#hysteroscopic

[jcrmhscasereports]

Massive volume overload with severe pulmonary edema during hysteroscopy: a case report by F.Fiedler in Journal of Clinical Case Reports Medical Images and Health Sciences  

INTRODUCTION

One of the most serious problems of therapeutic hysteroscopic procedures nowadays depending on a distending media in use, remains a fluid overload with concomitant electrolyte imbalance. This rare but very life threatening condition remains of great concern and requires interdisciplinary management from experts of different fields such as anesthesiology, intensive care, cardiology and nephrology.

The irrigating media plays an essential role during hysteroscopic operations because it distends a uterine cavity and so provides a necessary visibility. There are gasous and liquid types of media. The Carbon dioxide is obsolete because it provides insufficient visibility and can lead to severe complications such as embolism or systemic accumulation due to its high solubility.

The liquid ones vary according to their osmolality, viscosity and electrolyte content, respectively an overload can cause different kinds of pathological settings.

Depending on the type of current (monopolar vs. bipolar) the irriganting fluid may or may not content electrolytes. The electrolyte-free, low-viscosity fluids, such as Mannitol/ Sorbitol mixture, Glycin 1,5%, Glucose 5%, Sorbitol 3%  are standard media in monopolar surgery. The excessive absorption can lead to a hypoosmolal  hyperhydratation (also known as transurethral resection syndrome of prostate in urology patients) resulting in severe overload and dilutional hyponatriaemia, which can be a cause of different neurological clinical sequelae such as grand-mal-seizures and cerebral edema up to a brainstem herniation.

The isotonic solutions such as NaCl 0,9% or Ringer-Lactat on the other hand, are golden standard in bipolar hysteroscopic procedures and its systemic absorption can cause an isoosmolal hyperhydratation associated with hyperchloremic acidosis and pulmonary edema up to acute respiratory distress syndrome.

In this case report we will describe a particular clinical setting of excessive fluid overload with severe pulmonary edema in a 38-years-old female after a hysteroscopy and resectoscopy.

PATIENT’S MEDICAL HISTORY

38-years-old black woman, 55kg, presented herself for a hypermenorrhea caused by multiple submucous and intramural myomas. Due to longlasting, intense bleedings she developed iron-deficiency-anemia with hemoglobin level of 8,8g/dl. The anemia has been treated with iron infusions, vitamin-B12 and folic acid. However she was well adapted and didn’t show tachycardia or any kind of anemia- related symptoms.

Further on she suffered from infertility most likely caused by Uterus myomatosus, which had been previously treated by hysteroscopic and laparoscopic myomectomy.

Further preoperative assessment revealed an occasional smoker but otherwise healthy patient and routine laboratory analysis were unremarkable except for earlier mentioned anemia. The previous general anaesthesias were uneventful and she was classified as ASA II- patient. The premedication consisted of 7,5mg Midazolam p.o.

THE PROCEDURE AND INTRAOPERATIVE SETTING

After the general anesthesia has been inducted, consisting of 200mg Propofol, 0,2mg Fentanyl and 6mg Cisatracurium, patient was intubated uneventfully. A single-shot-antibiotic with 2g Cefazolin was administered before surgical start. Further anaesthesia was maintained with Sevoflurane (endexpiratory concentration 1,2 vol%) during low-flow-volume-controlled-ventilation.

The hysteroscopy was performed with a physiological saline solution as a distending medium administered by Karl Storz Hamou Endomat pump in hysteroscopy modul within preselected pressure- (max.150mmHg) and flow- range (max.400ml/min). The resectoscope had an active suction channel and myomectomy was facilitated with bipolar current.

After a resection time of 35 minutes the operating procedure became complicated due to big intracavitary myomas, consequently a larger amount of distending media was required to keep the visibility during the hysteroscopy. The efflux of the irrigating fluid wasn’t monitored because of the high amount lost in the sterile drapes.

In the meantime the patient developed mild tachycardia with descrete ST-depressions, that disappeared after deepening the anaesthesia. Further on she developed high respiratory pressures and the accurate examination of the patient lying in Trendelenburg position and in a dark operating theatre revealed swollen face that was missinterpreted as Quincke-edema and immediately treated with 4mg Dimetinden, 50mg Ranitidin and 500mg Prednisone.

