Ambulatory Hysteroscopy Research Articles

Ambulatory Hysteroscopy: Evaluating Pain and Determining Factors.

To measure pain using a visual analogue scale (VAS) and analyse its relationships with variables such asmenopausal status, parity,uterine and cervical pathology, procedure length, and anxiety in patients undergoing ambulatory hysteroscopy (AH). Prospective observational study. Dr DY Patil Medical Hospital and Research Centre, Dr.D.Y. Patil Vidyapeeth, Pimpri, Pune. Seventy-five women. Ambulatory hysteroscopy(AH). AH was performed in seventy-five patients using vaginoscopic approach. At the end of the procedure, the intensity of pain was assessed using the visual analogue scale (VAS), from the score of 0 (no pain) to 10 (intolerable pain). The factors determining pain were assessed. Patients who underwent AH reported mild pain in 66% of cases, moderate pain in 22%, and severe pain in 12% of cases. The most frequent reason for referral was abnormal uterine bleeding (AUB).In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors.In severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors. Hysteroscopy is a safe, painless and a gold standard procedure. Pain experienced during AH was significantly influenced by cervical pathology. Gynaecologists in practise should receive training and start using AH to assess the endometrial cavity.

Modified Dixon sequential method to determine the effective dose of alfentanil compounded with propofol for day-case hysteroscopy

Background: Propofol combined with alfentanil is suitable for intravenous anesthesia for day-case hysteroscopy. Objective: To investigate the median effective dose (ED50) and 95% effective dose (ED95) of alfentanil compounded with propofol for day-case hysteroscopy. Design: In all, 29 patients who volunteered for painless hysteroscopy in 2022 were recruited. 1.5 mg/kg propofol was given as a sedative to all patients. The trial was conducted using the modified Dixon sequential method, with an initial dose of 10 μg/kg of alfentanil, and the subject’s alfentanil dose depended on whether the prior hysteroscopy had failed, which was defined as inadequate cervical dilatation and hysteroscope placement with the patient exhibiting body movement, frowning, or a MOAA/S score &gt;1. If the hysteroscopy failed (i.e. a positive response), the subsequent subject’s alfentanil dosage was raised, and conversely (i.e. a negative response), the dose was decreased, with the adjacent dose ratio always being 1:1.2. The formal test begins with the first crossover wave and lasts until seven crossover waves materialize. Methods: The probit method was used to calculate the ED50, ED95, and corresponding 95% confidence intervals (CIs) of alfentanil compounded with propofol for hysteroscopy. Results: The ED50 and ED95 of alfentanil combined with propofol for day-case hysteroscopy were 5.701 (95% CI: 3.841–7.069) μg/kg and 8.817 (95% CI: 7.307–20.868) μg/kg, respectively. Conclusion: Alfentanil at 8.817 μg/kg in conjunction with propofol is a successful and safe approach for day-case painless hysteroscopy. Trial registration: The trial registry name: Modified sequential method to determine the half-effective dose of alfentanil compounded with propofol for ambulatory hysteroscopy. The URL of registration is https://www.chictr.org.cn/showproj.html?proj=171786 , where the full trial protocol can be accessed. Registration number: ChiCTR2200061619.

Ambulatory Hysteroscopy in Abnormal Uterine Bleeding: A Tertiary Care Hospital Perspective

Background: To avoid delays in outpatient facilities for managing benign gynecological conditions like abnormal uterine bleeding (AUB), there is a need to evaluate the usage of unconventional methods like outpatient hysteroscopy. Objectives: To evaluate the usage of outpatient diagnostic hysteroscopy in women with abnormal uterine bleeding. Methods: An observational study was conducted at the Obstetrics and Gynecology Department of Combined Military Hospital, Kharian. The study included 56 women having AUB with or without a history of failed medical treatment. The study participants underwent outpatient diagnostic hysteroscopy. Diagnostic hysteroscopy was done under the local para-cervical block in the Outpatient department. Procedure indications, outcome and biopsy findings were recorded on predesigned proformas. Results: Median age of the study participants was 44 years. The most common indications for diagnostic hysteroscopy were postmenopausal bleeding (34%) and heavy menstrual bleeding (28%). Hysteroscopy outcomes included endometrial biopsy (34%), discharge with no biopsy (25%), further test and evaluations required (21%), and admission due to failed outpatient procedures (20%). Sixty-two percent of the study participants had normal biopsy findings while other biopsy findings included polyps (20%), fibroids (14%) and endometrial hyperplasia (4%). Nine percent had unsuccessful hysteroscopy due to patient refusal to proceed. Conclusion: Outpatient hysteroscopy can be helpful in the early and rapid diagnosis of women with abnormal uterine bleeding.

