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Endometrial ablation: postoperative complications

2012; Elsevier BV; Volume: 207; Issue: 4 Linguagem: Inglês

10.1016/j.ajog.2012.04.011

1097-6868

Howard T. Sharp,

Gynecological conditions and treatments

Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions. Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions. Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. In the early era of manual resectoscopic endometrial ablation (REA), the energy source options were laser fiber or rollerball/rollerbarrel electrodes to desiccate the endometrium or a loop electrode to resect the endometrium. Inherent in the evolutionary process are unintended consequences. Unfortunately, the use of energy sources and intrauterine distending media resulted in intraoperative complications that were in some cases life threatening and, in rare cases, life ending.1Rosenberg M.K. Hyponatremic encephalopathy after rollerball endometrial ablation.Anesth Analg. 1995; 80: 1046-1048PubMed Google Scholar As technology advanced, automated systems were designed and termed nonresectoscopic endometrial ablation (NREA) devices, global endometrial ablation devices, or second-generation endometrial ablation devices. Although these systems obviated the need for manual resectoscopic skills and fluid management systems, intraoperative complications still occurred but of differing types. These newer technologies include 5 ablative methods including a thermal balloon, circulated hot fluid, cryotherapy, radiofrequency electrosurgery, and microwave energy. All 5 methods have been compared with rollerball endometrial ablation by way of randomized clinical trials and are in general associated with similarly high patient satisfaction rates (86–99%), regardless of the method, but with wide ranges of amenorrhea rates (13.9–55.3%).2Sharp H.T. Assessment of new technology in the treatment of idiopathic menorrhagia and uterine leiomyomata.Obstet Gynecol. 2006; 108: 990-1003Crossref PubMed Scopus (56) Google Scholar Although these 2 categories of ablation methods (REA and NREA) may have different types of intraoperative complications, they have fairly similar postoperative complications. As is common with all forms of endometrial ablation, the entirety of the endometrium is rarely destroyed. As a result, complications can occur because the residual endometrium may allow implantation of an embryo, cause continued bleeding that may become obstructed, unobstructed but enough to be considered a failure, or may develop neoplasia. Therefore, the goal of this review was to focus on 5 categories of postsurgical complications including the following: (1) pregnancy after endometrial ablation, (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome), (3) failure to control menses (repeat ablation, hysterectomy), (4) risk from preexisting conditions (endometrial neoplasia, cesarean section), and (5) infection. Intraoperative complications such as fluid overload, uterine perforation, and hemorrhage will not be addressed in this article. The issue of contraception is one of the most significant issues that should be addressed in patients considering endometrial ablation. Endometrial ablation is not considered a form of contraception. Unfortunately, although pregnancy after endometrial ablation is associated with significant maternal and fetal morbidity and mortality, the performance tubal sterilization also carries a risk for complications such as post blation tubal sterilization syndrome (see section in the following text). Pregnancy has been reported to occur in 0.7% of women who have undergone endometrial ablation.3Pugh C.P. Crane J.M. Hogan T.G. Successful planned pregnancy following endometrial ablation with YAG laser.J Am Assoc Gynecol Laparosc. 2000; 7: 391-394Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Pregnancy has been reported as early as 5 weeks after ablation4Maouris P. Letter.Aust N Z J Obstet Gynaecol. 1994; 34: 122-123Crossref PubMed Scopus (14) Google Scholar and as late as 12 years postoperatively (with subsequent tubal reanastamosis in a planned pregnancy).5Pinette M. Katz W. Drouin M. Blackstone J. Cartin A. Successful planned pregnancy following endometrial with YAG laser.Am J Obstet Gynecol. 2001; 185: 242-243Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar The chance of pregnancy occurring after endometrial ablation and tubal sterilization is estimated to be 0.002%, or 1 in 50,000.6El-Toukhy T. Hefni M. Pregnancy after hydrothermal endometrial ablation and laparoscopic sterilization.Eur J Obstet Gynecol Reprod Biol. 2003; 106: 222-224Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Pregnancy has also been reported in an amenorrheic woman.7Palep-Singh M. Angala P. Seela R. Mathur R. Impact of microwave endometrial ablation in the management of subsequent unplanned pregnancy.J Minimally Invasive Gynecol. 