Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Managing bleeding, fluid absorption and uterine

perforation at hysteroscopy
Olav Istre, MD, PhD, Assistant Clinical Professor *
Department of Obstetrics and Gynecology, Ulleval University Hospital, 0407 Oslo, Norway

Keywords:
Hysteroscopy is the current gold standard for evaluating
fibroids intrauterine pathology, including submucous fibroids, polyps,
hysteroscopy hyperplasia and cancer. However, there are still problems and
irrigation complications connected to hysteroscopy.
perforation Fluid overload of 1–2 l occurs in approximately 5.2% and >2 l in 1%
complication of cases. This article discusses the physiology, implications and
treatment of these cases. Uterine perforation is encountered in
nearly 1% of cases. We describe the precautions to avoid this
perforation and the methods to treat it.
The article also discusses excessive bleeding, which occurs in 3% of
operative hysteroscopies and describes strategies to avoid and to
deal with this complication. Emergency hysterectomy and other
surgical interventions are rarely indicated and are seen in 2% of
cases. Finally, death due to septicaemia or fluid overload has been
reported only very rarely (0.1%). These different complications are
discussed in detail.
Ó 2009 Elsevier Ltd. All rights reserved.

Menstrual disturbances are common in fertile and premenopausal women.1 Menorrhagia is the
most common cause of iron deficiency in these patients2,3 with more than 1 million general practi-
tioner (GP) consultations (or 30 per 1000 consultations) in the UK per year; some of these problems are
transient and many patients are treated effectively in general practice.4 When medical therapy fails,
hysterectomy has been the only surgical alternative and represents the most common major operation
performed for women of reproductive age in the United States.5 This operation is associated with
a hospital stay of about 1 week and subsequent sick leave of 4–6 weeks. The overall mortality rate is
16.1 per 10 000 operations and the complication rate 43% and 25% after abdominal and vaginal
hysterectomy, respectively.6 These data have motivated research into alternative, less-invasive

* Tel.: þ47 22119800; Fax: þ47 22119775.

E-mail address: post@oistre.com

1521-6934/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.bpobgyn.2009.03.003
620 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

procedures such as transcervical techniques for isolated removal of the endometrium and polyps and
fibroids with the aim of decreasing menstrual bleeding and the restoration of fertility.
Traditionally, operative hysteroscopy used the resectoscope and this tool is still the most used for
larger pathology; however, in recent years smaller-diameter hysteroscopes as well as second- and
third-generation ablation techniques have been developed.7–9
Hysteroscopy is the current gold standard for evaluating intrauterine pathology, including sub-
mucous myomas, polyps, hyperplasia and cancer.38 In the outpatient setting, hysteroscopy appears to
have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaes-
thesia. Apart from its diagnostic value, hysteroscopy can also be used for operative procedures including
ablation and resection. Both diagnostic and operative hysteroscopy have been used for a number of years
and various studies have described the success and complication rates of the hysteroscope.

Complication rate of hysteroscopic surgery

A series of 800 women underwent endometrial ablation in 54 hospitals. The indications for the
procedure were: abnormal uterine bleeding causing a disruption in lifestyle, abnormal bleeding whilst
taking hormone replacement therapy, poor surgical risk for hysterectomy and a desire to preserve the
uterus. Under appropriate anaesthesia, the cervix was dilated to 10 mm and the uterine cavity dis-
tended with 1.5% glycine solution under gravity inflow of 80–100-cm water and outflow suction of
80–100-mmHg pressure. The complication rate was 3.9%; the complications were as follows: false
passage during cervical dilatation (six), uterine perforation (seven: dilator four, resectoscope 2 and
laminaria one), fluid absorption greater than 1500 ml (eight), minor bleeding (five), endomyometritis
(four) and intrauterine pregnancy (one). In this study, the authors concluded that hysteroscopic
endometrial ablation is a safe and effective treatment for women with menometrorrhagia.10–12

Bleeding during hysteroscopy

Bleeding during operative hysteroscopy is encountered when the operator resects too deep into the
myometrum and when attempts are made to resect larger fibroids (types 1 and 2 according to the
European endoscopy classification; Fig. 1).13
The uterus has a very rich blood supply through two extrinsic arterial systems, the uterine and ovarian
arteries. The intrinsic uterine arteries consist of the ascending uterine, arcuate, radial and peripheral arteries