The immediate termination of the procedure revealed a general swelling of a patient especially in abdominal and facial region. The uterus perforation was denied by the gynaecologist but due to threatening abdominal compartment syndrome an urgent laparoscopy was preformed, which revealed 2,5l of intraabdominal fluid. At that point the gynaecologist declared 9l deficit between the in- and outflow of the irrigating fluid.

Meanwhile the ventilation was severly impeded by massive pulmonary edema and 1,5l clear fluid was suctioned from the endotrachal tube. The oxygen saturation dropped to 53% and the inspiratory peak pressure reached up to 60 mmHg. The diuresis was stimulated by 80mg furosemid.

Under full mechanical ventilation support with high positive endexpiratory pressure and analgosedation we transferred the patient to the ICU.

ICU-MANAGEMENT

By the admission to the ICU the arterial blood gas analysis revealed

pH 6,95

pO2 92,2 mmHg

pCO2 58 mmHg

SO2 87%

HCO3 12,7 mmHg

BE -17,8 mmHg

Hb 6,5 g/dl

K+ 2,9mmol/l

Na+ 142 mmol/l

Lactat acid 4,27 mmol/l

The combined (hyperchloremic and respiratory) acidosis reached it’s peak later, when HCO3 dropped to 6,9 mmHg and was treated aggressively by 200mg HCO3 8,4%. The potassium substitution was administered via central venous line.

Noradrenaline was used to stabilize the circulation and the volume therapy was monitored with invasive hemodynamic monitoring (PICCOR), which revealed hypovolemia (GEDI 444 ml/m2) and pulmonary edema (ELWI 13 ml/kg) despite sufficient systemic vascular resistance (SVRI 3949 dyn*s*cm-5*m2) and good pump function (Cardiac Index 3,34 l/min/m2).

The 30,6 C° body temperature was treated with an active warming system for the next 18h until the normal temperature was reached.

The intraabdominal pressure was measured by bladder pressure monitoring (14 mmHg).

The oxygenation increased with forced diuresis and positive endexpiratory pressure ventilation (12 cmH2O).

Figure 1: Chest X-ray reveals pulmonary edema after ICU admission

After 24h of fully controlled mechanical ventilation and 6800ml of diuresis the sedation medication was terminated and the patient extubated uneventfully. No further ventilation support or vasoactive medication was required. The patient recovered in the matter of 72 hours and was discharged from the hospital on the day 7 with a mild arterial hypertension, that was treated by Hydrochlorthiazide 25mg a day.

DISCUSSION

 The isoosmolar hyperhydratation due to massive absorption of irrigating fluid, also known as Operative Hysteroscopy Intravascular Absorption Syndrome (OHIA)  is a life threatening complication of the bipolar resectoscopic procedures.

There are three different manners the distending fluid can be absorbed:

the fluid instillation in peritoneal cavity via fallopian tubes causing a high amount of free abdominal fluid, which can lead up to an abdominal compartment syndrome

 the absorption via endo- and myometrium causing a massive subcutan fluid overload

the intravascular absorption due to exceed of the venous vascular pressure of  endometrium by an irrigating fluid pressure causing expansion of plasma volume and consequently intravascular fluid overload.

This case report shows a massive absorption of distending fluid mostly throughout the endometrium causing generalized and later on pulmonary edema and throughout fallopian tubes causing acute abdomen. The delayed diagnosis of this complication was due to unreported imbalance between the irrigating fluid instilled (12 litres) and the volume recovered (3 litres) from the patient. Other conditions that impeded the early diagnosis were darkened operating theatre because of the hysteroscopy and Trendelenburg position of the patient, fully covered in warm sheets in order to prevent hypothermia.

The threatening abdominal compartment was promptly treated by an urgent laparoscopy and the patient responded very well to a complex symptom-orientated intensive care therapy. A mild arterial hypertension is a residual symptom of a massive NaCl-absorption and respectively delayed sodium and water excretion and is expected to disappear within days.

The top priority is the prevention of the excessive absorption and once this complication occurred, its rapid, correct diagnosis as well as early-goal-therapy is essential. The fundamental knowledge of different distending media and its possible complications must be considered by the gynecologist and anesthesiologist. Once the distending medium has been determined, certain strategy must be applied in order to avoid the massive fluid overload. The exact amount of administered and removed irrigating fluid must be accurately monitored, which can be impeded be different factors such as spilling the media on the floor or in sterile sheets, not exact amount of media in the bag (varies up to 5%), difficult estimation of not-used fluid in the bag. The irrigation pressure limit should be lower then the mean arterial pressure whenever possible and complicated operative procedures that take longer time such as myomectomy require splitting in two sessions.

