Journal of Datta Meghe Institute of Medical Sciences University

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 15  |  Issue : 3  |  Page : 337--340

Minimal optimum uterine filling pressure for diagnostic hysteroscopy: A randomized study


Deepika K C. Dewani, Neema Acharya, Anup Patil, Kalyani Mahajan 
 Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India

Correspondence Address:
Dr. Deepika K C. Dewani
Room No S.27, Radhikabai Meghe PG Girls Hostel, JNMC Campus, DMIMS, Sawangi (Meghe), Wardha, Maharashtra
India

Abstract

Background: Hysteroscopy involves uterine cavity distension to allow adequate visualization. Higher uterine filling pressures ensure adequate visualization but might cause intravasation of the distension media into the vasculature and its various adverse effects. Aim: The aim of the study was to ascertain the minimum adequate filling pressure required for the optimal visualization of the uterine cavity during diagnostic hysteroscopy while minimizing the total fluid usage, thereby reducing the associated complications. Study Design: Randomized study. Materials and Methods: This was a study designed to assess whether optimal visibility can be achieved with lower uterine filling pressures for diagnostic hysteroscopy and whether patient discomfort can be reduced. A total of sixty patients were randomized and subjected to uterine distension pressure of 70 mmHg (thirty patients) or 100 mmHg (thirty patients). The primary outcome measure was the proportion of procedures where adequate visibility was achieved during diagnostic hysteroscopy. The secondary outcome was the level of pain experienced by the patient, duration of the procedure, and fluid deficit during the procedure. Results: Optimal visualization was achieved in 93.33% and 96.66% with a uterine filling pressure of 70 mm hg and 100 mm hg, respectively, and is comparable. Conclusion: The uterine filling pressure of 70 mm Hg was associated with optimum visualization as obtained that in 100 mmHg lower pain scores than 100 mmHg with no difference in the proportion of completed procedures.



How to cite this article:
Dewani DK, Acharya N, Patil A, Mahajan K. Minimal optimum uterine filling pressure for diagnostic hysteroscopy: A randomized study.J Datta Meghe Inst Med Sci Univ 2020;15:337-340


How to cite this URL:
Dewani DK, Acharya N, Patil A, Mahajan K. Minimal optimum uterine filling pressure for diagnostic hysteroscopy: A randomized study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Apr 20 ];15:337-340
Available from: http://www.journaldmims.com/text.asp?2020/15/3/337/308539


Full Text



 Introduction



Hysteroscopy was one of the very earliest approaches to the direct study of the uterine cavity.

Hysteroscopic inspection of the uterine cavity is a simple and well-accepted method for investigation of intrauterine pathology. The direct visualization, realtime, realcolor, hydrated, well-illuminated, and augmented vision of the uterine cavity make this diagnostic tool very accurate to detect minute focal endometrial pathology and small lesions otherwise not possible, complemented to the ability of performing guided direct biopsies and treatment on the same diagnostic setting. Hysteroscopic examination may predict endometrial lesions with a good accuracy as well as endometrial aspect characterization.

During the past decade, hysteroscopy has become the tool of choice for the evaluation of the endometrial cavity including assessment of abnormal uterine bleeding (AUB), infertility, recurrent pregnancy loss (RPL), location of intrauterine devices, and physiological studies are also possible.[1],[2],[3]

With the advent of advanced optics, safer distention techniques, and adequately trained surgeons, hysteroscopy is now the recommended gold standard for the assessment and management of intrauterine pathology, and is regarded as a safe, acceptable, and well-tolerated procedure.[4]

Hysteroscopy is currently the most informative investigation for women with AUB and uterine factor infertility.[5] The major advantages of hysteroscopic surgery include no laparotomy, no uterine wall scarring, shorter hospital stays, quicker recovery, and good patient compliance.[6]

Hysteroscopy involves uterine cavity distension to allow adequate visualization. Higher uterine filling pressures ensure adequate visualization but might cause intravasation of the distension media into the vasculature and its various adverse effects.

