA), also referred to as Asherman Syndrome (AS), results from uterine trauma in both pregnant and nonpregnant women. The IUA damages the endometrial bottom layer, causing partial or complete occlusion of the uterine cavity. This leads to irregular menstruation, infertility, or repeated abortions. Transcervical adhesion electroreception (TCRA) is frequently used to treat IUA, which greatly lowers the prevalence of adhesions and increases pregnancy rates. Although surgery aims to disentangle the adhesive tissue, it can exacerbate the development of IUA when the degree of adhesion is severer. Therefore, it is critical to develop innovative therapeutic approaches for the prevention of IUA. Endometrial fibrosis is the essence of IUA, and studies have found that the use of different types of mesenchymal stem cells (MSCs) can reduce the risk of endometrial fibrosis and increase the possibility of pregnancy. Recent research has suggested that exosomes derived from MSCs can overcome the limitations of MSCs, such as immunogenicity and tumorigenicity risks, thereby providing new directions for IUA treatment. Moreover, the hydrogel drug delivery system can significantly ameliorate the recurrence rate of adhesions and the intrauterine pregnancy rate of patients, and its potential mechanism in the treatment of IUA has also been studied. It has been shown that the combination of two or more therapeutic schemes has broader application prospects; therefore, this article reviews the pathophysiology of IUA and current treatment strategies, focusing on exosomes combined with hydrogels in the treatment of IUA. Although the use of exosomes and hydrogels has certain challenges in treating IUA, they still provide new promising directions in this field.
... Furthermore, some lengthy hysteroscopic operations (such as myomectomy) require proper cervical dilation to facilitate repeated insertions of the resectoscope. Inadequate cervical dilation prior to the hysteroscopy can lead to cervical laceration, uterine perforation, and the creation of a false passage during attempts to dilate the cervix [70]. Additionally, a proper degree of cervical dilation is required to extract previously excised lesions in the uterine cavity. ...
Cervical ripening is defined as the significant softening of the cervical tissue that usually begins before the onset of contractions during labor, and is required for cervical dilation and delivery. Osmotic dilators are medical implements that dilate the uterine cervix by increasing in size as they absorb fluid from the surrounding tissue. This article aims to review the mechanisms and applications of osmotic dilators for cervical ripening in the induction of labor and in gynecology procedures.
... A Cochran review and meta-analysis did not demonstrate any significant value in pain reduction from non-steroidal anti-inflammatory medication. According to the aforementioned coach review, the use of local anesthesia during office hysteroscopy reduces intraoperative pain and immediate postoperative pain for 30 min (14) . However, to lessen intra-and postprocedure pain, the Royal College of Obstetrics and Gynaecology advised women to take the necessary doses of non-steroidal anti-inflammatory medicines one hour before the office hysteroscopy as suggested in guideline number 59. ...
... Medicine before hysteroscopic myomectomy caused serious bleeding, prolonged operation time and reduced myometrium thickness, which could lead to uterine perforation. [10][11][12][13] Unfortunately, most studies have included patients with relatively small-sized leiomyomas, and only a few studies using GnRH agonist treatment before the hysteroscopic myomectomy of large-sized leiomyomas have been reported. [14] There are studies that even large-sized submucosal leiomyomas are contraindicated in hysteroscopic myomectomy. ...
To evaluate the efficacy and safety of a gonadotropin-releasing hormone (GnRH) agonist for treating large-sized submucosal leiomyoma before hysteroscopic myomectomy.
The data were retrospectively collected from patients who underwent a hysteroscopic myomectomy for a submucosal leiomyoma >3.5 cm in size from January 2009 to December 2018. The patients were divided into the GnRH group and the control group according to whether they were pretreated before surgery.
A total of 61 patients were included in the study, 31 in the GnRH agonist group and 30 in the control group. At diagnosis, the maximum leiomyoma diameter was similar between the 2 groups (4.67 ± 0.6 cm in the GnRH agonist group vs 3.82 ± 0.6 cm in the control group, P = .061). After pretreatment with the GnRH agonist, the maximum diameter was significantly smaller in the GnRH agonist group compared to the control group (3.82 ± 0.6 vs 4.33 ± 0.8 cm, respectively, P = .004). The leiomyoma volume in the GnRH agonist group decreased by 55.6%, from 41.68 ± 15.7 to 23.19 ± 10.4 cm³, which led to significant differences in leiomyoma volume between the 2 groups (23.19 ± 10.4 cm³ in the GnRH agonist group vs 33.22 ± 24.7 cm³ in the control group, P = .042). The GnRH agonist group showed a shorter operation time (37.7 vs 43.9 minutes, P = .040) and less uterine distention media was used (6800 vs 9373.3 mL, P = .037) compared to the control group. Postoperative complications such as estimated blood loss, remnant leiomyoma, and recurrence were similar between the 2 groups.
Treatment with a GnRH agonist before hysteroscopic myomectomy for large submucosal leiomyoma might decrease the volume of the leiomyoma, reduce operation time, and the amount of uterine-distension media used without surgical complications.
... Uterine myomectomy and polypectomy are among popular conventional and minimally invasive gynecological procedures in hysteroscopy (20). Despite numerous advantages of the hysteroscopic, absorption of irrigation fluid is one of the complications leading to hypervolemia in 3-6% of women (21). Hypotonic solutions, including a mixture of mannitol and sorbitol or glycine, are broadly used as hysteroscopic irrigation fluid. ...
Objectives: One of the most prevalent benign tumors in women is uterine leiomyoma. Large quantities of fluid absorbed during myomectomy may cause serious problems such as volume overload and hyponatremia. The aim was to see how intraoperative oxytocin infusion affected irrigation fluid absorption in individuals having hysteroscopic myomectomy. Materials and Methods: 50 women between 25-45 years who underwent hysteroscopic myomectomy and had an American Society of Anesthesiologists class I or II were evaluated in this randomized, double-blind clinical trial study. A 250 mL ringer solution containing 15 units of oxytocin was administered at a 125 mL/h in the oxytocin group (group S). In contrast, the placebo group (group P) received 1.5 mL of normal saline in the same amount of Ringer solution. Intraoperative hemodynamic alterations, fluid deficit, decreased hemoglobin, hematocrit, sodium, and albumin levels from baseline, complications, and the incidence of toxicity with the administered solutions were assessed intraoperative and 24 hours later. Results: Group S had considerably reduced irrigation fluid volume (P=0.021) and volume deficit (P=0.001). The frequency of hypotension in individuals receiving oxytocin did not differ significantly from the placebo group (P=0.26). In group S, serum hematocrit (P=0.036) and sodium (P=0.026) were decreased significantly. Conclusions: Intraoperative oxytocin infusion during hysteroscopic myomectomy may be associated with reduced irrigation fluid absorption and the problems that come with it. As a result, this approach might decrease the risks associated with high amounts of irrigation fluid being absorbed during hysteroscopic myomectomy.
