AOGS COM M ENT A R Y

Complications in operative hysteroscopy – is prevention

possible?
MEE KRISTINE AAS-ENG1 , ANTON LANGEBREKKE1 & GERNOT HUDELIST2
1
Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway, and 2Department of Gynecology,
Hospital St. John of God, Vienna, Austria

Key words Abstract

Operative hysteroscopy, early complications,
late complications, suboptimal outcomes,
prevention, education
Correspondence
Mee Kristine Aas-Eng, Department of
Gynecology, Oslo University Hospital,
Kirkeveien 166, Oslo, Norway.
E-mail: kristineaaseng@gmail.com
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Aas-Eng MK,
Langebrekke A, Hudelist G. Complications in
operative hysteroscopy – is prevention
possible? Acta Obstet Gynecol Scand 2017;
96:1399–1403.
Received: 27 March 2017
Accepted: 5 August 2017
Operative hysteroscopy in a hospital setting has revolutionized surgical
treatment of benign uterine disorders. It is minimally invasive, cost- and time-
effective, and may spare patients major surgical interventions. Operative
hysteroscopy in a day-case hospital setting is regarded as a safe and well-
tolerated procedure with low complication rates. However, prevention of
adverse events is crucial in daily practice to optimize patient care.
Complications in operative hysteroscopy can be divided into early
complications, including bleeding, uterine perforation, infection and fluid
overload, or late complications and suboptimal outcomes, such as incomplete
resection and intrauterine adhesions. Awareness and knowledge of
management of adverse events as well as the use of possible preventative
measures will increase the quality and safety of hysteroscopic surgery. The
present commentary focuses on these issues as an up-to-date basis for everyday
clinical practice.
Abbreviations: ESGE, European Society of Gynaecological Endoscopy; IUA,
intrauterine adhesions; OH, operative hysteroscopy; OHIA, operative
hysteroscopy intravascular absorption.

DOI: 10.1111/aogs.13209

heavy menstrual bleeding, removal of foreign bodies and

Introduction
The aim of hysteroscopic surgery is visualization and
treatment of benign changes of the uterine cavity. It is
minimally invasive with a short learning curve and is
regarded as safe, efficient, well-tolerated and cost-effec-
tive, with increasing availability and use in gynecological
surgery. Operative hysteroscopy (OH) plays a pivotal role
in surgical management of subfertility and recurrent
pregnancy loss aiming to optimize and restore cavitary
anatomy. Several pathologies contributing to infertility
can be corrected with OH, including cervical and uterine
polyps, adhesions, uterine septa, blocked tubal ostia and
submucosal myomas. OH also provides diagnostic
workup for abnormal uterine bleeding, treatment of
sterilization.
Complications in OH can be divided into early compli-
cations, such as bleeding, uterine perforation, infection
and fluid overload, or late complications and suboptimal
Key message
Operative hysteroscopy is safe and minimally invasive
for treatment of benign uterine disorders. Knowledge
and prevention of early and late adverse events are
crucial for the safety and quality of hysteroscopic sur-
gery. Preventative measures should be recognized and
undertaken.