2007; 14: 365-366Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Successful pregnancies have been reported; however, there appears to be a greater risk of complications in pregnancies that follow endometrial ablation including preterm birth, intrauterine scarring/uterine chambering (creating separate uterine compartments), and postpartum hemorrhage.8Foote M. Rouse A. Gil K.M. Crane S. Lavin Jr, J.P. Successful pregnancy following both endometrial ablation and uterine artery embolization.Fertil Steril. 2007; 88: 1676.e15Abstract Full Text Full Text PDF Scopus (9) Google Scholar, 9Kir M. Hanlon-Lundberg K.M. Successful pregnancy after thermal balloon endometrial ablation.Obstet Gynecol. 2004; 103: 1070-1073Crossref PubMed Google Scholar The authors have hypothesized that the preterm labor is in part because of narrowing or sometimes chambering of the endometrial cavity resulting in a smaller area for gestation. There are several reviews of pregnancy occurring after endometrial ablation, evaluating many of the same cases from the available literature and also adding information from their own case series while updating the cumulative number of pregnancies after endometrial ablation (n = 134).10Lo J.S.Y. Pickersgill A. Pregnancy after endometrial ablation: English literature review and case report.J Minim Invasive Gynecol. 2006; 13: 88-91Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 11Hare A.A. Olah K.S. Pregnancy following endometrial ablation: a review article.J Obstet Gynaecol. 2005; 25: 108Crossref PubMed Scopus (73) Google Scholar, 12Yin C.S. Pregnancy after hysteroscopic endometrial ablation without endometrial preparation: a case of five cases and a literature review.Taiwan J Obstet Gynecol. 2010; 49: 311-319Abstract Full Text PDF PubMed Scopus (21) Google Scholar This type of data (level III evidence) offers only limited confidence in making recommendations but does provide a reasonable platform for counseling patients and for anticipating potential complications. For patients presenting in the first trimester, these series report at least a 28% miscarriage rate and an ectopic pregnancy rate of up to 6.5%. This may not be a significant increase over the baseline miscarriage rate, considering unrecognized or subclinical pregnancies; however, with a risk for ectopic pregnancy that is approximately 3 times baseline (approximately 2%), this would warrant a recommendation that ectopic pregnancy precautions be followed. The miscarriage rate may be higher because nearly half of the women in these series terminated their pregnancy, some of which would likely have aborted spontaneously. In patients continuing a pregnancy past the viability range of 24 weeks, the larger series12Yin C.S. Pregnancy after hysteroscopic endometrial ablation without endometrial preparation: a case of five cases and a literature review.Taiwan J Obstet Gynecol. 2010; 49: 311-319Abstract Full Text PDF PubMed Scopus (21) Google Scholar reported a 31% risk of prematurity, a 16% risk of preterm premature rupture of membranes, a 25% risk of abnormal placentation (accreta spectrum), and a cesarean delivery rate of 44%. All of these complications occur more frequently than the general US population statistics in pregnancy. Approximately 60% of patients with abnormal placentation underwent hysterectomy at the time of delivery.12Yin C.S. Pregnancy after hysteroscopic endometrial ablation without endometrial preparation: a case of five cases and a literature review.Taiwan J Obstet Gynecol. 2010; 49: 311-319Abstract Full Text PDF PubMed Scopus (21) Google Scholar Amniotic band syndrome and spontaneous uterine rupture have also been reported with severe fetal arthrogryposis and scoliosis reported in some cases.13Mukul L.V. Linn J.G. Pregnancy complicated by uterine synechiae after endometrial ablation.Obstet Gynecol. 2005; 105: 1179-1182Crossref PubMed Scopus (27) Google Scholar, 14Bowling M.R. Ramsey P.S. Spontaneous uterine rupture in pregnancy after endometrial ablation.Obstet Gynecol. 2010; 115: 405-406Crossref PubMed Scopus (12) Google Scholar Ultrasonography might identify uterine synechiae, which are common after endometrial ablation. Cornual uterine rupture has been reported in a 27-week gestation with the use of radiofrequency ablation.14Bowling M.R. Ramsey P.S. Spontaneous uterine rupture in pregnancy after endometrial ablation.Obstet Gynecol. 2010; 115: 405-406Crossref PubMed Scopus (12) Google Scholar In this case, the patient experienced at prior midline fundal uterine perforation that would not explain the cornual location for rupture. Firm pregnancy management recommendations are difficult to establish based on limited data. However, the currently available data would suggest that patients should be managed as though they are a higher risk for preterm birth. Some authors have suggested that treatment with 17-hydroxyprogesterone is justified8Foote M. Rouse A. Gil K.M. Crane S. Lavin Jr, J.P. Successful pregnancy following both endometrial ablation and uterine artery embolization.Fertil Steril. 