... Cervical tears, uterine perforation, failed cervical dilatation, hemorrhage, and bowel and bladder injury are procedure-related complications. 15 However, systematic reviews have shown lower complication rates with misoprostol compared with placebo 7,9,13 and clinical trials evaluating misoprostol doses before operative The principal limitation of the present study is its sample size, based on cervical width. As we could not find a similar study in our bibliographic research, the sample size was calculated based on a paper that compared misoprostol 1000 μg with placebo. ...
Objective
To compare between 200 and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy.
Methods
Quadruple‐blind randomized clinical trial conducted between November 2019 and September 2020 involving 76 patients undergoing cervical dilatation before surgical hysteroscopy at teaching hospitals in Pernambuco, Brazil. Women received the vaginal misoprostol dosage of 200 or 800 μg,10–12 h before operative hysteroscopy. The cervical width was the primary outcome, and secondary outcomes were patient satisfaction, adverse effects, surgical complications, and duration of cervical dilatation. Chi‐square tests of association, Fisher's exact and Mann–Whitney U tests were used with an α error of <5%.
Results
There was no statistical difference between the groups in the mean of the cervical width (800 μg: 6.5 ± 1.6 mm vs 200 μg: 5.8 ± 1.8 mm, P = 0.055), patient satisfaction, and surgical findings, but the duration of cervical dilatation was lower in the 800‐μg group (28.16 ± 28.5 s vs 41.97 ± 31.0 s, P = 0.035). Among the adverse effects, diarrhea was more frequent in the 800‐μg group with statistical difference (100% vs 0%; P = 0.01).
Conclusion
For cervical ripening, 200 μg misoprostol is equally effective with fewer adverse effects than 800 μg before operative hysteroscopy. ClinicalTrials.gov: NCT04152317. https://clinicaltrials.gov/ct2/show/NCT04152317.
... Although diagnostic hysteroscopy is considered a safe procedure, the estimated risk of complications is 5%. 8,9 It is an invasive procedure and is associated with various complications 8,10,11 such as venous air embolism, urinary system trauma, fluid overload, uterine perforation, and hemorrhage. 12 Furthermore, diagnostic hysteroscopy is frequently performed under anesthesia, and is timeconsuming and expensive. ...
Objective
To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy.
Methods
This retrospective cohort study included all women referred to a university‐affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub‐group analysis relating to polyp size and other parameters.
Results
We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post‐menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV.
Conclusion
TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients.
... Adverse events for HSR procedures include peri-operative perforation of the uterus, bleeding, development of post-operative intrauterine adhesions and uterine rupture during subsequent pregnancy. The latter complication is very rare, but potentially catastrophic if not timely recognized and properly managed [26,27]. Indeed, although limited evidence suggests that patients who underwent hysteroscopic metroplasty for septate uterus are at no higher risk of adverse obstetric outcome at term and during labor [28,29], data are still scarce to draw a firm conclusion about the risk of uterine rupture: this complication is extremely serious and life-threating, and may also lead to maternal and fetal death in case of massive bleeding. ...
Purpose:
Uterine torsion (UT) in pregnancy is a rare condition in obstetric practice. It is defined as a rotation of the uterus of more than 45° around its long axis. Presentations are varied and, most of the time, this condition is recognized at laparotomy or cesarean section (CS). The aim of this study is to summarize the latest evidence about UT in pregnancy.
Methods:
A systematic research of the literature was conducted fetching all papers published from March 2006 to June 2020. We collected data regarding clinical features, treatment, and feto-maternal outcomes. Finally, we reported data of a case of UT associated with intrauterine growth restriction (IUGR) diagnosed and treated at our institution.
Results:
According to our search strategy, 38 articles were included. In 66% of the cases, acute symptomatology was present at the onset, most frequently abdominal pain was reported. In one-third of the cases, UT was diagnosed during CS without clinical suspicion. Only in two cases, including our case, IUGR was reported. Most (66%) of the cases presented a 180° torsion. In the majority of the cases, a CS was performed also with a deliberate or accidental posterior hysterotomy. One and six cases of maternal and fetal death were, respectively, reported.
Conclusion:
UT is an infrequent obstetric condition but should be considered in case of abdominal pain, vomiting, or shock presentation during pregnancy. It could lead to a reduction in uterine blood flow contributing to poor placental perfusion, even though more evidence is needed to clarify this link.
... The overall complication rate for hysteroscopy is around 2%. 1 Various complications reported are uterine perforation (0.76% in operative , 0.13% in diagnostic), fluid overload (0.2% in operative and nil in diagnostic) 2 and infectious complications (0.85% in operative hysteroscopy, no data for diagnostic). 3,4 Gas embolism is a hazardous complication of hysteroscopy and an incidence of 10% to 50% has been reported in a number of fatal or near-fatal cases. 5,6 Fatal and nonfatal venous air embolism (VAE) is described in several neurosurgical, laparoscopic, orthopedic, gynecological, and hysteroscopic surgeries as well as in association with central venous access devices and intraosseous cannulas. ...
... Complications associated with procedures include uterine and bladder perforation, cervical laceration, pelvic infection and haemorrhage. 29 Complications associated with distension media can be prevented by monitoring the usage and fluid loss during the surgery. 30 All serious adverse events will be reported to the Medical Ethics Committee. ...
Introduction
Recently, the rate of caesarean sections (CS) worldwide has risen and CS-associated complications such as niche have increased substantially. Until now, evidence-based clinical guidelines for the treatment of niche-related symptoms remain absent. In patients with postmenstrual spotting, it has not been studied if the effect of levonorgestrel 52 mg intrauterine system (LNG-IUS 52 mg) is superior to that of hysteroscopy. This study will answer the question of whether LNG-IUS 52 mg is more effective in improving postmenstrual spotting than hysteroscopic niche resection in women with niche-related spotting at 6 months after randomisation.
