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Cutting the risk of hysteroscopic complications

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Proper selection and treatment of patients and prompt intervention minimize complications and legal risks of this effective, underutilized procedure.



  • Preoperative treatment with a gonadotropinreleasing hormone agonist increases the odds of operative complications by a factor of 4 to 7.
  • Preoperative cervical ripening reduced the need for cervical dilation, minimized cervical complications, and reduced operative time.
  • CO2 should never be used for operative hysteroscopic procedures because of the high risk of CO2 embolism.
  • Ultrasound guidance may improve outcomes in selected hysteroscopic procedures.
The state of the art can be simply put: Hysteroscopy is underutilized. Most studies consistently demonstrate the safety and efficacy of operative hysteroscopy, as well as high patient satisfaction.

It is a valuable tool in the evaluation and treatment of infertility, recurrent pregnancy loss, and abnormal and postmenopausal uterine bleeding, and is useful when saline infusion sonography findings are equivocal.

Further, if a global ablation device fails, the surgeon can convert to hysteroscopic ablation rather than abandon the procedure altogether. This is not as unusual as it might appear: In US Food and Drug Administration trials, there was a staggering 10% to 22% malfunction of global ablation technology.1

Safe, easily learned

Although gynecologists are beginning to embrace this modality, many physicians avoid it because of inadequate training or exaggerated fears of complications. In reality, hysteroscopy is one of the safest and most easily acquired surgical skills in gynecology. For example, in a prospective evaluation of 13,600 diagnostic and operative hysteroscopic procedures performed at 63 hospitals in the Netherlands—which involved both established surgeons and residents—Jansen et al2 found an astonishingly low complication rate of 0.28%, with no deaths.

Proper selection and treatment of patients and prompt intervention minimize complications as well as legal risks. Surgical misadventures and lawsuits occur with delayed intervention, failure to recognize pathology or risky conditions, and inadequate preventive maneuvers.

Overall, emphasis on safety is vital to success, and thorough awareness of potential complications is just as important.

Three types of complications

Complications fall into 3 categories (TABLE):

  • Procedure-related
  • Media-related
  • Postoperative


Complication rates

In a retrospective investigation, Propst et al3 determined the rate of complications associated with specific hysteroscopic procedures. Demographic data and medical histories were collected for 925 women who had operative hysteroscopy in 1995 and 1996. The overall complication rate was 2.7%. Myomectomy and resection of uterine septa carried the greatest odds of complications; polypectomy and endometrial ablation had the lowest. Preoperative treatment with a gonadotropinreleasing hormone (GnRH) agonist increased the odds of complications by a factor of 4 to 7. Women under age 50 were more likely to experience complications than those over 50.

In the study by Jansen et al,2 38 complica-tions occurred in the 13,600 procedures. The greatest risk of complications occurred with adhesiolysis (4.48%), followed by endometrial resection (0.81%), myomectomy (0.75%), and polypectomy (0.38%).

Cervical entry requires special attention

Almost half of the complications in the Jansen study were related to cervical entry, so caution and, perhaps, preoperative cervical ripening are advised. Many premenopausal subjects were given GnRH analogues, which may render the cervix more resistant to dilation. Complications associated with a stenotic cervix include a cervical tear, creation of a false cervical passage, and uterine perforation.

Cervical ripening may help prevent uterine perforation. The most common complication, occurring in 14.2 cases per thousand, is uterine perforation.2 The risk of this is highest in postpartum procedures, followed by procedures in postmenopausal, then perimenopausal, women. Patients with endometrial cancer also have a higher rate of perforation.

Risk factors for uterine perforation include:

  • nulliparity
  • menopause
  • use of GnRH agonists
  • prior cone biopsy
  • markedly retroverted uterus
  • undue force
Modern operative hysteroscopes often require dilation of the cervix to a number 8-10 Hegar dilator. Navigation of the internal os is critical before operative instruments can be inserted and the surgical procedure performed. In the past, use of preoperative laminaria was recommended to soften the cervix, except in women with marked cervical stenosis and iodine allergy. Preoperative cervical softening still should be considered in high-risk patients.

Vaginal or oral misoprostol for cervical ripening prior to operative hysteroscopy was evaluated in a randomized trial.4 Researchers found a reduced need for cervical dilation, a minimum of cervical complications, and reduced operative time in study patients compared with controls.

When 400 μg oral misoprostol is given 12 and 24 hours before surgery, it also softens the cervix and eases dilation.5 Although misoprostol has several bothersome side effects (such as lower abdominal pain and slight vaginal bleeding), few if any prevent its use.

Signs of perforation. Patients who sustain uterine perforation with subsequent intraperitoneal bleeding often complain of pain in the abdomen and shoulder, and experience hemodynamic instability. A quick sonographic survey of the abdomen will demonstrate free intraperitoneal fluid. (It is rare for much intraperitoneal fluid to accumulate by transtubal regurgitation during operative hysteroscopy, despite the quantity of fluid used.)


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