Fig. 1. Ultrasound, laparocopic and hysteroscopic view of the different fibroids (type 0 inside the uterine cavity >50% type I <50%
and type II intramural).
 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629 621

that give free flow through the uterus. Fibroids receive their blood supply from the intrinsic arteries,
primarily from the branches of arcuate arteries, and the vessels are located in the pseudocapsule around the
fibroids. The ipsilateral uterine and ovarian arteries are connected by communicating branches. In addition
to its primary (uterine artery) and secondary (ovarian artery) extrinsic blood supply, the uterus enjoys a vast
network of lesser-known arterial collaterals14 (Figs 2 and 3).
Pre-treatment with gnRH analogues can be recommended when considering surgery on larger
fibroids in order to shrink and diminish the circulation around them15,16; it also reduces the compli-
cation rate and decreases the operation time for all major operative hysteroscopy.
How can one avoid bleeding during hysteroscopic procedures? The basic requirements are: to use
sufficient pressure and flow (preferably using an automatic pump), to administer oxytoxin 10 IU intrave-
nously during the procedure, to coagulate vessels during the operation and to have a control on the fluid loss.
Vasopressin injections have also been used during operative hysteroscopy but can have major side-
effects on the general circulation; however, the administration of dilute vasopressin solution (0.05 U ml1)
to the cervical stroma significantly reduces blood loss, the extravasation of distention fluid and the
operative time during hysteroscopy. Further evaluation is required to determine the optimum dosage.17
In case of major bleeding, control can be achieved by placing a Foley catheter in the endometrial cavity and
inflating the balloon with 25–35-ml saline. The catheter should be left in the cavity for 2–4 h before removal.18

Uterine perforation and making a false passage: (Figs 4 and 5)

In general, operative hysteroscopy is a safe procedure, is easily learned and has excellent surgical
outcomes. As more obstetricians/gynaecologists perform hysteroscopy, they must remain familiar with

Fig. 2. Ultrasound and hysteroscopic of the uterine circulation.

622 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

Fig. 3. Perforation of the uterus and laparoscopic suture.

the possible complications. The recognition of complications and prompt intervention helps in pre-
venting adverse sequelae as well as in minimising undesirable patient outcomes and reducing legal
risks. Nevertheless, hysteroscopy remains a relatively safe procedure. Diagnostic hysteroscopy has the
fewest risks, followed by operative hysteroscopic adhesiolysis, metroplasty and myomectomy.19
If in case of perforation the pressure suddenly drops and one is not able to continue the operation,
then a high suspicion of perforation should be raised. If the patient is still stable, immediate intervention
is not needed. However, it is advisable to retain the patient in the hospital and monitor for possible
bleeding, pain and infection. If the patient’s condition deteriorates, laparoscopy should be performed.

Uterine rupture following operative hysteroscopy

A MEDLINE and EMBASE search of the English, German and French literatures was performed to
retrieve case reports of uterine rupture following operative hysteroscopy. A total of 14 cases were
retrieved. Twelve patients had a history of hysteroscopic metroplasty. Uterine perforation complicated
the operative hysteroscopy in eight cases and electrosurgery was used in nine cases. The interval
between hysteroscopy and subsequent pregnancies varied from 1 month to 5 years with an average
range of 16 months. Hysteroscopic metroplasty subjected patients to a higher risk of uterine rupture
during subsequent pregnancies. Uterine perforation and/or the use of electrosurgery increase this risk
 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629 623

but are not considered independent risk factors. Uncomplicated hysteroscopic resection of submucous
myomas and endometrial polyps did not alter the obstetrical outcome. Apart from the use of scissors
for hysteroscopic metroplasty being associated with lower risk, no accurate methods to prevent or
detect rupture in subsequent pregnancies were found. Physicians providing care for patients with
a previous hysteroscopic metroplasty or complicated operative hysteroscopy should be aware of the
potential risks for uterine rupture during future pregnancies.20