Hence, the objective of the study was to compare and study the role of 70 and 100 mm Hg in diagnostic hysteroscopy in an attempt to find the lowest filling pressure allowing optimal visualization of the uterine cavity while minimizing the complications, pain, and increasing overall patient satisfaction.

Aim and objectives

The aim of the present study was to ascertain the minimum adequate filling pressure required for the optimal visualization of the uterine cavity during hysteroscopy.

Objectives

To determine the minimum adequate filling pressure for optimal visualization of the uterine cavityTo reduce the amount of total fluid usage during the procedure.

 Materials and Methods



This was a randomized single-blinded study. The study was conducted over a period of 6 months, from October 2016 to March 2017, after the approval from institutional ethical committee.

The study included two randomized groups with thirty patients in each, comparing 100 mmHg to lower uterine filling pressures of 70 mmHg. The patients in both the groups were taken up for diagnostic hysteroscopy under general anesthesia using normal saline as the distension medium. The primary outcome measure was the proportion of procedures where optimal visibility was achieved during diagnostic hysteroscopy. The secondary outcome measure was the level of pain experienced by the patient after half an hour and after 24 h of the procedure as assessed using a visual analog scale and time required to complete the procedure in both the groups.

The software using analysis was? SPSS 17.0 version SPSS version 21© software (SPSS Statistics for Windows, version x.0, SPSS Inc., Chicago, Ill., USA) and Graphism 4 (GraphPad Software, 2365 Northside Dr. Suite 560 San Diego, CA). Probability P < 0.05, were regarded as statistically significant.

Ethical clearance

The Institutional Ethics Committee of DMIMSDU has approved the Research work proposed to be carried out at Jawaharlal Nehru Medical College, Sawangi(M), Wardha. Date: 21st Jan 2016 with Reference no DMIMS(DU)/IEC/2016/151

 Results



There were a total of 60 patients taken into the study and the following data were obtained:

The two groups of uterine filling pressure were comparable with regard to age and parity.

There was no significant difference in the indications for hysteroscopy among the groups.

The mean duration of the procedure of patients who underwent hysteroscopy at 70 mm Hg pressure is comparable.

Optimal visualization and the proportion of completed procedures were not different between the 70 and 100 mm Hg groups, and this suggests that the filling pressure of 70 mm Hg is effective in obtaining optimal visibility during diagnostic hysteroscopy.

In two patients of low-pressure group, because of patulous and dilated cervical os, pressure had to be increased for optimal visualization.

The correlation between different uterine filling pressures and optimal visibility was statistically nonsignificant (P = 0.07).

The mean ± standard deviation (SD) pain scores with the visual analog scale were 2 ± 1.4 and 3.4 ± 1.3 for 70 and 100 mmHg pressure groups, respectively, at 30 min after the procedure. The difference between the groups was significant (P < 0.05).

The mean pain score of patients with pressure group 70 mm Hg pressure at 24 h after the procedure was 0.6 ± 0.7 and that of patients with pressure group 100 mm Hg pressure was 1.7 ± 1. The difference between the groups was significant (P < 0.05).

Thus with low pain score in low-pressure group resumption of routine activity is earlier.

The fluid deficit during hysteroscopy at 70 mm Hg pressure was 186 ml and that at 100 mm Hg pressure was 342 ml.

The difference in both the groups was significant with a fluid deficit being more in standard pressure group [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}

 Discussion



Visibility was described as optimal for diagnosis when it was possible to assess the entire uterine cavity to include the cornual areas from the level of isthmus satisfactorily.

The results of the present study will be discussed under the following headings:

Uterine filling pressures and indications of procedureUterine filling pressures and duration of procedureUterine filling pressures and optimal visualizationUterine filling pressures and pain perception after the procedure.

Uterine filling pressures and indications of procedure

In the present study, it was noted that the indication of procedure was infertility in 53.33% and 50%, AUB in 40% and 46.66% and RPL in 6.6% and 3.33% of patients with uterine filling pressure of 70 mmHg and 100 mmHg, respectively. There was no significant difference in the indications for hysteroscopy among the groups.