2007; 88: 1676.e15Abstract Full Text Full Text PDF Scopus (9) Google Scholar and have followed up with patients with serial ultrasonography because of the potential risk of intrauterine growth restriction. Because of the relatively high risk of abnormal placentation and cesarean delivery, having personnel experienced in cesarean hysterectomy and having access to a hospital with adequate blood banking services should be considered. When energy is applied to the endometrium, tissue necrosis and inflammation can result in uterine contracture and intrauterine scarring. This has been demonstrated with both resectoscopic endometrial ablation as well as newer devices.15Magos A.M. Baurmann R. Lochwood G.M. Experience with the first 250 endometrial resections for menorrhagia.Lancet. 1991; 337: 1074-1080Abstract PubMed Scopus (283) Google Scholar, 16Roy K.H. Mattox J.H. Advances in endometrial ablation.Obstet Gynecol Surv. 2002; 57: 789-802Crossref PubMed Scopus (28) Google Scholar, 17Leung P.L. Tam W.H. Yuen P.M. Hysteroscopic appearance of the endometrial cavity following thermal balloon endometrial ablation.Fertil Steril. 2003; 79: 1226-1228Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Persistent endometrium after endometrial ablation is common as evidenced by clinical, imaging, and histologic studies. As mentioned previously, randomized clinical trials have shown amenorrhea rates to be generally less that 50%, suggesting persistent endometrial glands after endometrial ablation. Magnetic resonance imaging (MRI) studies have shown endometrial tissue to be present in up to 95% of patients undergoing rollerball ablation including patients with amenorrhea.18Turnbull L.W. Bowsley S.J. Horsman A. Magnetic resonance imaging of the uterus after endometrial resection.Br J Obstet Gynaecol. 1997; 104: 934-938Crossref PubMed Scopus (60) Google Scholar In a comparative study of long-term histologic findings (more than 30 months) after rollerball ablation (n = 21) and endometrial resection (n = 24), hysteroscopy showed similar areas of persistent endometrium at the uterine fundus and cornual regions.19Onoglu A. Taskin O. Inal M. et al.Comparison of the long-term histopathologic and morphologic changes after endometrial rollerball ablation and resection: a prospective randomized trial.J Minim Invasive Gynecol. 2007; 14: 39-42Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Contracture and scarring in the presence of persistent endometrium can result in obstructed egress of menses. This can manifest as hematometra within the body of the uterine cavity (central hematometra) or at the cornual region. Postablation tubal sterilization syndrome (PATSS) was initially reported in 1993 as a series of 6 patients presenting with unilateral or bilateral pelvic pain and vaginal spotting who had previously undergone tubal sterilization and endometrial ablation.20Townsend D.E. McCausland V. McCausland A. Fields G. Kauuffman K. Post-ablation-tubal sterilization syndrome.Obstet Gynecol. 1993; 82: 422-424PubMed Google Scholar The patients were noted to have endometrial cavity scarring with one or both swollen proximal fallopian tubes. Symptom relief was reported in 5 of 6 patients with removal of the fallopian tubes. The incidence of PATSS is approximately 6-8% and usually develops 2-3 years after endomemtrial ablation.21Bae I.H. Pagedas A.C. Peekins H.E. Post ablation sterilization syndrome.J Am Assoc Gynecol Laparosc. 1996; 3: 435-438Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 22McCausland A.M. McCausland V.M. Frequency of symptomatic cornual hematometria and post ablation tubal sterilization after total rollerball endometrial ablation: a 10 year follow-up.Am J Obstet Gynecol. 2002; 186: 1274-1283Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 23Mall A. Shirk G. Van Voorhis B.J. Previous tubal ligation is a risk factor for hysterectomy after rollerball endometrial ablation.Obstet Gynecol. 2003; 101: 818-819Crossref PubMed Scopus (2) Google Scholar The mechanism of pain in PATSS is thought to be retrograde menstruation of cornual hematometra against an obstructed fallopian tube, causing visceral distention. It has also been associated with newer ablation devices.24Leung P.L. Yuen P.M. Postablation tubal sterilization syndrome following thermal balloon ablation.Acta Obstet Gynecol Scand. 2006; 85: 504-505Crossref PubMed Scopus (9) Google Scholar The definitive treatment of PATSS is hysterectomy.25Webb J.C. Bush M.R. Wood M.D. Hematosalpinx with pelvic pain after endometrial ablation confirms the post ablation tubal sterilization syndrome.J Am Assoc Gynecol Laparosc. 1996; 3: 419-421Abstract Full Text PDF PubMed Scopus (14) Google Scholar Hysteroscopic lysis of adhesions is possible but difficult to perform in the vulnerable cornual regions and will not reliably alleviate potential future bleeding against the proximal fallopian tube. As mentioned, in the original description of this syndrome, the authors performed salpingectomies20Townsend D.E. McCausland V. McCausland A. Fields G. Kauuffman K. Post-ablation-tubal sterilization syndrome.Obstet Gynecol. 