operative hysteroscopy is now routinely employed for endometrial ablation , septum resection , myomectomy and polypectomy . however , it has the potential for serious complications like uterine perforation , haemorrhage , gas or air embolism , sepsis and fluid overload with hyponatraemia . absorption of an excessive amount of this irrigation fluid may rarely lead to fluid overload and attendant toxicity syndrome called operative hysteroscopy intravascular absorption ( ohia ) syndrome . transurethral resection of prostate ( turp ) syndrome ; hence , the alternate term gynaecological turp syndrome . although the classic syndrome itself is rare ( < 1% incidence ) , its sudden intraoperative presentation is exceptional . a 57-year - old post - menopausal female presented with bleeding per vaginum for 2 months and was posted for hysteroscopic myomectomy under general anaesthesia ( ga ) . she had associated diabetes mellitus type 2 , dyslipidaemia and hypothyroidism and was controlled on medical management . she refused regional anaesthesia and was accepted for ga in american society of anaesthesiologists grade ii . premedication consisted of morphine 3 mg intravenous ( iv ) , glycopyrrolate 0.2 mg iv and ondansetron 4 mg iv . anaesthesia was induced with inj propofol 100 mg slow iv followed by succinylcholine 75 mg iv to facilitate endotracheal intubation employing a 7.5 mm cuffed endotracheal tube ( ett ) - portex . anaesthesia was maintained with 60% nitrous oxide and 1% isoflurane in oxygen and iv vecuronium . normal saline solution was given at 250 ml / h , and a total of 500 ml of this was administered . at the beginning of surgery , her intraoperative vitals were stable and she was monitored with electrocardiography ( ecg ) , non - invasive blood pressure ( nibp ) , end tidal carbon dioxide ( etco2 ) , pulse oximetry ( spo2 ) and temperature . hysteroscopic examination revealed a large submucous fibroid measuring 5 cm4 cm arising from the right lateral uterine wall . resection of the fibroid was started after distending the uterine cavity with 1.5% glycine employing karl storz hysteroscope and maximum 80 mmhg intrauterine pressure . after 45 min of surgery ( 2/3 of fibroid resected ) , the spo2 suddenly fell from 98% to 8890% ( fio2 1.0 ) . there was concomitant rise in airway pressure , diminished breath sounds , nibp 90/70 mmhg and pulse rate 100/min . subsequently , pink frothy secretions appeared in the ett and crackles were heard throughout both lung fields , substantiating a clinical diagnosis of acute pulmonary oedema . arterial blood gas ( abg ) revealed po2 : 165.3 mmhg , pco2 : 50.5 mmhg , ph : 7.17 , k : 5.3 mmol / l , na : 100 mmol / l , hco3 : 17.8 mmol / l , be : 8.2 a portable chest radiograph revealed perihilar interstitial infiltrates and increase in the pulmonary vasculature , suggestive of pulmonary oedema [ figure 1 ] . the measured glycine deficit was approx 1 l ( glycine used minus efflux via resectoscope , perineal drapes , suction ) and clinical deterioration was ascribed to glycine fluid overload in view of glycine deficit , hyponatraemia , metabolic acidosis and pulmonary oedema . right internal jugular vein and left radial artery were cannulated for haemodynamic monitoring and abg analysis . the patient was shifted to the intensive care unit for elective mechanical ventilation ( simv mode , fio2:1 ) with iv morphine sedation . sixty milliliters of 7.5% soda bicarbonate was given slow iv , 3% sodium chloride iv was started at 60 ml / h and inotropes were infused for persistent hypotension . an urgent echocardiogram was normal . serial abg were performed to monitor serum na levels and , when the target level of 120 mmol / l was reached ( over the next 12 h ) , 3% nacl was stopped . by the evening , the patient developed profuse bleeding per vaginum and endometrial tamponade was done with foley 's catheter . disseminated intravascular coagulation ( dic ) was suspected as she began oozing from other sites , with the nasogastric tube showing a coffee ground aspirate . her coagulation profile was deranged : haemoglobin 5 gm% , platelet count 90,000/mm , prothrombin time 22 s , partial thromboplastin time 68 s , international normalized ratio 1.94 and d - dimer positive with hypocalcaemia ( 7.6 gm / dl ) . fresh blood with blood products ( fresh frozen plasma , cryoprecipitate ) were transfused along with iv calcium . by day 2 , her coagulation profile improved and inotropic support was tapered off . simv mode ventilation with pressure support and progressive fio2 reduction was followed with a continuous positive airway pressure trial for 1 h and uneventful extubation , i.e. within 24 h of initiating ventilation . however , the patient became tachypnoeic on day 3 , with respiratory rate 36/min and bilateral wheeze with spo2 of 85% ( fio2 1.0 ) . chest x - ray showed opacities in left lower zone suggestive of pneumonitis [ figure 2 ] . fibreoptic bronchoscopy revealed long tubular casts in the left bronchial tree , which were removed . thereafter , she was managed with asthalin nebulization , chest physiotherapy , bipap support and broad - spectrum antibiotics as pseudomonas aeruginosa was grown on blood culture . on day 6 , nerve conduction studies revealed common peroneal nerve palsy , which was successfully managed with physiotherapy . the rest of the hospital stay was uneventful and she was discharged to home on day 14 and remained asymptomatic on follow - up . these may relate to patient positioning , uterine perforation , intraoperative bleeding , sepsis , anaesthetic complications and use