Role of Embryoscopy in Patients with Missed Abortion. A Preliminary Experience.

Study Objective Missed abortion occurs in 10-20% of pregnancies, the most frequent cause being genetic alterations such as aneuploidies, polyploidies, or monosomies. Embryoscopy is the direct visualization of the embryo by hysteroscopy. It allows to collect targeted biopsy of the embryo and trophoblast for genetic analysis minimizing the change of maternal contamination of the specimen To describe the hysteroscopic findings and the genetic results of the embryoscopies performed between January 2020 and 2021 at the Sanatorio Finochietto in Buenos Aires Argentina. Design We present a case series of 55 consecutive embryoscopies performed in patients diagnosed with missed abortion during the first trimester. Embryo and trophoblast biopsies under direct visualization were collected when possible. Setting Ambulatory hysteroscopy unit. Patients or Participants Patients diagnosed with missed abortion during the first trimester of pregnancy. Interventions Diagnostic embryoscopy with embryo and trophoblast biopsy. Measurements and Main Results 55 embryoscopies were performed in patients between 28 and 45 years old with a diagnosis of missed abortion. The average gestational age was 7.2 weeks. Of these, 38 genetic biopsies were collected, 13 patients had a normal karyotype, 13 had chromosomal abnormalities (10 trisomies, 3 triploidies) and in 12 the specimen was inadequate for evaluation. Embryoscopy revealed 5 macroscopic malformations, 3 in patients with normal type, and two with alterations, which presented syndactyly and hydrocephalus, prominent umbilical herniation. Conclusion Embryoscopy allows direct visualization of the morphological alterations of the embryos, obtain a direct biopsy for its genetic study, and evaluate the uterine cavity. This procedure could be very useful in couples with missed abortions, since it provides significant information for genetic counseling. Missed abortion occurs in 10-20% of pregnancies, the most frequent cause being genetic alterations such as aneuploidies, polyploidies, or monosomies. Embryoscopy is the direct visualization of the embryo by hysteroscopy. It allows to collect targeted biopsy of the embryo and trophoblast for genetic analysis minimizing the change of maternal contamination of the specimen To describe the hysteroscopic findings and the genetic results of the embryoscopies performed between January 2020 and 2021 at the Sanatorio Finochietto in Buenos Aires Argentina. We present a case series of 55 consecutive embryoscopies performed in patients diagnosed with missed abortion during the first trimester. Embryo and trophoblast biopsies under direct visualization were collected when possible. Ambulatory hysteroscopy unit. Patients diagnosed with missed abortion during the first trimester of pregnancy. Diagnostic embryoscopy with embryo and trophoblast biopsy. 55 embryoscopies were performed in patients between 28 and 45 years old with a diagnosis of missed abortion. The average gestational age was 7.2 weeks. Of these, 38 genetic biopsies were collected, 13 patients had a normal karyotype, 13 had chromosomal abnormalities (10 trisomies, 3 triploidies) and in 12 the specimen was inadequate for evaluation. Embryoscopy revealed 5 macroscopic malformations, 3 in patients with normal type, and two with alterations, which presented syndactyly and hydrocephalus, prominent umbilical herniation. Embryoscopy allows direct visualization of the morphological alterations of the embryos, obtain a direct biopsy for its genetic study, and evaluate the uterine cavity. This procedure could be very useful in couples with missed abortions, since it provides significant information for genetic counseling.

