Carbon dioxide hysteroscopy ERNST G. BARTSICH, M.D .. F.A.C.O.G. THOMAS F. DILLON, M.D., .F.A.C.O.G.
New York, New York
Hysteroscopy was performed on 75 patients undergoing a dilatation and curettage for routine gynecologic problems. For the distention of the uterine cavity carbon dioxide was used and found to be an adequate medium to establish a pneumometra. It provided good visualization and was simple and safe to use for the hysteroscopic examination. Arterial blood-gas determinations revealed no change in the Po 2, Pco 2, and pH with carbon dioxide insufflation. There were no complications in this series. The advantages and applications of carbon dioxide hysteroscopy are outlined.
THE DIRECT VISUALIZATION and exploration of the uterine cavity was introduced over l 00 years ago and has been greatly improved with the development of fiberoptic instruments. For adequate visualization the uterine cavity, a shallow cleft, has to be distended. Various media have been used in the past. Sterile water, 10 rubber balloons/· 9 sodium chloride solutions, 10 5 per cent dextrose in water solutions, 2 • 8 and dextran have been tried but no one achieved general acceptance. One alternate method is to use carbon dioxide as the agent to distend the uterine cavity and establish the pneumometra. Carbon dioxide was used for uterine and tubal insufflation by Rubin 11 as early as 1925. It was reintroduced in Europe for hysteroscopy in 1970 by Lindemann. 4- 6 It has been available in the United States only recently and experience with it is limited. Carbon dioxide provides an absorbable medium for distending the uterus and achieves good visualization of the uterine cavity.
prevent leakage of carbon dioxide. The hysteroscope (Fig. 2)* is then inserted through the adaptor and atraumatically advanced into the cervical canal. The carbon dioxide flow rate and the insufflation pressure can be predetermined with a quantity gauge in the hysteroscopy insufflator (Fig. 3 ), * which ensures constant flow and prevents fogging of the lens. The initial pressure setting should not exceed 80 mm. Hg, which provides adequate distention of the uterine cavity. The gas flow is interrupted once the predetermined pres· sure is reached, and an additional gauge continuously registers the actual pressure in the uterine cavity. Possible escape of gas through the cervix or through the Fallopian tubes will be registered in a sudden drop of pressure. The carbon dioxide flow is resumed automatically, which maintains distention of the uterine cavity during investigation. Less than 100 c.c. of carbon dioxide are sufficient for the entire procedure. A 150-watt lamp as a power sourcet provided sufficient light for observation and diagnosis. A 300-watt lamp was utilized for photography. An Olympus OM-1 camera with a 100 mm. lens and an Ektachrome-film ASA160 was used for photography. Hysteroscopy was performed on 75 patients between the ages of 22 and 58 undergoing a dilatation and curettage for routine gynecologic problems. Parity ranged from 0 to 8. The indications for the procedure are listed in Table I. The procedures were performed under general anesthesia. The endotracheal technique was used. The first 25 patients underwent blood-gas
Materials and methods The cervix is dilated to a No. 9 Hegar dilator. A vacuum adaptor (Fig. 1)* is placed against the cervix to From the Obstetric and Gynecologic Service, The Roosevelt Hospital, Department of Obstetrics and Gynecology, thr Collegr qf Physicians and Surgeons, Columbia University. Received for publication December 23, 1974. Revised April 1, 197.5. Awpted April 23, 1975. Reprint requests: Dr. Ernst G. Bartsich, Depart. of Obstetrics and Gynecology, The Roosevelt Hospital, 428 West .59th St., New York, New York 10019.
*Vacuum adaptor, hysteroscope, and hysteroscopy insufflator 20205, Richard Wolf Medical Instrument Company. Rosemont, Illinois. t"Heavy Duty" fiber light projector D-5008-U, Richard Wolf Medical Instrument Company, Rosemont, Illinois.
*Vacuum adaptor, hysteroscope, and hysteroscopy insufflator 2020S, Richard Wolf Medica/Instrument Compan~~· Rosemont, Illinoi1.
