PAPER AT FIGO SOUTH AFRICA IN OCT 2009

1. HYSTEROSCOPY In DUB Dr. Kawita Bapat ONE DAY HYSTERECTOMY SPECIALIST Bapat Hospital INDORE INDIA

2. Dr. Kawita Bapat Ms Obgyn Goldmedallist Special interest in pelvic gyn surgery One day hysterectomy Hysteroscopy and colposcopy First in Madhya Pradesh To start menopausal counseling clinic One day hysterectomy(MIVH) Cervical cancer vaccination Vice president of obgyn in Indore Start website for obgyn in Indore Diploma in computers

3. HYSTEROSCOPY hysteroscopy has become an important tool in the armamentarium of the gynecologist, especially in the evaluation of DUB

4. See and treat approach Revolutionized Cost convenience Accuracy Acceptable Current gold standard for endometrial evaluation Alert the physician Diagnostic hysteroscopy

5. Unexplained DUB (DUB) is one of the most common clinical problems in gynaecology Small endometrial polyp Small cervical polyp Adhesion at cornual cones Cornual polyp Endometrial atrophy or hyperplasia

6. HysteroscopyInstrumentation Lockable cabinet Telescope Sheath system Hysteroscope Diagnostic Operative Resectoscope Distention systems Gas insufflator Fluid delivery system Light source and cable Video cameras and monitors

7. Hysteroscopes / Sheaths Flexible (3-5 mm) Adv. Minimal risk of trauma, ability to deflect the view manually Disadv.Greater cost, inability to widen view or to magnify the image, inability to use the instrument Rigid (4 mm) 0-30 degrees Microhysteroscope (2.4-2.7 mm)

8. Light Source The optics of telescope 150 – W light source with flexible fiber optic cables Halogen or xenon types bulbs for video cameras and monitors

9. Distention media Normal saline , Ringer’s lactate ( Low-viscosity fluid) Best with continuous flow, clear view, costly insufflators and pumps are unnecessary, bipolar procedures Sorbitol, Glycine, Mannitol ( Low-viscosity fluid) Monopolar procedures

10. TIMING It is preferable to perform hysteroscopy in the proliferative phase or immediately following a menstrual period.

11. Hysteroscopy - Benefits Direct visualization of any pathology No X-ray exposure Insertion under visualization decreases chance of perforation

12. Indication hysteroscopy Unexplained uterine bleeding Suspected intra- uterine pathology(polyps, myomas, adhesions, foreign bodies)

13. HysteroscopyContraindications Active PID Active profuse uterine bleeding Recent uterine perforation Pregnancy Cx Ca Cardiovascular or systemic diseases

14. HysteroscopyComplications Uterine perforation Hemorrhage Infection Hypervolemia Hyponatremic encephalopathy and cardiac asystole, arrhythmia Hypercarbia, acidosis, gas embolism

15. OUTPATIENT HYSTEROSCOPY Because of excellent drainage, the risk for infection with office hysteroscopy is exceedingly low. ( 0.1%-2.8%)

16. OUTPATIENT HYSTEROSCOPY The outpatient hysteroscopy failure rate is less than half (2%) with the mini-hysteroscope compared with the traditional 5 mm hysteroscope (5%). De Angelis C Hum Reprod. 2003;18:2441-5.

17. OUTPATIENT HYSTEROSCOPY Office flexible minihysteroscopes (2.5 and 3.5 mm) can be successfully used in an office setting for gynecologic indications with high patient acceptance. Ross JW. J Am Assoc GynecolLaparosc. 2000 ;7:221-6.

18. OUTPATIENT HYSTEROSCOPY Saline diagnostic hysteroscopy offers at least all the advantages of the CO2 hysteroscopy, and gives the possibility to easily 'find and treat in situ' many of the lesions observed. Perez-Medina T Int J Gynaecol Obstet. 2000 ;71:33-8.

