A death following hysteroscopic myomectomy

Abstract

We report a fatal outcome using 1.5% glycine as distension/irrigation fluid for hysteroscopic myomectomy.

During general anaesthesia for transcervical endoscopic resection of myoma, a healthy 35-year-old woman developed severe pulmonary hyponatraemia and cerebral oedema, and was declared brain dead. Postmortem findings did not reveal pontine myelinolysis. Through the procedure, the net fluid absorption of 1.5% glycine was 1.6 L plus 1 L of maintenance intravenous Ringer’s lactate solution.

Regional anaesthesia is recommended for hysteroscopy, since general anaesthesia may mask neurologic signs, and meticulous attention should be paid to intraoperative fluid balance.