Increasing the adoption of ambulatory hysteroscopy in Australia – cost comparisons and patient satisfaction

We present the findings of a prospective cohort study in a single tertiary hospital to review the patient experience and economic benefit of ambulatory hysteroscopy (AH). Data were collected between May 2017 and February 2020. Patient satisfaction was measured with qualitative survey. Hospital level financial data were obtained over two financial years (2017/18 and 2018/19) to identify seasonal variation. The primary outcome was patient satisfaction and the secondary outcome was cost of AH compared to hysteroscopy under GA. Three hundred and twenty-nine patients underwent AH. Two hundred and ninety-eight responses (91%) were collected. Ninety-five percent of procedures were successful. Median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. The average hospital cost for AH was $259 compared with $3098 for hysteroscopy under GA. These findings support AH as a safe, well-tolerated and economically viable alternative to hysteroscopy under GA. Impact Statement What is already known on this subject? Hysteroscopy is traditionally performed in an operating theatre under general anaesthesia (GA). Technological advancements allow for the procedure to be performed in an outpatient setting. Despite advantages of ambulatory hysteroscopy (AH), GA hysteroscopy is still the predominant intervention in Australia. What the results of this study add ? Patient satisfaction in AH was assessed. The median pain score was five out of 10. Despite pain, 94% of patients would undergo AH again and 97% would recommend it. What the implications are of these findings for clinical practice and/or further research? AH is a well-tolerated alternative to hysteroscopy under GA with significant cost benefits to the hospital and high patient satisfaction. Further research should focus on direct comparison of the two procedure approaches using randomised controlled trials.

Impact of anxiety levels on the perception of pain in patients undergoing office hysteroscopy

ObjectiveThis study aimed at assessing the impact of anxiety on pain perception during hysteroscopy and to highlight the possible contribution of factors related to pain perception.Materials and methods104 women with indication for office hysteroscopy fullfilled anonymous self-report questionnaires during the waiting time, before the procedure. The first self-report questionnaire included general patient information and an overall assessment of the degree of satisfaction with the information received before the procedure. The level of pre-procedural anxiety was measured through the State-Trait Anxiety Inventory STAI-Y1 (state anxiety). The perceived stress was assessed using the Perceived Stress Scale (PSS). The intensity of pain during the procedure and 20 min later was assessed with VAS score.ResultsThe average waiting time was of 192.33 ± 91 min. 59 patients (56.7%) performed the examination without analgesia while 45 women (43.3%) required analgesia. 28 women (27%) experienced mild pain, 34 (33%) moderate pain and 42 (40%) severe pain. The patients who performed the procedure without analgosedation had an average STAI-Y1 score of 44.81 ± 1.20, compared to women who required analgosedation (average score of 49.40 ± 1.64). The perceived level of stress was also associated with the use of analgosedation. Patients who did not request any anesthetic intervention obtained a PSS average score of 16.66 ± 0.75, compared to the subgroup with anesthesia (score of 19.76 ± 0.90).ConclusionsAnxiety represents a key element for the success of ambulatory hysteroscopy. The management of anxiety can reduce the request for analgesia with a consequent optimization of time, costs and safety.

Complicaciones asociadas con la histeroscopia

Objetivo: describir las complicaciones más frecuentes en la histeroscopia comparando las técnicas mediante energía monopolar y la bipolar. Metodología: búsqueda en las bases de datos ELSEVIER, EBSCO, NCBI, SCIENCEDIRECT, SciELO y PUBMED/MEDLINE, aplicando en forma controlada los términos MeSH “hysteroscopy” y subencabezamientos como “complications”, “monopolar energy” y “bipolar energy”, seleccionando artículos de revisión e investigaciones originales en español e inglés publicados en los últimos cinco años. Resultados: los hallazgos sugieren que existe una estrecha relación entre las complicaciones y el tipo de intervención histeroscópica que se lleva a cabo por indicación, siendo el dolor la más frecuente en la de tipo oficinal y la perforación uterina en la quirúrgica. La histeroscopia con energía monopolar reporta un mayor riesgo de hiponatremia comparada con la bipolar. Conclusión: las complicaciones dependen del tipo de histeroscopia realizada y su indicación, siendo la hiponatremia la única prevalente asociada a la técnica que utiliza energía monopolar.