ª 2017 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 96 (2017) 1399–1403 1399
Complications in hysteroscopy
outcomes, such as incomplete resection and intrauterine
adhesions. Two large national studies including 24 191
OHs found a complication rate of <1% (1,2), whereas a
retrospective study of 925 hysteroscopies observed a com-
plication rate of 2.7% (3). A prospective study of 2515
OHs found that the strongest predictor of complications
was the type of procedure performed, adhesiolysis carry-
ing the highest risk of complications (4.5%), followed by
endometrial resection (0.8%), myomectomy (0.8%) and
polypectomy (0.4%) (2). Hence, awareness of the most
common complications and preventative measures to
avoid adverse events are key to high-quality patient care.
Early complications
Bleeding and uterine perforation
Bleeding may occur during or after OH as a result of
mechanical trauma to the endometrium and/or myome-
trial vessels. Uterine perforation may cause severe bleed-
ing, with injury of uterine arteries or even pelvic vessels.
Incidence of diffuse hemorrhage was 0.61% in a prospec-
tive study including 2116 surgical hysteroscopies (4).
Hemorrhage was subjectively defined by the surgeon as a
procedure requiring red blood cell transfusion or hemo-
static intervention. Risk of bleeding was associated with
the type of procedure and was five times higher in cases
of adhesiolysis than resection of the endometrium, polyps
or fibroids. There was no difference in risk of bleeding
complications when comparing endometrial ablation,
uterine septum division, polyp and fibroid resection.
However, rates of bleeding do vary between studies, as
other groups have found incidence rates of 0–0.16%
(1–3). Swift identification of bleeding and its possible
cause is crucial. Management options include intracavi-
tary placement of a Foley catheter with a 30-mL balloon
providing counter-pressure, or more, depending on uter-
ine size. In rare cases, the bleeding may require uterine
arterial embolization or hysterectomy.
Uterine perforation is one of the most common com-
plications of OH, with an incidence of 0.12–3% (1–3).
Perforation can be partial or complete and will in the lat-
ter case cause inability to maintain cavitary distention,
leading to termination of the procedure. Perforation
caused by a blunt instrument during dilation of the cervix
can be managed conservatively if major bleeding is not
suspected. However, damage by electrosurgical electrodes
may lead to more serious injuries (2). One case of mors
in tabula is known to the author G.H. (personal commu-
nication) due to perforation and injury of the aortic
bifurcation with a monopolar electrode. In cases of signif-
icant changes of red blood cell count or suspected ther-
mal bowel injury, explorative laparoscopy is warranted.
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M. K. Aas-Eng et al.
Importantly, uterine perforation is a potential cause of
uterine rupture in pregnancy (5).
The majority of the 19 perforations (0.76%) of 2515
OHs were entry-related, i.e. dilation caused by hystero-
scope or dilating devices resulting in four cases of severe
bleeding managed with hysterectomy, one laparotomy
and two laparoscopies, respectively. The small bowel was
perforated in one case, requiring a laparotomy to repair
the lesion (2). In contrast, a large multicenter survey
including 21 676 OHs demonstrated that most of the per-
forations (17 of 25, 68%) that occurred during fibroid or
polyp resection were not related to entry (1). Seven of
the 25 perforations led to laparotomies, including five
hysterectomies. Concurrent bladder or bowel injury was
observed in five of the seven perforations. Laparoscopies
with coagulation and/or sutures were performed in seven
cases. In 11 cases no further surgical treatment was
warranted.
Cervical ripening may prevent the risk of uterine perfo-
ration and thus more severe complications such as hem-
orrhage. A randomized controlled trial evaluating the use
of 200 lg of vaginal misoprostol before OH found a
reduced need for cervical dilation, thus reducing opera-
tive time, with fewer trauma-related complications (6). In
postmenopausal women, an additional 14-day pretreat-
ment with vaginal estradiol with 1000 lg of vaginal miso-
prostol has proved to be necessary to reach satisfactory
cervical dilation (7). In cases of suspected uterine perfora-
tion without hemodynamic instability and suspicion of
damage to major vessels, postoperative monitoring of red
blood cell count is essential and a single dose of prophy-
lactic antibiotic may be considered.
Infection
Infection is a rare complication of OH. In a retrospective
survey of 21 676 procedures the infection rate was 0.01%
(1), rising to 1.42% in a prospective observational study
of 2116 OHs consisting of endometritis (0.9%) and uri-
nary tract infections (0.6%) (8). Risk of infection was
higher for adhesiolysis than endometrial resection,
fibroma or polyp resection with a relative risk (RR) of
5–6. Prevention of infection may be possible by reducing
operation time. Prophylactic antibiotics are not routinely
recommended in OH (9).
Fluid overload – OHIA syndrome
The operative hysteroscopy intravascular absorption
(OHIA) syndrome may occur due to excessive fluid over-
load caused by intravasation of distension media (10,11),
leading to hyponatremia and volume overload (12). It is
caused by differences in venous pressure in myometrial
M. K. Aas-Eng et al.
vessels (10–15 mmHg) and intrauterine pressure for dis-
tention of the cavity (40–60 mmHg), causing rapid
intravasation, hyponatremia and, in severe cases, meta-
bolic acidosis, pulmonary and cerebral edema (11). The
amount of electrolyte disturbances is highly dependent on
the type of distension media used, i.e. isotonic NaCl in
the case of bipolar resectoscope or hypotonic solutions
used with monopolar instruments. Using isotonic solu-
tions, absorption of 1000–2000 mL occurs in 5–10% of
patients with mild OHIA, whereas the classic syndrome
develops in <1% with intravascular absorption in excess
of more than 2000 mL, with severe OHIA being associ-
ated with a mortality of 25% (11). Prevention of OHIA is
feasible by continuous fluid monitoring. A threshold of
fluid loss of about 1500–2500 mL should be observed
when performing OH. These values are less applicable
when using non-isotonic distension media. Thus, a recent
guideline by the British Society of Gynaecological Endo-
scopy (BSGE) and the European Society of Gynaecologi-
cal Endoscopy (ESGE) on fluid management in OH refers
to an upper threshold for isotonic media of 2500 mL and
