Patient Preparation

Malcolm G. Munro MD, FRCSC, FACOG
KEY POINTS
  • Preparation for any surgical procedure, including hysteroscopic surgery, is a strategy that comprises a synthesis of education, communication and a medical process. 
  • Informed consent is more than a signed document; it is an iterative process that combines questioning, counseling and balancing the risk of an intervention with the anticipated benefit in a way that allows the patient to formulate an informed decision. 
  • The risks associated with hysteroscopy are real but are minimized if the procedures are performed by individuals with appropriate training who are practicing in an environment with adequate staff, supplies and equipment.
  • Regardless, it is important that patients are provided information regarding the risks of hysteroscopic surgery that allow them to make the informed decision.
  • There exist a number of medical interventions that may improve the outcome of a hysteroscopic surgical procedure that include suppression of endogenous estrogenic activity to thin the endometrium, ripening of the cervix to reduce the force of dilation and preemptive analgesia to reduce procedure pain if the hysteroscopic intervention is performed under local anesthesia.
INTRODUCTION
The process of patient preparation comprises a spectrum of communication and educational processes combined with appropriate medical interventions designed to facilitate the successful, comfortable and safe performance of the procedure. Most understand that diagnostic hysteroscopy can be performed in an office or clinic setting. In some circumstances, some of which are patient related, while others are dictated by the prevailing medical system, diagnostic hysteroscopy is performed in a surgical center or formal operating room. Similarly, while many, and, in fact, most operative procedures can be accomplished safely and with comfort in the office or clinic setting, a number of circumstances exist where, because of patient-related variables or the complexity of the procedure, a formal operating room is considered necessary. Regardless of the location and type of anesthesia, there exist a number of obligatory preparatory steps that include the informed consent process, and, if deemed appropriate, preprocedural analgesia and preparation of the cervix and endometrium.
PATIENT COUNSELING - THE INFORMED CONSENT PROCESS
As with any procedure, the patient must understand the rationale, the anticipated related symptoms and discomfort and the potential adverse events that may ensue related to the hysteroscopic procedure. In general, written consent will be necessary and should be obtained in a fashion that comports with prevailing institutional, local, regional or national policies and regulations. Copies of such consent should become part of the patient record and should be provided to the patient and/or guardian as appropriate. 
The process of informed consent should include orientation to the anticipated and concerning experiences that ensue following the hysteroscopic procedure. After hysteroscopic surgery most women experience some degree of cramping and bleeding that ranges from minimal to heavy depending upon the procedure performed. If CO2 is used as the distention media, severe cramps, dyspnea, and upper abdominal and right shoulder pain may manifest if the media passes through the fallopian tubes into the peritoneal cavity.
Adverse events associated with operative hysteroscopy are still relatively infrequent particularly when performed by competent surgeons on well investigated individuals with appropriate technique. However, there are a number of risks that include those related to anesthesia as well as a spectrum of adverse events that include bleeding, infection, uterine perforation, air embolism and excessive absorption of distention media. The patient should understand that in the event of uterine perforation, the surgical procedure will be stopped and more serious complications could ensue including injury to bowel, urinary tract or blood vessels. In the unlikely event that such events transpire, laparoscopic or laparotomic approaches may be necessary for evaluation and repair of identified damaged structures. If excessive amounts of the distending media are absorbed, fluid overload and hyponatremia may ensue particularly if a hypotonic electrolyte-free fluid has been used for uterine distention.
PRE-PROCEDURE MEDICAL THERAPY
The use of medical therapy in preparation for diagnostic or operative hysteroscopy may comprise one of more of agents designed to reduce pain, ease access to the endometrial cavity, facilitate visualization or procedure completion and reduce the risk of infection. 
Medical Preparation of the Endometrium
Endometrial thickness varies from millimeters to more than two centimeters depending upon some combination of ovulatory status, and, for ovulatory individuals, the time of the cycle. A thick endometrium can compromise visualization and characterization of lesions such as polyps, leiomyomas and adhesions and can undermine procedures by fragmenting in a way that obscures the surgical field or interferes with the free flow of uterine distention media. As a result, there is value in taking steps to optimize visualization in a way that reduces procedure time, and, potentially, improves the chances of a successful procedure. Examples of suppressive therapy designed to thin the endometrium include progestins or estrogen-progestin combination formulations, androgens such as danazol and GnRH agonists. Such interventions also serve to reduce HMB that may compromise the evaluation but which, in addition, can contribute to iron deficiency anemia and related symptoms and debilitating manifestations such as fatigue and cognitive impairment.