Methods and analysis
This is a randomised controlled trial. A total of 208 women with postmenstrual spotting related to niche in the caesarean uterine scar of at least 2 mm and residual myometrium of at least 2.2 mm evaluated by MRI will be included. Women desiring to conceive within 1 year, with contraindications for LNG-IUS 52 mg or hysteroscopic surgery will be excluded. After informed consent is obtained, eligible women will be randomly allocated to LNG-IUS 52 mg or hysteroscopic niche resection at 1:1. The primary outcome is the efficacy in reducing postmenstrual spotting at 6 months after randomisation. The secondary outcomes include menstrual pattern, total days of blood loss per month, rate of amenorrhoea, side effects and complications.We will use a Visual Analogue Scale for chronic pelvic pain, urological symptoms and women’s satisfaction (five-point Likert scale).
Ethics and dissemination
The study was approved by the local medical ethics committee and by the Institutional Review Board of the International Peace Maternity and Child Health Hospital, Shanghai, China (No. GKLW 2019-08). Participants will sign a written informed consent before participation. The results of this study will be submitted to a peer-reviewed journal for publication.
Trial registration number
ChiCTR1900025677.
... Prostaglandins (PGs) are used as a safe way to dilate and soften the cervix in several office procedures leading to a less painful and technically easy procedure such as OH and intrauterine device (IUD) insertion [7][8][9]. Pre-procedure cervical ripening agents such as misoprostol and dinoprostone decrease OH pain and complications, although the evidence is conflicting [10,11]. ...
Study objective:
To determine optimal timing of vaginal dinoprostone administration before office hysteroscopy (OH) in nullipara.
Design:
Randomized double-blinded trial SETTING: Tertiary referral hospital PATIENTS: 180 nulliparous women undergoing diagnostic OH INTERVENTIONS: We randomly allocated women to long-interval or short-interval dinoprostone groups where 3 mg dinoprostone was administered vaginally 12 hours before OH in long-interval group or 3 hours before OH in short-interval group.
Measurements and main results:
The primary outcome was pain during OH measured by a 100-mm visual analog scale(0=no pain; 100=worst pain imaginable). Secondary outcomes were ease of hysteroscope passage, women satisfaction score, drug side effects. Long-interval dinoprostone had lower pain scores during OH(P <0.001). Contrarily, pain scores 30 minutes postprocedure were similar in both groups(P=0.1). Women were more satisfied, and clinicians found hysteroscope passage through the cervical canal easier and shorter in long-interval dinoprostone group than short-interval group(P<.001&P=0.003 &P<.001, respectively). Side effects were comparable in both study groups.
Conclusion:
Vaginal dinoprostone 12 hours before OH was more effective than vaginal dinoprostone administrated 3 hours before OH in reducing pain during OH in nulliparous patients with easier hysteroscope insertion, shorter procedure duration, and better women satisfaction score.
... Removal of septum during laparoscopy and hysteroscopy even when it is an incidentally finding is a safe procedure; it takes short time; it has low morbidity and hospital stay and results to significant improvement in obstetric outcome, and however the risk of postoperative adhesion is reduced [14]. ...
The purpose of study is to assess reproductive outcome in patients with septate uterus who have undergone hysteroscopic metroplasty by monopolar resectoscope. Nine hundred forty-eight women with septate uterus who were evaluated for infertility were included in this cohort study. All of them had hysteroscopic septum resection by monopolar resectoscope. They used hormone for 2 months after procedure, and hysterosalpingography was done for evaluating uterine cavity after surgery. The age, cause of infertility, pregnancy rate per cycle, and reproductive performance after surgery were evaluated in intracytoplasmic sperm injection (ICSI), frozen embryo transfer (FET), and intrauterine insemination (IUI) cycles. The mean age of patients in ICSI, FET, and IUI group was 34.78±2.25, 34.25±2.37, and 31.03±1.52, respectively. One hundred forty (23.9%) women in ICSI group and 60 (36.8%) women in frozen embryo transfer group and 42 (20.8%) patients in IUI group got pregnant after procedure. The main factor of infertility in ICSI and FET group was male factor 46.2% and 52%, respectively, while in IUI group, ovulatory factor was 39.9%. There was no uterine perforation in patients. Hysteroscopic metroplasty is a safe, simple, and effective procedure that improve reproductive outcome in infertility patients.
... Other complications include cervical tear, creation of false passage and uterine perforation. 1 Jansen et al. reported that uterine perforation was the most frequent surgical complication with a rate of 0.76%; 54.5% of those occurred during entry. 2 Half of the complications were entry-related, so attention has to be paid to the method of entry with hysteroscope. 3 The incidence of these complications could be reduced if the cervix is ripened before the procedure. 4 Cervical priming prior to hysteroscopy lessens the need of further cervical dilation pre-operatively, lessens the complications associated with the entry of the hysteroscope into the cervical os and offer minimal side effects and minimise the chances of failure to complete the procedure. ...
Background: Hysteroscopy a minimally invasive approach for evaluating uterine cavity, and has become an indispensable diagnostic and therapeutic procedure. The main limiting factor while performing office hysteroscopy is the level of pain or discomfort encountered during the procedure. The pain is attributed mainly to the difficulty in entering the internal cervical os with the hysteroscope and while distending uterine cavity. It could be reduced if cervix is ripened before the procedure. The purpose of this prospective observational study was to compare the effectiveness, adverse effects and surgery-related complications associated with two different doses of sublingual Misoprostol (100 and 200 µg) given 2-4 hours before hysteroscopy.Methods: A randomised comparative study was conducted in the department of Obstetrics and Gynaecology of ABVIMS and Dr. RML hospital New Delhi, from 1st November, 2018 to 31st March, 2020. One hundred and twenty women, fulfilling inclusion criteria were subjected to hysteroscopy. Women received either 100 µg (Group I) or 200 µg (Group II) of sublingual Misoprostol 2-4 hours prior to hysteroscopy. The primary outcome of the study was cervical dilatation as measured by the largest number of Hegar dilator that could be inserted without resistance at the beginning of procedure. The largest dilator that negotiated cervical canal without resistance at the beginning of procedure was recorded as the baseline cervical width. The secondary outcomes were subjective assessment of the surgeon of the ease of dilatation of cervix and adverse effects of drug (i.e. vaginal bleeding, shivering, fever and pain as measured on visual analog scale).Results: The mean baseline cervical width as measured by first Hegar dilator that could be passed through the cervical canal without resistance was 6.6±0.62 mm in group I and 6.94±1.21 mm in group II respectively (p value=0.016). Adverse effects like vaginal bleeding, shivering was more in group II compared to group I. No statistically significant difference was found between group I and II with regards to visual analog scale.Conclusions: 100 µg Misoprostol can be used for cervical ripening prior to hysteroscopy with minimal adverse effects.