As soon as the difference of instilled and recovered amount reaches the limit, that should be set a priori or a patient starts showing symptoms, the measurement of electrolytes, osmolality and arterial blood gasses should be preformed and the procedure terminated as soon as possible.

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[dr-sukhamoy-barik]

Ways to prepare for your hysteroscopy

Preparing for a hysteroscopy, a procedure to examine the inside of the uterus, can help ensure optimal results. Here are some practical steps by the best hysteroscopic surgeon to help you prepare for the procedure. 

How to prepare for a hysteroscopy?

1. Understand the Procedure: Before the procedure, take time to understand what a hysteroscopy involves. Your doctor will use a hysteroscope, a thin tube, to view the inside of your uterus.

2. Discuss with Your Doctor: Have a detailed discussion with your doctor about what to expect. This is the time to ask questions and clarify any doubts you may have.

3. Follow Pre-Procedure Instructions: The best hysteroscopic surgeon will provide specific instructions to follow before the procedure. These may include:

Fasting: You might be asked not to eat or drink for a certain period before the procedure, especially if you are having general anesthesia.

Medications: Inform your doctor about any medications you are taking. You may need to stop certain medications before the hysteroscopy.

Menstrual Cycle: Schedule the procedure when you are not menstruating. The best time is usually after your period ends and before ovulation.

4. Prepare for Anesthesia: Depending on the complexity of the hysteroscopy, local, regional or general anesthesia may be used. Your doctor will discuss the kind of anesthesia and how to prepare for it.

Conclusion

By being well-prepared, you can have a smoother experience and a quicker recovery. Consult with the best hysteroscopic surgeon for the best outcomes.

[drasmitadongare]

Best Gynecologist in Aundh| Female Gynecologist in Aundh| Best Lady Gynecologist in Aundh : Dr. Asmita Dongare

If you’re facing gynecological issues and living in Aundh, Pune or nearby areas then your search for the Best Gynecologist in Aundh ends here. With 15 years of extensive experience, Dr. Asmita Dongare is a compassionate and empathetic Obstetrician and Gynecologist in Aundh, Pune.

[drsukhamoybarik]

The highly certified and experienced hysteroscopic doctor in Dum dum uses state-of-the-art technology in examining patients and achieving success.

[healthify2u]

Hysteroscopic Myomectomy in Dubai | Dr Pranjali Singh

Hysteroscopic Myomectomy in Dubai, performed by the skilled hands of Dr. Pranjali Singh, offers a beacon of hope for women grappling with uterine fibroids. Uterine fibroids, though benign, can cause pain, heavy bleeding, and fertility issues. Dr. Singh's expertise in hysteroscopic myomectomy, a minimally invasive procedure, ensures a swift recovery and minimal scarring. Her dedication to women's health and state-of-the-art technology at Dubai's renowned medical facilities make her a sought-after specialist.

Patients trust Dr. Pranjali Singh for her compassionate care and commitment to their well-being. If you're seeking a solution to uterine fibroids in Dubai, her hysteroscopic myomectomy services provide a path to a healthier, fibroid-free future.

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[drnehalalla]

Is hysteroscopic myoma resection suitable for everyone?

Hysteroscopic myoma resection may not be suitable for everyone, and its appropriateness depends on various factors. Here are considerations regarding the suitability of hysteroscopic myoma resection:

Fibroid Type and Location: Most effective for submucosal fibroids.

Size of Fibroids: Larger fibroids may pose challenges.

Number of Fibroids: Suitable for a limited number; extensive cases may need alternatives.

Uterine Shape and Size: Feasibility depends on the uterus's shape and size.

Patient's Overall Health: Certain health conditions may impact suitability.

Desire for Fertility: Recommended for fertility preservation; discuss with a healthcare provider.

Prior Surgeries: Past uterine surgeries can influence safety and feasibility.

Patient Preferences: Individual comfort and preferences play a role.

Before hysteroscopic myoma resection, consult your healthcare provider for a thorough evaluation. The decision considers fibroid characteristics, overall health, and treatment goals. Alternative options may be recommended based on individual circumstances. Always consult with your healthcare provider for the most appropriate treatment plan.

For top-notch gynecological care in Dubai, look no further. Schedule a consultation with Dr. Neha Lalla, an expert Gynaecologist in Dubai. Experience specialized and compassionate women's health services. Book your appointment today.