746
Carbon dioxide hysteroscopy 747
Volume 124 Number 7
Table I. Hysteroscopy No. of
Indications for procedure
patients
Menometrorrhagia Postmenopausal bleeding Laparoscopic tubal sterilization. Uncertain dates of last menstrual period. Chronic pelvic pain Intrauterine contraceptive device Leiomyomata uteri Postpartum and postabortal bleeding (repeated D & C) Infertility Cervical dysplasia-£one biopsy
25 8
20 5 7 4 I 4 1
determinations during the hysteroscopy or simultaneous laparoscopy. At 5 to 7 minutes after the carbon dioxide had been started, serial arterial blood-gas determinations were performed on 25 patients. In all cases blood was drawn anaerobically from the radial artery with a heparinized syringe and was analyzed immediately for Po 2 , Pco2 , and pH. Fifteen patients underwent a laparoscopy simultaneously with the hysteroscopic procedure. Approximately 10 c.c. of indigo carmine was injected through the working channel on the hysteroscope into the uterine cavity. The pressure in the uterine cavity was then increased steadily and the fimbriated ends of the fallopian tubes were observed through the laparoscope for spillage of gas bubbles. Following the hysteroscopic examination, a curettage of the uterine cavity was performed. Special attention was given to the areas of abnormal findings. Fig. 1. Vacuum adaptor for C0 2 hysteroscopy.
Results The hysteroscopic findings are listed in Table II. A normal uterine cavity was found in 46 of 75 patients. In seven patients undergoing a hysteroscopic examination, polyps were noted in the uterine cavity and removed . The intrauterine contraceptive devices-mostly stainless steel bands-were located without difficulty, grasped with a forceps through the working channel of the hysteroscope, and extracted by removing the hysteroscope through the sleeve of the vacuum adaptor. Submucous leiomyomata were appreciated in three of the patients with menometrorrhagia, one patient with leiomyomata uteri, and one patient with infertility. One patient underwent a hysteroscopic procedure after a repeated dilatation and curettage for postabortal bleeding and was found to have necrotic trophoblastic tissue in the anterior fundal area. Three patients with intrauterine adhesions on hysteroscopic
examination had been admitted and evaluated for pelvic pain, menometrorrhagia, and infertility. In three patients intrauterine pregnancies were diagnosed and terminated. One patient with postmenopausal bleeding was found to have an adenocarcinoma of the endometrium. A stenotic cervical os prevented the planned procedure in two patients. There were no postoperative complications in this series. The statistical analysis of the blood-gas determinations showed no difference in Po 2 or Pco 2 in the samples taken prior to and during the hysteroscopic procedures (Table III). Escape of carbon dioxide through the Fallopian tubes was not observed with 80-100 mm. Hg in the uterine cavity. Once the pressure was increased over 100 mm. Hg, however, the carbon dioxide did escape
748
Bartsich and Dillon Am.
J.
April l. 1976 Obstet. Gynecol.
Fig. 2. Lumina-hysteroscope. Viewing angle 160°. A flexible probe (A) is in the working channel of the hysteroscope. A fiberoptic light-cable (B) is attached to the hysteroscope.
Fig. 3. Hysteroscopy insufflator 2020S. A. Quantity gauge with scale for pressure setting; B , pressure gauge for intrauterine pressure; C, flow-meter; D. gauge indicating amount of C0 2 used ; E attachment for vacuum adaptor; and F supply and pressure in C0 2 tank.
in most patients with normal Fallopian tubes. This was observed through the laparoscope and also registered on the pressure gauge of the insufflator with a sudden drop in the predetermined pressure. Shoulder pain secondary to the carbon dioxide in the peritoneal cavity did not occur postoperatively. Bleeding from the endometrium , which was occasionally encountered when the procedure was performed during the secretory phase of the menstrual cycle. decreased or subsided entirely with the increase of pressu re in the uterine cavity.
The visualization of the tubal ostia was easier when the hysteroscopic procedure was performed during the proliferative phase of the cycle. A thick secretory endometrium can obstruct the tubal ostia.
