Fluid deficit calculation at hysteroscopy in patients with and without tubal occlusion: could consideration of tubal passage change safety limits?

Abstract

Hysteroscopy (HSC) fluid management guidelines (1) are not well-defined regarding the contribution on the fallopian tube patency to the fluid deficit (FD) during HSC and most surgeons attribute the entire FD to intravasation (2). Women with patent tubes undergoing HSC have accumulation of distention media in the pelvis which can be seen during laparoscopy (LSC) and could be in part due to transtubal passage (3). We explored whether FD could be in part due to transtubal passage. Prospective observational study. We studied 164 patients aged 20-45 years, who underwent HSC using normal saline as distension media between January 2014 and August 2017. Tubal patency was previously assessed at sonohysterogram. FD and, in LSC cases, the amount of fluid found in the pelvis, were prospectively recorded. Whitney U test was used to compare distributions with a p value <0.05 defining statistical significance (SPSS v25 for Windows; Chicago, Illinois). 164 patients were included in the study. 77 underwent HSC prior to LSC and 87 patients underwent HSC only. In the LSC group, 69 had at least one patent tube with an average FD of 438.96 ml and a calculated FD due to extravasation of 175.61 ml; 8 patients had bilateral tubal occlusion and all were found to have 0 ml of peritoneal fluid with an average FD of 141. In the HSC only group, 83 had at least one patent tube with an average FD of 307.48 ml; 4 patients had bilateral tubal occlusion with an average FD of 375.75 ml. There was no correlation between intrauterine fluid pressure and the amount of FD, or the presence of peritoneal fluid.Tabled 1VariablesHSC + LSCTubal patency (N=69)HSC + LSCTubal occlusion (N=12)HSC onlyTubal patency (N=83)HSC onlyTubal occlusion (N=4)Fluid deficit (FD) ml438.96141307.48375.75Peritoneal fluid ml175.610N/AN/AProposed FD ml281.0990.18N/AN/A Open table in a new tab Most women with patent tubes undergoing HSC have accumulation of distension media in the pelvis and transtubal passage was not correlated with the intrauterine fluid pressure. FD in patients with tubal occlusion appears to be entirely attributed to intravasation. These findings add new insight to our understanding of fluid dynamics during operative hysteroscopy that can help develop more accurate and patient-centered safety protocols.