BJA Education, 21(7): 240e242 (2021)

doi: 10.1016/j.bjae.2021.03.001
Advance Access Publication Date: 6 May 2021

Matrix codes: 1I01,

2A06, 3A03

ESSENTIAL NOTES

Complications of operative hysteroscopy: an

anaesthetist’s perspective
H. Elahmedawy* and N.J. Snook
Leeds Teaching Hospitals NHS Trust, Leeds, UK
*Corresponding author: hazem.elahmedawy@nhs.net

Keywords: anaesthesia; complications; hysteroscopy

Operative hysteroscopy has revolutionised the management (i) Level 1: diagnostic hysteroscopy with a target biopsy or
of gynaecological diseases. There were 71,000 hysteroscopies removal of simple polyps.
performed in England in 2019e2020, of which almost half (ii) Level 2: proximal fallopian tube cannulation, removal of
were therapeutic. They are minimally invasive, cost and time pedunculated fibroid or large polyp.
effective and can spare patients major surgery. They are seen (iii) Level 3: resection of the uterine septum, endometrial
as low-risk procedures often performed in patients who are resection or ablation, resection of submucous fibroids
otherwise fit (ASA Grade 1 or 2), but complications in operative and repeat endometrial ablation or resection.
hysteroscopy can be immediate, severe and life-threatening.
Despite the advanced surgical training and the high level of
Over the past decade, multiple near-fatal and fatal events
expertise required, there can still be challenges for the sur-
have been reported.1e3 This article aims to increase aware-
geon in dilating the cervix or obtaining a good view, which
ness of those complications, provide guidance on preventa-
leads to a higher incidence of complications.
tive measures and outline the immediate management of
such events.

Surgical classification
Hysteroscopic surgery needs access through the cervix with a
hysteroscope or a resectoscope, distension of the uterus with
a fluid or a gas to visualise and the use of energy to coagulate
or excise tissue. The Royal College of Obstetricians and
Gynaecologists classifies operative hysteroscopy into three
levels for training purposes:4
Complications
The reported incidence of complications varies widely, but a
large prospective study found an overall incidence of 0.95%.5
The most frequently reported complications are haemor-
rhage (2.4%), uterine perforation (1.5%) and cervical lacera-
tion (1e11%). Complications are likely with complex
procedures, especially if associated with cervical stenosis,
uterine malposition, difficult uterine distension or obscuring
blood.

Immediate and early complications

Hazem Elahmedawy FRCA EDAIC MSc is a locum consultant
anaesthetist at St James’s University Hospital, Leeds Teaching
Hospitals NHS Trust. He was formerly an assistant lecturer of
anaesthesia at Alexandria University Hospitals, Egypt. His main
interests are obstetric anaesthesia and risk management.
Nicola Snook FRCA FFICM is a consultant in intensive care medicine
and anaesthesia at St James’s University Hospital, Leeds Teaching
Hospitals NHS Trust, and an examiner for the Royal College of
Anaesthetists.
These complications occur during surgery or in the early
postoperative period and the anaesthetist is likely to be
involved in their management. They are mainly caused by
cervical dilatation, distension media or surgical
technique.
(i) Arrhythmias.
(ii) Uterine perforation.

Accepted: 11 March 2021

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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240
 Complications of operative hysteroscopy

(iii) Distension media related, including fluid overload, The British Society for Gynaecological Endoscopy and the
hyponatraemia, ‘transurethral resection of prostate European Society for Gynaecological Endoscopy guidelines
(TURP)-like syndrome’ and glycine toxicity. recommend the following preventive measures:7
(iv) Venous gas embolism.
(i) The use of sodium chloride 0.9% as irrigation fluid.
(v) Haemorrhage caused by cervical or uterine lacerations.
(ii) Monitoring the inflow/outflow of fluid during the
(vi) Electrosurgical burns.
procedure.
(iii) Calculation of fluid deficit.
(iv) Informing other members of the team, particularly the
Late complications anaesthetist, if the fluid deficit reaches 1500 ml in the
case of sodium chloride 0.9% or 750 ml for glycine 1.5%,
Late complications occur weeks, months or even years after
and stopping the procedure.
the procedure.
(v) Restricting i.v. fluids.
(i) Intrauterine adhesions. (vi) Maintaining a normal MAP.
(ii) Infection and pelvic inflammatory disease. (vii) The use of local anaesthesia (paracervical block) with
(iii) Complications in subsequent pregnancies (e.g. uterine sedation may reduce fluid absorption.8
rupture).
(iv) Haematometra.
(v) Post-ablation sterilisation syndrome.
Table 1 Prevention and management of venous gas embolism
in operative hysteroscopy. CVC, central venous catheter; VGE,
venous gas embolism
Management of immediate severe
complications Prevention
Avoid exaggerated Trendelenburg
positions
Bleeding and uterine perforation
Height of irrigation fluid restricted to
Uterine perforation is one of the most common complications <1 m above the patient