Comment For adequate visualization of the uterine cavity a variety of media and instruments have been tried in the past and are still applied. Problems arising with the use of them have prevented a general acceptance. We found that carbon dioxide provides an adequate
Volume 124 Number 7
Carbon dioxide hysteroscopy 749
Table II. Hysteroscopy: Findings of hysteroscopic examinations No. of
patients 46
Findings
lndicatWns
Normal uterine cavity
Menometrorrhagia Postmenopausal bleeding Bilateral tubal ligation Pain Leiomyomata uteri Infertility Cervical dysplasia
14 6 16 4
3 2 1
7
Polyps
Menometrorrhagia Postmenopausal bleeding Bilateral tubal ligation
5 1 1
7 5
Intrauterine contracraceptive device
Intrauterine contraceptive device
7
Submucous leiomyomata
Menometrorrhagia Leiomyomata uteri Infertility
3
Necrotic trophoblastic tissue Intrauterine adhesions
Postabortal bleeding Pain Menometrorrhagia Infertility
l I I I
3
Intrauterine pregnancy
Bilateral tubal ligation
3
1
Cancer of endometrium
Postmenopausal bleeding
2
Stenotic cervical os
Menometrorrhagia
I
3
1 1
2
Table III. Statistical analysis of blood-gas determination prior to and after 5 to 7 minutes of C0 2 hysteroscopy
pH Patient No. 1 2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Mean S.D.
Pre
I
P0 2
Pco, Post
7.400 7.480 7.430 7.470 7.420 7.470 7.460 7.500 7.360 7.432 7.442 7.464 7.506 7.339 7.500 7.372 7.398 7.429 7.470 7.429 7.434 7.475 7.298 7.484 7.500
7.400 7.370 7.470 7.360 7.450 7.480 7.460 7.520 7.390 7.463 7.352 7.460 7.380 7.394 7.490 7.363 7.344 7.422 7.483 7.450 7.471 7.362 7.334 7.375 7.528
7.438 ±0.054 PO.l93
7.423 ±0.058 NS
I
I
Post
Pre
42.6 34.0 37.3 31.3 37.5 35.4 35.5 37.9 42.9 32.7 36.4 35.5 26.7 41.6 33.9 43.8 38.9 42.1 35.4 37.5 41.9 31.5 44.2 34.0 37.9
43.0 43.0 38.8 46.1 36.5 34.5 36.6 33.0 38.1 30.4 48.0 35.6 41.6 28.6 33.9 44.4 49.3 43.0 34.5 36.3 37.3 46.1 46.3 43.8 33.0
94.0 128.0 84.0 80.0 82.0 102.0 204.0 122.0 68.0 108.4 190.1 204.0 182.6 195.4 110.6 114.8 66.5 94.3 101.6 82.3 68.5 80.2 76.9 128.0 122.9
103.0 108.0 118.0 79.0 76.0 105.0 193.0 132.0 77.0 70.5 179.3 193.2 88.1 198.0 131.8 116.4 119.8 103.0 104.6 75.7 83.8 79.4 82.0 108.1 132.1
37.1 ±4.4 PO.l51
39.3 ±5.8 NS
115.6 ±44.7 P0.793
114.2 ±39.0 NS
Pre
Post
750
Bartsich and Dillon
April I, l97ti -~m.
Table IV. Hysteroscopy
I. Abnormal uterine bleeding
Unexplained infertility Uterine synechia and abnormalities Possible leiomyomata and polyps Examination of scars in the uterus after cesarean section 6. Location of intrauterine devices 7. Biopsy of intrauterine and endocervical lesions
medium to distend the uterine cavity and insures good visualization. The risk to the patient is minimal with the use of controlled gas delivery systems. It has been alleged that fatal and near fatal accidents occurred with the use of other gas delivery systems. No complications have been reported since the introduction of the hysteroscopy insufflator with a controlled carbon dioxide output. These systems deliver not more than the predetermined amount of 60 to 80 mi. C0 2 per minute at an also predetermined pressure. usually 80 to 100 mg. Hg. With the flow rate. pressure, and amount of carbon dioxide well controlled, the risks of gas embolism are quasi nonexistent. An adequate distention of the uterine cavity is achieved and maintained. The procedure is easily performed and does not prolong routine dilatation and curettage unnecessari-
Obstet. Gvneml.
Table V. Hysteroscopy
Indications for hysteroscopic procedures 2. 3. 4. 5.
J
Contraindications I. 2. 3. 4. 5.
