• Stenosis
• Dilated canal
• Lacerations
• Fragile Cervical Stenosis False Passage & Perforation
• Frequency: 1.3-3.0 %
• Reasons:
• Solution:
Perform diagnostic hysteroscopy to chart the endocervical canal
Open Speculum Cervical Dilators Stenosis of the Cervix
• Operative Hysteroscopy 22 – 26 F (7-9 mm)
• Global Ablations 15-24 F (5-8 mm) Cervix Dilatation Diameter Novasure Her Option ThermaChoice Inability to Dilate the Cervix - Stenosis
• Laminaria
• Misoprostol (Cytotec)
• Vasopressin Inability to Dilate the Cervix – Cytotec (Misoprostol)
• 200-400 mcg
• Oral or vaginal
• 3-24 hours prior to procedure
• Tmax: 12mins
• Time reduced: 40 vs 120 sec Cytotec (Misoprostol) Side Effects
• Nausea
• Diarrhea
• Uterine cramps
• Bleeding Inability to Dilate the Cervix - Vasopressin
• Vasopressin 20 mL (4U of 0.05 U/ml in 80mL of NS)
• Intracervically 4 & 8 o’clock positions • Decreased force from 37 to 20 lbs • Complications: MI, cardiac arrest Excessive Cervical Patency
• Complication: -Loss of a seal
• Solutions: -2 tenaculums -Gimpelson tenaculum -EndoLoop -Use ThemaChoice, Her Option, Microsulis Office Setting Recommended Anesthesia and Pain Management1
• Pre - Procedure
– NSAID: Toradol 10 mg, (Ibuprofen 800mg
(Ponstel 250mg, Cataflam® 50mg, Celebrex® )
– Anxiolytic: Ativan 1 mg, (Diazepam 10mg)
– Opiate analgesic: Lortab 10/500, (Vicodin® 2 ***All are taken at home 1 -2 hours pre procedure. NSAIDs are also taken the night before
– Toradol® 30 mg IM (peripheral PG blocker) + Atropine 0.4mg IM (prevents vaso-vagal) 30 min pre procedure
1Author’s experience and recommendation
Local Anesthesia Potocky® Needle Local Anesthesia
• Toxic Dose Lidocaine
¾1% Lidocaine Without Epi =
300mg (30cc) Uterine Pathology
• Endometrial hyperplasia
• Atypical endometrial hyperplasia
• Adenomyosis
• Polyps
• Fibroids Anticoagulated Patients
• Need to stop anticoagulation?
• Need to alter procedure?
• Is there a best method? Contraindications: Prior Surgical
• Classical C-section
• Myomectomy
• Metroplasty Repeat Ablations
• Was failure delayed or immediate?
• If immediate, what is the reason for failure:
¾ Technical problems ¾ Uterine deformity ¾ Adenomyosis ¾ New pathology: carcinoma, fibroids, Adenomyosis Repeat Ablations
• Pre operatively, repeat studies including biopsy and labs
• What method should be used for repeat ablation? Depends on the reason for failure
# 096 Diarrhea in Palliative Care, 2nd edhttp://www.mcw.edu/EPERC/FastFactsIndex/Documents/96DiarrheainPal. FAST FACTS AND CONCEPTS #96 Author(s): Jeffrey Alderman MD Diarrhea is a debilitating and embarrassing problem, defined as an abnormal looseness of the stools (increased liquidity or decreased consistency). Patients with uncontrolled diarrhea are at increased risk for dehydration, e
Referenten und Sponsoren der MARKETING ON TOUR 2008 adRom Media Marketing GmbH adRom ist im deutschsprachigen Raum unabhängiger Marktführer im Bereich Full-Service E-Mail- Marketing. adRom hat sich in der Abonnentengewinnung, dem Aufbau von großvolumigen „Permission“-E-Mail Verteilern sowie in der Bereitstellung von High-Performance E-Mail Versendesoftware als zuverlässiger Pa