Bacteriemia con afectación inflamatoria pélvica y miositis secundaria a histeroscopia diagnóstica. Reporte de un caso / Bacteremia with pelvic inflamatory involvement and secondary myositis due to diagnostic hysteroscopy. A case report

Resumen ANTECEDENTES: Las complicaciones infecciosas secundarias a la histeroscopia diagnóstica ambulatoria son bajas (0.6%). CASO CLÍNICO: Paciente de 46 años que a los 6 días posthisteroscopia diagnóstica ambulatoria por pólipos endometriales ingresó al servicio de Ginecología debido a un cuadro de piomiositis del músculo piriforme izquierdo, secundario a bacteriemia por Streptococcus pyogenes luego de un procedimiento ginecológico. Se trató con una dosis subcutánea de 40 mg de enoxaparina al día, y 2 g de ceftriaxona intravenosa cada 24 h, 240 mg de gentamicina intravenosa una vez al día. En las siguientes 48 horas se retiró la gentamicina y se prescribió 1 g de amoxicilina cada 8 h, por vía oral más 300 mg de clindamicina cada 8 h, también por vía oral que la paciente continuó durante 7 días más. En la resonancia magnética de control tomada a los 10 días quedó de manifiesto la tromboflebitis séptica en la vena iliaca interna izquierda y la persistencia del cuadro de piomiositis, con colección pélvica intra y extramuscular. Se decidió reingresarla para tratarla con el siguiente esquema: 1 g de amoxicilina por vía intravenosa cada 8 horas y 900 mg de clindamicina con igual pauta; se suspendió a las 24 h enseguida de la valoración por el infectólogo. Se indicó nuevo tratamiento antitrombótico con 0.5 mL de fraxiparina forte cada 24 horas, por vía subcutánea. El eco-Doppler descartó la trombosis venosa profunda; los hemocultivos que resultaron negativos. La paciente fue dada de alta con prescripción de fraxiparina Forte a dosis de 0.5 mL cada 24 horas durante 6 semanas; la evolución clínica fue favorable. La resonancia magnética de control a los 30 días reportó la desaparición completa del proceso inflamatorio. Luego de un año, la paciente permanece asintomática y continúa en seguimiento médico anual. CONCLUSIONES: La histeroscopia diagnóstica ambulatoria es una técnica eficaz y segura aunque excepcionalmente pueden sobrevenir complicaciones infecciosas derivadas de la técnica. Esto se previene con profilaxis antibiótica. La valoración previa a la histeroscopia es indispensable para advertir factores de riesgo que puedan controlarse o contraindiquen la realización del procedimiento.

Abstract BACKGROUND: Infectious complications due to diagnostic hysteroscopy are uncommon, being only 0.6% of all complications. CLINICAL CASE: A 46-year-old patient who, 6 days after performing an outpatient diagnostic hysteroscopy due to endometrial polyps, was admitted to the Gynecology Department, due to pyomyositis of the left piriformis muscle secondary to Streptococcus pyogenes bacteremia after gynecological procedure. Antithrombotic treatment was initiated with Enoxaparin 40 mg, 1/24h subcutaneously and antibiotic therapy with Ceftriaxone 2g/24h intravenously (iv) and Gentamicin 240 mg/24h iv, which 48 hours later were changed to Amoxicillin 1g/8h orally (VO) and Clindamycin 300 mg/8 hours orally for another 7 days. In the 10-day control magnetic resonance imaging (MRI), septic thrombophlebitis was seen in the left internal iliac vein as well as persistence of the pyomyositis condition, with intra and extramuscular pelvic collections. Therefore, a new admission was decided to start antibiotic therapy again with Amoxicillin 1g/8h IV and Clindamycin 900 mg/8h IV, which was suspended 24 hours after assessment by the Infectious Diseases Unit; and new antithrombotic treatment with Fraxiparin Forte 0.5 mL/24h subcutaneous, by consensus with the Vascular Surgery Service. ECO-DOPPLER was performed, which ruled out Deep Venous Thrombosis (DVT); and negative blood cultures. The patient was discharged with Fraxiparina Forte 0.5 mL/24h for 6 weeks presenting good clinical evolution. A new MRI control was scheduled for the following month, finding a complete resolution of the inflammatory process. Currently, one year later, the patient is asymptomatic and continues in annual follow-up in our consultations. CONCLUSIONS: Outpatient diagnostic hysteroscopy is an effective and safe technique. Infectious complications derived from the technique are infrequent, which is why it is not necessary to perform an antibiotic prophylaxis in patients who are going to undergo this test

Experience of hysteroscopy in a rural tertiary care center of Haryana, India

Background: During the last few decades hysteroscopy has become a tool of choice for evaluation of uterine cavity due to its “see and treat “benefits. It is more accurate and less invasive. Introduction of hysteroscopy in gynecological practice is the need of time. Aim of our study is to share the experience of hysteroscopy, its learning curve and limitations in a rural tertiary care center of Haryana.Methods: We retrospectively analyzed all the hysteroscopy procedure done from January 2016 to December 2018 from the hospital records.Results: Total 118 hysteroscopy were done but record of only 110 was available. Out of 110, 37(33%) were operative and 73(67%) were diagnostic. 36% were done for AUB, 33%  for infertility, 15% for misplaced cu t, 6% for amenorrhea, 2% in cases of RPL and rest for some less common indications. Out of operative hysteroscopy major procedures done were polypectomy and removal of misplaced Cu-T. Septal resection was also done in 3 cases. Number of operative hysteroscopy has increased over the time period of study.Conclusions: Hysteroscopic evaluation of uterine cavity is a reliable method for both diagnostic and treatment purpose. Proportion of hysteroscopy procedures and its learning curve will improve with persistent effort.