Esmolol does not improve quality of postsurgical recovery after ambulatory hysteroscopy: A prospective, randomized, double-blinded, placebo-controlled, clinical trial.

Introduction:Intraoperative systemic esmolol has been shown to reduce postsurgical pain. Nonetheless, it is unknown whether the use of intraoperative systemic esmolol can improve patient-reported postsurgical quality of recovery. The main objective of the current investigation was to evaluate the effect of intraoperative esmolol on postsurgical quality of recovery. We hypothesized that patients receiving intraoperative esmolol would report better quality of postsurgical recovery than the ones receiving saline.Methods:The study was a prospective randomized double-blinded, placebo-controlled, clinical trial. Healthy female subjects undergoing outpatient hysteroscopic surgery under general anesthesia were randomized to receive intravenous esmolol administered at a rate of 0.5 mg/kg bolus followed by an infusion of 5 to 15 μg/kg/min or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included postoperative opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test.Results:Seventy subjects were randomized and 58 completed the study. There was not a clinically significant difference in the global QoR-40 scores between the esmolol and saline groups at 24 hours, median (interquartile range) of 179 (171–190) and 182 (173–189), respectively, P = .82. In addition, immediate post-surgical data in the post-anesthesia care unit did not show a benefit of using esmolol compared to saline in regard to pain scores, morphine consumption, and postoperative nausea and vomiting.Conclusions:Despite current evidence in the literature that intraoperative esmolol improves postsurgical pain, we did not detect a beneficial effect of intraoperative esmolol on patient-reported quality of recovery after ambulatory surgery. Our results confirm the concept that the use of patient-centered outcomes rather than commonly used outcomes (e.g., pain scores and opioid consumption) can change the practice of perioperative medicine.

Influence Of Emotional Status On The Pain During The Outpatient Hysteroscopy

Introduction: The outpatient hysteroscopy is a minimally invasive technique, well tolerated by the majority of patients. However, the pain appears in a considerable percentage of patients, and this is the leading cause of failure. There are different factors related to pain. The aim of the present study is analyzing the association between emotional status and pain perception during the outpatient hysteroscopy. Material and methods: A retrospective survey. It was composed of 192 patients with sonographic diagnosis of endometrial polyp. An outpatient hysteroscopy was conducted from March 2013 to January 2015. Socio-demographic data and obstetrician history were collected. The intensity of pain during the test was evaluated by means of EVA, as well as the emotional state by means of Hospital Anxiety and Depression Scale (HADS). Results: The average score in VAS was 5.06. Regarding the score in HAD, it was 6.87 in anxiety and 4.25 in depression. For the entire sample, a positive correlation was evidenced between the intensity of pain (VAS) and the level of depressive symptomatology (HAD depression; p=0.001). This correlation was not shown in patients with anxiety symptomatology (p&gt;0.05). The patients who did not succeed during the procedure, a correlation with the pain perception was observed, with a higher punctuation in VAS and depression scale (p&lt;0.05). Conclusion: There are some factors such as the emotional status of the patient which could modulate the perception of the pain, showing a positive correlation between them. This is an important issue to considerer for the success of the ambulatory hysteroscopy.

Management of abnormal uterine bleeding - focus on ambulatory hysteroscopy.

