1. DISTENSION MEDIA IN
HYSTEROSCOPY
Dr Mandeep Bhandal

2. Uterine distention medium
Uterine cavity- a potential space
Minimum pressure
- 30 mmHg to separate uterine walls
- 45-80 mmHg to expand uterine cavity,
rarely >100 mmHg
MAP ~ 100 mmHg

4. Uterine distention medium
Choice depends on the type of procedure
TYPES
GASEOUS CO2
LIQUID
Electrolytic NS, Ringer lactate
Non-electrolytic Hyscon (32% dextran 70)
Glycine
Sorbitol
Mannitol

5. Comparison of hysteroscopic
medium
TYPE Operative use Office use Miscibility with Complex Safety
blood procedure
GASEOUS
+ +++ + + ++
CO2
LIQUID
Nonelectrolytic
Hyscon +++ +++ +++ ++ ++
Glycine +++ + ++ +++ +
Sorbitol +++ + ++ +++ +
Mannitol +++ + ++ +++ ++
LIQUID
Electrolytic
NS +++ + ++ +++ +++
RL +++ + ++ +++ +++
+++,Highly advantageous; ++, average; +, unsatisfactory

6. CO2
The only gaseous medium used
Yields a clear image of endometrial cavity
Easy to infuse
Does not clog essential instrumentation
Inexpensive
Readily available
Well tolerated
Rapidly absorbed and released.
Best suited for office diagnostic hysteroscopy

7. Disadvantages to the use of CO2
May produce bubbling, which is cumbersome and
may obscure the view.
Because CO2 gas is invisible, a leak in the system
may not be noticed for some time.
A specific machine is required for electronic
calibration of the CO2 flow rate and pressure.
Finally, use of a laser becomes cumbersome owing
to the smoke and fumes .

8. Flow rate
Ideal - 40-50ml/min
Maximum - should not exceed
100ml/min

9. Pressure
Should not exceed more than
100 to 150 mmhg

10. An electronic hysterosufflator
for uterine distention with
CO2 gas

11. Precautions
Standard monitoring of the
patient
Laparoscopic insufflation
equipment never to be used.
Patient not to be placed in
trendelenberg position

12. Limitations
Least advantageous for operative hysteroscopy
Foaming interaction between blood and gas makes
the visibility difficult
Has a tendency to flatten the endometrium, thereby
obscuring pathologic features.
Occasional reflux through the cervix in multiparous
patients

13. Complications
Category Examples
pCO2↑ ,pO2 ↓ ,Hypercarbia ,
Metabolic metabolic acidosis
CO2or Air embolus Respiratory collapse, cyanosis,
Cardiac arrest
Mechanical Tubal rupture , diaphragmatic
rupture

14. Pathophysiology of Air and Gas
Embolism
There is Incision of noncollapsed veins and the
presence of subatmospheric pressure in these
vessels
↓
Causing a pressure gradient between the point of
entry of gas and the right side of the heart
↓
Entry of the gas into venous system.

15. Small amounts of air do not always produce
symptoms.
More than 3 mL/kg of air (intravenous) is required for
significant clinical effects.
The gas transported to the lungs through the
pulmonary arteries, causing –
Gas exchange disturbances
Cardiac arrhythmias
Pulmonary hypertension.
Outflow obstruction
Decreased pulmonary venous return,
Decreased left ventricular preload and cardiac
output .

16. Paradoxical arterial gas embolism
The high pulmonary arterial pressure pushes small microbubbles
through the pulmonary vasculature, which subsequently may be
detected in the left atrium, causing cardiovascular problems
such as coronary artery occlusion or cerebral artery occlusion.
The central nervous system may be affected similarly.
Postoperative altered mental status, focal deficits, or even
coma may be attributed to the cardiovascular collapse but
cerebral emboli may also play a role.
These emboli may occur by a patent foramen ovale and through
the a forementioned migration of emboli through the pulmonary
vasculature.