for hyptonic fluids of 1000 mL in healthy women (13).
Lower thresholds should be applied in patients with
comorbidities and advanced age with upper fluid deficit
levels of 750 mL for hypotonic solutions and 1500 mL
for isotonic solutions (13). To minimize the risk of
hyponatremia and its consequences, isotonic media and
bipolar equipment are preferred.
Late complications and suboptimal
outcome
Incomplete resection
Patients with acute menstrual bleeding, heavy menstrual
bleeding or infertility issues and submucosal myomas can
be treated successfully. The ESGE classification of submu-
cosal myomas with type 0 (pedunculated submucous
fibroid without intramural extension) and I (sessile and
with an intramural part of <50%) are more successfully
treated with OH compared with type II (an intramural
part of 50% or more) (14–16). The extent of myometrial
penetration predicts whether submucosal resection is
complete (17). The incidence of incomplete resection
rates range from 5 to 20.5% (12,16,18). In a retrospective
study of 235 women, 12 patients (5%) had incomplete
resection and all had repeat procedures (12). There were
no synechiae at follow-up hysteroscopy at one to two
months, although 70% of the myomas were type II
lesions. Uterine size and number of submucosal myomas
are prognostic factors for recurrence and need for repeat
surgery (18). A prospective observational study of 122
patients found that the RR for fibroid-related surgery
ª 2017 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 96 (2017) 1399–1403
Complications in hysteroscopy
within four years of follow up was significantly lower in
women with fibroids measuring <3 cm in diameter with
RR 0.21 compared with fibroids >3 cm in diameter, and
the risk was lower among intracavitary lesions (types 0
and I) with RR 0.26 compared with intramural lesions
(type II) (19). Reoperations are usually performed, but
may not always be necessary. In a follow-up study of
incomplete hysteroscopic resection of 41 women with
abnormal uterine bleeding, only 44% underwent further
fibroid-related and symptom-associated surgery within
three years (12).
Classification of submucous myomas can predict and
thus prevent incomplete resection. The STEP-W (size,
topography, extension, penetration, wall) classification
system (14) and the ESGE classification (15) have been
validated and described for such purposes. The ESGE
classification is a simpler classification that is easier to use
in daily practice. However, the STEP-W has been shown
to predict completeness of myoma resection with higher
accuracy compared to the ESGE classification (17).
Intrauterine adhesions
Intrauterine adhesions (IUA) may lead to recurrent preg-
nancy loss, infertility, hypermenorrhea and amenorrhea.
The incidence of IUA after OH is unknown due to the
small number of studies, with low patient numbers. There
is no consensus on which classifications to use and the
underlying pathologies are various. The adhesion rate fol-
lowing resection of uterine septa reached 6.7% (1 of 15)
and appears to be higher in OHs for fibroids (20). IUA
rates after resection of more than one myoma, i.e. multi-
ple myomas, were 45.5% (9 of 20) vs. single myomas
31.3% (10 of 32) (20). Risk factors for IUA after hystero-
scopic treatment of retained products of conception were
analyzed in a retrospective cohort study (21). Eighty-four
women had a second-look hysteroscopy and the rate of
IUA was 19%, 3.6% of which were severe. Acknowledg-
ment of significantly increased risk of IUA in women
undergoing OH for multiple fibroids and/or type III
lesions is essential in the prevention of IUA. Therefore,
risks and benefits of myoma surgery in patients with cav-
ity-related subfertility issues should be weighed against
the risk of IUA. In a prospective study, the incidence of
IUA diagnosed by hysteroscopy after dilation and curet-
tage has been found to be 16.3% (16 of 98 cases) (22).
Immediate and short-term complications have been
found to be significantly lower in the group treated with
misoprostol than with surgical treatment (23). Problems
presenting six months after discharge, problems such as
menstruation, pain and infection were less common in
the medically treated group. Surgical treatment carries a
higher risk of perforation, damage to the endometrial
1401
Complications in hysteroscopy
lining and infection, which may lead to a higher inci-
dence of IUA.
Despite a high risk of IUA recurrence after OH, the
need for preventative measures remains controversial. A
prospective randomized trial, comparing two patient
groups with grade III synechiae, all of which had an
intrauterine device inserted, received estrogen and pro-
gestin treatment for two months following OH (24).
Group 1 underwent a second adhesiolysis one week later.
Group 2 did not undergo another procedure. There was
no difference in spontaneous pregnancy rates or live birth
rates. However, there was a significant difference between
group 1 and 2 in terms of mild and severe adhesion for-
mation at two months: 2.7% vs. 37% (p < 0.01) and
2.7% vs 14.2% (p < 0.05), respectively. Estrogen therapy
is often used after adhesiolysis to prevent IUA; however,
the evidence for this is poor and there are no randomized
controlled trials. One trial with 60 women randomly
assigned to estrogen and progestin treatment or no treat-
ment following curettage for first trimester abortions
found a significant increase in endometrial thickness
(0.84 vs. 0.67 cm, p = 0.02) and volume (3.85 vs.
1.97 m2) (25). The authors suggested that the findings
may be significant in prevention of IUA.
Conclusion
Prevention of the most common complications is feasible
with precautionary measures and awareness of risk fac-
tors. However, some complications such as IUA may be
inevitable, due to lack of evidence-based preventative
treatment options. Entry-related complications such as
perforation and bleeding may be prevented by appropri-
ate teaching of OH, identifying patients at high risk, cer-
vical ripening with misoprostol in pre-menopausal
women and with estradiol and misoprostol in post-meno-
pausal women. Routine prophylactic antibiotics are not
recommended. OHIA syndrome can be reduced, if not
avoided, by close monitoring of fluid balance. In addi-
tion, presurgical classification of submucous myomas can
identify patients at risk for prolonged operative time and/
or incomplete resection and thus reduce the risk of OHIA
syndrome. OH retains a significant role in gynecological
endoscopy.
Funding
No funding was received for this study.
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