Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice...

Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.

Complications of HysteroscopyComplications of Hysteroscopy

Franklin D. Loffer, M.D.Franklin D. Loffer, M.D.Executive Vice President/Medical DirectorExecutive Vice President/Medical Director

A A G L A A G L “Advancing Minimally Invasive Gynecology Worldwide”“Advancing Minimally Invasive Gynecology Worldwide”


Uterine PerforationUterine Perforation

Diagnostic (1° in office)Diagnostic (1° in office) 1/40001/4000 0.03%0.03%

Ablation/resectionAblation/resection 69/574869/5748 1.2%1.2%

Submucous myomaSubmucous myoma 7/9687/968 0.7%0.7%

AdhesionsAdhesions 1.0%1.0%

SeptumSeptum 1.0%1.0%

AAGL survey 1988/1991/1993AAGL survey 1988/1991/1993 1.3 / 1.1 / 1.4%1.3 / 1.1 / 1.4%

F D Loffer literature reviewF D Loffer literature review


Prevention of Uterine PerforationsPrevention of Uterine Perforations

• Good visualizationGood visualization

• Adequate distensionAdequate distension

• Not resecting below uterine cavityNot resecting below uterine cavity

• Ultrasound or laparoscopy monitoringUltrasound or laparoscopy monitoring


Problems from PerforationProblems from PerforationDuring HysteroscopyDuring Hysteroscopy

• Partial Partial

- increased fluid intravesation- increased fluid intravesation

- lost orientation- lost orientation• Complete Complete

- procedure discontinued- procedure discontinued

- bleeding (vaginal and/or abdominal)- bleeding (vaginal and/or abdominal)

- intrabdominal organ injury higher with - intrabdominal organ injury higher with

thermal energy sources than mechanical.thermal energy sources than mechanical.


Hemorrhages Hemorrhages

Submucous myomasSubmucous myomas 2.2%2.2%

Endometrial ablation/resectionEndometrial ablation/resection 0.5%*- 0.8%0.5%*- 0.8%

AAGL survey 1988/1991/1993AAGL survey 1988/1991/1993 0.1/0.03/0.25%0.1/0.03/0.25%

FD Loffer literature reviewFD Loffer literature review


Causes of HemorrhageCauses of Hemorrhage

• Deep myometrial vesselsDeep myometrial vessels

• Uterine or cervical artery and branchesUterine or cervical artery and branches

• Intraabdominal vesselsIntraabdominal vessels

• Not from:Not from: - superficial myometrial vessels- superficial myometrial vessels

- transection of submucous - transection of submucous

fibroidsfibroids

- fundal perforation- fundal perforation


Managing P.O. HemorrhageManaging P.O. Hemorrhage

• Tincture of time (wait and see)Tincture of time (wait and see)

• Dilute pitressin (3 mgm / 10 cc)Dilute pitressin (3 mgm / 10 cc)

• Balloon / FoleyBalloon / Foley

• Pitressin packPitressin pack


Types of Distention MediaTypes of Distention Media

• Gas: COGas: CO22

• High viscosity fluidHigh viscosity fluid– Dextran 70Dextran 70

• Low viscosity fluidLow viscosity fluid– GlycineGlycine– SorbitolSorbitol– MannitolMannitol– Saline / Ringers LactateSaline / Ringers Lactate


Problems From Fluid OverloadProblems From Fluid Overload

• Congestive heart failure (all media)Congestive heart failure (all media)• Hyperammonemia (glycine)Hyperammonemia (glycine)• Coagulopathies and/or allergic reactions Coagulopathies and/or allergic reactions

(dextran)(dextran)• Hyponatremia/hypo-osmolarity Hyponatremia/hypo-osmolarity → death → death

(electrolyte free media)(electrolyte free media)


Fluid Intravasation Is : Fluid Intravasation Is :

• The loss of uterine distending media into The loss of uterine distending media into

open uterine vesselsopen uterine vessels

• Most critical with electrolyte free mediaMost critical with electrolyte free media

• Less critical with electrolyte mediaLess critical with electrolyte media


Frequency of Fluid Overload Frequency of Fluid Overload

• AAGL surveyAAGL survey - 1988- 1988 0.34%0.34%- 1991- 1991 0.14%0.14%- 1993- 1993 0.2%0.2%

• Submucous myomaSubmucous myoma 1.1%1.1%

• Endometrial ablation / resectionEndometrial ablation / resection 1.5%1.5%

FD Loffer Literature ReviewFD Loffer Literature Review


Direction of Flow Relates to PressureDirection of Flow Relates to Pressure

lessless

AA

moremore

BB

equalequal

CC

moremore lessless equalequal

(in fluid at rest the pressure is equal (in fluid at rest the pressure is equal everywhere in the system)everywhere in the system)

Pressure in:Pressure in:

