Hysteroscopy Complications and Safe Fluid Management: A Guide for Gynaecologists

Hysteroscopy is one of the safest procedures in gynaecology, but complications do occur, especially in operative cases. Knowing how to prevent, recognise and manage them is as important as the surgical technique itself.

Key takeaways

• The main complications of hysteroscopy are perforation, fluid overload, bleeding, infection and, rarely, gas embolism.
• The vaginoscopic no-touch approach and never advancing the scope blindly reduce the risk of perforation.
• Fluid deficit must be monitored throughout operative hysteroscopy, with lower limits for hypotonic electrolyte-free fluids than for isotonic saline.
• Clear written consent and a plan for stopping the procedure are part of safe practice.

The main complications

• Uterine perforation, most often during cervical dilatation or resection
• Fluid overload from absorption of distension media
• Bleeding, usually minor
• Infection, which is uncommon
• Cervical injury during dilatation
• Gas embolism, rare but serious

The risk is much lower in diagnostic and office procedures than in longer operative procedures such as myomectomy or septum resection.

Preventing perforation

• Use the vaginoscopic "no-touch" approach where possible, which avoids the speculum, tenaculum and often dilatation
• Use cervical preparation in selected patients when dilatation is expected to be difficult
• Keep the uterine cavity in view at all times and never advance the scope blindly
• Stop if the view is lost or the anatomy is unclear

Understanding distension media

The choice of fluid depends on the energy source:

• Isotonic, electrolyte-containing fluids (such as normal saline) are used with bipolar energy and for diagnostic procedures
• Hypotonic, electrolyte-free fluids (such as glycine) are needed with monopolar energy and carry a higher risk of dangerous hyponatraemia if absorbed

Fluid deficit limits

Monitoring the fluid deficit (fluid in minus fluid out) is essential in operative hysteroscopy. Commonly cited guideline thresholds, such as those from the AAGL practice report on fluid management, are:

• Hypotonic electrolyte-free fluids: stop the procedure at a deficit of around 1,000 mL in healthy women, and at a lower limit (around 750 mL) in older women or those with medical conditions
• Isotonic fluids: stop at a deficit of around 2,500 mL

Always follow your unit's protocol, use an automated fluid management system where available, and have a nominated person record the deficit throughout.

Recognising fluid overload

Warning signs include nausea, headache, confusion, breathlessness and falling oxygen saturation. If overload is suspected, stop the procedure, check electrolytes and manage according to protocol with anaesthetic support.

Patient safety and consent

Patients should be told about the purpose of the procedure, the alternatives and the main risks before giving written consent. Office procedures also need a clear plan for pain relief and for stopping if the patient is uncomfortable.

Frequently asked questions

Is office hysteroscopy safer than hysteroscopy in theatre?

Diagnostic and minor office procedures have a low complication rate, partly because they are shorter and usually avoid dilatation, but correct case selection is essential.

Why is fluid monitoring so important?

Because absorbed fluid can cause fluid overload and, with hypotonic media, serious electrolyte disturbances. Monitoring lets the surgeon stop before harm occurs.

How can gynaecologists build safe operative skills?

Through structured simulation, supervised operative cases starting with simpler procedures, and keeping a logbook of cases and complications.

Train in safe hysteroscopy at ReproNest

ReproNest's Hysteroscopy Training Course covers vaginoscopic technique, distension media and fluid management, with simulator practice and supervised OT observation at registered partner clinics. Read about diagnostic vs operative hysteroscopy training, or contact us.

This article is educational content for healthcare professionals and trainees. It is not medical advice and does not replace clinical judgement, current guidelines or the ART (Regulation) Act 2021 and Rules 2022.