... Adverse events for HSR procedures include peri-operative perforation of the uterus, bleeding, development of post-operative intrauterine adhesions and uterine rupture during subsequent pregnancy. The latter complication is very rare, but potentially catastrophic if not timely recognized and properly managed [26,27]. Indeed, although limited evidence suggests that patients who underwent hysteroscopic metroplasty for septate uterus are at no higher risk of adverse obstetric outcome at term and during labor [28,29], data are still scarce to draw a firm conclusion about the risk of uterine rupture: this complication is extremely serious and life-threating, and may also lead to maternal and fetal death in case of massive bleeding. ...
Introduction
In this study, we reviewed the cases of uterine rupture in our setting, identified which of them had previously undergone hysteroscopic septum resection (HSR), and evaluated the main clinical characteristics for each case.
Material and methods
We retrospectively analyzed (ClinicalTrial ID: NCT04449640) the delivery outcomes from the National Perinatal Information System of the National Institute of Public Health of the Republic of Slovenia of the last 20 years (1 January 1999 − 31 December 2019) and cross-linked the patients with surgical data from our electronic database. We collected baseline characteristics, surgical details and obstetrical outcomes. We excluded women who had undergone previous myomectomy or cesarean section (CS) and described the clinical course of each case since no statistical analysis was performed.
Results
We found four patients who had uterine rupture in pregnancy after HSR. Median time to pregnancy was 17 months (range 1–60), all the women underwent CS and fetal-maternal outcomes were acceptable in half of the cases. Symptoms were nonspecific and included pain, fetal distress and vaginal bleeding.
Conclusion
Uterine rupture in pregnancy after a previous HSR is a very rare, but life-threatening event. Prompt diagnosis can ensure successful management and avoid adverse maternal-fetal outcomes.
... However, there are common operative complications, such as uterine perforation, excessive bleeding and fluid overload. 2 Uterine perforation is the most severe complication during TCR (using an electrode). Thermal bowel injury, arising from the use of activated electrosurgical loop, has been implicated in uterine perforation during TCR. 3 In such cases, the site of the injury should be confirmed and immediately repaired either by laparotomy or laparoscopy. ...
Transcervical resection is widely used in the management of submucosal fibroids. However, uterine perforation and thermal bowel injuries are known complications associated with the procedure. This is a case report of a 44-year-old woman who presented with heavy menstrual bleeding and anemia. Magnetic resonance imaging and hysteroscopy revealed multiple fibroids, including a submucosal type 1 fibroid. She had previously undergone a total proctocolectomy with intestinal pouch-anal anastomosis for ulcerative colitis. Because there was a high risk of permanent colostomy in the event of a bowel injury, an electrode-free, operative hysteroscopy using the Intrauterine Bigatti Shaver (IBS), a hysteroscopic morcellator system, was employed to prevent thermal bowel injury. The fibroid was completely removed using the IBS system with no complications. Therefore, we recommend the electrode-free use of a hysteroscopic morcellator system in patients with a history of extensive pelvic surgery.
Introduction
This case of misoprostol-induced coronary vasospasm demonstrates the rare but potentially serious cardiac-related adverse events which arose from the use of misoprostol in a young healthy adult with no past cardiac history of note.
Case Presentation
A 37-year-old female with a history of idiopathic vasculitis but no known cardiovascular risk factors was administered misoprostol vaginally for an elective outpatient hysteroscopy. She developed typical cardiac symptoms of severe chest pain and her initial electrocardiogram demonstrated changes mimicking an anterolateral ST-elevation myocardial infarction. Fortunately, her symptoms resolved shortly before her presentation to the Emergency Department, and her cardiac troponin levels were within normal limits. She underwent further workup during her inpatient stay in a Cardiology ward which revealed no evidence of coronary artery disease, and she was discharged with the rare diagnosis of misoprostol-induced coronary vasospasm.
Discussion and Conclusion
This case illustrates the importance of physician awareness to patients who present with cardiac symptoms following misoprostol administration. We recommend that misoprostol be administered with caution in patients with vasculitis or traditional cardiovascular risk factors and that these high-risk patients should be counselled for the potential of rare but serious cardiac-related adverse events arising from coronary vasospasm.
Aim
To compare and evaluate the efficacy of the levonorgestrel‐releasing intrauterine system (LNG‐IUD) and resectoscopy remodeling procedure for intermenstrual bleeding associated with previous cesarean delivery scar defect (PCDS).
Methods
A retrospective comparative study was conducted on patients with PCDS receiving LNG‐IUD (levonorgestrel 20 μg/24 h, N = 33) or resectoscopy remodeling ( N = 27). Treatment outcomes were compared over 1, 6, and 12 months. Outcomes in patients with a retroverted or large uterus size, defect size, and local vascularization also were evaluated.
Results
At 12 months post‐treatment, there were no significant differences between groups in efficacy rate; however, the reduction of intermenstrual bleeding days was higher in the LNG‐IUD group than in the resectoscopy group (13.6 vs. 8.5 days, p = 0.015). Within the first year, both groups experienced a reduction in bleeding days, but the decrease was greater in the LNG‐IUD group. Individuals exhibiting increased local vascularization at the defect site experienced more favorable outcomes in the LNG‐IUD group than the resectoscopy group ( p = 0.016), and who responded poorly tended to have a significantly larger uterus in the LNG‐IUD group ( p = 0.019). No significant differences were observed in treatment outcomes for patients with a retroverted uterus or large defect in either group.
Conclusions
Our findings support that the LNG‐IUD is as effective as resectoscopy in reducing intermenstrual bleeding days associated with PCDS and can be safely applied to patients without recent fertility aspirations. Patients with increased local vascularization observed during hysteroscopy may benefit more from LNG‐IUD intervention than resectoscopy.