How to avoid uterine perforation during operative hysteroscopy

The loop should always be used in a way that it moves towards the operator, and not pushed into the
uterus. Furthermore, never activate the power if you do not have a clear view of the loop or needle. The
preoperative use of misoprostol or laminaria might decrease the risk of uterine perforation associated
with dilation of the cervix.
In our hospital, we conducted a study using misoprostol and compared the impact of 1000 mg of
self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoper-
ative cervical ripening in both pre-menopausal and post-menopausal women before operative hys-
teroscopy. Two separate but identical, parallel, randomised, double-blind, placebo-controlled
sequential trials were carried out: one in pre-menopausal women and the other in post-menopausal
women. Eighty-six women were referred to outpatient operative hysteroscopy. On the evening before
outpatient operative hysteroscopy, the women were randomised to either 1000 mg of self-administered
vaginal misoprostol or self-administered vaginal placebo. In the pre-menopausal women, the mean
cervical dilatation was 6.4 mm (SD 2.4 mm) in the misoprostol group and 4.8 mm (SD 2.0 mm) in the
placebo group, the mean difference in cervical dilatation being 1.6 mm (95% confidence interval (CI):
0.5–2.7). Among the pre-menopausal women receiving misoprostol, 88% achieved a cervical dilatation
of 5 mm compared with 65% in the placebo group. Of the women who received misoprostol, 12% were
difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the miso-
prostol group. Misoprostol had no effect on cervical ripening in post-menopausal women compared
with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of
21 post-menopausal women and 65 pre-menopausal women after arriving at a conclusion on the
primary outcome with only 28% of the number of women needed in a trial with fixed sample size.
Three of the 45 women who received misoprostol experienced severe lower abdominal pain, and there
was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did
not experience misoprostol-related adverse effects. The majority (83% of pre-menopausal and 76% of
post-menopausal women) found self-administered vaginal misoprostol at home to be acceptable.
There were two serious complications in the pre-menopausal misoprostol group: uterine perforation
with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion. However,
these were not judged to be misoprostol related. Complications were otherwise comparatively minor
and distributed equally between the two dosage groups. We could conclude that 1000 mg of self-
administered vaginal misoprostol 12 h prior to operative hysteroscopy has a significant cervical
ripening effect compared with placebo in pre-menopausal, but not in postmenopausal, women. Self-
administered vaginal misoprostol of 1000 mg at home, the evening before operative hysteroscopy, is
safe and highly acceptable, although a small proportion of women experienced severe lower
abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this
regimen, which is very inexpensive and easy to use21 (see Fig. 4). As a result of these data, we feel that
the use of misoprostol is a sensible approach in pre-menopausal women prior to cervical dilatation.

Fluid overload during hysteroscopy

The absorption of irrigating solution may be associated with serious complications during hystero-
scopic surgery. This absorption occurs mainly into the vessels opened during the procedure. Careful
perioperative monitoring of the deficit of the collected irrigating medium during transcervical surgery is
mandatory. Significant absorption seems to cause the development of discrete cerebral oedema (Fig. 5)
and nausea, secondary to dilutional hyponatraemia and the elevation of several amino acids.
624 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

Fig. 4. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy
using a sequential trial design. BJOG. 2008; 115: 663.

We evaluated the postoperative changes in serum electrolytes in relation to the amount of irrigating
fluid absorbed and the occurrence of nausea and vomiting after transcervical resection of endome-
trium and submucous fibroids. In the early days of hysteroscopy, non-electrolyte-containing media
were used during operative hysteroscopy due to the use of monopolar energy. We investigated this
from May 1989 to October 1991. A total of 101 consecutive patients underwent transcervical resection
of either the endometrium or submucous fibroids using glycine 1.5% for uterine irrigation. The deficit of
glycine was assessed during and at the end of the operation. During the postoperative course, the
patients were monitored for the occurrence of cerebral confusion, nausea (defined by at least one
incident of vomiting) and dyspnoea. The serum levels of sodium, potassium and chloride were assessed
before the operation, at the end of the procedure and after 4, 8 and 12 h. No marked water intoxication
or signs of volume overload were seen, but 33% of the patients had nausea and vomiting in the
postoperative period. These patients showed a more pronounced postoperative decrease in serum
sodium (P ¼ 0.0001) and a larger glycine deficit (P ¼ 0.004) than did patients without nausea. The
postoperative decrease in serum sodium correlated significantly to the glycine deficit (R2 ¼ 0.83,
P < 0.001). Postoperative hyponatraemia after transcervical resection of the endometrium correlated
with the deficit of irrigation fluid but not with the operation time or the total amount of irrigation fluid
used. In patients with nausea and vomiting, we recommend that serum sodium be measured and
corrected if necessary postoperatively.
Clearly, the absorption of irrigating solution during transcervical resection of endometrium can
cause dilutional hyponatraemia, nausea and cerebral oedema. We studied six patients who absorbed
more than 1500 ml of 1.5% glycine, and 14 patients who absorbed less. Cerebral oedema was diagnosed
by blinded, paired comparison of computed tomography (CT) scans 3–6 h and 3–6 days after operation.
The absorbed volume of irrigating glycine solution was correlated with preoperative decrease in serum
sodium. Ten patients who absorbed 500 ml of glycine or more had postoperative nausea, with cerebral
oedema suspected in nine. None of the 10 patients who absorbed less than 500 ml had nausea; changes
on CT scan suggestive of cerebral oedema were found in one. Eight patients who absorbed 1000 ml or
more had a decrease in serum sodium of 10 mmol l1 or more, nausea and cerebral oedema on CT scan.
Cerebral oedema may contribute to the development of postoperative nausea in patients undergoing
transcervical surgery who absorb more than 500 ml of 1.5% glycine irrigating solution22–25 (Fig. 5).
Fluid management is critical for intra-operative safety. Meticulous detail should be paid to fluid
management, and consultation sought with a critical care specialist when fluid overload or hypona-
traemia is suspected.
The use of 1.5% glycine solution for uterine irrigation was adapted from urological practice, where it
was introduced in 1948.26 Several deaths secondary to the absorption of irrigating fluid during
intrauterine surgery have been reported.27
 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629 625