The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

Spotlight on … gynaecological surgery

Obstetrics and gynaecology has always been a popular career choice. The fact that one can develop a significant surgical interest is cited as one of the many reasons for its popularity. The editor (a very persuasive man!) asked me to write a review of past TOG publications dealing with gynaecological surgery. Readers who practice pure obstetrics will also find something of interest and education in some of the following highlighted papers. The days of ‘see one, do one, teach one’ have gone. Training has to be more focused and structured. Bisson et al. (TOG 2006;8:107−12) drew attention to the then newly introduced tools for trainee assessment (objective structured assessment of technical skills [OSATS]) and the research that underpins their usefulness. Simulation training shortens the learning curve and Ramsey-Marcelle et al. (TOG 2011;13:253−7) explained how to do it and the importance of the choice of facilitators. If we understand the basis of acquiring psychomotor skills we would be better equipped to teach them. White et al. (TOG 2016;18:53−63) explained the theory and practicalities of teaching laparoscopic surgical skills. Open surgery (including caesarean section) will always be required, though is difficult to simulate. An article on how best to teach open surgery would be interesting. Raghavan et al. (TOG 2014;16:13−18) reviewed abdominal incisions and suture choice, an area previously covered by Hogston (TOG 2001;3:127−31), who also described the factors that affect tissue healing. Aslam and Moran (TOG 2014;16:161−8) reviewed the indications for catheter use in gynaecology and Foon et al. (TOG 2006;8:78−85) discussed the technique and indications for cystoscopy. Laparoscopic surgery is a quantum leap, though is associated with surgeon fatigue and physical strain. Quinn and Moohan (TOG 2015;17:77−82) provided useful tips regarding ergonomics in the laparoscopic operating theatre. Torbé et al. (TOG 2013;15:263−8) described how enhanced recovery is good for the patient and the hospital. All these areas are poorly covered in our teaching and these papers should be compulsory reading for all trainees. Heavy menstrual bleeding is a common presenting symptom. Justin et al (TOG 2007;9:223−232) reviewed minimal access techniques for its treatment, whilst Oláh (TOG 2005;7:233−240) argued the case for vaginal hysterectomy in the absence of prolapse. Perhaps the time has come to argue for laparoscopic hysterectomy? I also enjoyed Jefferis et al.'s challenge of vaginal hysterectomy in the treatment of prolapse (TOG 2016;18:17−23). Practice for long enough, and you will see a patient with vaginal agenesis. Minto and Creighton's article on vaginoplasty (TOG 2003;5:84−9) described the surgical approach and will be of interest as background information for many of us. However, referral to a centre of expertise with a multidisciplinary team must be the current standard of care. Gibb and Saridogan (TOG 2015;18:117−25) described the indications for transabdominal cervical cerclage, which will benefit a few well selected patients and Cooper and Clark (TOG 2013;15:159−66) reviewed ambulatory hysteroscopy, which benefits many patients. All operations carry risk, some more so than others. Biswas and Hogston (TOG 2011;13:87−91) taught us about the risks of obesity and Frappell (TOG 2012;14:207−209) discussed laparoscopic entry after previous surgery. Both issues are increasing in frequency. Relph et al. (TOG 2016;18:65−8) told us how to reduce the risk of failed hysteroscopy and management options if failure does occur. Uterine perforation is well recognised; Shakir and Diab (TOG 2013;15:256−61) described when it is more likely to occur and what to do if it does. Large specimens and laparoscopic surgery pose a conundrum. Stavroulis et al. (TOG 2013;15:26−30) provided useful tips for specimen extraction. The urinary tract is at risk of damage in our practice. Jha et al. (TOG 2004;6:203−8) reviewed ureteric injury in obstetric and gynaecological surgery. Minas et al. (TOG 2014;16:19−28) updated this by looking at urinary tract injuries in laparoscopic surgery. Reading both articles should reduce the fear of the urinary tract. I was also unaware of the importance of nerve injuries associated with gynaecological surgery until I read Kuponiyi et al.'s paper (TOG 2014;16:29−36). Read and James covered a broad range of immediate postoperative complications (TOG 2002;4:29−35) – another compulsory read. The TOG reviews have been informative, educational and challenging. Just what I want from my CPD journal! An online collection of all TOG gynaecological surgery articles is available at http://onlinetog.org.

Local Anesthesia Combined With Sedation Compared With General Anesthesia for Ambulatory Operative Hysteroscopy: A Randomized Study.

