Complications of Hysteroscopy: Diagnosis and Management

By Rahul Manchanda

Complications of Hysteroscopy- Diagnosis and Management is a step-by-step reference to explain various problems that can encounter during a hysteroscopy procedure. It is a complete guide about the diagnosis and management of the different causes of hysteroscopy mishaps to master how to diagnose and select the most appropriate strategy of all aspects of what could go wrong and applying that knowledge in different clinical settings. It is an essential reference for anyone in the research and medical field.

• Includes evidence-based information summarized by worldwide recognized experts on each topic
• Offers tips and tricks when dealing with complications such as bleeding and hemorrhaging
• Discusses electrosurgical complications, both unipolar and bipolar energies
• Documents and presents a registry of actual cases collected from all over the world and discusses their management
• Provides the medicolegal aspects, along with the rehabilitation of the medical professional

• Language: English
• Publisher: Elsevier Science
• Release date: Nov 19, 2023
• ISBN: 9780443216176

Book preview

Chapter 1: Anesthesia and patient position

Péter Török, and Rudolf Lampé     Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Abstract

Popularity of hysteroscopy has been increasing intensively recently. Minimal invasive solution for many gynecological problems is attractive all over the world. Several types of diagnostic and operative procedures can be performed by hysteroscopy. Thanks to the technical developments, these surgeries can be performed in an out-patient setting, as well. For the traditional hysteroscopies, performed in the OR under regional or general anesthesia may have complications not only due to the hysteroscopy but the used anesthesia, too. Medication for the general anesthesia can have general side effects, as hyperreaction, and can have special complications dedicated to the active agent of it. Positioning during hysteroscopy can cause neurological complications, due to the compression of the peripheral nerves of lower limb. By performing hysteroscopy for awake patients, so-called office hysteroscopy, most of the complications of anesthesia and compressions could be avoided.

Keywords

Anesthesiologic complication; Inhalation anesthesia; Local anesthesia; Nerve compression; Office hysteroscopy; Paracervical anesthesia; Patient positioning

Introduction

The number of performed hysteroscopies have been increasing dramatically during last decades. Beyond accurate diagnostics of the uterine cavity, intrauterine lesions, and abnormality of the shape of uterine cavity, due to the see and treat principle, there is opportunity for the treatment at the same time, as well.

To make it easy to understand, when publications, presentations, or simply discussions were about hysteroscopy, an international consensus statement was created by three leader societies (AAGL, ESGE, GCH). This work was aiming to clear the terminology of hysteroscopy. According to this statement, report of a hysteroscopic procedure should classify the type of pain management, the setting, the model of care, the type and the approach the procedure (Carugno et al., 2022).

Regarding anesthesia, we can classify two different procedures. There are hysteroscopies performed under general or regional anesthesia (independently of the model of care) done by anesthesiologist, mainly in an OR and other surgeries without these types of anesthesia, in an outpatient setting.

The type of the chosen procedure is up to many conditions, like personal expertise, instrumentation, traditions. The office procedures have advantages over in-patient ones in term of cost-effectiveness, burden of the health-care system, need for the ICU and OR (was important in COVID times) (Vitale et al., 2020), but still in many situation hysteroscopies are performed in OR all over the world.

To induce or maintain general anesthesia inhalational (Nitrous Oxide, Isoflurane, Sevoflurane, Desflurane, and Xenon) and intravenous (Propofol, Etomidate, Ketamine, Methohexital, and Thiopental) anesthetics are used. Major complications of these medications vary from the cardiovascular (myocardial infarction), respiratory, renal, or long-term cognitive dysfunctions. Minor complications can be postoperative vomiting and nausea. Incidence of all these complications is higher in case of preexisting comorbidities, so careful preoperative assessment of the patient by anesthesiologist can result in less chance evolving complications (Franks and Lieb, 1994). Due to the shorter duration of procedures (mainly less than 1 h), compared to other surgeries, the amount of the used medication and that is why the rate of these complications are lower. These hysteroscopies are performed in an OR where anesthesiologist is present, so the treatment of the complication can be multidiscipline task.

Positioning of the patient is important during the hysteroscopy. Lithotomy position is used worldwide for these types of procedures (Fig. 1.1.).

Complications of positioning are peripheral nerve injuries. While the patient is not awake, cannot tell if any of her legs, or nerves are under pressure (Fig. 1.2).

Nerves pressed to a hard surface cause numbness, tingling, or weakness in the legs in most cases. While duration of these procedures is not long (generally less than 1 h), these injuries are temporary in most cases. Peroneal and sciatic nerve injury may occur in the lithotomy position do to the hip flexion in combination with knee extension causing stretch of the nerves (Burkhart and Daly, 1966). Common perineal nerve goes around the head of the fibula and is easily compressed. Isolated injury of the tibial nerve is an uncommon complication. It can happen in dorsal lithotomy position if the nerve is compressed against the femur at the level of the popliteal space by support behind the knee (Glenn, 1981). Femoral nerve may also be compressed if the patient's legs are hyperflexed or hyperextended. Postoperatively patient presents with weakness in the quadriceps muscles, knee jerk response is attenuated or absent. There is also numbness over the medial and anterior thigh (Moore and Stringer, 2011).