Fig. 5. Postoperative cerebral oedema after transcervical endometrial resection and uterine irrigation with 1.5% glycine. Lancet 1994;
344: 1187–9.

Up to 2003, monopolar electrosurgery has been the only equipment available for operative hys-
teroscopy. However, with the introduction of bipolar equipment the situation has changed, and we
believe that this modality will replace monopolar surgery in the coming years.28 The advantage is the
use of normal physiological saline as irrigation leading to the complications associated with gylcine
absorption being obviated. However, despite this, currently monopolar surgery is the main operative
hysteroscopic tool used around the world.

Irrigation solution related problems of mono-electrosurgery

The ideal irrigation fluid during electrosurgery should have the following characteristics:

1. it is isotonic;
2. it is non-haemolytic;
3. it is non-toxic when absorbed;
4. it is not metabolised;
5. it has clear visibility;
6. it does not crystallizes;
7. it does not influence osmolality;
8. it is rapidly excreted and is an osmotic diuretic;
9. it can lead to an expansion of plasma and extra-cellular fluid volume;
10. the fluid absorption should be low and transient

Three different solutions are in use in monopolar surgery, although we prefer to use a non-
electrolytic solution:

Glycine: an amino acid, freely distributed through the vascular space and is metabolised.

Its half-life (T1⁄2 ) ¼ 85 min.

Mannitol: six-carbon alditol isomer, only 10% is metabolised and the kidney filters the rest.
T 1⁄2 ¼ 15 min. It is diuretic but expands the extra-cellular space.
626 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

Sorbitol: six-carbon alditol isomer, metabolised in the liver to glucose and fructose, causes hyper-
glycaemia and is an osmotic diuretic.

Research related to various irrigation media has concentrated on glycine-containing solutions. The
theoretical physiology is discussed below.
The complications associated with fluid use in hysteroscopic surgery have their analogues in
urology. The transurethral surgery (TURP syndrome), which is a clinical entity, is related to massive
absorption of the irrigating solution.29 Although toxic effects of glycine and its metabolites may
contribute to the syndrome, absorption of water with dilutional hyponatraemia, water intoxication,
cerebral oedema and cardiac overload is considered to be a main characteristic of the syndrome.30–32 In
hysteroscopic surgery, absorption of the irrigating medium is presumably related to the intrauterine
pressure applied during the procedure. In operative hysteroscopy, a maximum pressure of about
100 mmHg is usually applied to the infusion system, but the pressure drop along the infusion line and
the application of suction to the effluent make the intrauterine pressure difficult to assess.
If there is sufficient peroperative monitoring of the deficit, pressures of up to 100 mmHg can be
applied within the uterine cavity without the occurrence of the sort of complications associated with
the TURP syndrome.