The purpose of this study was to compare two anesthetic techniques for postoperative pain after ambulatory operative hysteroscopy. A randomized trial. Women (N = 153) scheduled for ambulatory operative hysteroscopy were assigned to receive either paracervical local anesthesia combined with sedation (group LA+S; n = 76) or general anesthesia (group GA; n = 77). Primary outcome was the worst pain intensity score in the postanesthesia care unit (PACU) rated by the patients on a numerical rating scale. Data from 144 patients were available for analysis (LA+S: n=69; GA: n = 75). There were no significant differences in worst pain intensity between groups in the PACU (P = .13) or after discharge from PACU (P = .40). In group LA+S, fewer patients received treatment with intravenous fentanyl intraoperatively (P < .01) and time until discharge from PACU was shorter (P < .01). More patients in group LA+S experienced vomiting after discharge (P < .05). Local anesthesia with sedation can be recommended asa first choice anesthetic technique for operative ambulatory hysteroscopy.

Setting up of ambulatory hysteroscopy service

There is an obvious trend towards developing ambulatory procedures in gynaecology with ambulatory hysteroscopy as its mainstay. In the recent years, the fast pace of modern technological advances in gynaecologic endoscopy, and particularly in the field of hysteroscopy, have been both thrilling and spectacular. Despite this, the uptake of operative hysteroscopy in ambulatory settings has been relatively slow. There is some apprehension amongst gynaecologists to embark on therapeutic outpatient hysteroscopy, and an organisational change is required to alter the mindset. Although there are best practice guidelines for outpatient hysteroscopy, there are unresolved issues around adequate training and accreditation of future hysteroscopists. Virtual-reality simulation training for operative hysteroscopy has shown promising preliminary results, and it is being aggressively evaluated and validated. This review article is an attempt to provide a useful practical guide to all those who wish to implement ambulatory hysteroscopy services in their outpatient departments.

New technologies and innovations in hysteroscopy

Ambulatory services, with the performance of diagnostic and operative hysteroscopy as an outpatient or office procedure, are providing much of the stimulus for the development of devices that will offer women a better hysteroscopy experience. For the many women who are readily able to tolerate outpatient hysteroscopy, it offers significant advantages, as they can receive safe, efficient and effective assessment and treatment of abnormal uterine bleeding, with avoidance of the disadvantages of general anaesthesia and hospital admission. In addition, provision of such services is cost effective. Whilst the focus for the development of new devices has been the improvement of ambulatory hysteroscopy services, new instrumentation may be beneficial for hysteroscopy procedures in any setting. For ambulatory services, important goals are to reduce pain and the duration of procedures, and to enable the ready delivery of both diagnostic and therapeutic outpatient hysteroscopy. This article discusses innovations for both diagnosis and treatment. Much of the information available about these new devices has been obtained from the manufacturers or from published abstracts submitted for presentation at international meetings that have not been peer-reviewed. Some of the reported studies have been randomised controlled trials, others the results of early investigations.

Office Hysteroscopy: TROPHYscope CAMPO Compact Hysteroscope (®): Manufacturer: KARL STORZ, Tuttlingen, Germany.