17. Air Embolism
An air embolism is derived from room air and
is, therefore, primarily composed of nitrogen
and oxygen
Nitrogen is the main culprit for air embolism

18. Room air is introduced into the uterus-
 by air bubbles in the fluid system,
 by means of reintroduction of the
hysteroscopic instruments that have a
pistonlike effect forcing air into the uterus
with each reinsertion,
 by leaving the cervix and the vagina open to
air when vascular injury is present.
 When the patient is placed in Trendelenburg
position

19. Signs/symptoms indicative of air/gas embolism in the
different anesthetic methods
Epidural or spinal anesthesia General anesthesia
Chest pain Oxygen saturation ↓
Dyspnea
ECG changes: bradycardia,
tachycardia, premature
Oxygen saturation ↓
ventricular contractions, heart
block, ST-T changes
Wheezing, rales
Mill wheel murmur
Mill wheel murmur
Detection of air/gas in the heart
Detection of air/gas in by transesophageal echocardiography or
the heart by precordial Doppler ultrasound
precordial Doppler ultrasound

20. Therapy in case of Suggested
Air/Gas Embolism
Rapid identification
Prevention of further gas entrainment by closing the
point of air entry.
Put the patient in a reverse Trendelenburg position
The Durant maneuver- With this maneuver the
patient is placed on the left side while using
Trendelenburg position

21. 100% of oxygen administered to the patient.
Nitrous oxide anesthesia not to be used in cases with
a high risk of air embolism.
Air retrieval using a central venous catheter, or
direct needle puncture of the right heart in the case
of cardiac arrest
Inotropic support /CPR
Hyperbaric oxygen therapy useful in patients with
severe CNS or cardiac manifestations

22. Monitoring During Operating
Department Hysteroscopy
Standard monitoring
 pulse oximetry,
 3-lead electrocardiography,
 blood pressure measurements
 etCO2 monitoring
 standard ventilatory monitoring.

23. Monitoring of etCO2
A change of 2 mm Hg etCO2 or more may be a
sign of embolism.
Physiologic changes such as
hypovolemia, ventilatory changes, and
artefacts may also result change in value.

24. Electrocardiographic
monitoring
Early signs when large volumes of air enter the
circulation
Electrocardiographic changes
Bradycardia or tachycardia,
Premature ventricular contractions
Heart block
ST-segment depression

25. Other monitoring methods
Trans esophageal echocardiography
Precordial Doppler ultrasound
Conventional stethoscope

26. Combination of symptoms in
embolism
A sudden decrease in etCO2, especially when
accompanied by a decrease in blood pressure
A decrease in hemoglobin oxygen saturation
Cardiovascular collapse
Sustained hypotension not explained by hypovolemia
alone
Electrocardiography changes

27. Prevention of complications
The complication are extremely rare if the correct
insufflator is used.
The hysteroflator delivers CO2 at a rate of not more
than 100ml per minute whereas the laparoflator
can deliver 1-6 litres in the same time
A laparoflater should NEVER be used for
hysteroscopy.

28. Recommendations
Operating Department Personnel
Educate, raise risk awareness, and train staff.
Resuscitation protocols should be easily available.
Knowledge, maintenance, and upkeep of equipment for accurate distending
medium measurement.
Safe use and maintenance of fluid management systems includes avoiding air
to enter into fluid lines at any time.
Pumps should be turned off during bag changes, and fluid balance should be
monitored closely.
Use a Y-connector on the fluid inflow line to reduce air entrainment during
bag changes.

29. Recommendations
Surgeon
The cervix is to be kept closed at all times.
Reintroduction of the hysteroscopic instruments
should be kept at a minimum .
Air bubbles in the uterus are removed frequently
by using a continuous outflow system.

30. If room air or gas embolism is suspected, the
surgeon should
Terminate surgery immediately,
Deflate the uterus,
Remove sources of fluid and gas.
Cervical Os should be occluded (e.g., with wet
gauzes).

31. Recommendations
Anesthesiologist
Preventing air or gas embolism is of paramount
importance
Nitrous oxide anesthesia, should be avoided when
possible in operative hysteroscopy
Patients at high risk undergoing operative
hysteroscopy should have, extensive intraoperative
monitoring, specifically sensitive in recording gas
emboli such as transesophageal echocardiography
or precordial Doppler ultrasound.

