Boston Medical Center

Policy and Procedure Manual

Page: 1

Policy #: 15.05.002
Issued: 6/10
Reviewed/
Revised:
Section: 15.0 Operative Services

Guideline for Management of a Patient Undergoing Hysteroscopy

Definitions:
Diagnostic hysteroscopy: Endoscopic visualization of the uterine cavity and tubal orifices to aid
in the diagnosis of intra-uterine disease.
Operative hysteroscopy: Endoscopic visualization of the uterine cavity and tubal orifices as
well as instrumentation of the uterus and or fallopian tubes. Examples include hysteroscopic
polypectomy, myomectomy, tubal occlusion (Essure), endometrial ablation (Novasure).
Fluid Deficit: The amount of fluid retained through extravasation during a hysteroscopic
procedure. The fluid deficit is of the amount of distending fluid infused during a procedure
minus the amount of fluid recovered either by manual measurement of by measurement by a
fluid management system.
Statement of Procedure:
Hysteroscopic procedures are used to treat a variety of intra-uterine abnormalities (i.e.,
menorrhagia, uterine polyps and fibroids). Both diagnostic and operative hysteroscopic
procedures involve the use of distention fluid to adequately visualize the uterine cavity.
Hysteroscopy is contraindicated in patients who are pregnant, have known genital tract
infections, or known uterine cancer.
Hemorrhage is the most common complication, followed by fluid overload and cervical
laceration. Hemorrhage is usually managed using cautery. Fluid overload results from
extravasation of distention fluid used to maximize visualization of the intrauterine cavity. If the
intrauterine pressure exceeds the mean arterial pressure or if uterine perforation occurs, the
distention fluid can be forced into open vessels or through the fallopian tubes into the peritoneal
cavity (extravasation). The type and amount of distention fluid used may affect the patients
outcome if excessive fluid absorption occurs. Distention fluid deficit levels must be monitored
throughout the procedure, using a fluid management system or manual calculation, and
termination of the procedure must occur when maximum fluid deficit levels are reached.

Section # 15.0 Operative Services

Policy #: 15.05.002

Boston Medical Center

Policy and Procedure Manual

Page: 2

Distending Fluid and Associated Equipment and Clinical Guidelines

Sorbitol (non
electrolyte)

Normal Saline
(electrolyte)

Monopolar
Instrumentation
(ACMI resectoscope,
Storz mini
resectoscope, Storz
hysteroscope)
ACMI or Storz mini
hysteroscopes
Bipolar
(Versapoint)
Mechanical
Instrumentation
(Smith & Nephew)

Maximum
Deficit
1000cc*

Can cause
hyponatremia and
decreased serum
osmolality

Maximum Deficit
2500cc *

Less risk for

hyponatremia but
excessive deficit can
cause pulmonary
edema

Deficit limits are suggested for patients with an ASA class I, II or stable III (AAGL,
2000 guidelines). Older patients and those with cardiovascular or renal disease may
not be able to tolerate these amounts.

Nursing Guidelines
Fluid Management
1. AORN suggests that a hysteroscopic fluid management system be used on every
hysteroscopic procedure. In the event that a fluid management system is not used,
manual calculation of the fluid deficit is required. A fluid management system is
required for all hysteroscopies performed in the operating room.
2. To ensure an accurate monitoring of outflow fluid, measurements will be collected
from the following collection locations:
a. Fluid drape pouch under the patients buttocks
b. Hysteroscope outflow sheath
c. Best estimate of any fluid spilled on the floor/drapes. Use of a floor suction
device is suggested.
3. The circulating nurse monitors and records the inflow and outflow of hysteroscopic
fluid at least every 15 minutes during the procedure and informs the attending
surgeon
d. If there is a sudden rise in fluid deficit at any time
e. When a non-electrolyte fluid (sorbitol) deficit reaches 500ml or a saline deficit
reaches 1500ml.

Section # 15.0 Operative Services

Policy #: 15.05.002

Boston Medical Center

Policy and Procedure Manual

Page: 3

f. The procedure should be terminated when the fluid deficit reaches 1000ml of a
non- electrolyte solution (sorbitol) or 2500ml of normal saline.
4. The type of distention media used, the total fluid volume instilled and the total fluid
deficit are documented in the clinical record at the end of the procedure.
5. If the fluid has approached or exceeded the maximum for saline or sorbitol, monitor
the patient for signs and symptoms of fluid overload or hyponatremia. Consider the
following:
g. ABGs (for acidosis and oxygenation)
h. Electrolytes
i. Foley catheter
j. Consider admission for observation and fluid monitoring.
k. Consider Medicine/ICU consult.

Hyponatremic Stages and Associated Signs and Symptoms

130-135mEq/L
Mild

Changes in mental status,

apprehension, disorientation,
irritability, twitching nausea,
vomiting and shortness of
breath.

Moderate

125-130 mEq/L

Signs of impending
pulmonary edema, moist skin
and mucous membranes,
pitting edema, polyuria, dilute
urine, pulmonary rales.

Severe

120 125mEq/l

Hypotension, bradycardia,
anemia, jaundice, cyanosis, or
further changes in mental
status.

Responsibility:
Forms:
References:
Bradley, L. (2009). Hysteroscopy: Managing fluid and gas distention media. UpToDate retrieved
from
www.uptodate.com

Section # 15.0 Operative Services

Policy #: 15.05.002

Boston Medical Center

Policy and Procedure Manual

Page: 4

Loffer, F.D., et al. Hysteroscopic fluid monitoring guidelines. J Amer Assoc. Gynecol
Laparos. 2000; 7:167-8.
Young, E., Sherrard-Jacob, A., Knapp, K., Craddock, T., Kemper, C., et al. (2009).
Perioperative Fluid Management. AORN, 89, 167-180.
Hysteroscopy. ACOG Technology Assessment in Obstetrics and Gynecology No. 4 American
College of
Obstetricians and Gynecologists. Obstet Gynecol 2005;106: 439-42.

Section # 15.0 Operative Services

Policy #: 15.05.002