1993; 82: 422-424PubMed Google Scholar; however, currently some of those authors are suggesting hysterectomy as a better and more definitive treatment for this condition.22McCausland A.M. McCausland V.M. Frequency of symptomatic cornual hematometria and post ablation tubal sterilization after total rollerball endometrial ablation: a 10 year follow-up.Am J Obstet Gynecol. 2002; 186: 1274-1283Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The diagnosis of PATTS is initially suspected clinically in patients with cyclic cramping with or without menses with a history of endometrial ablation and tubal sterilization. Usually the confirmatory diagnosis is made surgically; however, MRI imaging during times of symptomatic cramping may be useful using T2-weighted images looking for blood trapped in the cornu. Ultrasound has not been reliably sensitive at diagnosing PATSS. Preventing PATTS is challenging. When performing resectoscopic endometrial ablation, the cornu is particularly challenging because of the thin muscular density in that region that poses increased risk for perforation. Laparoscopic devices such as bands and clips are not designed for the first centimeter of the fallopian tube, and fulguration should be performed in the midportion of the fallopian tube rather than the proximal portion because of the risk of fistula formation. Transcervical sterilization devices (Essure; Conceptus Inc, San Carlos, CA. Adiana; Hologic Inc, Marlborough, MA) have now been approved by the Food and Drug Administration. Whether these devices will prevent PATSS is unknown; however, neither of these devices should be used concomitant with endometrial ablation because of the potential for intrauterine synechiae, which can compromise the 3 month confirmation test (hysterosalpingogram).26American College of Obstetricians and GynecologistsACOG committee opinion no. 458 Use of hysterosalpingography after tubal sterilization.June 2010Google Scholar If endometrial ablation is to be used after a transcervical sterilization, it is recommended that it be performed following the 3-month hysterosalpingogram has been performed. Upon the hysterosalpingogram confirmation of tubal occlusion, data are limited on whether endometrial ablation is safe and effective in women who have undergone hysteroscopic sterilization. Two hysteroscopic sterilization studies have reported success, one with Essure and thermal balloon ablation27Valle R.F. Valdez J. Wright T.C. Kenney M. Concomitant Essure tubal sterilization and Thermachoice endometrial ablation: feasibility and safety.Fertil Steril. 2006; 86: 152Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar and a second with Adiana and bipolar radiofrequency ablation.28Garza-Leal J. Castillo L. Hernandez I. et al.Concomitant use of Adiana permanent contraception and NovaSure impedance controlled endometrial ablation: a peri-hysterectomy study (abstract).J Minim Invasive Gynecol. 2009; 16: S69Abstract Full Text Full Text PDF Google Scholar The pathologic analysis of the extirpated uteri in both of these studies found no thermal injury to the fallopian tubes. Laparoscopic tubal occlusion can be performed concurrent with the ablation procedure. Central hematometra is most likely to occur when the cervical canal is damaged at the time of endometrial ablation and has an incidence of 1-3%.29Hill D.J. Hematometria—a complication of endometrial ablation/resection.J Am Assoc Gynecol Laparosc. 1994; 1: S14Abstract Full Text PDF PubMed Google Scholar, 30Hubert S.R. Marcus P.S. Rothenburg J.M. Hematometria after thermal balloon ablation in a patient with cervical incompetence.J Laparoendosc Adv Surg Tech A. 2001; 11: 311-313Crossref PubMed Scopus (10) Google Scholar Menses are obstructed at the level of the cervix, and therefore, the patient typically presents with cyclic pelvic pain. Central hematometra can be seen on imaging (ultrasound or MRI) at the time of cyclic pain. Central hematometra can usually be successfully treated with cervical dilatation29Hill D.J. Hematometria—a complication of endometrial ablation/resection.J Am Assoc Gynecol Laparosc. 1994; 1: S14Abstract Full Text PDF PubMed Google Scholar; however, in some cases, hysteroscopic adhesiolysis may be necessary. To avoid this complication, it has been suggested that the endometrial ablation should be terminated at the lower uterine segment to avoid thermal damage to the cervical canal. Partial rollerball ablation, wherein only the anterior or posterior endometrium is treated, avoiding the cornua, has also been suggested as a method to avoid postablation hematometra, including PATSS.31McCausland A.M. McCausland V.M. Partial rollerball ablation: a modification of total ablation to treat menorrhagia without causing complications from intrauterine adhesions.Am J Obstet Gynecol. 