Failed hysteroscopy and further management strategies

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Failed Hysteroscopy and Further Management Strategies Relph S, Lawton T, Broadbent M, Karoshi M. Failed hysteroscopy and further management strategies. TOG 2016;18:65–68. doi:10.1111/tog.12261

4.2% 61.7% 400 µg OUTPATIENT HYSTEROSCOPY FAILURE RATE FAILED ENTRY DUE TO INTERNAL OS STENOSIS STANDARD VAGINAL MISOPROSTOL DOSE

DO N' T-M IS S FA C TS

  1. Outpatient hysteroscopy failure rate 4.2%; internal os stenosis accounts for 61.7% and external os stenosis 23.3% of failed entries

  2. Consent must include risk of difficult entry/abandoned procedure (nearly half of complications relate to it) and risk of uterine perforation, especially in nulliparous/postmenopausal women or those with prior cervical surgery

  3. Misoprostol 400 µg vaginally is standard dose; benefits only shown in premenopausal women (25-RCT meta-analysis) – balance against perforation risk through a softened cervix

  4. Postmenopausal stenosis: consider 1000 µg vaginal misoprostol 24h pre-op + 2-week vaginal estradiol 25 µg/day (small RCT evidence)

  5. 1–2 mm lacrimal duct probes risk false passages – experienced operator only, ideally under USS guidance; avoid with Pipelle/2 mm scope check first

  6. Hydrodilatation orientation (30° scope): 6 o’clock anteverted, 12 o’clock retroverted uterus; always safer than blind mechanical dilatation

  7. Cervical stenosis after previous surgery: 10.2% post-laser conisation, 4.3% post-LEEP

  8. If entry impossible: consider cruciate incision, size 20 spinal needle saline infusion hysterography (Pisal et al.), following IUCD strings, or operating during menstruation

TECHNIQUE QUICK-REFERENCE

Misoprostol 400µg vaginal Hegar/Sims dilators 3–10mm Laminaria tents 3–4mm Hydrodilatation (direct vision)

USS-guided sound/scope Lacrimal probes – false passage risk Blind mechanical dilatation

ABBREVIATION KEY

MRI — magnetic resonance imaging LEEP — loop electrosurgical excision procedure

CT — computed tomography IUCD — intrauterine contraceptive device

USS — ultrasound scan RCT — randomised controlled trial

AUB — abnormal uterine bleeding

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.12261

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