HYSTEROSCOPY IN GYNAECOLOGY Flashcards
Definition and types of hysteroscopy
Endoscopic visualization of the cervical canal and the uterine cavity
Diagnostic and therapeutic
T/F: Hysteroscopy is considered the ‘gold standard’ procedure for the diagnosis and management of women with intrauterine pathology
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T/F: Routine use of Hysteroscopy as a screening tool in the general population of subfertile women with normal USS or HSG in the basic infertility work-up for improving reproductive success rate – No high-quality evidence
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T/F: Outpatient hysteroscopy before in vitro fertilisation treatment in women with normal ultrasound of the uterine cavity and a history of two to four failed in vitro fertilisation treatment cycles does not improve live birth rate
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5 advantages of diagnostic hysteroscopy
- Confirm the presence of the lesion.
- Identify the location of the
lesion. - Identify the nature of the lesion.
- Plan and undertake treatment
measures at a later date. - “See and treat”
5 advantages of operative hysteroscopy
- Increases the precision of
surgery - Minimizes trauma to the
endometrial lining - Preclude major surgical
intervention. - MIS
- Shorter hospital stay and
recovery time.
T/F: There is no reason to avoid diagnostic hysteroscopy before surgery in patients with endometrial cancer especially in early stages
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T/F: No evidence to support an association between preoperative hysteroscopy and a worse prognosis in endometrial cancer
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Levels of pain management in hysteroscopy
Level 1 to level 5
Level 3 divided into a and b
3 settings for hysteroscopy
Office
Outpatient clinic
Operating room
2 approaches of hysteroscopy
Vaginoscopy and speculum assisted
5 models of care in hysteroscopy
Office
Outpatient
Ambulatory
Extended recovery
Inpatient
3 indications for diagnostic hysteroscopy
- Abnormal uterine bleeding
- Infertility:
IUA (Asherman’s syndrome)
Submucous fibroids
Endometrial polyps
Uterine malformations (e.g
Uterine Septum)
Fetal bone - Recurrent miscarriages
11 indications for therapeutic hysteroscopy
- Adhesiolysis
- Myomectomy
- Polypectomy
- Septum resection
- Removal of foreign body & IUD
- Fallopian tubal cannulation
- Placement of intratubal device
for sterilization - Evacuation of RPOC
- Removal of Cornual ectopic
pregnancy after MTX - Treatment of caesarean scar
pregnancy - Treatment of Focal
adenomyosis - Haemangioma and A-V
malformation
Pattern of findings in hysteroscopy depends on 5 factors:
Geographical location
Group of patients
Age
Comorbidity
Drug use e.g Tamoxifen
2 absolute contraindications for hysteroscopy
Active uterine/pelvic infection
Cervical Cancer
5 relative contraindications to hysteroscopy
Severe systemic illness (Cardiopulmonary disease)
Pregnancy
Heavy uterine bleeding!
Inexperienced Surgeon
Unstable patient
Classification of operative hysteroscopy (RCOG)
Level 1
Level 2
Level 3
Level 1 hysteroscopy involves –, – and –
- Diagnostic hysteroscopy with
target biopsy - Removal of simple polyps
- Removal of IUCD
3 procedures in level 2 hysteroscopy
- Proximal fallopian tube
cannulation - Minor Asherman’s syndrome
- Removal of pedunculated fibroid
(Type 0) or large polyp
5 procedures in level 3 hysteroscopy
- Division/resection of uterine
septum - Major Asherman’s syndrome
- Endometrial resection or
ablation - Resection of submucous fibroid
(Type 1 & 2) - Repeat endometrial ablation or
resection
5 components of patient evaluation for hysteroscopy
History
Physical examination
Investigation
Timing of the procedure
Consent
The ideal patient positioning for hysteroscopy
Modified lithotomy position
Anaesthesia for level 1 hysteroscopy
No medication or the use oral non-sedative medication
Anaesthesia for level 2 hysteroscopy
Local anaesthetic to the genital tract
T/F: Conscious sedation for level 3 hysteroscopy
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Anaesthesia for level 3a hysteroscopy
Oral or inhalational medications with a sedative effect
Anaesthesia for level 3b hysteroscopy
Parenteral medications with a sedative effect
Anaesthesia for pain level 4 hysteroscopy
Regional anaesthesia
Anaesthesia for level 5 hysteroscopy
General anaesthesia
14 instruments required for hysteroscopy
Troley
Monitor (LED)
Camera unit
Light source (LED, Xenon, Halogen)