1999; 180: 1512-1521Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar The rationale for this technique is that when total endometrial ablation or resection is performed, the endometrium is destroyed and the opposing myometrial walls are exposed and can grow together as part of the generated inflammatory response. In their series of 50 patients, with an average follow-up of 42 months, no hematometra were formed and their reported satisfaction rate was 76%, with 5 patients undergoing a hysterectomy (all with deep adenomyosis). When does the failure to control menses become a problem? This question is difficult to answer for 2 reasons. First, failure is subjective and will vary among patients. Second, as more is published about failure, it is becoming clearer that there are individual risk factors that will affect the clinical response. Therefore, a discussion about result expectations is an important aspect in preoperative counseling. As mentioned, most women who undergo endometrial ablation will not experience amenorrhea, yet approximately 85% will be satisfied with the procedure at the 1 year mark.1Rosenberg M.K. Hyponatremic encephalopathy after rollerball endometrial ablation.Anesth Analg. 1995; 80: 1046-1048PubMed Google Scholar The evidence for long-term failure of endometrial ablation may be examined by a 4-5 year reoperation rate of 18–38%.32Comino R. Torrejon R. Hysterectomy after endometrial ablation-resection.J Am Assoc Laparosc. 2004; 11: 495-499Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 33Aberdeen Endometrial Ablation Trials GroupA randomized trial of endometrial ablation versus hysterectomy for the treatment of dysfunctional uterine bleeding: outcome at four years.Br J Obstet Gynaecol. 1999; 106: 360-366Crossref PubMed Scopus (132) Google Scholar In a study of 816 women undergoing endometrial ablation, risk factors for treatment failure included age younger than 45 years, parity of 5 or greater, prior tubal sterilization, and a history of dysmenorrhea (Table 1).34El-Nashar S.A. Hopkins M.R. Creedon D.J. et al.Prediction of treatment outcomes after global endometrial ablation.Obstet Gynecol. 2009; 113: 97-106PubMed Google Scholar Women with a preoperative ultrasound suggestive of adenomyosis had a hazard ratio of 1.5 (95% confidence interval, .05–4.9). In a study of hysterectomy specimens after failed endometrial ablation in 67 women, bleeding was the most common complaint (51%), followed by pain (28%), and lastly both bleeding and pain (21%).35Carey E.T. El-Nashar S.A. Hopkins M.R. et al.Pathologic characteristics of hysterectomy specimens in women undergoing hysterectomy after global endometrial ablation.J Minim Invasive Surg. 2011; 18: 96-99Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Surgical pathology findings included hematometra in 26% of the women who had pain complaints and intramural fibroids in 44% of women who listed bleeding as a primary reason for requesting hysterectomy.TABLE 1Preoperative predictors of treatment failure after endometrial ablationAdapted, with permission, from El-Nashar.34El-Nashar S.A. Hopkins M.R. Creedon D.J. et al.Prediction of treatment outcomes after global endometrial ablation.Obstet Gynecol. 2009; 113: 97-106PubMed Google ScholarPredictorsHazard ratio95% CIP valueThermal balloon vs radiofrequencyaMultivariable hazard ratio used in adjusted final analysis.1.50.7–2.9.27Age <45 yaMultivariable hazard ratio used in adjusted final analysis.2.65.1.008Parity ≥5aMultivariable hazard ratio used in adjusted final analysis.1.3–6.02.5–14.8< .001Tubal sterilizationaMultivariable hazard ratio used in adjusted final analysis.2.21.2–4.0.01Preoperative dysmenorrheaaMultivariable hazard ratio used in adjusted final analysis.3.71.6–8.5.003Hemoglobin ≥12 g/dL1.80.9–3.6.08Ultrasonogram suggestive of adenomyosis1.50.5–4.9.003CI, confidence interval.Sharp. Endometrial ablation. Am J Obstet Gynecol 2012.a Multivariable hazard ratio used in adjusted final analysis. Open table in a new tab CI, confidence interval. Sharp. Endometrial ablation. Am J Obstet Gynecol 2012. For patients who are not satisfied with endometrial ablation, most case series report hysterectomy as the next step. This assumes that either therapy has failed in these patients or the patients declined other conservative options. Should a repeat endometrial ablation be offered? Repeat endometrial ablation was not evaluated as part of the Food and Drug Administration approval process and would be considered off-label use with the newer devises; however, there are few studies examining this question. A repeat endometrial ablation in the presence of intrauterine synechiae can be challenging and place the patient at increased risk for complications. In a prospective cohort comparing primary (n = 800) and repeat endometrial ablation (n = 75), serious complications, defined as uterine perforation, hemorrhage, excess fluid absorption, and genital tract burns, were significantly more likely to be associated with repeat ablation (9.3% vs 2%). A small series (n = 21) of repeat endometrial ablation successfully used ultrasound guidance to assist with resectoscopic ablation without complications. At a mean of 23 months' follow-up, they reported an 88% success rate in avoiding hysterectomy.36Wortman M. Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection.J Am Assoc Gynecol Laparosc. 2001; 8: 272-277Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Endometrial ablation is not a treatment for endometrial hyperplasia or cancer and may interfere with subsequent evaluation of the endometrium because of synechiae that may make endometrial sampling difficult. The safety of endometrial ablation has not been well studied in women who are at an increased risk of developing endometrial cancer. These risks include nulliparity, chronic anovulation, obesity, diabetes mellitus, tamoxifen therapy, and hereditary nonpolyposis colorectal cancer. Therefore, weighing options and risks is an important part of the informed consent process. Ablation itself does not appear to increase the risk of subsequent endometrial cancer.37Krogh R.A. Lauszus F.F. Guttorm E. Rasmussen K. Surgery and cancer after endometrial resection Long-term follow-up on menstrual bleeding and hormone treatment by questionnaire and registry.Arch Gynecol Obstet. 2009; 280: 911Crossref PubMed Scopus (19) Google Scholar Endometrial hyperplasia has been linked to endometrial adenocarcinoma and should be considered a contraindication to endometrial ablation.38Gimpelson R.J. Not so benign endometrial hyperplasia: endometrial cancer after endometrial ablation.J Am Assoc Gynecol Laparosc. 1997; 4: 507Abstract Full Text PDF PubMed Scopus (30) Google Scholar Although there are few data regarding endometrial ablation in women taking tamoxifen, such women are at an increased risk of endometrial cancer, and ablation may interfere with the later diagnosis of this disorder. Therefore, tamoxifen therapy should also be considered a relative contraindication to endometrial ablation. Women with hereditary nonpolyposis colorectal cancer have a 27–71% lifetime risk of developing endometrial cancer39Hendriks Y.M. Wagner A. Morreau H. et al.Cancer risk in hereditary nonpolyposis colorectal cancer due to MSH mutations: impact on counseling and surveillance.Gastroenterology. 2004; 127: 17-25Abstract Full Text Full Text PDF PubMed Scopus (348) Google Scholar and are advised to undergo hysterectomy after they have completed child-bearing and are therefore not good candidates for endometrial ablation. Previous low transverse cesarean section is not considered a contraindication to endometrial ablation. However, there have been cases of urinary tract injuries in such patients. Vesicouterine fistula formation was reported in a patient with three prior cesarean sections,40Rooney K.E. Cholhan H.J. Vesico-uterine fistula after endometrial ablation in a patient with prior cesarean deliveries.Obstet Gynecol. 2010; 115: 450Crossref PubMed Scopus (15) Google Scholar and ureteral injury resulting in an ureterocutaneous ostomy was reported through the MAUDE database without details of the number of prior cesarean sections.41Gurtcheff S.E. Sharp H.T. Complications associated with global endometrial ablation: the utility of the MAUDE database.Obstet Gynecol. 2003; 102: 1278-1282Crossref PubMed Scopus (85) Google Scholar It is hypothesized that cases of asymptomatic lower-segment myometrial dehiscence covered only by a thin serosal layer may be a predisposing risk factor for urinary tract injury. However, in a series of 162 patients with more than 1 prior cesarean delivery, there were no urinary injuries.42Khan Z. El-Nashar S.A. Hopkins M.R. Famuyide A.O. Efficacy and safety of global endometrial ablation after cesarean delivery: a cohort study.Am J Obstet Gynecol. 2011; 205: 450.e1-450.e4Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Further study is warranted to assess the risk of multiple cesarean sections and endometrial ablation. In a metaanalysis comparing endometrial ablation procedures, the incidence of infectious complications included the following: endometritis (1.4–2.0%); myometritis (0–0.9%); pelvic inflammatory disease (1.1%); and pelvic abscess (0–1.1%).43Lethaby A. Shepperd S. Cooke I. Farquhar C. Endometrial resection and ablation versus hysterectomy for heavy menstruation.Cochrane Database Syst Rev. 2000; (CD000329)Google Scholar Infection after endometrial ablation typically presents with fever and uterine or adnexal tenderness and/or cervical or vaginal discharge, occurring within the first 3 days after surgery44Salmeen K. Morgan D. Sepsis after bipolar radiofrequency endometrial ablation.Obstet Gynecol. 2009; 114: 445-448Crossref PubMed Scopus (5) Google Scholar, 45Amin-Hanjani S. Good J.M. Pyometra after endometrial resection and ablationm.Obstet Gynecol. 1995; 85: 893-894Crossref PubMed Scopus (21) Google Scholar, 46Das S. Kirwan J. Drakeley A.J. Kingsland C.R. Pelvic abscess following microwave endometrial ablation.BJOG. 2005; 112: 118-119Crossref PubMed Scopus (12) Google Scholar, 47Halawa S. Kassab A. Fox R. Clostridium perfringens infection following endometrial ablation.J Obstet Gynaecol. 