Recent uterine perforation Advanced intrauterine pregnancy Active pelvic inflammatory disease Active uterine bleeding Cervical stenosis
ly. The hysteroscopic observation is usually completed within five minutes. and absorption of gas from the endometrium is minimal. Occasional gas bubblesbubbles occur also with the use of Dextran and other fluids-do not interfere with the visibility and disappear within a short time. The amount of information obtained by direct visualization is enormous and the true nature and size of a lesion can be easily determined. Indications for hysteroscopic examinations are listed in Table IV. Contraindications for a hysteroscopic procedure are few and are listed in Table V. Carbon dioxide hysteroscopy is a simple and safe method for the diagnosis of intrauterine disease. It has overcome many of the initial drawbacks of the procedure. While curettage is a blind procedure, hysteroscopy actually visualizes the uterine cavity and helps to establish the correct diagnosis.
REFERENCES l. Brueschke. E. E., and Wilbanks, G. D.: A steerable fiberoptic hysteroscope. Obstet. Gynecol. 44: 273, 1974. 2. Cohen, M. R., and Dmowski, W. P.: Modern hysteroscopy: Diagnostic and therapeutic potential, Fertil. Steril. 24: 905. 1973. 3. Edstrom, K., and Fernstrom, ].: The diagnostic possibilities of a modified hysteroscopic technique. Acta Obstet. Gynecol. Scand. 49: 327, 1970. 4. Lindemann. H. J.: Transuterine tubal sterilization bv hysteroscopy,]. Reprod. Med.l3: 21,1974. 5. Lindemann, H. J.: The use of C0 2 in the uterine cavity for hysteroscopy, Int.]. FertiLI 7: 221. 1972. 6. Lindemann, H. J.: Historical aspects of hysteroscopy, Fertil. Steril. 24: 230, 1973.
7. Lyon. F. A.: Intrauterine visualization by means of hysteroscope, AM.]. 0BSTET GYNECOL. 90: 443, 1964. 8. Quinones Guerrero. R .. Alvarado Duran, A., and Aznar Ramos, R.: Tubal catheterization: Applications of a new technique, AM.]. 0BSTET. GYNECoL. 114: 674, !972. 9. Silander, T.: Hysteroscopy through a transparent rubber balloon. Surg. Gynecol. Obstet. 114: 125, 1962. I 0. Mohri, T.: Demonstration of the Machida hysteroscope, Seventh World Congress on Fertility and Sterility, Tokyo and Kyoto, October, 1971. 11. Rubin, J. C.: Uterine endoscopy, endometroscopy with the aid of uterine insufflation, AM. ]. 0BSTET. GYNECOL. 10: 313, 1925.
New York, New York
Hysteroscopy was performed on 75 patients undergoing a dilatation and curettage for routine gynecologic problems. For the distention of the uterine cavity carbon dioxide was used and found to be an adequate medium to establish a pneumometra. It provided good visualization and was simple and safe to use for the hysteroscopic examination. Arterial blood-gas determinations revealed no change in the Po 2, Pco 2, and pH with carbon dioxide insufflation. There were no complications in this series. The advantages and applications of carbon dioxide hysteroscopy are outlined.
THE DIRECT VISUALIZATION and exploration of the uterine cavity was introduced over l 00 years ago and has been greatly improved with the development of fiberoptic instruments. For adequate visualization the uterine cavity, a shallow cleft, has to be distended. Various media have been used in the past. Sterile water, 10 rubber balloons/· 9 sodium chloride solutions, 10 5 per cent dextrose in water solutions, 2 • 8 and dextran have been tried but no one achieved general acceptance. One alternate method is to use carbon dioxide as the agent to distend the uterine cavity and establish the pneumometra. Carbon dioxide was used for uterine and tubal insufflation by Rubin 11 as early as 1925. It was reintroduced in Europe for hysteroscopy in 1970 by Lindemann. 4- 6 It has been available in the United States only recently and experience with it is limited. Carbon dioxide provides an absorbable medium for distending the uterus and achieves good visualization of the uterine cavity.