Objectives:
To analyze the risk factors of sulfur hexafluoride microbubble contrast agent intravasation during hysterosalpingo-contrast sonography (HyCoSy), and to explore a simple prediction model by the obvious clinical history.
Methods:
This was a retrospective study included 299 infertility women who had undergone HyCoSy examination from July 1, 2018 to June 31, 2019. The factors were recorded, including age, endometrial thickness, balloon length, infertility type, history of intrauterine surgery, history of pelvic surgery, and tubal patency. The method of multivariate logistic regression analysis was adopted to analyze the risk factors affecting the contrast agent intravasation, and the receiver operating characteristic curves were plotted to test their efficacy.
Results:
Secondary infertility, a history of intrauterine surgery, thin endometrial thickness, and tubal obstruction were all risk factors of the occurrence of intravasation (P < .05). And the area under the receiver operating characteristic curves of the multifactor-combined prediction model of the intravasation was significantly larger than that of single-factor.
Conclusions:
Sonographers and gynecologists should be familiar with the risk factors of intravasation and select the appropriate timing of HyCoSy toward reducing the occurrence of intravasation and other complications after thoroughly explaining and communicating with the patients.
Introduction
We aimed to reveal the effectiveness of hysteroscopic septum resection on the reproductive outcomes of infertile patients.
Material and methods
We included 46 infertile women who underwent hysteroscopic septum resection of septate uterus (complete: group 1, n = 21; incomplete: group 2, n = 25). Only patients with a septate uterus as the cause of infertility were included in the study. Patients’ age, body mass, duration of infertility, type of infertility, duration of surgery, surgical complications, remnant septa, and postoperative reproductive results were recorded.
Results
Preoperative abortion was found to be nine (42.9%) in group 1 and 15 (60.0%) in group 2. In the postoperative control HSG, remnant septa was found to be significantly higher in group 1 compared to group 2 (three patients or 14.3% and 0%, respectively). Pregnancy was detected in 13 patients (61.9%) in group 1 and 18 patients (72%) in group 2 at the postsurgical follow-up. Abortion occurred for two patients (9.5%) in group 1 and three patients (12%) in group 2.
Conclusion
We obtained positive growth results after hysteroscopic septum resection in both the complete and incomplete cases. However, we found that the duration of surgery was prolonged and the rate of remnant septa increased in cases with a complete septum.
Advances in operative hysteroscopy make the procedure easily accessible in our clime as a result of the safe perioperative environment that anaesthesia provides. Some of the procedures are done on day case basis with the aim of fast-tracking recovery for home readiness. All elements of the pre-anaesthetic review and the choice of the appropriate anaesthetic technique, judicious use of intraoperative fluid, and adequate patient monitoring influence the satisfactory outcome. Operative hysteroscopy could be done under general anaesthesia with or without tracheal intubation, single-shot spinal technique, combined spinal and epidural technique and epidural technique. Regional anaesthesia with the single-shot spinal technique is widely used except for cases of absolute contraindications.
Even though uterine fibroids are extremely common, location tends to play a pivotal role in whether they are symptomatic or cause issues with fertility. Submucosal fibroids have the most profound impact on fertility and bleeding and are thus most important to address. Surgical excision of submucosal subtype of fibroids is the mainstay of therapy. Larger size and deeper location within the uterine wall pose challenges to surgery. This chapter will summarize a general approach to submucosal fibroids and explain the rationale for therapy. Various approaches to submucosal myomas will be highlighted and key preop considerations, intraoperative surgical issues, and tips and tricks for successful excision in one surgical sitting will be discussed. Finally, common surgical complications will be included at the end of the chapter.
Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.
Background
False passage is a possible complication during operative hysteroscopy and can lead to termination of the intended procedure. The aim of this study is to describe two techniques to overcome the complication of false passage during operative hysteroscopy.
Results
This is a retrospective case series of 9 patients who had a false passage during operative hysteroscopy for Müllerian anomaly or endometrial polyps. The diagnosis was immediately made by visualization of a lattice network of myometrial fibers without normal landmarks of the endometrial cavity and tubal ostia. Once a false passage was suspected, an attempt was made to overcome this complication and complete the intended operative hysteroscopy. The hysteroscope was slowly withdrawn to identify both the false passage and the opening towards the internal cervical os. The hysteroscope was tilted towards the opening to the internal cervical os, and it was carefully advanced under direct vision into the endometrial cavity. In two patients, this technique failed because the opening to the internal cervical os was small, so the bridge of tissue between the internal os and false passage was partially divided using hysteroscopic scissors or a straight resectoscope loop, allowing for entry into the endometrial cavity. The intended procedures were completed successfully in all patients. No intraoperative or postoperative complications occurred as a result of the two techniques.
Conclusions
The techniques described in this study, to overcome false passage during operative hysteroscopy, appear to be safe, effective, and easy to perform. They enable the surgeon to complete the intended procedure.
The aim of this prospective study was to analyse the complications of operative hysteroscopy over the last 25 years and determine whether such complications were related to patient characteristics, surgery type, surgical time or distension-medium balance. Three thousand and sixty-three operative hysteroscopies were performed; 52.7% were polypectomies and 31.5% were myomectomies. Myectomies had the highest incidence of complications, at 14%, followed by septolysis, at 6.9%. The most common complications were mechanical (52%). Myomectomies had seven times higher risk than polypectomies of distension-medium complications (RR 7.5, p
To estimate the prevalence and types of intrauterine abnormalities in subfertile women: a prospective study was carried out at Albayda Fertility Teaching Centre-Libya. The study was conducted on 115 infertile women attending Albayda Fertility Centre between January and May 2019. Diagnostic hysteroscopy was conducted after initial basic infertility assessment workup to assess the presence and types of uterine cavity pathologies. The duration of infertility ranged from 1-17 years, and the majority of the patients were presented with primary infertility (62.6%), 64.3% of the women had abnormal findings, and the most common lesion detected was endometrial polyp representing 44.6% of the lesions, followed by endometritis 17.6%. Seven cases had septum, and 20 patients had more than one pathology. Corrective measures were taken accordingly. 6.1% of the patients had a spontaneous pregnancy within three months of follow up. The prevalence of abnormal hysteroscopy findings among the studied population was high. Intrauterine endometrial polyps, endometritis, and uterine septum were the most frequent abnormality detected. These findings may indicate a need to incorporate hysteroscopy in the routine evaluation of infertility.