of distending media ( fluid overload , electrolyte disturbance , gas emboli ) . during gynaecological surgery , fluid absorption occurs more often with resection of fibroid , with pre - menopausal women at higher risk for neurologic sequelae from even modest hyponatraemia , as sex hormones adversely affect the sodium pump in brain cells leading to cerebral oedema . the frequency of complications of hysteroscopic surgery is reported to be as low as 0.24% , but may go up to 10% with more complicated surgeries like hysteroscopic myomectomy . although ohia syndrome has a similar pathogenesis as turp syndrome , the uterine wall is thicker and requires higher distending pressures . the pressure in large venous sinuses in the myometrium is 1015 mmhg , while the intrauterine pressure for distention and flow is generally kept above 4060 mmhg . intracavitary pressure in excess of mean arterial pressure , i.e. 80 mmhg ( or 40 inches height of water ) , can result in rapid intravasation . the absorbed volume of fluid employed for uterine distention depends on the extent of transection of vascular beds , intrauterine distention pressures , duration of the procedure and surgical experience . accurate intake output estimates have also to contend with 510% more irrigating fluid in packed containers and  returning  fluid being lost in drapes or on the floor . the present case had measured absorption of about 1 l , but higher amounts were likely absorbed . in fact , absorption of small amounts ( 12 l ) occurs in 510% of patients with a mild easily overlooked tur syndrome , while the classic syndrome develops in < 1% with intravascular absorption in excess of 2 l. severe tur syndrome following 1.5% glycine absorption is associated with a mortality of 25% . 1.5% glycine is commonly used as irrigating fluid as it is non - conductive and non - haemolytic , with a refractive index close to that of water . however , it is hypotonic ( osmolarity 200 mosml / l ) . the clinical presentation of glycine toxicity and hyponatraemia may be difficult to distinguish from sepsis or dic , and usually manifests 3045 min after completion of surgery . awake patients may initially complain of prickling sensation in face and neck , restlessness , headache , visual disturbances while bradycardia , hypotension and decreasing oxygen saturation are consistent early signs . pulmonary oedema usually presents after end of surgery , although , rarely , it may occur on the operating table , particularly where the blood loss is not significant . transient bilateral common peroneal nerve palsy in our patient reinforces the importance of careful lithotomy positioning , especially in prolonged or repeat surgery . treatment of glycine intoxication and fluid overload should start early . besides supportive measures , iv hypertonic saline ( commonly 3% ) should be given for na+ < 120 mmol / l , keeping the rate of sodium replacement < 1 mmol / l / h as rapid correction may result in pontine myelinolysis . the main indication of iv furosemide is to treat acute pulmonary oedema or induce diuresis where this does not occur spontaneously . volumetric fluid balance and gravimetry are traditional methods for assessment of fluid absorption during resectoscopic surgery , and deficits should be calculated at least every 10 min . while manual closed systems of fluid balance may not always be practical or precise , the newer automated fluid management systems may prove to be more accurate , especially for advanced resections like myomectomy , and 5% mannitol is probably safer than other distending media . as with the turp syndrome , it may be advantageous to use regional anaesthesia because awake patients are likely to display precursor symptoms ( akin to a  miner 's canary  ) that portend impending brain or cardiac dysfunction . during ga , it is advisable to adhere to a pre - determined schedule for sampling patient blood for serum sodium concentration . the parotid area sign ( intraoperative increase in philtrum - mastoid prominence distance ) and the ethanol breath test employing 1.5% glycine with added 1% ethanol for irrigation bipolar resectoscopes employing normal saline as distending medium and vaporization techniques are being explored as safer alternatives for the future . this report points out the potential for sudden development of glycine fluid overload in hysteroscopic surgery . ga during such surgical procedures precludes the use of patient 's mental status as an indicator of glycine intoxication and dilutional hyponatraemia . anaesthetic management of these otherwise healthy women should underline the prevention of ohia syndrome and its attendant morbidity and possible mortality .
operative hysteroscopy has emerged as an effective alternative to hysterectomy and has become standard surgical treatment for varied gynaecological conditions like abnormal uterine bleeding and uterine myomas . 
 this procedure requires distention of the uterine cavity for adequate visualization of the operative field . 
 1.5% glycine is a widely used distention medium because it has good optical properties and is non - conductive . 
 however , the intraoperative absorption of this electrolyte - free fluid can cause hyponatraemia , hypoosmolality , hyperglycinaemia and volume overload , including pulmonary oedema . 
 we report a case of operative hysteroscopy intravascular absorption ( ohia ) syndrome , presenting abruptly during hysteroscopic myomectomy , employing 1.5% glycine as the fluid distention medium . 
 successful management of the case and prevention strategies are discussed .