prevent leakage of carbon dioxide. The hysteroscope (Fig. 2)* is then inserted through the adaptor and atraumatically advanced into the cervical canal. The carbon dioxide flow rate and the insufflation pressure can be predetermined with a quantity gauge in the hysteroscopy insufflator (Fig. 3 ), * which ensures constant flow and prevents fogging of the lens. The initial pressure setting should not exceed 80 mm. Hg, which provides adequate distention of the uterine cavity. The gas flow is interrupted once the predetermined pres· sure is reached, and an additional gauge continuously registers the actual pressure in the uterine cavity. Possible escape of gas through the cervix or through the Fallopian tubes will be registered in a sudden drop of pressure. The carbon dioxide flow is resumed automatically, which maintains distention of the uterine cavity during investigation. Less than 100 c.c. of carbon dioxide are sufficient for the entire procedure. A 150-watt lamp as a power sourcet provided sufficient light for observation and diagnosis. A 300-watt lamp was utilized for photography. An Olympus OM-1 camera with a 100 mm. lens and an Ektachrome-film ASA160 was used for photography. Hysteroscopy was performed on 75 patients between the ages of 22 and 58 undergoing a dilatation and curettage for routine gynecologic problems. Parity ranged from 0 to 8. The indications for the procedure are listed in Table I. The procedures were performed under general anesthesia. The endotracheal technique was used. The first 25 patients underwent blood-gas
Materials and methods The cervix is dilated to a No. 9 Hegar dilator. A vacuum adaptor (Fig. 1)* is placed against the cervix to From the Obstetric and Gynecologic Service, The Roosevelt Hospital, Department of Obstetrics and Gynecology, thr Collegr qf Physicians and Surgeons, Columbia University. Received for publication December 23, 1974. Revised April 1, 197.5. Awpted April 23, 1975. Reprint requests: Dr. Ernst G. Bartsich, Depart. of Obstetrics and Gynecology, The Roosevelt Hospital, 428 West .59th St., New York, New York 10019.
*Vacuum adaptor, hysteroscope, and hysteroscopy insufflator 20205, Richard Wolf Medical Instrument Company. Rosemont, Illinois. t"Heavy Duty" fiber light projector D-5008-U, Richard Wolf Medical Instrument Company, Rosemont, Illinois.
*Vacuum adaptor, hysteroscope, and hysteroscopy insufflator 2020S, Richard Wolf Medica/Instrument Compan~~· Rosemont, Illinoi1.
746
Carbon dioxide hysteroscopy 747
Volume 124 Number 7
Table I. Hysteroscopy No. of
Indications for procedure
patients
Menometrorrhagia Postmenopausal bleeding Laparoscopic tubal sterilization. Uncertain dates of last menstrual period. Chronic pelvic pain Intrauterine contraceptive device Leiomyomata uteri Postpartum and postabortal bleeding (repeated D & C) Infertility Cervical dysplasia-£one biopsy
25 8
20 5 7 4 I 4 1
determinations during the hysteroscopy or simultaneous laparoscopy. At 5 to 7 minutes after the carbon dioxide had been started, serial arterial blood-gas determinations were performed on 25 patients. In all cases blood was drawn anaerobically from the radial artery with a heparinized syringe and was analyzed immediately for Po 2 , Pco2 , and pH. Fifteen patients underwent a laparoscopy simultaneously with the hysteroscopic procedure. Approximately 10 c.c. of indigo carmine was injected through the working channel on the hysteroscope into the uterine cavity. The pressure in the uterine cavity was then increased steadily and the fimbriated ends of the fallopian tubes were observed through the laparoscope for spillage of gas bubbles. Following the hysteroscopic examination, a curettage of the uterine cavity was performed. Special attention was given to the areas of abnormal findings. Fig. 1. Vacuum adaptor for C0 2 hysteroscopy.
Results The hysteroscopic findings are listed in Table II. A normal uterine cavity was found in 46 of 75 patients. In seven patients undergoing a hysteroscopic examination, polyps were noted in the uterine cavity and removed . The intrauterine contraceptive devices-mostly stainless steel bands-were located without difficulty, grasped with a forceps through the working channel of the hysteroscope, and extracted by removing the hysteroscope through the sleeve of the vacuum adaptor. Submucous leiomyomata were appreciated in three of the patients with menometrorrhagia, one patient with leiomyomata uteri, and one patient with infertility. One patient underwent a hysteroscopic procedure after a repeated dilatation and curettage for postabortal bleeding and was found to have necrotic trophoblastic tissue in the anterior fundal area. Three patients with intrauterine adhesions on hysteroscopic
examination had been admitted and evaluated for pelvic pain, menometrorrhagia, and infertility. In three patients intrauterine pregnancies were diagnosed and terminated. One patient with postmenopausal bleeding was found to have an adenocarcinoma of the endometrium. A stenotic cervical os prevented the planned procedure in two patients. There were no postoperative complications in this series. The statistical analysis of the blood-gas determinations showed no difference in Po 2 or Pco 2 in the samples taken prior to and during the hysteroscopic procedures (Table III). Escape of carbon dioxide through the Fallopian tubes was not observed with 80-100 mm. Hg in the uterine cavity. Once the pressure was increased over 100 mm. Hg, however, the carbon dioxide did escape
748
Bartsich and Dillon Am.