The future

Although 1.5% glycine has been used traditionally for resectoscopic procedures, alternative irrigating
solutions should now be actively sought. Moreover, the data available should make surgeons carefully
monitor the inflow pressure applied and the fluid absorption during transcervical resectoscopic surgery.
New hysteroscopes and resectoscopes with continuous-flow designs have greatly facilitated
diagnostic and therapeutic hysteroscopy. Saline is the ideal distending medium for hysteroscopic
procedures in which mechanical or bipolar instruments are used; regardless of the medium chosen,
careful fluid monitoring is essential.33
In our hospital, another study regarding this issue was undertaken in 200 pre-menopausal women
with menorrhagia caused by dysfunctional bleeding, fibroids or polyps. Hysteroscopic resection was
performed either with monopolar electrodes using 1.5% glycine as irrigant or with two different types of
bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA,
USA) using saline as the irrigant. The change in serum sodium as a result of irrigant absorption, operating
time and amount of tissue removed were recorded. A statistically significant reduction in mean serum
sodium from 138.7 mmol l1 to 133.8 mmol l1 was seen in the monopolar group, compared with the
case of the saline groups with no reduction. The amount of resected tissue in the monopolar and TCRis
group was approximately 1.00 g min1, compared with 0.65 g min1 in the Versapoint group. The loss of
fluid during the procedure was significantly higher in the two bipolar groups. Therefore, bipolar elec-
trodes appear to have a safer profile compared with monopolar electrodes because of the unchanged
serum sodium. Irrigation fluid consumption was significantly higher in the two bipolar groups, without
any side-effects during or after the procedure. Furthermore, as regards operating time and amount of
tissue removed, the TCRis loop appears to be superior to the Versapoint loop (Fig. 6).
The development of bipolar equipment in hysteroscopic surgery will be the second-generation tools
in hysteroscopic treatment of fibroids, polyps and menorrhagia.
Sufficient data are not available to give exact recommendation regarding the safe amount of fluid
allowed to be absorbed. However, theoretical consideration would allow a higher deficit to be accepted.
The Se-Na bipolar equipmentwill be stable, but the bolus of fluid volume can lead to high pressure in
the left cardiac system and subsequently pulmonary and brain oedema. The volume of saline allowed
during these circumstances remains to be determined.

Mini-hysteroscopy

The development of smaller-diameter hysteroscopes with working channels and continuous-flow

systems together with the establishment of bipolar technology, have made possible the outpatient
 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629 627

Fig. 6. A randomized trial comparing monopolar electrodes using glycine 1.5% with two different types of bipolar electrodes (TCRis,
Versapoint) using saline, in hysteroscopic surgery.22

treatment of small (>1.5 cm), totally intracavity type I fibroids as well as those with minimal intramural
extension, thus avoiding both cervical dilatation and any anaesthesia or analgesia.34 Conversely, the
resection of fibroids with intramural extension is advisable only for expert surgeons as it is technically
difficult and has a higher risk of complications than other hysteroscopic procedures.35 The frequency of
complications and the chance of achieving complete resection of the lesion at one surgical visit may
widely vary, depending on the extension of the intramural component and the operative technique.36
Furthermore, while differences in equipment do not seem to have significant effects on surgery for type
0 fibroids, advanced state-of-the-art equipment is necessary for carrying out safe hysteroscopic myo-
mectomy for fibroids with intramural extension. Several techniques have been developed to completely
remove such fibroids, all of those aiming at the transformation of an intramural fibroid into a totally
intracavitary lesion, thus avoiding a deep cut into the myometrium.37 While type 0 fibroids may be often
completely removed in one step, as the uterus contracts and tends to expel the intramural component
into the cavity during surgery, the removal of type 1 and 2 fibroids may be much more problematic.

Conclusions

Diagnostic hysteroscopy is relatively safe, whereas complications occur more frequently when
operative hysteroscopy is used. These complications include uterine perforation, haemorrhage, fluid
overload, gas embolisation and hyponatraemia. The rate of these complications depends on the type of
the hysteroscopic procedure, the distending medium and the experience of the hysteroscopist.

Practice points

 Always keep the electrical loop in view when performing operative hysteroscopy.
 The loop should always move towards the surgeon.
 Always use irrigation pumps and critically monitor the fluid deficit.
 Pre-treat the patient with GnRH agonist for big fibroids.
 Suspect perforation when the operative view disappears or when there is a sudden and large
deficit.
 In the event of heavy bleeding, place an 18-channel Foley catheter in the endometrial cavity
and fill the balloon with 20–30 ml of saline. The balloon should be left in the cavity for 2 h
before removing it.
628 O. Istre / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 619–629

Research agenda

 The development of smaller resectocopes.

 Further evaluation of the benefit of the long-term result of bipolar hysteroscopic surgery.
 Comparison of mini-hysteroscopy vis-à-vis traditional resectoscopy in terms of their
limitations.
 Evaluation of further indications of adenomysis and adenomyoma treatment.

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