Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Targeted Hysteroscopic Resection of a Missed Spontaneous Abortion?
- What are the Risks of Targeted Hysteroscopic Resection of a Missed Spontaneous Abortion?
- Video Transcript
Video Description
This video demonstrates a technique for the hysteroscopic resection of a missed spontaneous abortion.
Presented By
Affiliations
University of Saskatchewan
Watch on YouTube
Click here to watch this video on YouTube.
What is Targeted Hysteroscopic Resection of a Missed Spontaneous Abortion?
Targeted hysteroscopic resection of a missed spontaneous abortion involves using a hysteroscope to precisely remove retained pregnancy tissue from the uterine cavity. This minimally invasive procedure is performed under direct visualization, allowing for careful and thorough removal of the tissue to prevent complications such as infection or heavy bleeding. The use of a hysteroscope ensures that only the necessary tissue is removed, preserving the health of the uterine lining and reducing the risk of scarring, which can impact future fertility. Postoperative care typically includes monitoring for any signs of infection or excessive bleeding and may involve follow-up imaging to ensure complete removal of retained tissue.
What are the Risks of Targeted Hysteroscopic Resection of a Missed Spontaneous Abortion?
The risks of targeted hysteroscopic resection of a missed spontaneous abortion include several potential complications related to the procedure itself and the patient’s overall health. Key risks include:
- Infection: There is a risk of infection in the uterine cavity or surrounding tissues, which may require antibiotic treatment.
- Bleeding: Excessive bleeding can occur during or after the procedure, necessitating further medical intervention or, in rare cases, a blood transfusion.
- Perforation: The hysteroscope or surgical instruments can accidentally perforate the uterine wall, leading to injury to surrounding organs such as the bladder or bowel, which may require additional surgery to repair.
- Scarring (Asherman’s Syndrome): The formation of scar tissue within the uterine cavity can occur, potentially leading to menstrual irregularities, infertility, or recurrent pregnancy loss.
- Anesthesia Risks: Complications from anesthesia, such as allergic reactions, respiratory issues, or cardiovascular problems, can arise, particularly in patients with underlying health conditions.
- Incomplete Removal: There is a possibility of incomplete removal of the retained tissue, which may necessitate additional surgical procedures.
Patients undergoing this procedure should be fully informed of these risks and receive thorough preoperative and postoperative care to minimize complications and ensure a successful recovery.
Video Transcript: Asherman Syndrome: Targeted Hysteroscopic Resection of a Missed Spontaneous Abortion
We present the case of a 38-year-old gravida 6, para 1 woman with a history of recurrent pregnancy loss. She has notably had four consecutive first trimester losses, all previously managed surgically via suction dilatation and curettage. She had undergone investigations for recurrent pregnancy loss and was found to have a large uterine septum. Uterine septoplasty under a hysteroscopy was performed and the patient was conceived spontaneously soon thereafter.
She had a generally unremarkable early first trimester. Her viability ultrasound performed at seven weeks and five days gestation by last menstrual period showed the gestational sac measuring 25.6 mm, the crown rump length of 6 mm and absent embryonic cardiac activity. A diagnosis of missed spontaneous abortion was therefore made. Intrauterine pregnancy losses occur in approximately 15 to 20% of gestations.
And in North America, about half of these losses are managed surgically. Current standard of care for surgical uterine evacuation of early non-viable pregnancies is via a suction dilatation and curettage or commonly called D&C. This is a blind procedure involving suction, followed by sharp cartage of the entire uterine cavity. Operative hysteroscopy has been successfully used for management of multiple intrauterine pathologies, including endometrial polyps, myoma, septums and adhesions.
FDA-approved MyoSure Tissue Removal System by Hologic is a suction-based hysteroscopic morcellation device that relies on mechanical energy delivered through a tubular cutter. The device allows for targeted resection of retained products of conception under direct visualisation. Recent research has showed that hysteroscopic resection may be preferred to suction D&C in patients with retained products of conception.
A systematic review reported few intrauterine adhesions and incomplete evacuations with similar reproductive outcomes when comparing hysteroscopic resection with suction D&C. Our objective was to assess the feasibility and efficacy of targeted hysteroscopic resection for a missed spontaneous abortion. The surgery took place at the Regina General Hospital in the gynaecology surgery suite.
Patient was placed in the dorsal lithotomy position and received general anaesthesia without complications. She was then prepped and draped in the usual sterile fashion. A speculum was placed in the vagina and the anterior lip of the cervix was grasped transversely with the single tooth tenaculum. The operative hysteroscope was introduced through the cervix, allowing visualisation of the uterine cavity.
Hysteroscopic visualisation of the uterine cavity revealed products of conception, including the gestational sac. Normal saline was used for uterine cavity distension connected to the Aquilex fluid management system. Then proceeded with targeted hysteroscopic resection using the MyoSure device. MyoSure device was developed in 2009. It has a rate of 6,000 revolutions per minute and is able to remove 1.5 g of tissue per minute.
As demonstrated, the morcellator was able to remove the gestational sac in a sequential fashion with little bleeding. The tissue was first drawn into the morcellator window and is then resected and suctioned away. We were able to achieve complete removal of all products of conception. Common risks of this procedure include fluid overload, electrolyte disturbance, bleeding, infection, uterine perforation with subsequent injury to bowel, bladder and surrounding pelvic structures, retain products of conception and risk of anaesthesia.
Once the resection was complete, the uterine cavity was deinsufflated. All instruments were removed and patient was taken to the recovery room in stable condition. The fluid deficit was 350 ml at the end of the procedure and there were no other operative complications. Estimated blood loss was minimal and total surgical time was a little under ten minutes. To the best of our knowledge, this is the first surgical video of a targeted hysteroscopic resection of a missed spontaneous abortion.
Our patient was discharged home on the day of surgery. Post-operative bleeding resolved within 24 hours of surgery and she had adequate pain control with oral analgesics. At the six-week post-operative follow-up visit, she underwent a second-look hysteroscopy, which showed no evidence of retained products of conception or intrauterine adhesion formation.
In summary, targeted hysteroscopic resection using a suction-based morcellator device is a safe and effective way of surgically managing first trimester missed spontaneous abortions, especially in patients with a prior history of recurrent pregnancy losses or intrauterine pathologies.