Similarly, Shahid et al. in their study found that the three groups with uterine filling pressure of 40 mm Hg, 70 mm Hg, and 100 mm Hg were comparable with regards to indication for hysteroscopy.[7]

Haggag and Hassan in their study found that the indication of procedure was infertility in 30%, 36.2% and 37.5%, bleeding in 42.5%, 38.8% and 33.8% and recurrent miscarriage in 12.5%, 12.5%, and 5%, suspected intrauterine lesion in 15%, 12.5%, and 23.7% of patients with uterine filling pressure of 30 mmHg, 50 mmHg, and 80 mmHg, respectively.[8]

Uterine filling pressures and duration of procedure

It was found in the present study that the mean duration of the procedure of patients who underwent hysteroscopy was 3 min 20 s and 3 min 30 s in patients with a uterine filling pressure of 70 mm Hg and 100 mm Hg, which was comparable.

In their study, Haggag and Hassan found that the mean duration of the procedure was 2 min, 1.9 min and 2 min in patients with uterine filling pressure of 30 mmHg, 50 mm Hg, and 80 mm Hg. There were no significant differences among the groups in the duration of the procedure.[8]

Uterine filling pressures and optimal visualization

In the present study, it was noted that optimal visualization was obtained in 93.33% and 96.66% patients with uterine filling pressure of 70 mm hg and 100 mm hg, respectively. The correlation between different uterine filling pressure and optimal visibility was statistically nonsignificant.

In the study done by Shahid et al., it was concluded that there was adequate visibility in 87%, 94.9%, and 97.5% patients with uterine filling pressure of 40, 70, 100 mm hg, respectively. The difference in optimal visibility, between two groups, i.e., 70 mm hg and 100 mm hg was statistically nonsignificant.[7]

Similarly, in their study Haggag and Hassan observed that there was no statistically significant difference in terms of optimal visualization between groups with uterine filling pressure of 50 mm hg and 80 mm hg (97.5% vs. 98.7%, P > 0.999).[8]

Uterine filling pressures and pain perception postprocedure

In the present study, it was noted that the mean ± SD pain scores with the visual analog scale were 2 ± 1.4 and 3.4 ± 1.3 for 70 and 100 mmHg pressure groups, respectively at 30 min after the procedure. The difference between the groups was significant (P < 0.05).

The mean pain score of patients with pressure group 70 mm Hg pressure at 24 h after the procedure was 0.6 ± 0.7 and that of patients with pressure group 100 mm Hg pressure was 1.7 ± 1. The difference between the groups was significant (P < 0.05).

Thus with low pain score in low-pressure group resumption of routine activity is earlier.

Similarly, in their study Haggagand Hassan found that there was a significant and progressive increase in pain scores from the lower to the higher pressure groups during the procedure, immediately after the procedure and 30 min after completing the procedure. The mean ± SD pain scores with the visual analog scale were 0.1 ± 0.3, 0.6 ± 0.7, and 1.7 ± 1 for 30, 50 and 80 mmHg pressure groups, respectively, at 30 min after the procedure.[8]

However, Shahid et al. randomized 234 women undergoing diagnostic outpatient hysteroscopy to have a uterine filling pressure of 40, 70 or 100 mmHg. The mean pain score was not significantly different among the groups.[7]

Furthermore, Shahid et al. in their study found that the mean ± SD pain scores with the visual analog scale were 3.84 ± 2.35, 4.56 ± 2.75, and 4.30 ± 2.51 for 40, 70, and 100 mmHg pressure groups, respectively. The differences between the groups were not significant.[8],[9],[10],[11],[12],[13],[14],[15]

 Conclusion



We conclude that 70 mm Hg was associated with optimum visualization as obtained that in 100 mmHg and lower pain scores than 100 mmHg with no difference in the proportion of completed procedures.

The significant increase in pain scores from the low to the high-pressure group observed in this study demonstrates that higher filling pressures can cause more pain. Patients with low pain scores can resume their routine activity earlier.

Furthermore, in low-pressure group as the fluid deficit is less thus the chances of complications related to distension media and fluid overload are reduced.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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