Automated fluid irrigation pumps
of operative hysteroscopy with an incidence of 0.8e1.5%.5

Limit uterine distension pressures to
Uterine perforation can happen during cervical dilation or <100 mmHg
during insertion of the hysteroscope. Such a perforation may
Maintain normal MAP
be recognised when an instrument passes beyond a depth of
Avoid nitrous oxide
the uterine fundus, when there is a sudden loss of visual-
Consider transoesophageal
echocardiography or precordial Doppler
isation, when omentum or bowel or peritoneal structures can monitoring in high-risk patients for par-
be visualised at the uterine fundus or when there is a sudden adoxical emboli (e.g. septum defects)11
increase in the fluid deficit.6 The fluid deficit is the difference
Early detection
A sudden decrease in PE0 CO2
between irrigation inflow and outflow volumes.
Hypotension or hypoxia or
Uterine perforation can lead to vaginal bleeding, visceral bronchospasm
injury and, rarely, concealed intra-abdominal haemorrhage. If
Classic ‘mill-wheel’ murmur on
a perforation is suspected, the procedure should be stopped, auscultation

Dyspnoea and chest pain if awake
the haemodynamic status of the patient assessed and urgent
Wide PaCO2/PE0 CO2 gap
laparotomy considered if internal haemorrhage is suspected.
Targeted ultrasound of the inferior vena
cava or echocardiography can be used
to confirm the diagnosis10,12
Distension media complications Prevent further
Stop the surgery
entrainment
Immediate supine position
During hysteroscopy, the uterine cavity needs to be distended,
Disconnect the distension medium and
and this is achieved with either fluid or carbon dioxide. Car- check irrigation lines
bon dioxide is used mainly in diagnostic hysteroscopy and
Deflate the uterus and occlude the cervix
fluid for operative procedures. Fluid allows continuous irri- with wet gauze

FIO2 1.0 and stop nitrous oxide if used
gation, provides a clearer picture and enables the use of both

Aim for higher MAP (fluids or
mechanical and electrosurgical instruments. Fluid absorption vasopressors)
happens through exposed venous sinuses and fallopian tubes.
Resuscitation
Immediate call for help and escalation
Factors increasing the absorption include duration of the
Cardiopulmonary resuscitation if
(massive VGE)
procedure, the pressure of irrigation fluid, the tumour size and indicated
depth of tumour penetration and the presence of false tracks
Tracheal intubation, CVC and inotropes
or cervical lacerations. Although the reported incidence of
Consider lengthy cardiopulmonary
resuscitation (automated chest
fluid overload during hysteroscopic surgery is generally low
compression if available)
(<5%), the consequences can be serious, especially in high-risk
Echocardiography or abdominal
patients.7 Complications vary depending on the type of fluid ultrasound to confirm the diagnosis
used. In the case of the most common, isotonic fluid, fluid
Consider extracorporeal membrane
overload can occur when fluid deficit exceeds 2,500 ml in oxygenation if feasible

otherwise healthy patients or 1,000 ml in high-risk patients Consider
Aspirate from CVC
(e.g. those with heart failure). If a hypotonic solution is used,
Left lateral position (Durant position)

Hyperbaric oxygen
severe hyponatraemia and a syndrome similar to TURP syn-

Precordial thump/chest compressions
drome, with or without fluid overload, are described. Glycine
toxicity has also been reported.8