The notion of performing the hysteroscopic procedure in the early phase of the ovulatory menstrual cycle is noted and an appropriate approach. However, for many groups and clinicians, the logistics of timing an intervention such as hysteroscopy to a time in the cycle is difficult to achieve. In our center, for women who are not already using systemic or intrauterine progestins or combined estrogen and progestin contraceptives, medroxyprogesterone acetate is administered 20 mg twice daily for at least 4 weeks prior to the procedure.  
Cervical Preparation
In some instances, it is difficult to dilate the cervix to a diameter adequate to allow access of the hysteroscopic system. Consequently, the requirement for pre- or intraoperative ‘cervical preparation”, is determined in part by the outside diameter of the device to be used, and, in part by features of the patient’s cervix. When the instrumentation has a narrow outside diameter (OD), 4.0 mm or less), it id usually possible to inserted the system through the cervical canal absent cervical dilation and with no or minimal anesthesia. However, resectoscopes with an OD of 8 to 9 mm may be difficult to position through the cervical canal and, consequently, there may be value in considering preoperative cervical preparation(1, 2). 
There is high quality evidence demonstrating that prostaglandin E1 (misoprostil) 200-400 mcg administered orally, vaginally or via the sublingual route from 4 to 24 hours prior to hysteroscopy softens and dilates the cervix such that there is a reduced force required for mechanical dilatation to more than 6 mm (1). Unfortunately, there are side effects to the use of misoprostil that include severe cramping, abdominal pain and associated nausea, vomiting and fever(2). Consequently, one must consider the value of such an agent, and, consequently routine use is to be avoided. 

There exist a number of options to misoprostil, one of which is mechanical preparation using laminaria inserted positioned in the cervix the day prior to the procedure(2-4) although severe cramps and abdominal pain may occur with these as well(4). A third option is the use of dilute intraoperative intracervical vasopressin, immediately before the dilation, an approach associated with a 50% reduction in the force needed for dilation (5). Care must be taken with injection as severe side effects can occur if it is injected directly into vessels. This is discussed in more detail in the section on access. 
Preemptive Analgesia
For those who undergo hysteroscopy under no or local anesthesia, some of the pain experienced is related to myometrial contractions. Consequently, the use of preprocedural analgesia with non-steroidal anti-inflammatory agents with anti prostinoid activity such as mefenamic acid may have value (6, 7) although the available evidence is inconsistent(8, 9). We suspect that self-administration of such analgesics for a longer time prior to the procedure, 24 to 48 hours is beneficial, but there are no currently-available studies assessing this approach. There is evidence supporting the hypothesis that filling the hysteroscopic procedure room with music of the patient’s preference reduces anxiety and periprocedure pain (10).
Prophylactic Antibiotics
At the current time, there is no evidence supporting the use of prophylactic antibiotics either diagnostic or operative hysteroscopy. Although infection is a risk, it is a very uncommon complication, occurring in 0.01 to 1.42% of cases(11-13). There may be value in considering prophylactic antibiotics empirically for operative procedures in selected high-risk patients such as those with valvular heart disease or previous pelvic infections as well as women with other non-gynecologic risk factors. 
OTHER ADJUNCTIVE MEASURES 
Printed, Web or App-based instructions
The information provided to patients regarding their procedure can sometimes be overwhelming, particularly if their native language is not that of the provider and staff. Consequently, it is important to provide information and instructions that will assist with understanding the rationale for the hysteroscopic procedure and the necessary steps that will be required in the days and hours ahead. It is suggested that the instructions are available in a spectrum of formats – paper, web-based, an app – to address the different means by which women of different ages and generations best consume information. 
Contact 48 hours Before Procedure
An extremely useful approach to patient preparation is contact about 48 hours prior to the procedure. While typically this is a telephonic contact, other options exist such as text, Facetime and other electronic communication platforms. The patient is reminded of the time and location of the appointment and the instructions such as analgesic medications and dietary restrictions or guidelines. For those undergoing conscious (procedural) sedation or general anesthesia there will be a need to avoid all but clear liquids for at least six hours and clear fluids for at least two hours prior to the procedure; for those undergoing a procedure with no or local anesthesia, eating and drinking normally but particularly being well hydrated are useful instructions.

For all of those undergoing procedural sedation or general anesthesia, it will be necessary to have a responsible individual of appropriate age and standing to take the patient home following the procedure. We generally recommend, but don’t require, that these instructions be the same for those undergoing no or local anesthesia. This is also a time to answer additional questions that the patient might have and to provide any additional information that may be necessary to make her comfortable with the decision to go ahead with the procedure.
REFERENCES