Light source cable
Telescopes (0, 12, 30 degrees)
Distension media
Infusion pumps (Manual/Automated)
Hysteroscope
Accessory instruments
Electrosurgical generator
Monopolar and bipolar resectoscopes
Electrodes
Advanced tissue removal systems
The 3 degrees of telescopes used for hysteroscopy
0, 12 and 20 degrees
3 types of light source used for hysteroscopy
LED
Xenon
Halogen
Wattage of the different light sources
Halogen - 200w
Xenon - 300w
LED - 150 to 175w
The material for the different light sources
Halogen - tungsten
Xenon - Silica quartz
LED - semiconductors mainly gallium
Colour temperature of the various light sources
Halogen - 5000 to 5600K
Xenon - 6000 to 6400K
LED - up to 6500K
Heat generated by the light sources
Halogen - High
Xenon - High
LED - Less
Life (hours) of the light sources
Halogen - 1000 to 2000
Xenon - 2000
LED - 30,000
Colour of light from the light sources
Halogen - white with yellowish tint
Xenon - white with bluish tint. More natural compared to halogen
LED - White
Cost comparison of the different light sources
Halogen - inexpensive
Xenon - expensive
LED - economical and energy efficient
Diameter of rigid telescopes
1 - 5mm
Diameter of flexible telescopes
2.7 - 5mm
T/F: Distention media for hysteroscopy can be fluid or gas
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2 classes of low viscosity fluids for hysteroscopy
- Electrolyte/Ionic:
(N/Saline/Ringer’s lactate) - Non-electrolyte/Non-ionic:
(Glycine 1.5%, Sorbitol 3%, Mannitol 5%, Dextrose/water 5%)
High viscosity fluid for hysteroscopy
(Dextran 70, Hyskon{32% Dextran-70 in 10% Glucose})
IUP for hysteroscopy
below MAP (70 – 150mmHg)
Methods of fluid delivery for hysteroscopy
(a)Gravity
(b)Infusion pumps
Manual
Electronic
The 2 types of hysteroscopic sheath
Single channel and dual-channel
T/F: the single channel hysteroscopic sheaths are for diagnostic hysteroscopy only
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T/F: the dual channel hysteroscopic sheaths are for both diagnostic and operative hysteroscopy
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5 accessory instruments in hysteroscopy
Scissors
Grasping forceps
Biopsy forceps
Morcellators
Myoma screw
2 types of resectoscopes
Monopolar and bipolar
The 3 basic electrodes of the resectoscopes
Roller ball
Collins knife
Cutting loop
T/F: Compared to resectoscopes, Truclear/Myosure tissue removal system has shorter operative time and higher likelihood of complete lesion removal
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T/F: Truclear/Myosure tissue removal system is more expensive compared to resectoscopes
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T/F: The use of antibiotics appears not to be beneficial to prevent infection after hysteroscopy
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During hysteroscopy in the absence of an automated fluid monitor, how often do you calculate the fluid deficit
Calculate deficit every 5 to 10minutes in the absence of fluid monitor
Predetermined limit to TERMINATE the procedure IN HEALTHY FIT WOMEN for fluid deficit
300 to 500ml – Dextran
1000ml – Hypotonic (Glycine)
2500ml – Isotonic (N/Saline)
10mmol/L Dec. Serum Na
How do you prevent intrauterine adhesions with hysteroscopy
- Pre-hysteroscopic treatment
Oestrogen
GnRH analogue
SPRM - Barrier methods
IUD
Intrauterine Balloon catheter
Foley catheter
Malecot catheter
Cross-linked HA Gels
Anti-adhesive barrier - Delicate surgical techniques
Surgical instruments
Cold scissors
Electrosurgery
T/F: Rate of complication with hysteroscopy is <1%, 2.7%
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Complication rate for diagnostic hysteroscopy
0.13%
Complication rate for operative hysteroscopy
0.96%
Strongest predictor of complications with hysteroscopy is
type of procedure performed.
Adhesiolysis (4.5%)
Endometrial resection (0.8%)
Myomectomy (0.8%)
Polypectomy (0.4%)
Complication rate with hysteroscopic adhesiolysis
4.5%
Complication rate of hysteroscopic endometrial resection
0.8%
Complication rate of hysteroscopic myomectomy
0.8%
Complication rate of hysteroscopic polypectomy
0.4%
T/F: Postoperative complications of hysteroscopy can be early or late
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2 early complications of hysteroscopy
Infection
Post operative bleeding
3 late complications of hysteroscopy
Intrauterine adhesions
Haematometria
Uterine rupture during pregnancy
2 neurological complications that usually manifest immediately after hysteroscopy
Acute compartment syndrome.