The pharmacologic preparation of the endometrium before hysteroscopy may be achieved with the use of various drugs. This systematic review aims to summarize the available evidence regarding the use of desogestrel for endometrial preparation before hysteroscopic procedures. A literature search for suitable articles published in English language from inception of the database until August 2019 was performed using the following databases: PubMed/MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. All original articles concerning desogestrel-only pretreatment before hysteroscopic surgery were considered eligible. Reviews, case reports/series, conference papers, studies including the use of combined hormonal preparation, and articles in languages other than English were excluded from the analysis. The literature search retrieved 3 studies that met all the inclusion criteria. The data demonstrated that desogestrel may be considered as a hormonal pretreatment drug before hysteroscopic procedures. The drug was distinctly effective and assessed as helpful by the operating surgeon in numerous patients who were administered the pretreatment of 75 μg daily. Oral desogestrel is a cheap, easily available, safe, and quite efficient alternative for endometrial preparation before hysteroscopic procedures.
This chapter discusses the history of hysteroscopy, emerging technology, and potential applications in adolescent gynecology, including both diagnosis and for therapeutic procedures, with approaches that preserve the hymen. Hysteroscopy is safe and with rare complications, particularly when performed with a narrow diameter hysteroscope. Potential vaginal, cervical, and endometrial pathologies that are closely associated with endometriosis are also described, demonstrating the utility of hysteroscopy when assessing endometriosis. Hysteroscopy is also useful for evaluating and treating dysfunctional bleeding, dysmenorrhea, recurrent discharge, abnormal imaging of the genital tract, genital tract anomalies, adenomyosis, polyps, and myomas.
Leiomyoma, often called as myoma, is the most common benign neoplasm in the female genital tract [1]. It is estimated to be caused by oestrogens and progesterones which proliferate tumour growth. Hence, fibroids are a rare occurrence before menarche and reduce after menopause.
Uterine fibroids are very common in women of reproductive age and are mostly benign. However, they are often a cause of abnormal bleeding and, in severe cases, can cause infertility. This comprehensive guide reviews the clinical management of uterine fibroids, with a particular focus on practical surgical techniques. Engage with topics such as the anatomy of the pelvis, key theatre equipment and surgical treatments including hysteroscopic and laparoscopic techniques. Features also include debates around morcellation, and less invasive treatments such as uterine artery embolisation are also covered. An online video library of surgical procedures reinforces the practical techniques taught in the book and detailed colour images supplement the book's thorough coverage of fibroid management. This makes Modern Management of Uterine Fibroids an essential resource for practicing gynaecologists and IVF specialists, as well as students.
Pregnancy following endometrial ablation is uncommon, and the literature does not allow an estimation of the likelihood of complications. Women with Asherman's syndrome, which is regarded as similar to a postablation uterus, have a 30% chance of progressing to term delivery. We report four pregnancies following endometrial ablation, bringing the total number of published cases to 37. The outcomes are analyzed to provide evidence for patient counseling and for management of those women who are pregnant following endometrial ablation. Just over half of the reported pregnancies following endometrial ablation were therapeutically aborted, and an additional 11% aborted spontaneously. The 11 continuing pregnancies were complicated by perinatal death in 2 (18%) and intrauterine growth retardation in 5 (45%). There was premature rupture of membranes in 3 (27%), preterm delivery in 7 (64%), and placenta accreta in 6 (55%). Preterm deliveries were by emergency cesarean section, except in 1 case, and all placental adherence complications occurred in this group. Three women required hysterectomy. Only 4 (36%) continuing pregnancies reached term, and 3 of these were delivered by elective cesarean section. No term pregnancy had a third stage complication.
To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost.
A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage.
Office-based hysteroscopy suite in the outpatient building of a tertiary institution.
Women referred to this institution for gynecologic evaluation between February 1992 and December 1993.
Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block.
A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475.
Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.
To assess the frequency of clinically apparent and undetected cardiopulmonary emboli during diagnostic CO(2) hysteroscopy, to determine the causes of these events, and to define a risk profile.
Retrospective and prospective case study (Canadian Task Force classification II-2).
Obstetric-gynecologic clinic of an academic teaching hospital.
Five thousand one hundred ninety-three women.
Diagnostic CO(2) hysteroscopy performed between September 1990 and December 1998. MEASUREMENTS and
From September 1990 to December 1996, 1 (0.03%) severe but nonfatal embolism occurred in 3932 diagnostic CO(2) hysteroscopies. Undetected emboli were present in 20 patients (0.51%). Starting in January 1997 the gas supply tube (volume 40 ml) was deaerated before the procedures, and no emboli occurred in the next 1261 examinations up to December 1998. The decrease in frequency was statistically significant (p = 0.009). No pathologic flow sounds were found in any of 50 hysteroscopies monitored by Doppler stethoscope.
A manifest gas embolism is rare in diagnostic CO(2) hysteroscopy. The 10% to 50% frequency of undetected gas emboli cited by other authors could not be confirmed. If the supply tube system that holds room air is purged with CO(2) before the procedure, the already low risk drops to zero or almost zero, confirming the theory that emboli that occur during CO(2) hysteroscopy are caused by room air.
During a diagnostic CO2-hysteroscopy in general anesthesia, a manifest gas embolism with a resulting drop of the endexpiratory CO2 partial pressure occurred upon insertion of the instrument. By ending the procedure and through appropriate anesthesiological measures, the occurrence was brought under control and the embolism had no clinical consequences. The incidence encouraged us to reconsider the CO2-hysteroscopy examination technique. As a result, we describe an up to now neglected mechanism which may lead to air embolism in gas hysteroscopy: Similar to hysteroscopy with fluid distension, the whole system has to be purged from air by insufflating CO2 prior to examination. If this step is neglected, up to 40 cm3 of room air may be insufflated into the patient, considering a connective tubing of 200 cm length and 0.5 cm lumen. The scientific organisations as well as the endoscopic training centers and the manufacturers of hysteroflators are challenged to deal with this newly described potential cause of complications.
To evaluate the efficacy and safety of ultrasound (US) guidance as compared to laparoscopic monitoring during operative hysteroscopy.
Prospective, open study including 81 patients undergoing operative hysteroscopy under US guidance for uterine septum and submucous myoma. Clinical and surgical outcomes were compared with those in an historical control group of 45 patients undergoing the same operation under laparoscopic guidance.