[rituivf]

The Promise of Fertility Enhancing Surgery

Discover how Fertility Enhancing Surgery opens new avenues for prospective parents. Explore its potential to overcome fertility challenges and make parenthood dreams a reality. Delve into the innovative procedures that offer hope, empowerment, and a brighter path toward creating a loving family. For More Info: Fertility Enhancing Hysteroscopic Surgery

[gynecologyhospital]

Understanding Hysteroscopy: A Minimally Invasive Diagnostic and Therapeutic Procedure

Hysteroscopy is a revolutionary medical procedure that has transformed the way gynecological conditions are diagnosed and treated. It offers a minimally invasive approach, providing numerous benefits to both patients and healthcare providers. In this article, we will delve into the world of hysteroscopy, exploring its purpose, procedure, and the advantages it brings to women’s healthcare.

What is Hysteroscopy?Hysteroscopy is a medical technique that involves inserting a slender, lighted instrument called a hysteroscope into the uterus through the vagina and cervix. This enables direct visualization of the uterine cavity, allowing for accurate diagnosis and treatment of various conditions. It is typically performed on an outpatient basis and is considered a safe and effective procedure.

Benefits of a Minimally Invasive Approach:One of the significant advantages of hysteroscopy is that it is minimally invasive, meaning it requires only small incisions or no incisions at all. This leads to reduced pain, shorter recovery time, and minimal scarring compared to traditional open surgeries. It also lowers the risk of complications and allows for a quicker return to daily activities.

Diagnostic Hysteroscopy:Hysteroscopy plays a vital role in diagnosing various gynecological conditions. It provides a clear view of the uterine cavity, allowing the healthcare provider to identify abnormalities such as polyps, fibroids, adhesions, or structural issues. With hysteroscopy, precise biopsies can be taken, and tissue samples can be obtained for further evaluation.

Therapeutic Hysteroscopy:Not only is hysteroscopy diagnostic, but it is also therapeutic. It offers the opportunity to treat certain conditions directly during the procedure. For example, polyps or fibroids can be removed, adhesions can be released, and abnormal tissue can be excised. Hysteroscopy enables targeted interventions, reducing the need for more invasive surgeries and promoting optimal patient outcomes.

Advancements in Women’s Healthcare:Hysteroscopy has brought about significant advancements in women’s healthcare. It has revolutionized the management of conditions such as abnormal uterine bleeding, infertility, endometrial abnormalities, and uterine malformations. The procedure allows for precise and tailored treatments, improving patient satisfaction and quality of life.

Patient Experience and Recovery:Patients undergoing hysteroscopy often report a positive experience. The procedure is usually performed under anesthesia or conscious sedation, ensuring patient comfort. Recovery is typically quick, with minimal discomfort and a short hospital stay, if any. Within a few days, the majority of people are able to return to their normal activities.

Conclusion:Hysteroscopy has emerged as a valuable tool in the field of women’s healthcare, providing a minimally invasive approach to diagnosis and treatment. Its ability to visualize and address uterine conditions with precision has transformed the management of various gynecological issues. As advancements continue to be made, hysteroscopy promises even better outcomes for women worldwide, empowering them with improved health and well-being.

[womenhealthspecialist]

Advanced laparoscopy near me greenbelt

If you're looking for a gynecologist near me, we're the best option. We have the most experienced and qualified staff that can help you with any of your Gyno needs. Uterine fibroids treatment near me greenbelt Our services include pelvic exams, pap tests, and painful urination treatment in Greenbelt MD.

Used to treat symptoms of pelvic relaxation and stress urinary incontinence. Many women have difficulty controlling their urine in certain situations or notice changes in their bowel habits. These two symptoms may be related to a common set of problems that may occur as a result of childbirth, aging or a combination of both. Grouped together these problems are referred to as pelvic relaxation. The pelvic organs include the vagina, uterus, bladder, and rectum. Some, or all, of these organs, may be affected by pelvic relaxation. When the uterus drops out of its normal position, this is called uterine prolapse. Relaxation of the front wall of the vagina and/or bladder is a cystocele, and relaxation of the back wall of the vagina in front of the rectum is called a rectocele. Sometimes after a hysterectomy, the top of the vagina relaxes or “droops.” This is called vaginal vault prolapse. At times, a small amount of small bowel falls into this area (enterocele). The decision on how to treat pelvic relaxation depends on what part of the pelvis is affected.

