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The Dangers of Hysteroscopy and Polypectomy in 2021

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The Dangers of Hysteroscopy and Polypectomy in 2021

A letter to the British Society of Gynaecological Endoscopy


I do some medicolegal work and have a special interest in hysteroscopic surgery.  The reason for writing to you is that I have now prepared 6 reports on women who have suffered uterine perforation and bowel injury after hysteroscopy and “blind polypectomy” under GA. In all cases, there was a failure to diagnose the problem until the patients were severely ill with sepsis due to peritonitis, requiring laparotomy and treatment in ITU.  One of these patients died and we have also had one death in our hospital.  This is a small personal sample and I wonder how many deaths are caused every year by this technique in the UK.

 

All these injuries would be avoidable, if the polyps were removed under direct vision with hysteroscopic morcellators or other techniques.  Furthermore, if a perforation did occur, it would be recognised straightaway and investigated with laparoscopy. 

 

There seem to be no national guidelines about the correct performance of hysteroscopic surgery and this is surely the responsibility of the BSGE/RCOG.  I would suggest that these should include the following points:

 

  1. All polyps should be removed under direct vision, whether in outpatients or in theatre under GA..
  2. “Blind polypectomy” should no longer be performed as part of “Hysteroscopy and Polypectomy” under GA.
  3. If there is no alternative to the use of polyp forceps, it should be mandatory to perform a hysteroscopy afterwards to ensure that the polyp has been completely removed, as well as excluding a perforation.
  4. There should be some guidance about the management of uterine perforation – conservative management vs laparoscopy.
  5. More training is needed about the symptoms and signs of uterine perforation and bowel injury to avoid delay in diagnosis.

 

I suspect that the inhibiting factors are the cost of hysteroscopic morcellators and the lack of training of established consultants in the use of these instruments: national guidelines are needed to ensure that standards improve.

 

Best wishes,

 

Richard Pyper

Consultant Gynaecologist

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Ruth Mason
Consultant Obstetrician
pms@pypermedical.co.uk
+44 1903 741154

Ruth Mason joined Pyper Medical Services in 2016 and has completed the Cardiff University Bond Solon Civil Expert Witness certificate. She is a Consultant Obstetrician at Western Sussex Hospitals NHS Foundation Trust, in post since 2010. She has a broad experience of all aspects of Obstetrics including Risk Management, Intrapartum Management and Fetal USS.

Ruth Mason obtained her medical degree at the University of Edinburgh. She completed an MD in Fetal Immunology at the University of London / Imperial College before commencing her Registrar rotation in the Wessex Deanery. During her training she was awarded the RCR/RCOG Diploma in Fetal Ultrasound Scanning. She became a Member of the Royal College of Obstetricians & Gynaecologists in 2006 and was elevated to Fellow in 2019.

Ruth was appointed as Labour Ward Lead Consultant at Western Sussex Hospitals NHS Foundation Trust Worthing Hospital in 2010 and led the unit to achieve CNST level 1, 2 and 3 in sequential years, a feat never previously achieved by an Acute NHS Trust. Risk Management reviews sparked her interest in the medico-legal sector leading to her joining Richard at Pyper Medical Services to provide expertise on Obstetric cases in 2016. She completed the Cardiff University, Bond Solon Civil Expert Certificate and has used this to inform her reports and court appearances.

Ruth now regularly acts as Expert Witness for HM Coroner in cases involving Intrapartum and Early Neonatal deaths (with corresponding court experience).

Having undertaken a project looking at the importance of medical record keeping as a junior doctor, Ruth has been influential in improving the approach to record keeping at Worthing Hospitals as part of her role as RCOG college tutor, a post she held for 8 years. As tutor she gained extensive experience supporting trainees with root cause analysis investigations into pregnancy cases. The majority of her clinical care now comprises the management of complex pregnancies including the use of ultrasound to support these pregnancies.

Outside work Ruth plays hockey for a local club, now also managing the junior team and enjoys skiing with her family in the winter.

