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Complications of Hysteroscopic Surgery: Predicting Patients at Risk

From the Department of Obstetrics, Gynecology and Reproductive Biology, the Division of Reproductive Medicine, and the Department of Obstetrics and Gynecology Epidemiology Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

Address reprint requests to: Anthony M. Propst, MD Brigham and Women’s Hospital Department of Obstetrics and Gynecology 75 Francis Street Boston, MA 02115 E-mail: ampropst{at}bics.bwh.harvard.edu

	Abstract

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Objective: To determine the frequency of operative complications and whether they can be predicted by specific patient characteristics or type of hysteroscopic procedure.

Methods: We collected demographic and medical history information on 925 women who had hysteroscopies from 1995 through 1996. We compared differences in rates of operative complications of specific hysteroscopic procedures. Operative complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia, hemorrhage (500 mL or more), bowel or bladder injury, inability to dilate the cervix, and procedure-related hospital admissions.

Results: Operative complications occurred in 25 (2.7%) of 925 hysteroscopies. Excessive fluid absorption was the most frequent complication. Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4–7 times higher odds for operative complications.

Conclusion: Complications during hysteroscopic surgery are rare. Among hysteroscopic procedures, myomectomies and resections of uterine septa have significantly higher rates of complications, especially excessive fluid absorption. Meticulous fluid management might limit the number of serious complications of these higher-risk procedures.

During the past decade, the number of gynecologists doing operative hysteroscopy and the number of procedures done have increased.¹ The incidence of complications from hysteroscopy varies widely by institution and operative procedure.^1–3 Appropriateness and safety of hysteroscopy depend on predicting complications. Our objectives were to determine frequency and to identify predictors of complications of different hysteroscopic operations.

	Materials and Methods

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We reviewed medical records of 925 women who had hysteroscopies by general obstetrician-gynecologists, reproductive endocrinologists, and gynecologic oncologists at Brigham and Women’s Hospital between January 1, 1995, and December 31, 1996. During the study, seven reproductive endocrinologists, four gynecologic oncologists, and more than 30 general obstetrician-gynecologists performed 1034 hysteroscopic surgeries. Ninety percent of subject records were available for review. The institutional review board approved our study.

Information abstracted from medical records included age, gravidity, parity, height, weight, uterine surgery, medications, menopausal status, index hysteroscopy (diagnostic procedure, polypectomy, myomectomy, endometrial ablation, uterine septum resection, lysis of adhesions, endometrial curettage), concomitant procedures (laparoscopy, laparotomy), preoperative and postoperative diagnoses, surgeon, anesthesia, operative time, estimated blood loss, type and amount of distention media, media deficit, and preoperative and postoperative hematocrit and sodium levels. Surgical complications were defined as uterine perforation, excessive glycine absorption (1 L or more), hyponatremia (less than 130 mEq/L), hemorrhage (estimated blood loss of 500 mL or more), blood transfusion, unplanned hospital admission directly related to hysteroscopy, bowel or bladder injury, inability to dilate the cervix, or inability to complete the surgery because of poor visibility or excessive fluid absorption. The amount of leiomyoma tissue removed was calculated from aggregate measurements of resected tissue from the pathologist’s report.

We compared differences in complication rates by type of procedure and used stratified analyses and ² tests to estimate statistical significance. Estimates of the relative risks (RR) of operative complications by patient characteristics and medical histories were determined by logistic regression analyses and are presented as odds ratios (ORs) with 95% confidence intervals (CIs). All analyses were done using the SAS system (SAS Institute, Cary, NC).

	Results

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The mean (± standard deviation [SD]) age of the subjects was 46.5 ± 10.8 years, and the mean body mass index (BMI) was 26.0 ± 6.3 kg/m². Thirty-four percent were nulliparous, 39.1% had one or two live births, and 27.7% had more than two live births. Operative complications occurred in 25 (2.7%) of 925 procedures, and five women had more than one complication. The complications are listed in Table 1. Seven women had excessive absorption, and of those, hyponatremia developed in three women. There were five cases in which the procedure was stopped before completion because the glycine deficit approached 1 L. More than 98% of the procedures used hypotonic 1.5% glycine as the uterine distention medium. Excessive glycine absorption occurred only in more complex procedures, including myomectomy, uterine septum resection, and endometrial ablation. There were four (0.4%) uterine perforations without additional damage, two caused by the operative hysteroscope, one by a metal curette, and the other by Hegar dilators during cervical dilation. No woman needed laparoscopy or laparotomy because of a complication. Four (0.4%) women were admitted overnight, two for observation after excessive fluid absorption, one for intravenous antibiotics to treat postoperative endomyometritis, and one because of persistent nausea after general anesthesia. Both women treated for postoperative endomyometritis had hysteroscopic myomectomies. No women hemorrhaged, needed blood transfusions, had bowel or bladder damage, or developed serious sequelae from hyponatremia such as pulmonary edema or encephalopathy.