US guidance proved satisfactory in all patients, and there were no complications due to insufficient visualization of the pelvic structures; in no case was conversion to laparoscopic guidance required. US scanning was most useful in determining the outer limit of the intramural component of submucous partial intramural myoma, allowing complete resection. During metroplasty, US guidance allowed extension of the resection beyond the normal limit conventionally defined by hysteroscopy; none required reintervention. By comparison, in the control group, a second attempt was required because the operation was insufficiently radical in four patients.
US guidance was used successfully as the only visual aid for hysteroscopic surgery, comparing favorably with laparoscopy in terms of efficacy and safety.
The late complications of operative hysteroscopy result from either persistent endometrium after ablation or myometrial damage during surgery. Residual endometrium can become neoplastic, cause pain, or support a pregnancy. Myometrial damage can produce catastrophic consequences during a later pregnancy. These long-term problems place the impetus on the operating physician to select patients carefully, prepare the endometrium, and operate in such a way as to minimize the likelihood of residual endometrium and unnecessary myometrial damage. The value of operative hysteroscopy for infertility secondary to adhesions and uterine septa is unequivocal. Hysteroscopic surgery offers increased fertility rates while avoiding the risks of open surgery. For the treatment of abnormal uterine bleeding, endometrial ablation can be performed safely, and the long-term benefits are durable. As more operative hysteroscopy is performed, more delayed complications will arise. Easy-to-perform global ablation techniques and multifunctional operative hysteroscopes have enticed more gynecologists to test the waters of endometrial ablation and operative hysteroscopy. Although they empower the hysteroscopist to offer more advanced and more valuable minimally invasive options to patients, these tools simultaneously can tempt the surgeon to forego meticulous preoperative evaluation. Evidence exists that too often women undergo surgery without complete diagnostic assessment. In one study, 50% of women underwent hysterectomy without any diagnostic evaluation of the endometrium. Hysterectomy possesses a saving grace in that it provides cover for many missed diagnoses. Conservative, nonextirpative procedures offer no such life raft. Meticulous diagnostic assessment and preoperative consideration of risk factors for residual endometrium and future pregnancy remain the keys to minimizing late complications.
With preoperative evaluation, meticulous technique, and vigilance for impending problems, intraoperative and early postoperative complications of operative hysteroscopy are largely preventable. Fluid overload is the most common serious complication. The hysteroscopist must understand the significant differences between hypotonic, electrolyte-free distention media and isotonic, electrolyte-containing media and their respective sequelae. As new operative tools become available, hypotonic and electrolyte-free distention media may become obsolete. The physiology and management of air embolism, the most grave intraoperative complication, are essential to the knowledge base of any active hysteroscopist. Mechanical accidents, anesthetic complications, laser and electrical injury, and infections can be reduced by knowledge and preparation. Technologic advances, ongoing research, and postgraduate training in hysteroscopic technique continue to expand the safe and beneficial applications of hysteroscopy into the next century.
Objective:
To assess the efficacy of lignocaine gel in reducing the overall pain and pain of individual steps during outpatient hysteroscopy in comparison with placebo (no anesthesia).
Design:
A prospective, randomized, double-blind, placebo-controlled trial.
Setting:
Outpatient hysteroscopy clinic in a regional hospital in Hong Kong.
Patient(s):
A total of 500 Chinese patients undergoing outpatient hysteroscopy.
Intervention(s):
Application of lignocaine gel to the cervix during outpatient hysteroscopy.
Main outcome measure(s):
Mean pain score using present pain intensity, overall pain score measured by total area under the curve, and the pain score of individual steps in the procedure in patients receiving lignocaine gel were compared with those of patients having no anesthesia. The failure rate and poor-view rate in both groups were also compared.
Result(s):
There were no statistically significant differences in mean pain score, overall pain score, and pain score of individual steps between the lignocaine group and controls. The failure rate and poor-view rate also showed no statistically significant differences.
Conclusion(s):
Outpatient hysteroscopy without anesthesia is acceptable to most Chinese women, and the local application of lignocaine gel is not effective in reducing pain.
To estimate the incidence of complications of diagnostic and operative hysteroscopic procedures in the Netherlands and describe their nature.
Data on complications were recorded by 82 hospitals in 1997. Participating hospitals had a 100% response rate. Any unexpected events that required intraoperative or postoperative intervention were defined as complications in two groups: approach (entry-related) and technique-related (caused by surgical instruments).
Thirty-eight complications occurred among 13,600 hysteroscopic procedures (rate 0.28%). Diagnostic hysteroscopic procedures had a significantly lower complication rate (0.13%) than operative procedures (rate 0.95%; P <.01). Fluid overloads of distention medium were recorded five times (rate 0.20%). The most frequent surgical complication was perforation of the uterine cavity (rate 0.76%). Approximately half the perforations (18 of 33) were entry-related. Bleeding caused by perforation was seen in 0.16% of cases. Incidences of complications were: intrauterine adhesiolysis 4.48%, endometrium resection 0.81%, myomectomy 0.75%, and removal of a polyp 0.38%.
Diagnostic hysteroscopic procedures had very low complication rates, so are safe procedures with which to evaluate intrauterine pathology. Operative hysteroscopic procedures were more risky, but the removal of polyps had a very low complication rate (12 times lower than synechiolysis). Half the complications were entry-related, so attention has to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision). The other half of complications were related to surgeons' experience and type of procedure.
To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure.
We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions.
Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4-7 times higher odds for operative complications.
Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.
To investigate the effectiveness of vaginal misoprostol for cervical priming before operative hysteroscopy and to assess the cervicouterine complications related to cervical dilatation and hysteroscopic surgery in nulliparous women.
One hundred fifty-two women with definite intrauterine lesions were randomly assigned to receive either 200 microg vaginal misoprostol or placebo. Cervical response and outcome and complications of operative hysteroscopy were assessed.
Thirty-five subjects were needed in each arm to detect a type I error of 0.01 with a power of 0.99. The mean cervical dilatation estimated by Hegar dilator was significantly different between the treated group (7.3 +/- 0.7 mm) and the control group (3.8 +/- 1.1 mm, P <.001). In the misoprostol group, 55 (75.3%) patients needed cervical dilation, compared with 75 (94.9%, P =.001) in the placebo group. The median time of cervical dilation to Hegar number 9 was significantly shorter in the treated group (40 seconds) compared with the control group (120 seconds, P <.001). The mean operative time was significantly shorter in the treated group (36.4 +/- 10.9 minutes) compared with the control group (45.9 +/- 14.2 minutes, P <.001). Cervical tears occurred in nine (11.4%) patients in the control group and in one (1.4%, P =.018) in the misoprostol group. Creation of a false tract was more common in the control group. Two uterine perforations occurred in the placebo group.