Click to view Ruth’s CV

Specialty: Consultant Obstetrician

Degrees: MD MRCOG

Rahila Khan
Consultant Obstetrician & Gynaecologist

pms@pypermedical.co.uk
+44 1903 741154

Rahila Khan joined Pyper Medical Services in 2021 and has completed `Expert Report Writing course’ of InSpire MediLaw. Her current post is Consultant Obstetrician and Gynaecologist at University Hospitals Sussex NHS Foundation Trust. Since 2010, she has been the lead in Maternal Medicine and Diabetic pregnancy at Worthing Hospital with broad experience in all aspects of Obstetrics and Gynaecology, including high-risk pregnancies and intrapartum management.

She obtained her medical degree from Dhaka Medical College Hospital, Bangladesh, and moved to UK for higher training in 1989. She became the member of RCOG in 1993. She then enrolled in a Fellowship Programme in Maternal Fetal Medicine at University of Connecticut Health Centre, USA, which included management of complex cases and obstetric ultrasound scanning.

After completion of the Fellowship, she worked as an Assistant Professor in O&G at BIRDEM General Hospital (Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders) and used her UK and USA experience to improve care in complex cases. She was the lead in establishing epidural analgesia in labour at BIRDEM.

Rahila is an excellent team player, who can adapt to new situations, and this was the key factor which helped her to blend in with the different systems of working in UK, USA, and Bangladesh. This has given her extensive experience of O&G in 3 continents and different perspectives on treatment.

She has always had a special interest in audit and many recommendations from studies have been implemented in clinical practice to improve care and patient safety. She has been the principal investigator of several multi-centre research projects.

In her present post, she established a Maternal Medicine clinic to treat pregnant women with complex medical conditions and liaise with tertiary centres. She is also the lead for Diabetic Pregnancy and runs the joint antenatal clinic with a consultant endocrinologist.

Women with abnormal or traumatic experiences are seen in a postnatal debrief clinic and these cases are often discussed in Obstetric Risk Review meetings and presented in ‘Joint Perinatal Meetings’, developing her interest in risk management. Reflection on these cases, and several obstetric serious incident reviews, have led to an interest in medico-legal work.

Outside work, Rahila enjoys singing and has participated in various cultural programmes. Her hobbies include gardening and painting.

Click to view Rahila’s CV

Specialty: Consultant Obstetrician & Gynaecologist

Degrees: MBBS, MD, FRCOG

Richard Pyper
Director & Consultant Gynaecologist

pms@pypermedical.co.uk
+44 1903 741154

A career obstetrician and gynaecologist from the start, Richard sought a broad experience of general surgery as a basis for specialist training in gynaecological surgery. His training was in London, starting at the Middlesex Hospital, St Mary’s Hospital, Queen Charlotte’s Hospital, Guys Hospital and then as Senior Registrar at St Bartholomew’s Hospital.

He was appointed as an NHS Consultant to Western Sussex Hospitals in 1992. He was Clinical Director for 6 years until 1998 and was Chairman of the Labour Standing Committee from 1999 to 2003.

Enjoying the intellectual challenges of being the Clinical Tutor for the Royal College of Obstetricians and Gynaecologists (RCOG) on behalf of the hospital from 2004 to 2012, Richard expanded into the medico-legal sector where he now runs a busy practice. He has been an Expert Witness since 1994 and has prepared more than 900 reports on a wide variety of subjects for both claimants and defendants. He was instructed as a Single Joint Expert in the Liverpool Urogynaecology litigation from 2011-2014 and wrote 90 reports on Breach, Causation, Condition and Prognosis after consultations with each patient.

Consultations with clients for Condition and Prognosis reports take place in the local private hospital in Sussex. Richard undertakes 30 medicolegal conferences per year with solicitors and barristers and has attended court on 12 occasions. Richard’s aim is to contribute towards rising standards of clinical care, and he is dedicated to improving patient safety through risk management and training. He enjoys teaching and training junior doctors in both clinical practice and surgery.

Outside of work, his hobbies include skiing, hiking in the alps and playing strategy board games with his family.

Click to view Richard’s CV

Specialty: Director & Consultant Gynaecologist

Degrees: MB BChir, FRCS(Ed), FRCOG

Training: Cambridge University