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Hysteroscopy and D&C - Indications and Complications

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This is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

Indications

  1. Abnormal uterine bleeding
    1. Postmenopausal and unable to get adequate endometrial specimen and endometrial stripe >=5mm
    2. Postmenopausal and endometrial polyp or any hyperplasia on specimen
    3. Postmenopausal and negative endometrial sampling but persistent bleeding and failed HRT or HRTcontraindicated
    4. Postmenopausal and abnormal endometrial cavity contour on ultrasound or abnormal sonohysterogram
    5. Premenopausal > age 40 and unable to sample endometrium
    6. Premenopausal > age 40 and abnormal endometrial cavity contour on ultrasound or abnormal sonohysterogram
    7. Premenopausal age 35-40 and high risk with irregular ovulation, hypertension, obesity and unable to sample endometrium
    8. Premenopausal and polyp or any hyperplasia on endometrial sampling
    9. Premenopausal and abnormal endometrial cavity contour on ultrasound or abnormal sonohysterogram suggesting polyp or fibroid
    10. Premenopausal with negative endometrial sampling and treated for abnormal bleeding hormonally (oral and/or IUCD) for >=3 months and no resolution of abnormal bleeding (normal TSH and coagulation studies)
  2. Suspected Mullerian abnormalities
  3. Suspected intrauterine synechiae
  4. Prior to ablation procedures
  5. Prior to intrauterine tubal occlusion procedures

Complications (<4.0%)

  1. Cervical laceration
    1. Use graduated dilatators to dilate cervix to internal uterine os to size of hysteroscope or curette
    2. Avoid excess downward traction on cervical tenaculum
  2. Uterine perforation
    1. At exam under anesthesia, determine version and flexion position of the uterus
    2. Put downward traction on cervical tenaculum to straighten out cervical-uterine axis
    3. Avoid excessive cephalad pressure with dilator
  3. Inability to visualize endometrial cavity and complete the procedure
    1. Avoid sounding uterus or dilating cervix above the internal os
    2. Visualize endometrium when inserting hysteroscope into the uterine cavity so as not to disturb the endometrium
  4. Excessive Bleeding
    1. Introduce instruments into the uterus in the midline sagittal plane
  5. Fluid distension media problems glycine solution (hyponatremic fluid overload)
    1. Keep track of distension fluid used and returned; discrepancy to be less than 250ml
    2. Maintain intrauterine pressure at or below the patient’s mean arterial pressure
    3. Try to keep procedure less than 45 minutes
    4. Avoid preoperative overhydration
  6. Infection
    1. Preoperatively, culture for G.C. and Chlamydia if any discolored cervical mucous
    2. Avoid contaminating intrauterine instruments with vaginal blood and secretions
  7. Thermal energy problems
    1. Check weighted specula and other instruments for excessive heat
    2. Use instruments for ablation according to manufacturers’ instructions
  8. Interruption of an intrauterine pregnancy
    1. Test preoperatively within 48 hours of surgery for pregnancy in any reproductive age woman
    2. Avoid procedures in the luteal phase of menses in women without sterilization or using effective contraception
  9. Bladder, bowel or omental injury
    1. Avoid uterine perforation
    2. If instrument penetration is suspicious for or strongly indicates uterine perforation, discontinue procedure

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