Vaginal misoprostol applied before operative hysteroscopy reduced the need for cervical dilation, facilitated hysteroscopic surgery, and minimized cervical complications.
Hysteroscopy is becoming a more widely used technique. Diagnostic hysteroscopy is replacing conventional dilatation and curettage in the diagnosis of intrauterine pathologies. Transcervical endometrial resection is often the first-line surgical treatment for dysfunctional uterine bleeding and carries less associated morbidity and morality. Overall, the technique is extremely safe, but vigilance is required particularly for intravasation of irrigation media. Complications such as gas embolus and hypo-osmolar hyponatremia require prompt treatment to reduce associated morbidity and morality. Careful monitoring of fluid deficit is paramount in avoiding the latter problem. Regional or general anesthetic techniques can be used and, in the ambulatory or office-based setting, in which these procedures are increasingly performed, the need for "street readiness" can influence the choice of the agents used.
To describe a case in which hysteroscopic removal of a fibroid that had migrated through the uterine wall induced formation of a uterine fistula.
After embolization of uterine fibroids, an investigative clinical, sonographic, and hysteroscopic protocol was followed.
Gynecologic clinic of a university hospital.
A 38-year-old woman undergoing embolization of uterine arteries for uterine fibroids.
Angiography-guided transcatheter bilateral embolization of uterine arteries, with clinical, sonographic, and hysteroscopic follow-up.
Patient morbidity and satisfactory intercourse.
Six months after embolization of the uterine arteries, the patient presented migration of the fibroid through the uterine wall. Hysteroscopic removal of the fibroid induced posthysteroscopic formation of a uterine fistula.
After embolization of the uterine arteries, thorough follow-up examination of the uterine cavity is strictly recommended. Diagnosis of a uterine wall perforation can identify an abnormal source of uterine bleeding, and patients should be counseled to avoid pregnancy until the lesion heals completely.
Most medical malpractice lawsuits that involve gynecologic endoscopy and laparoscopy result from either improper prevention, inadequate recognition, or delayed intervention. Continuing recognition of this will prevent many and mitigate most such cases. We can learn much from the events and rapid progress of the past decade. Although most laparoscopic improvements have been technical and instrument driven, a basic understanding of anatomy, physiology, and diagnostics remains essential to high-quality patient care and risk reduction.
To compare the composition of gases generated by bipolar hysteroscopic vaporizing electrodes using electrolyte-rich medium (normal saline) with those of monopolar vaporizing electrodes using nonelectrolytic medium (1.5% glycine).
In vitro study (Canadian Task Force classification II-1).
Laboratory.
Fresh morbid bovine cardiac muscle was fully immersed in normal saline for the bipolar vaporizing electrode and 1.5% glycine for the monopolar vaporizing electrode. Standard hysteroscopic electrodes were activated at usual and maximum power outputs from radiofrequency electrosurgical generators appropriate for each system. The gases generated were captured and analyzed by gas chromatography and fast Fourier transform.
Gaseous by-products of electrosurgical vaporization of test tissues largely consisted of hydrogen, carbon monoxide, and carbon dioxide. The composition of gases generated by hysteroscopic monopolar and bipolar electrodes in this laboratory model appear to be similar.
These gases are all highly soluble in serum. This observation suggests that emboli of gaseous by-products of electrosurgery are unlikely to have an adverse impact on patients. On the other hand, air emboli, largely composed of relatively insoluble nitrogen, are more likely to result in clinically significant cardiopulmonary events.
Fulminant hepatic failure due to herpes simplex in healthy adults is a rare condition with a high mortality rate. The lack of specific symptoms and the absence of typical herpetic lesions in a majority of cases contribute to delayed diagnosis.
We describe a fatal case of fulminant hepatic failure due to herpes simplex in a healthy woman presenting after laparoscopy and hysteroscopy for tubal infertility. The patient lacked evidence of mucocutaneous lesions or jaundice. The surgery likely contributed to viral dissemination.
Although rare, disseminated herpes should be considered a possible cause of postsurgical pelvic infections, even in the absence of ulcerative lesions. Until a definitive diagnosis is made, antiviral therapy should be considered in patients with high fever, leukopenia, and abnormal liver function.
To determine the diagnostic accuracy and possible role of treatment of hysteroscopic endometrial resection in women with abnormal uterine bleeding (AUB) diagnosed with endometrial adenocarcinoma.
Retrospective analysis (Canadian Task Force classification II-2).
University-affiliated center.
Thirteen women with AUB and eight with postmenopausal bleeding.
Preablation endometrial office biopsy and hysteroscopic evaluation.
Preablation endometrial biopsy was inadequate, inconclusive, or difficult to obtain in these women, and endometrial cancer was found at the time of resectoscopic surgery. Total endomyometrial resection including the tubal ostia was completed in eight women (group 1) and partial resection in five (group 2). Endometrial adenocarcinoma was confirmed histologically in all patients. A small focus of cancer was found in only two women in group 1 after total resection; in one the procedure was performed 9 years earlier and in the other it was completed hastily after absorption of 800 ml of 1.5% glycine irrigation solution. In women in group 2 malignancy was highly suspected and total resection was considered unwise.
All patients were alive and well 0.5 to 9 years after hysterectomy, with no evidence of recurrent cancer.
To describe a patient who underwent hysteroscopic resection of a uterine septum for recurrent miscarriage. The subsequent labor caused uterine rupture.
Case report.
Academic medical center.
A 37-year-old nullipara with three previous miscarriages.
Resection of the septum by cutting diathermy using the operating hysteroscope.
Pregnancy and delivery.
The patient had an uneventful pregnancy and spontaneous labor at 41 weeks. Cesarean section was performed because of suspected fetal distress. During cesarean section, the uterus was ruptured transversely along the fundus at the line of the attachment of the septum.
When fetal distress occurs after previous uterine surgery, uterine rupture must be considered as a possible cause and appropriate treatment is necessary.