	Discussion

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There is little information published on predictors of complications for hysteroscopic surgery despite its increasing use. Smith and colleagues² reported a 25% complication rate in 100 women who had advanced hysteroscopic procedures, such as ablation, myomectomy, lysis of synechiae, and resection of uterine septa. Complications included uterine perforation (8%), technical problems (8%), fluid imbalance (5%), and postoperative sepsis (4%). A Scottish survey of operative hysteroscopies for menorrhagia between 1991 and 1993 reported a 12% complication rate, including fluid imbalances greater than 1 L in 6% of women, uterine perforation in 1%, excessive bleeding in 4%, and emergent laparoscopy or hysterectomy for uterine perforation in 1%.³ The 1991 American Association of Gynecologic Laparoscopists member survey reported 17,298 operative hysteroscopies with a complication rate of 3.8%, including perforation in 1%, hospital admission in 0.7%, hemorrhage in 0.2%, and unplanned laparotomy in 0.2% of women.¹ Our complication rates were similar to those findings, although we had no cases of hemorrhage, transfusion, or unplanned laparotomy.

In our study, type of procedure was the strongest predictor of complications. Excessive glycine imbalance (at least 1 L) was the most common complication. Most fluid imbalances were identified quickly and treated. Among women with excessive glycine absorption, the lowest serum sodium recorded was 126 mEq/L.

We use an automatic hysteroscopic monitoring system with inflow and outflow monitors to measure fluid imbalances (Flo-Stat, FemRx, Sunnyvale, CA). Our protocol for hysteroscopic surgery is to stop the procedure when the glycine deficit is 1 L or greater. Serum sodium levels decrease about 10 mEq/L for every 1 L of hypotonic fluid absorbed.⁶ A large volume of uterine distention medium can be absorbed quickly with a uterine perforation or during a fibroid resection. The pressure in large venous sinuses in leiomyomas or the myometrium is 8 to 10 mmHg. Rapid intravasation can occur because the intrauterine pressure necessary for distention and flow is 40 to 60 mmHg.⁶

Hysteroscopies done by reproductive endocrinologists were 3.5 times more likely to have complications than those done by other gynecologic surgeons. We believe this difference is because of the type of procedure not the type of surgeon. Reproductive endocrinologists did more complex hysteroscopic myomectomies per total cases than general gynecologists, and they removed more leiomyoma tissue.

Women pretreated with GnRH agonists had greater risk of operative complications than those not pretreated. However, this higher risk was probably more a function of complication rates from specific hysteroscopic procedures rather than pretreatment with a GnRH agonist. Compared with women not pretreated, those pretreated had a significantly higher percentage of complex hysteroscopic procedures (24% versus 81%, P = .001, ²); 55% had myomectomies and 26% had endometrial ablations. Pretreatment with GnRH agonists did not reduce glycine deficits. For myomectomies, women pretreated with GnRH agonists had higher glycine deficits than those not pretreated (430 mL versus 290 mL, P = .12). Other investigators reported that pretreatment with GnRH agonists reduced uterine blood flow and intraoperative uterine fluid absorption.^6,7

Obesity, cervical stenosis, and history of cesarean or myomectomy did not increase the risk of operative complications. Only one woman with cervical stenosis had a uterine perforation, which suggests that in certain patients, dilation of cervical stenosis can be done safely in the operating room.

A limitation of this study was that not all of the medical records had complete information. Specifically, gravidity and parity were not recorded in 30%, and the total glycine and glycine deficit were not recorded in 47% and 20% of the records, respectively.

	Footnotes

 
Diane Bernstein and Natalie Sinclair assisted in data collection.

The opinions and conclusions in this paper are those of the authors and are not intended to represent the official position of the Department of Defense, United States Air Force or any other government agency.

PII S0029-7844(00)00958-3

Received January 13, 2000. Received in revised form April 19, 2000. Accepted May 11, 2000.

	References

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1. Hulka JF, Peterson HB, Phillips JM, Surrey MW. Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993;38:572–3.[Medline]

2. Smith DC, Donohue LR, Waszak SJ. A hospital review of advanced gynecologic endoscopic procedures. Am J Obstet Gynecol 1994;170: 1635–42.[Medline]

3. Scottish Hysteroscopy Audit Group. A Scottish audit of hysteroscopic surgery for menorrhagia: Complications and follow up. Br J Obstet Gynaecol 1995;102:249–54.[Medline]

4. Derman SG, Rehnstrom J, Neuwirth RS. The long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas. Obstet Gynecol 1991;77:591–4.[Abstract/Free Full Text]

5. Hallez JP. Single-stage total hysteroscopic myomectomies: Indications, techniques, and results. Fertil Steril 1995;63:703–8.[Medline]

6. Issacson KB. Complications of hysteroscopy. Obstet Gynecol Clin North Am 1999;26:39–51.[Medline]

7. Parazzini F, Vercellini P, De Giorgi O, Pesole A, Ricci E, Crosignani PG. Efficacy of preoperative medical treatment in facilitating hysteroscopic endometrial resection, myomectomy and metroplasty: Literature review. Hum Reprod 1998;13:2592–7.[Abstract/Free Full Text]

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