UterusUterus

BloodBloodVesselVessel


Amount of Flow Relates to PressureAmount of Flow Relates to Pressure(with equal hole size)(with equal hole size)

Pressure = 2xPressure = 2x Pressure = 4xPressure = 4x


Amount of Flow Relates to Hole SizeAmount of Flow Relates to Hole Size(with equal pressure)(with equal pressure)

Pressure = 4xPressure = 4x Pressure = 4xPressure = 4x


Relation Between Fluid Loss, Relation Between Fluid Loss, Operative Time & MyomasOperative Time & Myomas

0

500

1000

1500

2000

2500

10 20 30 40 50 60 70 80 90 100

Type 0

Type I

Type II

Emanual, et al., “An analysis of fluid loss during transcervical resection of Emanual, et al., “An analysis of fluid loss during transcervical resection of submucous myomas”, Fertility & Sterility. 68:5, 1997 pp. 881-886submucous myomas”, Fertility & Sterility. 68:5, 1997 pp. 881-886


Relative PressuresRelative Pressures(approximate)(approximate)

• Uterine distensionUterine distension - 50 – 70 mm Hg- 50 – 70 mm Hg

• Fallopian tubes openFallopian tubes open - 55 – 110 mm Hg- 55 – 110 mm Hg

• Mean arterial blood pressure Mean arterial blood pressure

- 120/70 mm Hg- 120/70 mm Hg


Use only in Use only in diagnostic diagnostic

casescases


Fluid ManagementFluid Management

• Fluid management is required for operative Fluid management is required for operative

hysteroscopehysteroscope

• Manual calculation is inadequateManual calculation is inadequate

-- Approximately 10% error in fluid Approximately 10% error in fluid packagingpackaging

-- Time delaysTime delays

-- Nursing calculation errorsNursing calculation errors


Fluid Delivery /Fluid Delivery /Monitoring SystemsMonitoring Systems

• Gravity vs. mechanical pumpsGravity vs. mechanical pumps(pressure is pressure)(pressure is pressure)

• Eyeball vs. measuringEyeball vs. measuring(seeing is not believing)(seeing is not believing)


Fluid Delivery /Fluid Delivery /Monitoring SystemsMonitoring Systems

• PumpsPumps – Convenience– Convenience

• Monitoring Monitoring – Early warning– Early warning– Exact amounts– Exact amounts– Evaluating rapidity – Evaluating rapidity

Value of:Value of:


Osmolality of Distending MediaOsmolality of Distending Media

• Glycine 1.5%Glycine 1.5% 200 mOsmol/l200 mOsmol/l

• Sorbitol 3% - Mannitol 0.5%Sorbitol 3% - Mannitol 0.5% 178 mOsmol/l178 mOsmol/l

• Mannitol 5%Mannitol 5% 280 mOsmol/l280 mOsmol/l

(Normal serum osmolality(Normal serum osmolality 290 mOsmol/l)290 mOsmol/l)

Cerebral Edema Following Absorption of Glycine Irrigating SolutionCerebral Edema Following Absorption of Glycine Irrigating Solution

[H2O][H2O]

Vascular space

Interstitial space

Intracellular space

AA BB

[H2O][H2O]

CC DD

[H2O]

[H2O]

Brain

Skull

Interstitial space

Intracellular space

BrainSkull

[H2O]

[H2O]

H2O crossesblood-brain barrier

Intravascular half-life

85 minutes


Is Mannitol A BetterIs Mannitol A BetterMedia Than Glycine?Media Than Glycine?

1½% Glycine1½% Glycine 5% Mannitol5% Mannitolpt 1pt 1 pt 2pt 2 pt 1pt 1 pt 2pt 2

Vol. Deficit (L)Vol. Deficit (L) 2.1242.124 2.4482.448 3.6403.640 2.7352.735

P.O. Na (mmol/L)P.O. Na (mmol/L) 124124 124124 105105 110110

Na diff (mmol/L)Na diff (mmol/L) 1818 1515 3636 3131

Serum osmolality diff (mmol/L)Serum osmolality diff (mmol/L) -13-13 -11-11 11 -3-3

Nausea & vomitingNausea & vomiting ++ ++ 00 00

Phillips, DR et al. JAAGL 1997;4:567Phillips, DR et al. JAAGL 1997;4:567


5% Mannitol5% Mannitol

• MetabolismMetabolism– AbsorptionAbsorption 6-10%6-10%– ExcretionExcretion 90-94%90-94%– Plasma half lifePlasma half life 15-102 min15-102 min

• Excessive intravasationExcessive intravasation– HypervolemiaHypervolemia– HyponatremiaHyponatremia– Normal plasma osmolalityNormal plasma osmolality