In the early 1990s, outpatient procedures have increased in importance in gynecology since advances in technology and techniques made hysteroscopy less painful and less invasive [1, 2]. A major point for office hysteroscopy (“See and Treat Hysteroscopy”) is that there is no need to use a speculum. A new atraumatic hysteroscopic technique, the so-called vaginoscopic, or no-touch technique was developed and the widespread saline solution as the preferred distension medium as an alternative for CO2. Nowadays, office hysteroscopy can be considered as the gold standard if it comes to the examination of the uterine cavity. In fact, it is overcoming the significant restrictions of intrauterine diagnostic curettage [2]. The above-mentioned “See and Treat” concept is what patients are asking for. They consult a gynecologist with their issue and want to leave the office without the problem. For that purpose, the physician has to invest in extracurricular training and equipment to perform ambulatory hysteroscopy [1] (Fig. 1). Fig. 1 The TROPHYscope® However, modern office hysteroscopy benefits from the use of hysteroscopes with an outer diameter of less than 5 mm which can be used for diagnostics and minor operative procedures. Those hysteroscopes also eliminate the need to dilate the cervical canal which leads only to minimal discomfort for the patient. The new TROPHYscope® CAMPO Compact Hysteroscope from KARL STORZ, Tuttlingen, Germany, is specially designed for the above-mentioned purpose. It is based on a 2 mm HOPKINS® rod lens system with an integrated inflow channel. A continuous flow sheath or an operating sheath is positioned either in an active or passive position on the TROHPYscope®. At the start of the intervention, the primary access into the uterine cavity is carried out with an outer diameter of 2.9 mm, only, the corresponding sheath in the passive position. This small diameter facilitates the introduction of the hysteroscope into the uterine cavity and minimizes discomfort of the patient. It is advantageous for the examination of infertility patients and nullipara, as well as postmenopausal patients. If there is a need to clean the cavity (need for continuous flow), then further dilation up to 3.7 mm can be done by pushing the continuous flow sheath forward into the cavity guided by the telescope. For minor interventions, the extra operating sheath (overall diameter of 4.4 mm) with working channel for 5 Fr. instruments is used. For visualization in hysteroscopy a compact, versatile and portable system like the TELE PACK X LED is ideal for the gynecologists’ office. This system includes a 15″ LCD TFT-monitor, a camera, a light source, and a module for data processing as well as data management via USB or SD card [2]. As mentioned above, hysteroscopic procedures require distension of the uterine cavity. The most common medium in use is saline solution [2]. Saline solution offers a neutral vision of the uterine cavity, permits specific evaluation of the endometrial pathologies, and offers the possibility to work with bipolar electrodes. With an electronic irrigation and suction pump like the HAMOU® ENDOMAT, a pressure- and flow-controlled constant intrauterine distension is provided [3] (Fig. 2). Fig. 2 Tele pack + LED-System Nowadays, hysteroscopy is the gold standard for evaluation and treatment of intrauterine pathologies. But as a matter of fact, it is still not widely used in daily practice. The major reason for this is the lack of teaching in hysteroscopy during conventional medical training. Furthermore, the conviction of the gynecologist and the patient that an office hysteroscopy, without anesthesia, may be more painful leads to interventions favoring the so-called traditional approach [2]. Traditional surgery and office surgery are no longer mutually incompatible. Indeed, they have undergone a Hegelian synthesis. Both interventions are complementary to each other. The pathology itself distinguishes if traditional surgery or office surgery is appropriate as many diseases that can be treated hysteroscopically and can be done within an ambulatory setting [2]. Most women who have undergone an office hysteroscopy are satisfied with the procedure, and prepared to recommend it or undergo this experience again if necessary [4].

Editorial

Editorial

Detection of hypoventilation during deep sedation in patients undergoing ambulatory gynaecological hysteroscopy: a comparison between transcutaneous and nasal end-tidal carbon dioxide measurements

Detection of hypoventilation during deep sedation in patients undergoing ambulatory gynaecological hysteroscopy: a comparison between transcutaneous and nasal end-tidal carbon dioxide measurements

Efficacy of intrauterine lignocaine plus vaginal misoprostol for pain relief in premenopausal women undergoing endometrial aspiration and ambulatory hysteroscopy

To compare the effectiveness of a combination of intrauterine lignocaine and vaginal misoprostol in reducing pain at hysteroscopy and endometrial aspiration (EA). Prospective randomized trial (Canadian Task Force Classification I). Tertiary care referral hospital. Forty-nine premenopausal women undergoing hysteroscopy plus EA. Patients were randomized into misoprostol plus intrauterine lignocaine group (Group I) and only misoprostol group (Group II). Pain scores at hysteroscope insertion (T (time) 1), during and after hysteroscopy (T2, T3), during EA (T4), 15 minutes after the procedure (T5) and at discharge (T6). Satisfaction and procedure acceptability was assessed by a questionnaire. The mean age of patients in Group I and Group II was 35.4 +/- 8.6 years and 38.9 +/- 13.2 years, respectively. The mean pain scores in Group I were 23.6% lower at T2 and 27% lower at T4 when compared with Group II; the difference of latter being significant. A combination of intrauterine lignocaine plus vaginal misoprostol reduced the pain score in premenopausal women undergoing hysteroscopy and EA.