32. Fluid media
The advantage of fluid over gas
A symmetric distension of uterus with fluid
Its ability to flush blood, mucus , bubbles & small
tissue fragments
A pressure of 75 mm hg is usually adequate for
uterine distension
Both low viscosity and high viscosity media are
used

33. Various delivery systems
To accurately record volumes of inflow and outflow
Air should be flushed from all hysteroscopic
tubings before distension
Pressure cuffs on low viscosity –fluid bags are for
short procedures
Minimum pressure to be used for minimal
intravasation (30-100 mm hg)

34. Delivery system
Syringe
Gravity fed containers
Hysteroscopic Pumps

35. High molecular weight fluids
Dextran
A high molecular weight (MW) – 70 000 MW – in a 10% water
solution.
Used for both diagnostic and operative hysteroscopy
Non electrolytic
Non conductive
Immiscible with blood
Minimally leaks through cervix and tubes (viscous)
Excellent visibility

36. Delivery system
Administered through a 60 ml syringe
through tubing to the operative
hysteroscope
Hyskon pumps were used

37. Fluid management system with an electronic
pump for use in an office or operating suite

38. High molecular weight fluids
Dextran
It may produce
Anaphylactic reaction,
Adult onset respiratory distress syndrome
(ARDS) or
Pulmonary oedema.
Coagulopathies.
Oliguria & Acute renal failure

39. Anaphylaxis can occur due to
Immediate histamine response to Dextrans
Previous sensitization to naturally
occuring antigens
Cross reactivity with bacterial antigens
(streptococci, pneumococci, salmonellae)

40. Anaphylaxis should be treated by the
administration of
1. Oxygen,
2. Intravenous /intratracheal epinephrine
3. Antihistamines,
4. Glucocorticoids and
5. Intravenous fluids.

41. ARDS (Pathomechanism )
Use of larger volumes of fluid (> 500 ml)
Direct toxic effects on pulmonary vasculature
Expansion of plasma volume
↓
Intravascular volume overload.

42. Adult onset RDS requires the
administration of
Diuresis
Glucocorticoids
Oxygen
Assisted respiration
Plasmapheresis

43. Oliguria & Acute renal failure
Inravascular absorption of dextran
↓
Increased intravascular oncotic pressure
↓
↓ GFR
↑
Mechanical obstruction within renal nephrons
and arteries
↑
Precipitation of dextran in renal tubules

44. Management
Diuresis
Plasmapheresis

45. Coagulation disorders
Dextrans have antithrombotic
properties
↓ platelet adhesiveness
Alter fibrin clot structure
↓ Fibrinogen
↓ Clotting factors (V, VIII, IX)

46. Management
Diuresis
Plasmapheresis

47. Low molecular weight fluids
Electrolyte free - 1.5%Glycine
3% Sorbitol
5 % Mannitol
Used in operative hysteroscopy using
monopolar resectoscope.
.

48. Electrolyte containing
Normal saline
Ringer’s lactate soln
Used in
Diagnostic hysteroscopy
Operative hysteroscopy using bipolar
electrode

49. Advantages.
They can clear debris, mucus and blood clots from
the operative field and continuously wash the
uterine cavity, permitting good visualization.
Should the mechanism be faulty and leakage of
fluid occur, it will be immediately visible, and
the fluid instilled and recovered can easily be
measured.

50. 1.5 % Glycine
Simple amino acid that is mixed in
water & supplied in 3 liters bags
as a 1.5% soln
Non electrolytic
Hypo-osmolar (200mOsm/L)
Non hemolytic
Non Immunogenic

51. Complications related to
glycine toxicity
Hyperammonemia
Hypervolumic ,hypo-osmolar hyponatremia
Central pontine Myelinosis (CPM)

52. Hyperammonemia
glycine
Oxidative
deamination
Glyoxylic
Ammonia
Acid

53. SYMPTOMS
Nausea
Vomiting
Altered mental status
Muscle Aches
Decreased visual acuity

54. Treatment
L-Arginine
(to stimulate metabolism of
ammonia by the urea cycle )

55. Hypervolumic hypo-osmolar hyponatremia
Half life of glycine- 85min.
Eventually gets absorbed intracellularly
resulting in a surplus of intravascular
free water
Exacerbated by ADH released during
surgery

56. Serum Na levels decrease by
10 mmol/L for every liter of
hypotonic fluid absorbed.
A patient will absorb at least 1
litres of medium before
demonstrating symptoms
Also depend on pre-operative Na
levels