[thebadgerssett]

This is something I've been turning in my head for the last few years after a conversation I had, but I think it's a good time to mention it. You don't ever have to tell anyone you've had an abortion; not even the person you're with. If you wish to tell your partner, think it over; a couple times in my life I have seen openly pro-choice men suddenly become anti-choice the moment it's 'theirs,' and I highly doubt those are isolated events. Go with your gut!

You might be wondering how to hide an abortion (aside from destroying any documentation); in the case of surgical abortion, there are other gyn. procedures that can require some form of sedation & temp. abstinence, and can sometimes cause nausea, cramping, and some bleeding for hours to days, for example: cone biopsy, IUD insertion, or hysteroscopic polypectomy. Hiding a medical abortion can be a little trickier (and occasionally, not everything is expelled, which can result in complications requiring surgical treatment), but the good news is that periods can be weird and unpredictable, and therefore a great cover! It's not out of the ordinary to have an unusually heavy or painful period that even includes vomiting or diarrhea. Anyways, people's experiences with abortion vary, so please do your own research to make the decision & plan that's best for your situation! I Need an Abortion | ineedana.com Abortion - Planned Parenthood Toronto In-Clinic Abortion Procedure | Abortion Methods

[sarajcsmicasereports]

Case Report- A challenging case of severe Asherman’s syndrome in Reproductive MedicineFollowed by twin delivery by Lamiya Mohiyiddeen in Journal of Clinical Case Reports MedicaI Images and Health Sciences 

INTRODUCTION

This is a case report of a severe case of Asherman’s Syndrome who underwent multiple hysteroscopic procedures and embryo transfers over a span of 10 years. Her last embryo transfer was successful after the 5th hysteroscopy and high dose estrogen treatment. She delivered preterm twin babies.

CASE REPORT

Mrs. A was first seen with infertility and secondary amenorrhea. She was nulliparous with history of two surgical evacuations.

Her pelvic scan showed very thin endometrium of 2.5mm. She had hysteroscopy done 3 times to manage intrauterine adhesions in other centers.

When she then attended to start IVF treatment at St. Mary’s her FSH/LH level was very high and she was diagnosed premature ovarian failure. She underwent In Vitro Fertilization (IVF) cycle with donor eggs and partner’s sperm, had hormone replacement therapy (HRT) & fresh embryo transfer with single blastocyst but this was unsuccessful. Three blastocysts were frozen in that cycle.

First frozen embryo transfer with single embryo was unsuccessful. Prior to next embryo transfer scan showed fluid in endometrium. Diagnostic hysteroscopy diagnosed recurrence of Asherman’s Syndrome. Following this yet another operative hysteroscopy at our centre was done using versa point mainly and cold knife dissection towards the corneal ends. Hyalo-barrier gel was instilled, and copper coil was inserted, high dose estrogen was given for 6 weeks post operatively. Coil was removed after 3 months. She then had frozen embryo transfer with two blastocysts.

This transfer was successful and confirmed twin gestation. However, she had preterm prelabour ruptured membranes at 28 weeks gestation and delivered by Caesarean Section at 29+4 weeks. The birthweights of the babies were normal centiles for that gestation and were discharged home in good condition.

DISCUSSION

Treating patients with Asherman’s syndrome and thin endometrium is an ongoing challenge in the field of Reproductive Medicine.

Although the syndrome has been widely investigated, evidence of both prevention of the syndrome and the ideal treatment are missing.

Surgical management offers favorable fertility outcomes and is often successful in restoring menstruation. Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment and adopting an office-based approach offers several advantages.

Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority.

Cell-based therapies using endometrial stem/progenitor cells hold promise for future use in regenerating inadequate endometrium.

The recurrence rate following treatment is as high as 33%-66% depending on severity.

CONCLUSION

Increased awareness of the symptoms suggestive of intrauterine adhesive disease, as well as recognition of common causes and preceding events, is crucial for early diagnosis, patient counselling and treatment.

Type of adhesiolysis (versa point vs cold-knife), with judicious use of hyalo-barrier, coil & oestrogen led to success in this challenging case.  

[drasmitadongare]

Choosing the right gynecologist is important for every woman’s health and well-being. Whether seeking routine check-ups, managing a pregnancy, or dealing with complex gynecological issues, having a trusted and experienced specialist can make a significant difference in your healthcare journey.

[partoftheairforce]

i’m getting freaking hysteroscopic surgery today i’m shitting my pants