2008; 28: 360Crossref PubMed Scopus (5) Google Scholar, 48Haj M.A. Robbie L.A. Croll A. Adey G.D. Bennett B. Fibrinolytic changes in a patient with toxic shock syndrome: release of active u-PA.Intensive Care Med. 1998; 24: 258-261Crossref PubMed Scopus (8) Google Scholar; however, infection may present as late as 20-50 days postoperatively.49Schlumbrecht M. Balgobin S. Word L. Pyometra after thermal endometrial ablation.Obstet Gynecol. 2007; 110: 538-540Crossref PubMed Scopus (8) Google Scholar, 50Roth T.M. Rivlin M.E. Tuboovarian abscess: a postoperative complication of endometrial ablation.Obstet Gynecol. 2004; 104: 1198-1199Crossref PubMed Scopus (13) Google Scholar An elevated white blood count is common among patients with serious pelvic infections. Imaging with pelvic sonography or computed tomography has been reported as helpful in identifying pelvic pathology such as gas within the uterus in a case of Clostridium perfringens,47Halawa S. Kassab A. Fox R. Clostridium perfringens infection following endometrial ablation.J Obstet Gynaecol. 2008; 28: 360Crossref PubMed Scopus (5) Google Scholar tuboovarian abscess,50Roth T.M. Rivlin M.E. Tuboovarian abscess: a postoperative complication of endometrial ablation.Obstet Gynecol. 2004; 104: 1198-1199Crossref PubMed Scopus (13) Google Scholar pyometra,45Amin-Hanjani S. Good J.M. Pyometra after endometrial resection and ablationm.Obstet Gynecol. 1995; 85: 893-894Crossref PubMed Scopus (21) Google Scholar, 49Schlumbrecht M. Balgobin S. Word L. Pyometra after thermal endometrial ablation.Obstet Gynecol. 2007; 110: 538-540Crossref PubMed Scopus (8) Google Scholar pelvic abscess,46Das S. Kirwan J. Drakeley A.J. Kingsland C.R. Pelvic abscess following microwave endometrial ablation.BJOG. 2005; 112: 118-119Crossref PubMed Scopus (12) Google Scholar and cornual abscess.51Jansen N.E. Vleugels M.P. Kluivers K.B. Vierhout M.E. Bilateral cornual abscess after endometrial ablation following Essure sterilization.J Minim Invasice Gynecol. 2007; 14: 509-511Abstract Full Text Full Text PDF PubMed Google Scholar Among 8 case reports of significant infection after endometrial ablation, surgery was performed in all cases including drainage of pyometra, abscess drainage, and hysterectomy. Most patients recovered rapidly with the exception of a woman with acute renal failure, fascial dehiscence, and vesicovaginal fistula who was hospitalized for several weeks49Schlumbrecht M. Balgobin S. Word L. Pyometra after thermal endometrial ablation.Obstet Gynecol. 2007; 110: 538-540Crossref PubMed Scopus (8) Google Scholar and a woman with sepsis followed by adult respiratory distress syndrome, acute renal failure, and toxic shock syndrome, who subsequently died48Haj M.A. Robbie L.A. Croll A. Adey G.D. Bennett B. Fibrinolytic changes in a patient with toxic shock syndrome: release of active u-PA.Intensive Care Med. 1998; 24: 258-261Crossref PubMed Scopus (8) Google Scholar (Table 2). In most of the reported cases of significant infection, prophylactic antibiotics were not given, with the exception of a woman with diabetes and a mechanical heart valve requiring mitral valve prophylaxis.49Schlumbrecht M. Balgobin S. Word L. Pyometra after thermal endometrial ablation.Obstet Gynecol. 2007; 110: 538-540Crossref PubMed Scopus (8) Google Scholar Of the 8 subjects in Table 2, the most commonly cultured organism was Escherichia coli (5 of 8), and the most common definitive therapy was hysterectomy (5 of 8). All patients were treated with broad-spectrum antibiotics.TABLE 2Characteristics of postoperative infectionsAuthorInfection typeOnset, dOrganism(s)TherapiesSchlumbrecht et al49Schlumbrecht M. Balgobin S. Word L. Pyometra after thermal endometrial ablation.Obstet Gynecol. 2007; 110: 538-540Crossref PubMed Scopus (8) Google ScholarPyometra20E coliAntibioticsEnterococcusHysterectomySalmeen and Morgan44Salmeen K. Morgan D. Sepsis after bipolar radiofrequency endometrial ablation.Obstet Gynecol. 2009; 114: 445-448Crossref PubMed Scopus (5) Google ScholarEndometritis1E coliAntibioticsHysterectomyDas et al46Das S. Kirwan J. Drakeley A.J. Kingsland C.R. Pelvic abscess following microwave endometrial ablation.BJOG. 2005; 112: 118-119Crossref PubMed Scopus (12) Google ScholarPelvic abscess3ColiformsAntibioticsAnaerobesLaparotomyAbscessDrainageAmin-Hanjani and Good45Amin-Hanjani S. Good J.M. Pyometra after endometrial resection and ablationm.Obstet Gynecol. 1995; 85: 893-894Crossref PubMed Scopus (21) Google ScholarPyometra3E coliAntibioticsAbscessDrainageRoth and Rivlin50Roth T.M. Rivlin M.E. Tuboovarian abscess: a postoperative complication of endometrial ablation.Obstet Gynecol. 2004; 104: 1198-1199Crossref PubMed Scopus (13) Google ScholarTuboovarianAbcess50E coliAntibioticsB fragilisHysterectomyJansen56Jansen N.E. Vleugels M.P. Kluivers K.B. Vierhout M.E. Bilateral cornual abscess after endometrial ablation following Essure sterilization.J Minim Invasive Gynecol. 2007; 14: 509-511Abstract Full Text Full Text PDF PubMed Scopus (16) Google ScholarCornual abscess>14H influenzaeAntibioticsCornualResectionHalawa et al47Halawa S. Kassab A. Fox R. Clostridium perfringens infection following endometrial ablation.J Obstet Gynaecol. 