Operative hysteroscopy — structured SAQ (15 marks)

(a) Fluid-management set-up and monitoring (4 marks)

One mark per point. ^[1][4]

• Use a fluid-management system that delivers and measures the medium at a set intrauterine pressure and displays the fluid deficit (input minus output) in real time, with a running tally.^[4]
• Pre-set a stop point for the deficit matched to the medium and the patient: for this hypotonic medium in a woman with comorbidity, the lower threshold of 750 mL applies.^[4]
• Keep the intrauterine pressure as low as allows vision, because higher pressure drives more medium into open venous sinuses and raises absorption.^[4]
• Allocate a member of the team to call out the deficit at set intervals, so the deficit is treated as a vital sign, not a footnote.^[1]

(b) Medium and energy match (3 marks)

One mark per point. ^[2][4]

• Glycine (an electrolyte-free hypotonic medium) is required because monopolar current cannot run through an electrolyte-rich medium — it would disperse outside the operative field.^[2][4]
• The alternative that changes the medium is switching to a bipolar resectoscope, which requires an electrolyte-rich medium (normal saline) to complete its circuit and avoids, by design, the electrolyte-imbalance risk of monopolar.^[2]
• Bipolar electrodes are clinically as effective as monopolar in resectoscopy, and randomised trials show bipolar prevents the electrolyte imbalance observed after monopolar surgery — although the safer profile in daily practice is not yet proven.^[2]

(c) Immediate management of a rising deficit with symptoms (5 marks)

One mark per step, in the right order. ^[3][4]

• Stop the procedure now — a 900 mL deficit with a hypotonic medium and symptoms (nausea, headache) is approaching the 1000 mL healthy / 750 mL comorbid threshold and signals absorption.^[4]
• Send an urgent serum sodium and osmolality to quantify hyponatraemia, and assess for cerebral oedema (headache, nausea, dizziness, seizures).^[3]
• Restrict free water; for severe symptomatic hyponatraemia with neurology, consider hypertonic saline with neurology and neurocritical-care input, correcting slowly to avoid osmotic demyelination.^[3]
• Support the circulation and breathing; treat pulmonary oedema if it develops with oxygen and diuresis.^[4]
• Debrief, document the deficit, medium and duration, and arrange HDU-level monitoring for a symptomatic hyponatraemia.^[4]

(d) Outpatient versus operating-room hysteroscopy (3 marks)

One mark per point. ^[5]

• A systematic review and meta-analysis found no significant difference in treatment success between outpatient and operating-room hysteroscopy, and office procedures offer higher patient satisfaction and faster recovery.^[5]
• For this patient the office was a poor fit because of the lesion size and depth (a 3 cm type I fibroid), the likely need for a resectoscope and glycine, and the comorbidity — selection turns on lesion size and depth, patient willingness, comorbidities, surgeon skill and equipment.^[4]
• Counsel her that an office see-and-treat is preferred where feasible (small polyps, suitable patient), and that a staged or operating-room approach was appropriate for her lesion.^[4]