Avaliação da dor em histeroscopia ambulatorial: comparação entre duas técnicas

to compare the pain reported by patients submitted to hysteroscopy by the standard technique with carbon dioxide (CO2) and to vaginal hysteroscopy with physiological saline (0.9% NaCl). this was a prospective cohort study conducted at an ambulatory hysteroscopy service. A total of 117 patients with indication for the exam were included, being randomly assigned to one of the groups. All patients answered an epidemiological questionnaire and scored the pain expected before the exam and that felt after the end of the procedure on a verbal pain scale from 0 to 10. A speculum, traction of the cervix, insertion of a 30 masculine light source and a diagnostic shirt with a total diameter of 5 mm were used for the standard technique. The cavity was distended with CO2 under a pressure of 100 mmHg controlled with a hysteroflator, and a biopsy was obtained with a Novak curette. Vaginoscopy was performed without a touch by distention of the vagina with fluid, direct visualization of the cervix and introduction of the light source with two continuous-flow shirts, with an accessory channel with an oval profile, the whole set measuring 5 mm in diameter. The medium distention was 0.9% NaCl and the pressure used was that considered to be necessary for an adequate visualization of the canal and of the cavity with an external pneumatic pressurizer. The biopsy was obtained in a directed manner using an endoscopic clamp. The mean and standard deviation were calculated for the quantitative variables and the frequency was calculated for the qualitative variables. The Student's t-test was used to compare the means, and the chi-square or exact Fisher test was used (when n<5) for the categorical analysis using the SPSS 15.0 software. The study was designed for a 95% test power, with the level of significance set at p<0.05. the groups were similar regarding age, parity, previous uterine surgeries, menopausal status, and the need for a biopsy. In comparison to the group submitted to the standard technique, the vaginoscopy group involved a lower technical difficulty (5.1 versus 17.2%, p=0.03), a higher rate of exams considered to be satisfactory (98.3 versus 89.7%, p=0.04) and a lower pain index (4.8 versus 6.1; p=0.01), as the difference were more evident when patients who never had a previous normal delivery were compared (4.9 versus 7.1; p=0.0001). When the pain scale was stratified as mild (0-4), moderate (5-7) or intense (8-10), the vaginoscopy technique was found to be associated with a 52% reduction of the frequency of intense pain (p=0.005). vaginohysteroscopy was proved to be a less painful procedure than the technique based on the use of a speculum and CO2, regardless of age, menopause or parity, with more satisfactory results and lower technical difficulty.

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine-sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia. Retrospective study. University-affiliated tertiary referral centre. All consecutive women who had an embolisation with or without uterine-sparing surgery (vessel ligation and/or uterine compression) for postpartum haemorrhage between 1994 and 2007 were included. Data were retrieved from medical files and telephone interviews. Fertility and pregnancy outcomes, synechia. Data were available for 68 of the 85 women (80%) included in the study. Among the 15 women who complained of amenorrhoea or decreased flow of menstruation, synechia was found in all those who decided to undergo an ambulatory hysteroscopy (n = 8). Seventeen women had 26 pregnancies with 19 term deliveries, one ectopic pregnancy, two abortions and four miscarriages. The clinical courses of the 19 complete gestations were uneventful, but postpartum haemorrhage recurred in six women (31.6%) (caused by placenta accreta in two women). Fertility and pregnancy outcomes did not differ between women who had undergone embolisation versus both embolisation and a uterine-sparing surgical procedure. The occurrence of synechia was significantly associated with a higher rate of placenta accreta/percreta (P < 0.001) and postpartum fever above 38.5 degrees C (P = 0.04). Embolisation, whether or not associated with a uterine-sparing surgical procedure, for postpartum haemorrhage does not appear to compromise a woman's subsequent fertility and obstetric outcome. Nevertheless, these women should be considered at high risk for postpartum haemorrhage during future deliveries.