Figure 1.1  Positioning of patient during traditional hysteroscopy in general anesthesia.

Figure 1.2  Positioning of patient during traditional hysteroscopy, sites of nerve compression.

To avoid nerve injuries, proper positioning of the patient should be set before the induction of general anesthesia, so the patient can communicate about any discomfort. Physical therapy is all that is required for most patients.

For hysteroscopic surgeries performed in an out-patient setting there are several methods available for reducing pain or discomfort. For pain management inhalational drugs, analgesic administration, local and regional anesthesia can be used, as well.

For inhalation nitrous oxide gas is a cheap and widely available choice. It is well known as laughing gas, often used in delivery rooms. It has a rapid onset and offset due to its very low blood solubility with analgesic and anxiolytic properties. It has minimal hemodynamic effects. Complication of the usage can be nausea, vomiting, bowel distension, but due to the rapid offset, these complications are resolving fast. N2O should be avoided in patients with disorders of B12, folate, or methionine synthesis or metabolism ("Nitrous oxide is used in labor analgesia, as well as occasionally postpartum (American College of Obstetricians and Gynecologists (ACOG, 2019)").

Several types of medication are used as analgesic. Superiority of one over others is still under debates. Many researches can be found in literature trying to evaluate and compare different medications.

For cervical ripening vaginal isoniazid (isonicotinic acid hydrazide: INH), vaginally administrated misoprostol (Haghighi et al., 2020), or rectal misoprostol (Karasu et al., 2022) are recommended. Side effects of misoprostol administration could be like fever and shivering, gastrointestinal symptoms (abdominal cramping, diarrhea, and vomiting). The incidence of these complications could be reduced by proper dosage and shorter time between the administration and the procedure (Gupta, 2018).

Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used to provide pain relief during hysteroscopy. NSAIDs are a class of drugs that work by blocking the production of prostaglandins, which are chemicals that are responsible for inflammation and pain. By reducing the production of prostaglandins, NSAIDs can effectively relieve pain and inflammation. Several studies have investigated the use of NSAIDs for pain relief during hysteroscopy, and it is proven that oral administration of NSAIDs 1 h before the procedure can reduce the pain (De Silva et al., 2020). NSAIDs are generally safe and well-tolerated when used for short periods of time. However, like all medications, NSAIDs can cause side effects, but overdosage is a very rare complication using the doses available in pharmacies (Keyhan and Munro, 2014). The most common side effects of NSAIDs include stomach upset, nausea, and diarrhea. In rare cases, NSAIDs can cause more serious side effects such as stomach ulcers, bleeding, and kidney problems (LaForge et al., 2023). Patients with a history of stomach ulcers or bleeding, kidney problems, or allergies to NSAIDs should not take these medications.

Preoperative administration of Tramadol is effective in reducing pain, but it frequently has nausea as a side effect. Celecoxib, a selective COX-2 inhibitor, was found to be not inferior to tramadol in reducing discomfort or pain during hysteroscopic procedures, with the advantage that its use doesn't have the side effects often reported with tramadol (Hassan et al., 2016).

Local anesthetics can be used for pain management of hysteroscopy paracervically injected, or diluted in distention medium (Mahomed et al., 2016). Discomfort of the paracervical injection can be a usage of speculum and the pain caused by injection. Major complications of local anesthetics can result in the intravascular penetration. By entering vascular system, local anesthetic systemic toxicity (LAST) can occur, by affecting the cardiovascular and central nervous system. Major LAST events (seizure, hypotension, dysrhythmias, acute respiratory failure, cardiac arrest) associated with regional anesthesia is very low, such events may be fatal. Bupivacaine is the most cardiotoxic, followed by levobupivacaine, ropivacaine, and lidocaine (Mörwald et al., 2017). Risk factors for LAST are extremes of age, renal, hepatic, or cardiac disease and metabolic disturbances. To prevent emergencies limitation the dose of local anesthetic to the lowest effective dose is recommended. By adding epinephrine 1:200,000 to 1:400,000 to the local anesthetic solution as an intravascular marker, aspiration prior to each injection and injection of small incremental doses (e.g., 3–5 mL), assessing for signs of LAST during injections are also can decrease the incidence of complications (Long et al., 2022).

In treatment for LAST intravenous lipid emulsion is recommended as first-line therapy (Harvey and Cave, 2017).

Positioning of the patients during office hysteroscopy is the same dorsal lithotomy position as during in-patient procedures. Due to the awakens of the patient, complication caused by pressing nerves can be avoided (Fig. 1.3).

Using trendelenburg position can result in easier access to the uterine cavity and can reduce the chance for vasovagal reaction caused by the distension of the uterus (Vitale et al., 2021).

Figure 1.3  Positioning of patient during office hysteroscopy, patient is awake.

Conclusion

As a conclusion it can be stated that decreasing the chance for anesthetic and positioning complication in those cases that have proper personal and instrumental conditions, hysteroscopy should be performed in an out-patient setting. Feedback of the awake patient is always the best way to avoid adverse events of a procedure.

References

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