Principles of safe and effective hysteroscopy

What is Hysteroscopy? “Looking inside the uterus” Can be diagnostic Can be therapeutic

Why Hysteroscopy? Abnormal bleeding Subfertility Recurrent miscarriage Pre-op assessment To remove something (‘lost IUCD’) Sterilisation

Keeping it safe

Know your patient History Examination Investigations

Valid consent

What to expect in this lecture Anaesthetic Positioning the patient/equipment Cleaning/draping Equipment Distension medium Negotiating cervix Effective diagnostic survey

1. Anaesthetic None Local General

2. Positioning the patient Dorsal lithotomy Beware back, hips, peroneal N, other bits Awake patients can position themselves!

2. Positioning equipment

3. Cleaning/draping Sterile or clinically clean? Avoid all risk of patient to patient transfer of infection (viral, MRSA, CDiff, B Strep) Minimise risk of ascending infection It is difficult to completely cleans the vagina in an outpatient setting but the cervix should be cleaned.

4. Know your equipment General gynae equipment Hysteroscopic equipment

5. Distension medium Uterine cavity is virtual until distended Saline Dextran/Glycine CO2

5. Distension medium Technique for optimum cavity distension Use medium to dilate cervix for entry Aim for continuous flow (single or two channel) Limit amount of trauma to uterine cavity Cavity distension pressure usually limited to 50mmHg under no/local anaesthetic because of pain

5. Distension medium Fluid overload and hysteroscopic surgery Absorption of non ionic distension medium used with monopolar resection/ablation Hyponatraemia Pulmonary oedema Cerebral oedema Seizures Risk increases with fibroid resection

Fluid overload and hysteroscopic surgery 5. Distension medium Fluid overload and hysteroscopic surgery Fluid absorption/TCRE

6. Negotiating cervix Method Dilation not usually required Distend cervix with medium Enter under direct vision Understand angled tip Double channel continuous flow for hysteroscopic surgery

7. Effective diagnostic survey Methodological approach Understand aims of procedure Rotation of scope to allow angled tip to visualise entire cavity Appropriate record of findings Written Photography (consent especially if used for educational use at a later date)

Contraindications Active uterine infection Severe systemic illness Pregnancy Heavy uterine bleeding! (Cervical Cancer)

Complications Failed procedure Problems due to distension media - <2% - Cervical stenosis - Blood, gas bubbles Problems due to distension media - Fluid overload Problems due to procedure itself - Infection - Bleeding - Cervical/uterine damage/perforation Anaesthetic problems Incidence serious complications in DIAGNOSTIC hysteroscopy 0.012%

Now show video: Basic hysteroscopy