MetabolismMetabolism


Intravasation Increased ByIntravasation Increased By

• Open vascular channelsOpen vascular channels

• High infusion pressureHigh infusion pressure

• High flow rateHigh flow rate

• Long operative timeLong operative time


Gaseous EmbolizationGaseous Embolization


Trendelenberg positioning is Trendelenberg positioning is not necessary and should be not necessary and should be

avoided in hysteroscopyavoided in hysteroscopy


Diagnosing Gas Embolism

end tidal CO2

• Millwheel murmur

central venous pressure

cardiac output

• Doppler echocardiography


Hysteroscopic Venous Gas EmbolizationHysteroscopic Venous Gas Embolization- Critical Issues- Critical Issues

• Room airRoom air

• Products of combustionProducts of combustion

• VolumeVolume


Carbon Dioxide Embolism FollowingDiagnostic Hysteroscopy

• 33 y/o - diagnosis: ectopic vs. SAB

• L/S H/S @ 150 mm Hg + 100 ml/min

• 4 min H/S D&C

• Cardiac arrest from gas embolism4 min after H/S

Brink, DM. Brit J OBG. 1994;101:717.


CompostionCompostion11 of Gases Found by of Gases Found byHysteroscopic Electrosurgical VaporizationHysteroscopic Electrosurgical Vaporization

BipolarBipolar UnipolarUnipolar AirAir(normal saline)(normal saline) (glycine)(glycine)

HydrogenHydrogen 51.051.0 49.049.0 0.000050.00005

COCO 25.725.7 26.126.1 0.000010.00001

COCO22 6.56.5 7.57.5 0.03140.0314

OO22 2.92.9 3.03.0 20.947620.9476

NN 1.41.4 2.32.3 78.08478.084

CC22HH22 3.63.6 4.14.1

CHCH44 2.82.8 2.52.5 0.00020.0002

MiscMisc22 6.06.0 5.6 5.6

Munro et al. JAAGL Nov 2001Munro et al. JAAGL Nov 2001

1 - Measured in mole percent1 - Measured in mole percent2 - Acetylene, Propane, C3 Olefin, Isobutane, n-Butane, C4 Alkene, C5 Hydrocarbon2 - Acetylene, Propane, C3 Olefin, Isobutane, n-Butane, C4 Alkene, C5 Hydrocarbon

----

----


Toxicology and Solubility of Gases Formed Toxicology and Solubility of Gases Formed By Electrosurgical VaporizationBy Electrosurgical Vaporization

SolubilitySolubilityToxicToxic in Bloodin Blood Risk to PtRisk to Pt

HydrogenHydrogen lowlow moderatemoderate volume onlyvolume only

COCO high high highhigh dependsdependson amounton amount

COCO22 low low highhigh littlelittle

NN lowlow lowlow volume onlyvolume only

OO2 2 none high volume onlynone high volume only

Munro et al. JAAGL Nov 2001Munro et al. JAAGL Nov 2001


Frequency of Gas Embolization -Frequency of Gas Embolization -Monopolar Resectoscope Using GlycineMonopolar Resectoscope Using Glycine

• Detected in hepatic vein or right heartDetected in hepatic vein or right heart

- 3 control patients- 3 control patients 00

- 11 operative patients - 11 operative patients 10/1110/11

• No significant patient problemsNo significant patient problems

• Hepatic vein traps gas firstHepatic vein traps gas first

Bloomstone et al. JAAGL Feb 2001Bloomstone et al. JAAGL Feb 2001


Avoiding Risks of Gaseous Avoiding Risks of Gaseous IntravesationIntravesation

• Purge air from linesPurge air from lines

• No TrendelenbergNo Trendelenberg

• Alert anesthesiologistAlert anesthesiologist

• Protect open cervixProtect open cervix

• Avoid high pressures (intravasation)Avoid high pressures (intravasation)

• Inadequate uterine flushingInadequate uterine flushing


Preventing Fluid OverloadPreventing Fluid Overload

• Anticipate possibility of problemAnticipate possibility of problem

• Minimal distension pressuresMinimal distension pressures

• Operate quicklyOperate quickly

• Use mannitol solution?Use mannitol solution?

• Use of oxytocin, vasopression or GnRh Use of oxytocin, vasopression or GnRh agonists?agonists?

• Accurate intake & outputAccurate intake & output


ConclusionsConclusions

• Fudal perferations carry a low risk unless Fudal perferations carry a low risk unless

accompanied by thermal injury.accompanied by thermal injury.

• Fluid intravesation is a major risk of Fluid intravesation is a major risk of

hysteroscopy.hysteroscopy.

• It occurs primarily in operative cases.It occurs primarily in operative cases.

• 5% Mannitol may be a better media.5% Mannitol may be a better media.


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Franklin D. Loffer, M.D. Complications of Hysteroscopy Franklin D. Loffer, M.D. Executive Vice...

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