19. ANALGESIA ANESTHESIA Pain, cramping, vagal reaction 10% Para cervical block In severe problem; Atropine 0.1-0.2 mg IM with/without Ketorolac 30 mg IM IV sedation (rarely)

20. TECHNIQUE Analgesia-anesthesia-vaginal region cleaning, No speculum- no tenaculum (Vaginoscopical approach) Bettocchi S. J Am Assoc Gynecol Laparosc. 1996 ;3: Supplement-S4. Fluid distention media, continuous flow Endomat; irrigation pressure=75-100 mm Hg, Flow=200-350 ml/min; suction= (-) 0.25 bar 2.9 mm scopy (30o) Operating canal (1.6 mm) (Operative office hysteroscopy)

22. Immediate evaluation Direct visualization endometrium and endocervix Detect focal pathology ADVANTAGES

23. Need of expensive equipments Skillful Cost But with in comparison it is cost effective Disadvantage

24. Simple Decrease patient anxiety Adequate instructions Informed consent Clear explaination to patient Knowledgeable assistant Appropriate instruments Technique

25. No vaginal speculum No tantalum No cervical dilatation Instrument Semi rigid hysteroscop 4-5 mm Instruments Grasp, cut, biopsy, vaporize or coagulate TECHNIQUE

26. Bimanual examination Position Size Shape Characteristic of cervix Consistency position Transvaginal sonography

27. Clean vagina No systemic sedatives Gentle advance of scope through cervical canal Uterine distension pressure exerted by two connected by 3 lit bag of saline situated 1 mt above the level of vagina Pressure 70 mm of HG Procedure

29. Systematically

30. Small micro cavity by liquid

31. Endo cervical canal

32. Internal cervical os

33. Allow panoramic view of uterine cavity

34. Uterotubal cornu

35. Tubal Ostia

36. Explain patient Examination

37. Simple Expeditious Comfortable Full value for decreasing expense decreasing Inconvenience

38. Out patient Good optical properties Little time Excellent success rate Less pain Greater patient satisfaction Lower risk of vasovagal Rigid hysrteroscope

39. Minimize patient discomfort Inconvenience Reduce complication Optimize safety Clinical outcomes

40. Abnormal uterine bleeding Peri menopausal females Age between 45 to 50 Persistent abnormal bleeding Normal sonography in 90% of cases No history of pregnancy or menopause Regular previous menstrual cycles Irregular menstrual bleeding Inclusion criteria

42. Suspected intrauterine pathology

43. Opportunity to obtain selected biopsies of abnormal or suspicious area of endometrium

45. Targeted biopsy Suspicious areas of endometrium Enhances evalution of architectural distorson Visual exploration Additional benefit

46. It is most important to insure prevention of complications and their recognition, and their management, if they occur. Complication may occur due to Instrumental procedure Distension media. Inadequate visualization Anesthetic agent

47. Data from patients' histories clinical examinations transavaginal sonography hysteroscopy pathologic results gathered and analyzed For analyzing, statistical description methods such as distribution frequency tables and calculation values for sensitivity, specificity and predictive value were used

48. Hystroscopy in different age groups

49. Hysteroscopicand pathologic results

50. ectocervix endocervical canal internal os

51. OUTPATIENT HYSTEROSCOPY Hysteroscopy done as out patient procedure in patients of DUB, has low complication rate, high requirement and adds little equipment & cost. Positive hysteroscopic findings were found in many cases (21.8 %) despite having normal TVS and no suggestive history of uterine lesion.

52. HYSTEROSCOPY

53. OUTPATIENT HYSTEROSCOPY It is no more acceptable for a gynecologist to insert a sharp curette into a uterine cavity blindly to discover and remove suspected pathology than it is for an orthopedist to insert a curette into a knee joint blindly.

55. 17 patients (21.8%) were abnormal hysteroscopically

56. Cervical canal polyps may be missed by transvaginal sonography

57. but diagnosed by hysteroscopyIn patients with AUB and normal TVS, hysteroscopy can be used as the second step.

59. According to high conformity between the hysteroscopy and pathology, diagnostic ability of hysteroscopy was higher than transvaginal sonography. Conclusion

61. Sufficiently advanced technology is indistinguishable from magic Thank you One Day hysterectomy