Abordaje vaginoscópica para la realización de histeroscopía oficinal: experiencia, resultados y revisión de la literatura / Vaginoscopic approach to perform officinal hysteroscopy: experience, results and literature review

OBJETIVO: Presentar nuestra experiencia y una revisión de la literatura sobre la utilización de la vaginohisteroscopia oficinal. Describir las principales indicaciones, su tolerancia, los procedimientos realizados y las complicaciones resultantes. MÉTODO: Estudio descriptivo de todos los procedimientos vaginohisteroscópicos ambulatorios realizados en la Unidad de Medicina Reproductiva e Infertilidad del Departamento de Obstetricia y Ginecología del Hospital Clínico de la Universidad de Chile, entre el 1° de enero de 2008 y el 31 de enero de 2014. RESULTADOS: Se realizaron un total de 632 vaginohisteroscopias: 63,7% diagnósticas y 36,2% quirúrgicas. El tiempo promedio de realización fue de 13 ± 8 minutos. La percepción de dolor presentó una mediana de EVA 4 con intercuartiles de 3 y 6. La principal indicación fue por sospecha de pólipos endometriales (33%) y engrosamiento endometrial en un 12%. El hallazgo histeroscópico más frecuente fue cavidad endometrial normal (27%) y pólipos endometriales (27%). Los procedimientos más frecuentes fueron polipectomías (27%) y biopsias endometriales (20%). Se registraron 17 complicaciones (2,6%): 14 reacciones vasovagales (2,2%) y 3 lipotimias (0,4%). CONCLUSIONES: El abordaje vaginohisteroscópico ha demostrado ser una técnica segura, resolutiva, bien tolerada por las pacientes y de menor costo.

OBJECTIVE: To present our experience and a review of the literature of the vaginohysteroscopic technique. To describe the main indications, the tolerance, the procedures performed and their complications. METHOD: This is a descriptive study of all outpatient procedures performed with the vaginohysteroscopic technique in the Reproductive Medicine and Infertility Unit of the Department of Obstetrics and Gynecology at University Hospital of Chile between 1st January of 2008 and 31st January of 2014. RESULTS: A total of 632 vaginohysteroscopys were performed: 63.7% diagnostic and 36.2% surgical. The average procedure time was 13 ± 8 minutes. Pain showed a median of VAS of 4. The main indication was suspected endometrial polyps (33%) and endometrial thickening (12%). The most frequent finding was normal endometrial cavity (27%) and endometrial polyps (27%). The most common procedures were polypectomy (27%) and endometrial biopsies (20%). We registered 17 complications (2.6%): 14 vasovagal reactions (2.2%) and 3 lipothymias (0.4%). CONCLUSIONS: vaginohisteroscopy approach has proven to be a safe and very resolutive technique, well tolerated by patients and considerably cost-effective.

Correlation Between D&C, USG and Hysteroscopy Findings in Diagnosing a Cause for Abnormal Uterine Bleeding.

Introduction: Abnormal uterine bleeding (AUB) is the most often encountered gynecological problem. A newly coined term describes the condition wherein there is any deviation from a normal menstrual pattern. An estimated 5% women aged 30-49 years consult a gynecologist each year for treatment. This makes it imperative to accurately diagnose and treat the cause. This study aims at judging the place of diagnostic hysteroscopy in obtaining an accurate diagnosis of the etiology of AUB and amp; outlining a mode of treatment. This is done by correlating the findings on hysteroscopy and those found on a dilation and curettage (D&C) and ultrasonography (USG). Material and methods: This prospective study was performed in the Dept. of Obstetrics and Gynecology, National Institute of Medical Sciences, Jaipur. Fifty cases of AUB were chosen based on inclusion and exclusion criteria. The patients were subjected to routine investigations, USG, D&C and hysteroscopy. The findings of the three were compared and analyzed. Results: AUB was most common between 30-39 years (44%). Maximum patients had complaints since 3-6 months (50%). Menorrhagia was the most common presenting complaint (46%). Normal findings were observed in 40% cases with D&C, 16% with USG, 22% with hysteroscopy. Abnormal findings were seen in 60% cases with D&C, 84% with USG, 78% with hysteroscopy. The over-diagnostic role of USG is also highlighted. Conclusion: This study reveals the superior ability of hysteroscopy in evaluating patients with AUB, when compared to D&C and USG. These findings are in agreement with those of many other studies.