J.
April l. 1976 Obstet. Gynecol.
Fig. 2. Lumina-hysteroscope. Viewing angle 160°. A flexible probe (A) is in the working channel of the hysteroscope. A fiberoptic light-cable (B) is attached to the hysteroscope.
Fig. 3. Hysteroscopy insufflator 2020S. A. Quantity gauge with scale for pressure setting; B , pressure gauge for intrauterine pressure; C, flow-meter; D. gauge indicating amount of C0 2 used ; E attachment for vacuum adaptor; and F supply and pressure in C0 2 tank.
in most patients with normal Fallopian tubes. This was observed through the laparoscope and also registered on the pressure gauge of the insufflator with a sudden drop in the predetermined pressure. Shoulder pain secondary to the carbon dioxide in the peritoneal cavity did not occur postoperatively. Bleeding from the endometrium , which was occasionally encountered when the procedure was performed during the secretory phase of the menstrual cycle. decreased or subsided entirely with the increase of pressu re in the uterine cavity.
The visualization of the tubal ostia was easier when the hysteroscopic procedure was performed during the proliferative phase of the cycle. A thick secretory endometrium can obstruct the tubal ostia.
Comment For adequate visualization of the uterine cavity a variety of media and instruments have been tried in the past and are still applied. Problems arising with the use of them have prevented a general acceptance. We found that carbon dioxide provides an adequate
Volume 124 Number 7
Carbon dioxide hysteroscopy 749
Table II. Hysteroscopy: Findings of hysteroscopic examinations No. of
patients 46
Findings
lndicatWns
Normal uterine cavity
Menometrorrhagia Postmenopausal bleeding Bilateral tubal ligation Pain Leiomyomata uteri Infertility Cervical dysplasia
14 6 16 4
3 2 1
7
Polyps
Menometrorrhagia Postmenopausal bleeding Bilateral tubal ligation
5 1 1
7 5
Intrauterine contracraceptive device
Intrauterine contraceptive device
7
Submucous leiomyomata
Menometrorrhagia Leiomyomata uteri Infertility
3
Necrotic trophoblastic tissue Intrauterine adhesions
Postabortal bleeding Pain Menometrorrhagia Infertility
l I I I
3
Intrauterine pregnancy
Bilateral tubal ligation
3
1
Cancer of endometrium
Postmenopausal bleeding
2
Stenotic cervical os
Menometrorrhagia
I
3
1 1
2
Table III. Statistical analysis of blood-gas determination prior to and after 5 to 7 minutes of C0 2 hysteroscopy
pH Patient No. 1 2 3 4
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Mean S.D.
Pre
I
P0 2
Pco, Post
7.400 7.480 7.430 7.470 7.420 7.470 7.460 7.500 7.360 7.432 7.442 7.464 7.506 7.339 7.500 7.372 7.398 7.429 7.470 7.429 7.434 7.475 7.298 7.484 7.500
7.400 7.370 7.470 7.360 7.450 7.480 7.460 7.520 7.390 7.463 7.352 7.460 7.380 7.394 7.490 7.363 7.344 7.422 7.483 7.450 7.471 7.362 7.334 7.375 7.528
7.438 ±0.054 PO.l93
7.423 ±0.058 NS
I
I
Post
Pre
42.6 34.0 37.3 31.3 37.5 35.4 35.5 37.9 42.9 32.7 36.4 35.5 26.7 41.6 33.9 43.8 38.9 42.1 35.4 37.5 41.9 31.5 44.2 34.0 37.9
43.0 43.0 38.8 46.1 36.5 34.5 36.6 33.0 38.1 30.4 48.0 35.6 41.6 28.6 33.9 44.4 49.3 43.0 34.5 36.3 37.3 46.1 46.3 43.8 33.0
94.0 128.0 84.0 80.0 82.0 102.0 204.0 122.0 68.0 108.4 190.1 204.0 182.6 195.4 110.6 114.8 66.5 94.3 101.6 82.3 68.5 80.2 76.9 128.0 122.9
103.0 108.0 118.0 79.0 76.0 105.0 193.0 132.0 77.0 70.5 179.3 193.2 88.1 198.0 131.8 116.4 119.8 103.0 104.6 75.7 83.8 79.4 82.0 108.1 132.1
37.1 ±4.4 PO.l51
39.3 ±5.8 NS
115.6 ±44.7 P0.793
114.2 ±39.0 NS
Pre
Post
750
Bartsich and Dillon
April I, l97ti -~m.