Femoral neuropathy
2 manifestations of neurological complications following hysteroscopy
Foot drop
Lower extremity paresthesia
6 risk factors for neurological complication with hysteroscopy
Patient malpositioning
Excessive hip flexion, abduction and ext rotation
Excessive pressure over the fibula head
Prolonged operation time
Nerve compression
Assistant surgeons resting on the patient legs
4 examples of anaesthetic complications seen in hysteroscopy
- Inadvertent systemic injection of
LA - Palpitation & Anxiety from
vasoconstrictors (Adrenaline) - Complications of regional
anaesthesia
Hypotension
Spinal headaches
Infection - Complications of GA
5 complications of absorption of non-ionic distension medium used with monopolar resection/ablation
Hyponatraemia
Pulmonary oedema
Cerebral oedema
Seizures
Death
8 types fluid used as of distension media
- N/S
- 5% glucose
- 1.5% glycine
- 5% DW
- 5% Mannitol
- 3% Sorbitol
- Mannitol/sorbitol (purisol)
- 32% Dextran 70 (hyskon)
The only hypertonic fluid used for liquid distension
32% Dextran 70 (Hyskon)
The 2 isotonic fluids used for distension
N/S and 5% mannitol
T/F: Apart from N/S, 5% mannitol and 32% Dextran all the other fluids used for distension are hypotonic
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The only distension fluid that contains physiologic electrolytes is
N/S
The only distension fluid that has high viscosity is
32% Dextran (hyskon)
Normal serum level of Na
135 - 145
At what serum Na level will the patient become restless and what is the treatment
120 -135
Oxygen
IV Frusemide 40 – 60mg
0.9% Normal saline
At serum Na levels of 110 - 120 what 4 symptoms will the patient have and how will you treat the patient
Nausea, Headache, Confusion, Cardiac irregularities
Ventilator support if PE
IV Frusemide 1mg/Kg 4 to 6hrs.
3% hypertonic saline
At what serum sodium level will the patient have arrhythmias, Convulsions, Severe hypotension. Coma,
<110
6 complications of complicated access to the uterine cavity
Failed procedure (<2%)
Cervical laceration
Uterine perforation
Avulsion of the endometrium
False passage
Haemorrhage
10 risk factors for complicated access to the uterine cavity
Nulliparity
Menopausal state
Uterine synechiae
Cervical stenosis
Retroverted uterus
Uterine malformation
Excessive traction
Forceful dilatation
Cervical hypoplasia
Endometrial malignancy
Uterine perforation usually occurs during these 3 parts of the procedure
Dilatation of the cervix
Insertion of hysteroscope
Resectoscope use
3 risk factors of uterine perforation
Poor entry technique
Retroverted uterus
Cervical stenosis
8 ways of preventing complications arising from difficult access to the uterine cavity
Osmotic dilators
PG Gel or Tablet
Preoperative GnRHa
Estrogen prep
Vasopressin (0.05 – 0.1U/ml at 4’ & 8’)
Adhesiolysis with Scissors
Small diameter hysteroscope
Ultrasound/Laparoscopic guidance
5 electrosurgical complications
Prolonged operation time
Myoma chips removal
Fluid absorption
Fluid overload
Electrolyte derangement
T/F: Infection is a commonly seen early complication of hysteroscopy.
F. Rare
2 risk factors for infection as an early post operative complication of hysteroscopy
History of PID
Endometritis
Use antibiotics prophylaxis
T/F: Hematometria is a late post operative complication of hysteroscopy
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2 ways of preventing hematometria as a late post operative complication of hysteroscopy
Avoid the isthmus and cervical canal during resection.
Use of Foley catheter
2 causes of intrauterine adhesions as a late postoperative complication of hysteroscopy
Excessive resection
Endometrial avulsion
3 ways of preventing intrauterine adhesions as a postoperative complication of hysteroscopy
Endometrial regeneration (Cyclical Hormonal tablets)
Intrauterine device/balloon catheter
Cross-linked HA gel
T/F: Uterine rupture and placenta accreta are late postoperative complications of hysteroscopy
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Prevent by preventing intrauterine adhesions