Avaliação da acurácia da histeroscopia diagnóstica no estudo da cavidade uterina e do endométrio, utilizando-se o exame histopatológico como padrão / Evaluation of the accuracy of the diagnostic hysteroscopy in the study of the uterine cavity and the endometrium, using histopathologic exam as standard

Objetivo. Determinar a acurácia da histeroscopia diagnóstica ao exame da cavidade uterina e de anormalidades endometriais, com uso de exames histológicos como padrão. Métodos. Estudo retrospectivo de 812 mulheres com média de idade de 50,4 anos e mediana de 45 anos, nas quais a histeroscopia foi realizada, no Hospital de Base do Distrito Federal, em Brasília, durante o período de março de 2001 a abril de 2004. A acurácia da histeroscopia foi avaliada com base no diagnóstico estabelecido pelos exames histológicos. Foram calculados a sensibilidade, a especificidade, os valores preditivos positivos e negativos, acurácia e índice kappa. Foi usado o teste do qui-quadrado. Resultados. A sensibilidade da histeroscopia diagnóstica variou de 30 por cento a 87,6 por cento em dependência do tipo do endrométrio ou da doença, mais elevada quando se consideram pólipos (x2 = 82,8 e p menor 0,00005) e mais baixa em tumores fibróides submucosos (x2 = 7,4 e p menor 0,006). A especificidade variou de 27,3 por cento a 95,6 por cento em dependência dos achados à histeroscopia. É maior no câncer endometrial (x2 = 117,2 e p menor 0,00005) e menor quando se consideram todas as alterações da cavidade uterina e do endométrio. Houve moderada concordância entre a histeroscopia diagnóstica e os exames histológicos na avaliação câncer endometrial (k = 0,52). Conclusões. A histeroscopia diagnóstica é opção para avaliação direta da cavidade uterina e do endométrio com elevada taxa de sucesso no estabelecimento do diagnóstico. A melhor precisão da etiologia no diagnóstico de sangramento uterino anormal permite mais opções para o tratamento programado, assim reduzindo potencialmente o número de operações, particularmente em pacientes com útero anatomicamente normal. Entretanto, este estudo sugere que a biopsia com pinça do tipo saca-bocado de 3,5 mm pode falhar em diagnosticar alterações intra-uterinas focais benignas, mas ainda oferece material suficiente para diagnosticar câncer do endométrio.

To determine the accuracy of the diagnostic hysteroscopy, in the study of the uterine cavity and endometrial abnormalities, using histological exams as standard. Methods. Retrospective study of 812 women with mean age 50.4 years and median of 45 years, on whom DH was performed at Hospital de Base do Distrito Federal, in Brasilia, during the period from March 2001 to April 2004. The accuracy of the DH was evaluated on the basis of the diagnosis established by histological exams. Sensitivity, specificity, positive, negative predictive values, accuracy and kappa index were calculated. The chisquare test (x2) was used. Results. The sensibility of the diagnostic hysteroscopy varied from 30 percent to 87.6 percent depending on the type of endometrium or disease, higher when we consider polyps (x2 = 82.8 and p minor 0.00005) and lower in submucous fibroids (x2 = 7.4 and p minor 0.006). The specificity varied from 27.3 percent to 95.6 percent depending on the findings at hysteroscopy, higher in endometrial cancer (x2 = 117.2 and p minor 0.00005) and lower when all the alterations of the uterine cavity and the endometrium was considered. There was moderate agreement between diagnostic hysteroscopy and histological exams in the evaluation of the endometrial cancer (k = 0.52). Conclusions. The diagnostic hysteroscopy is an option for direct evaluation of the uterine cavity and endometrium, with high tax of success in the diagnostic clarification. The better precision in diagnosing the etiology of abnormal uterine bleed allows for increased options for targeted treatment, thus potentially reducing the number of surgeries, particularly in patients with anatomically normal uteri. However, this study suggests that an endometrial sampling with a clamp type biopsy punch of 3.5 mm fails to diagnose focal benign intrauterine alterations while still offering sufficient sample to diagnoses cancer of the endometrium.

Effect of diagnostic hysteroscopy on peritoneal cytology and prognosis in patients with clinical stage one endometrial cancer / 重庆医科大学学报

Objective: To explore the safety of using diagnostic hysteroscopy in patients with clinical stage one endometrial cancer,whether diagnostic hysteroscopy can increases the risk of positive peritoneal cytology in such patients and affects their post-operative prognosis.Methods: Medical records of 52 patients with clinical stage one endometrial cancer diagnosed by pre-operative hysteroscopy in our hospital were reviewed in this retrospective study,informations about cytological test of abdominal peritoneal fluid,type of operation,post-operative surgical stage and follow-up were collected.Results: The mean interval between hysteroscopy and laparotomy was 36 days(5~82d),2/52(3.8%) present positive peritoneal cytology,the mean survival time was 81 months(9~130m),the 5-year survival rate was 91.5%.Conclusion: Diagnostic hysteroscopy had not increase the risk of positive peritoneal cytology,also had no adverse effect on prognosis in clinical stage one endometrial cancer patients.