BJA Education - Volume 21, Number 7, 2021 241

Complications of operative hysteroscopy
Venous gas embolism
Gas embolism is the most serious complication of operative
hysteroscopy and is the main cause of fatal and non-fatal
events reported in the literature.1e3 In one study, using
transoesophageal echocardiography to detect gas embolism
in operative hysteroscopy, gas emboli were detected in 49 out
of 50 patients; in 40% of these patients, the amount of gas was
considered significant.9 In another study of 150 patients, evi-
dence of continuous air emboli was found in 34% of patients.10
Despite the high incidence of air emboli, serious conse-
quences are considered rare: one in 1,140 in one study.3
The pathophysiology involves the passage of gas into the
exposed vessels caused by cervical laceration or venous sinuses
within the uterus. Gas present around vessels can be air,
gaseous products of electrocoagulation or carbon dioxide if
used as the distension medium. A pressure gradient as a
consequence of Trendelenburg position or high infusion pres-
sures will drive gas into the vessels. In operative hysteroscopic
procedures, the source of the gas is either from electro-
coagulation (hydrogen, carbon monoxide and carbon dioxide)
or from room air. Multiple reinsertions of the instruments
during a difficult cervical dilation and prolonged exposure of a
lacerated cervix to room air are major risk factors.
Strategies to prevent and manage venous gas embolism are
shown in Table 1.
Conclusion
Most studies report a high degree of safety, effectiveness and
patient satisfaction with operative hysteroscopy. However,
serious complications, such as venous gas embolism, may
occur and potentially lead to mortality in otherwise healthy
women. The most common complications are preventable if
risk factors are considered and precautionary measures
taken.
Declaration of interests
The authors declare that they have no conflicts of interest.
References
1. Van Dijck C, Rex S, Verguts J, Timmerman D, Van de
Velde M, Teunkens A. Venous air embolism during
242 BJA Education - Volume 21, Number 7, 2021
hysteroscopic myomectomy: an analysis of 7 cases.
Gynecol Obstet Invest 2017; 82: 569e74
2. Storm BS, Andreasen S, Hovland A, Nielsen EW. Gas
embolism during hysteroscopic surgery?: three cases and
a literature review. A A Case Rep 2017; 9: 140e3
3. Vilos GA, Hutson JR, Singh IS, Giannakopoulos F,
Rafea BA, Vilos AG. Venous gas embolism during hyster-
oscopic endometrial ablation: report of 5 cases and re-
view of the literature. J Minim Invasive Gynecol 2020; 27:
748e54
4. Royal College of Obstetricians and Gynaecologists. Oper-
ative hysteroscopy. 2019. Available from: https://elearning.
rcog.org.uk/uterine-cavity-surgery/operative-
hysteroscopy. [Accessed 14 January 2021]
5. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J,
Trimbos JB, Trimbos-Kemper TC. Complications of hys-
teroscopy: a prospective, multicenter study. Obstet Gynecol
2000; 96: 266e70
6. Agostini A, Cravello L, Bretelle F, Shojai R, Roger V,
Blanc B. Risk of uterine perforation during hysteroscopic
surgery. J Am Assoc Gynecol Laparosc 2002; 9: 264e7
7. Umranikar S, Clark TJ, Saridogan E et al. BSGE/
ESGE guideline on management of fluid distension
media in operative hysteroscopy. Gynecol Surg 2016; 13:
289e303
8. Bergeron ME, Ouellet P, Bujold E et al. The impact of
anesthesia on glycine absorption in operative hysteros-
copy: a randomised controlled trial. Anaesth Analg 2011;
113: 723e8
9. Dyrbye BA, Overdijk LE, van Kesteren PJ et al. Gas embo-
lism during hysteroscopic surgery using bipolar or
monopolar diathermia: a randomized controlled trial. Am
J Obstet Gynecol 2012; 207: 271e6
10. Liu S-Q, Zhao S-Z, Li Z-W, Lv S-P, Liu Y-Q, Li Y. Monitoring
of gas emboli during hysteroscopic surgery: a prospective
study. J Ultrasound Med 2017; 36: 749e56
11. Groenman FA, Peters LW, Rademaker BM, Bakkum EA.
Embolism of air and gas in hysteroscopic procedures:
pathophysiology and implications for daily practice.
J Minim Invasive Gynecol 2008; 15: 241e7
12. Leibowitz D, Benshalom N, Kaganov Y, Rott D, Hurwitz A,
Hamani Y. The incidence and haemodynamic signifi-
cance of gas emboli during operative hysteroscopy: a
prospective echocardiographic study. Eur J Echocardiogr
2010; 11: 429e31