57. Potential Effects
Hyponatremic encephalopathy-
Irreversible brain damage
Cerebral odema
Increased intracranial
pressure
Decreased cerebral
blood flow
Hypoxemia & pressure
necrosis of neurons

58. Symptoms depend upon the amount of medium
absorbed
Serum Na(mEq/L) Associated signs and symptoms
135-142 Normal serum Na
130-135 Mild hyponatremia-
apprehension,disorientation,nausea,vomiting,irritability,t
witching,shortness of breath
125-130 Mild to moderate hyponatremia
Dilute urine ,moist mucous memb, moist skin, pitting
oedema ,polyuria , pulm.rales
<120 Severe hyponatremia
Hyponatremic encephalopathy, CHF, lethargy, confusion
,twitching, focal weakness, convulsions, death.
<115 Possible brainstem herniation, grandmal seizures, coma,
resp.arrest, mortalityupto85%

59. Treatment
Diuresis
Correction of hyponatremia
Expectant management and
spontaneous diuresis not an option

60. Central pontine myelinolysis
Represent brain injury resulting from
brain dessication due to too rapid
correction of hyponatremia.
Also described as
“osmotic demyelinating syndrome”

61. An electronic pump for uterine
distention with low viscosity
fluid

62. Accountancy of fluid input and
output is mandatory in any
hysteroscopic procedure.
The severity and management
of fluid overload depends on the
nature of the medium in use.

63. Techniques of Measuring of
fluid intake and output
Gravitometry
Serial serum Na measurements
Volumetric fluid balance
Ethanol monitoring method
Parotid area sign

64. Gravitometry
A continuous automated weighing
system
The patient undergoes operation
on a bed-scale
Increase in weight is considered
to imply fluid absorption.

65. Serial serum Na measurements
Best used where non-electrolyte
distending medium is used
Best applied repeatedly during
surgery
A poor guide to the degree of
extracellular overhydration in
the postop phase

66. Ethanol monitoring method
Considered to be one of the
best methods
Not available to all surgeons
Does not detect extravasation
of fluid until 15 to 20 minutes
later.

67. Volumetric fluid balance
method
Calculation of the difference
between the amount of
irrigating fluid instilled &
the volume recovered

68. Can lead to significant underestimation of
fluid absorption
Several pitfalls D/T
Variations in bag-to-bag content
Spillage
Blood loss
Urinary excretion.
Commercially available containers of fluid
may contain 5% to 10% more fluid than is
specified.

69. Parotid area sign

70. This sign is a reflection of the interstitial edema
that develops as a
result of the fluid overload.
Significant increase in the measured philtrum-
mastoid prominence distance when fluid absorption was
1000 mL and above.
when the fluid absorption is equal to or more than
1000 mL,for every 500-mL increase in
absorption, there is an approximately 0.5-cm increase
in the philtrum-mastoid prominence distance.
Beyond 1500 mL fluid absorption, the
distance is generally above 0.5 cm and above 2 L, the
distance increases by more than 1 cm

71. Sorbitol
6 –Carbon alcohol
Metabolised in liver to fructose and glucose- then to
CO2 and H2O
3 % soln. is used for resectoscopic procedures
Hypo-osmolar
Non conductive

72. Overload with sorbitol
hyperglycaemia in the diabetic
patient,
haemolysis
hyper-volemia.

73. Mannitol
6 Carbon alcohol
non –conductive
Osmolarity similar to that of serum (isotonic)
Only 6-10% is absorbed
cleared by kidneys
diuretic properties

74. Saline
Produces a simple hypervolaemic state
which may be treated by:
Insertion of a central venous line
Administration of a diuretic & oxygen
Cardiac stimulants if necessary.

75. Saline overload
A blood pressure cuff may
be applied to each limb to
occlude venous return
which, in effect, performs
a bloodless phlebotomy.

76. Fluid Overload
Usually occur in the immediate post-
operative period.
Begin resuscitative procedures .
Surgery must be abandoned.

77. Prevention of Fluid Overload
1. Using appropriate distension media and delivery systems
2. Keeping operating times to a minimum
3. Avoiding entering the vascular channels
4. Keeping fluid pressures below 80mmHg and gas pressures
below 100mmHg.
5. Meticulous accountancy of fluid balance.
6. The procedure must be abandoned if the deficit rises to 2
litres or there is evidence of venous congestion..

78. THANK YOU