2008; 28: 360Crossref PubMed Scopus (5) Google ScholarEndometritis1C perfringensAntibioticsHysterectomyHaj et al48Haj M.A. Robbie L.A. Croll A. Adey G.D. Bennett B. Fibrinolytic changes in a patient with toxic shock syndrome: release of active u-PA.Intensive Care Med. 1998; 24: 258-261Crossref PubMed Scopus (8) Google ScholarEndometritis1S aureusAntibioticsB fragilis, Bacteroides fragilis; C perfringens, Clostridium perfringens; E coli, Escherichia coli; H influenzae, Haemophilis influenzae; S aureus, Staphylococcus aureus.Sharp. Endometrial ablation. Am J Obstet Gynecol 2012. Open table in a new tab B fragilis, Bacteroides fragilis; C perfringens, Clostridium perfringens; E coli, Escherichia coli; H influenzae, Haemophilis influenzae; S aureus, Staphylococcus aureus. Sharp. Endometrial ablation. Am J Obstet Gynecol 2012. Antibiotic prophylaxis is recommended for major obstetric and gynecologic procedures such as hysterectomy and cesarean section.52American College of Obstetricians and GynecologistsAntibiotic prophylaxis for gynecologis procedures ACOG practice bulletin no. 104.2009Google Scholar, 53Chelmow D. Ruehli M.S. Huang E. Prophylactic use of antibiotics for nonlabouring patients undergoing cesarean delivery with intact membranes: a meta-analysis.Am J Obstetr Gynecol. 2001; 184: 656-661Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar Most minor gynecologic procedures do not require routine prophylaxis52American College of Obstetricians and GynecologistsAntibiotic prophylaxis for gynecologis procedures ACOG practice bulletin no. 104.2009Google Scholar. Endometrial ablation may be different from other transcervical procedures such as dilatation and curettage, diagnostic hysteroscopy, and hysterosalpingography. Although it is likewise a minimally invasive and relatively quick procedure, it results in endometrial destruction and necrosis, raising further questions about antibiotic prophylaxis. A randomized controlled trial to assess the effect of prophylactic antibiotics on the incidence of bacteremia following endometrial ablation or resection found the incidence of bacteremia to be 16% in 61 women in the nonantibiotic group and 2% of the 55 women in the antibiotic group.54Bhattacharya S. Parkin D.E. Reid T.M.S. et al.A prospective study of the effects of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery.Eur J Obstet Gynecol Reprod Biol. 1995; 63: 37-40Abstract Full Text PDF PubMed Scopus (42) Google Scholar Although there was a difference in the incidence of bacteremia, none of the women became ill, regardless of their blood culture status. The authors concluded that the role of prophylactic antibiotics in patients undergoing endometrial ablation remains unclear. A Cochrane review of prophylactic antibiotics for transcervical intrauterine procedures deemed there was no evidence to either support or discourage the use of antibiotics to prevent infection for transcervical intrauterine procedures. The authors concluded that prophylactic antibiotics might be considered in populations and areas in which the incidence of infection after transcervical intrauterine procedures is high.55Thinkhamrop J. Laopaiboon M. Lumbiganon P. Prophylactic antibiotics for transcervical intrauterine procedures.Cochrane Database Syst Rev. 2007; (CD005637)PubMed Google Scholar One population to consider at risk are patients with an implantable transcervical sterilization device.51Jansen N.E. Vleugels M.P. Kluivers K.B. Vierhout M.E. Bilateral cornual abscess after endometrial ablation following Essure sterilization.J Minim Invasice Gynecol. 2007; 14: 509-511Abstract Full Text Full Text PDF PubMed Google Scholar Currently the American College of Obstetricians and Gynecologists recommends against the use of prophylactic antibiotics in patients undergoing endometrial ablation.52American College of Obstetricians and GynecologistsAntibiotic prophylaxis for gynecologis procedures ACOG practice bulletin no. 104.2009Google Scholar Serious infection should be suspected in all patients who present with fever after endometrial ablation. A thorough examination including a pelvic examination should be performed to assess for uterine or adnexal tenderness or mass. Broad-spectrum antibiotics should be administered promptly, and the patient should be evaluated for signs of sepsis. It is not clear which patients will have a milder form of infection and perhaps respond to broad-spectrum antibiotics only because reported cases have focused on serious infections. Imaging studies including pelvic sonography or computed tomography may be useful to diagnose serious conditions that require surgery. Pregnancy occurring after endometrial ablation has been reported to be associated with risks throughout each trimester with a significant risk of ectopic pregnancy, preterm birth, and abnormalities of placentation (accreta spectrum). Practitioners who care for such women should be aware of and prepare for these risks.