Table IV. Hysteroscopy
I. Abnormal uterine bleeding
Unexplained infertility Uterine synechia and abnormalities Possible leiomyomata and polyps Examination of scars in the uterus after cesarean section 6. Location of intrauterine devices 7. Biopsy of intrauterine and endocervical lesions
medium to distend the uterine cavity and insures good visualization. The risk to the patient is minimal with the use of controlled gas delivery systems. It has been alleged that fatal and near fatal accidents occurred with the use of other gas delivery systems. No complications have been reported since the introduction of the hysteroscopy insufflator with a controlled carbon dioxide output. These systems deliver not more than the predetermined amount of 60 to 80 mi. C0 2 per minute at an also predetermined pressure. usually 80 to 100 mg. Hg. With the flow rate. pressure, and amount of carbon dioxide well controlled, the risks of gas embolism are quasi nonexistent. An adequate distention of the uterine cavity is achieved and maintained. The procedure is easily performed and does not prolong routine dilatation and curettage unnecessari-
Obstet. Gvneml.
Table V. Hysteroscopy
Indications for hysteroscopic procedures 2. 3. 4. 5.
J
Contraindications I. 2. 3. 4. 5.
Recent uterine perforation Advanced intrauterine pregnancy Active pelvic inflammatory disease Active uterine bleeding Cervical stenosis
ly. The hysteroscopic observation is usually completed within five minutes. and absorption of gas from the endometrium is minimal. Occasional gas bubblesbubbles occur also with the use of Dextran and other fluids-do not interfere with the visibility and disappear within a short time. The amount of information obtained by direct visualization is enormous and the true nature and size of a lesion can be easily determined. Indications for hysteroscopic examinations are listed in Table IV. Contraindications for a hysteroscopic procedure are few and are listed in Table V. Carbon dioxide hysteroscopy is a simple and safe method for the diagnosis of intrauterine disease. It has overcome many of the initial drawbacks of the procedure. While curettage is a blind procedure, hysteroscopy actually visualizes the uterine cavity and helps to establish the correct diagnosis.
REFERENCES l. Brueschke. E. E., and Wilbanks, G. D.: A steerable fiberoptic hysteroscope. Obstet. Gynecol. 44: 273, 1974. 2. Cohen, M. R., and Dmowski, W. P.: Modern hysteroscopy: Diagnostic and therapeutic potential, Fertil. Steril. 24: 905. 1973. 3. Edstrom, K., and Fernstrom, ].: The diagnostic possibilities of a modified hysteroscopic technique. Acta Obstet. Gynecol. Scand. 49: 327, 1970. 4. Lindemann. H. J.: Transuterine tubal sterilization bv hysteroscopy,]. Reprod. Med.l3: 21,1974. 5. Lindemann, H. J.: The use of C0 2 in the uterine cavity for hysteroscopy, Int.]. FertiLI 7: 221. 1972. 6. Lindemann, H. J.: Historical aspects of hysteroscopy, Fertil. Steril. 24: 230, 1973.
7. Lyon. F. A.: Intrauterine visualization by means of hysteroscope, AM.]. 0BSTET GYNECOL. 90: 443, 1964. 8. Quinones Guerrero. R .. Alvarado Duran, A., and Aznar Ramos, R.: Tubal catheterization: Applications of a new technique, AM.]. 0BSTET. GYNECoL. 114: 674, !972. 9. Silander, T.: Hysteroscopy through a transparent rubber balloon. Surg. Gynecol. Obstet. 114: 125, 1962. I 0. Mohri, T.: Demonstration of the Machida hysteroscope, Seventh World Congress on Fertility and Sterility, Tokyo and Kyoto, October, 1971. 11. Rubin, J. C.: Uterine endoscopy, endometroscopy with the aid of uterine insufflation, AM. ]. 0BSTET. GYNECOL. 10: 313, 1925.
