hsg case review - srpeweb.org
TRANSCRIPT
Hysterosalpingography
Leslie E. Partridge, RRA, MSRT(R)
Objectives Review indications, contraindications, risks and
possible complications of HSG. Review basic technical aspects and patient care
related to the HSG procedure. Demonstrate normal anatomic appearances of the
endocervical canal, uterus and fallopian tubes. Discuss abnormal findings diagnosed during HSG
procedures. Try to accept that we are out of bed at 8 am in
Las Vegas on a Saturday. I have no disclosures.
HSG Indications
Infertility
Prior miscarriage or abortion
Abnormal uterine bleeding
Postoperative evaluation
– Female sterilization procedures
– Other prior GYN surgery
Other (less common)
– Incompetent cervical os
HSG Contraindications
Active PID
Recent uterine or tubal surgery
Active uterine bleeding
Pregnancy
Contrast allergy
Preparing the Patient
Schedule days 7-10 of the menstrual cycle
Premedicate with analgesic or mild sedative 1 hour before
Pregnancy test– Urine POC
Remove clothing waist down– Provide washcloth, towel and pad for after
Explain procedure
Screen for prior abdominal/GYN surgeries, allergies, recent abdominal pain or fever
Consent?
HSG Risks & Complications
Pain/discomfort
Vasovagal reaction
Injury & bleeding
Uterotubal perforation
Vascular intravasation
Contrast media reaction
Post procedure infection
Radiation exposure
HSG Therapeutic Effect
Mechanical lavage of tubes
Release of peritubal adhesions
Stimulate cilia of tubal mucosa
Alteration of cervical mucus
Bacteriostatic effect
HSG Supplies Contrast – Omnipaque 300 mgI/mL
Light – gooseneck lamp
Sterile gloves
Procedure tray
– Speculum and lube
– Dilator/Sound
Disposable flexible cervical dilator
– Tenaculum forceps (Braun or atraumatic)
– Hysterectomy forceps (slightly curved)
– Cannula
Soft metal with rubber acorn tip
HSG balloon catheter, 5Fr & 7Fr
– 20 mL syringe for contrast
– Containers for contrast & betadine
– Betadine + swabsticks
– Gauze and sterile towels
HSG Procedure
Supine modified lithotomy position– Table pad, sheet and chux– Leg holders?
Draw up contrast and flush through catheter Insert vaginal speculum
– Clear view of cervix and external os
Clean cervix and absorb excess solution Secure tenaculum to large piece of anterior cervical lip
tissue Insert cannula/tubular end of acorn into the external os
– Inflate balloon if using disposable catheter
Remove speculum? Slow contrast injection with constant fluoro and
intermittent spot images
HSG Technique
Fluoroscopy principles– 70-90 kV range– Small focal spot for
thin patients, if available
– Pulse fluoro: 7.5 p/s– Fluoro time: 0.5 – 2.5
min (0.8 – 1.2 min)
Imaging– DVR, cine recording or
other– R/L marker– Measurement
calibrator*– Live fluoro + spot
images Uterine body
– Minimal, partial, full
Fallopian tubes– Early– Spill
– AP position Obliques as needed
Technical Problems Check equipment to avoid instrumentation issues Air bubbles
– Reposition patient– Aspirate then refill
External contrast leakage– Patulous cervical os
Larger acorn or balloon Intrauterine balloon placement Increase traction
– Stenotic cervical os Dilate Smaller catheter or acorn
Intravasation Tubal occlusion vs. spasm
– Slow injection with constant pressure– Reinjection, change position– Glucagon 1mg IV
Patient discomfort– Slow injection with constant pressure– Vasovagal reactions
Normal Anatomy
http://apbrwww5.apsu.edu/thompsonj/Anatomy%20&%20Physiology/2020/2020%
20Exam%20Reviews/Exam%205/CH27%20Uterine%20Anatomy.htm
Normal Anatomy
Normal Variants Smooth convexity
– Overdistended– Instrumentation
Smooth concavity– Perpendicular line connecting cornua
<1cm deep
Spiculated uterine lining– Thin, inactive endometrium and atrophic
uterus caused by lack of hormone stimulation
Smooth longitudinal uterine folds– Undulations of myometrium
Double-outlined uterus– Contrast dissection into endometrium
Positional variants –inverted/anteflexed/retroflexed, not midline
Congenital Abnormalities Segmental müllerian duct agenesis Unicornuate uterus
– With contralateral rudimentary horn With endometrial cavity
– Communicating– Noncommunicating
Without endometrial cavity
– Without contralateral rudimentary horn
Uterus didelphys Bicornuate uterus
– Complete– Partial– Arcuate
Septate uterus– Complete– Incomplete
DES (diethylstilbestrol) drug related
Classification system of müllerian duct anomalies developed by the American Fertility Society
Troiano R N , McCarthy S M Radiology 2004;233:19-34
H
L
Arcuate vs Septate vs Bicornuate
A. Arcuate – distance between the middle of the fundus and a line connecting the cornua of the uterus should be more than 10 mm but not exceeding 15 mm.
B. Septate – angle less than 75o suggests septate; line from cornu to cornu measures less than 1 cm
C. Bicornuate – angle exceeding 105o indicative of bicornuate; line from cornu to cornu measure greater than 4 cm
J. O
bst
et.
Gynaeco
l. R
es.
Vol. 3
7, N
o. 3:
178–186,
Marc
h 2
011
Endocervical Changes
Caliber
– Narrowing
Normal variant
DES exposure
Postoperative
Neoplasm
– Dilatation
Normal variant
Incompetent os
Postoperative
Filling defects– Air bubble
– Mesonephric remnant
– Synechiae
– Polyp
– Neoplasm
Contour irregularity– Normal variant
– Diverticulum
– Perforation
– Postoperative
– Neoplasm
Endocervical Diverticulum
Uterine Cavity Changes
Size
– Small
Hypoplasia
Nulliparity
DES exposure
Synechiae
– Large
Multiparity
Pregnancy
Molar pregnancy
Neoplasm
Shape
– Arcuate
– Septate
– Unicornuate
– Bicornuate
– Other congenital
– DES exposure
– Synechiae
– Neoplasm
– Postoperative
Septate Uterine Cavity
Uterine Filling Defects
Congenital fold
Air bubble
Blood clot
Mucoid material
Pseudoadhesions
Leiomyoma
Polyp
Synechiae
Adenomyoma
Septated uterus
IUD
Postoperative
Endometrial carcinoma
Pregnancy
Molar pregnancy
Retained conceptus
Uterine Cavity Leiomyomas
Uterine Cavity Polyp
Uterine Irregularity
Synechiae
DES exposure
Intravasation
Neoplasm
Normal variant
Endometrial hyperplasia
Adenomyosis
Tuberculosis
Postoperative
Embedded IUD
Uterine fistula
Gartner’s duct remnant
Am J Ro.ntgenol 131 :499-500, September 1978
Tubal Visualization
Absent visualization– Technical
– Cornual spasm
– Mucosal plugging
– Obstruction
– Postoperative Salpingectomy
Essure
Tubal dilatation– Obstruction (hydrosalpinx)
– Perifimbrial adhesions
– Ectopic pregnancy
Partial visualization– Technical
– Postoperative Ligation
Salpingectomy
Essure
– Obstruction
– Congenital
Tubal Appearance
Filling defects
– Air bubble
– Polyp(s)
– Neoplasm
– Ectopic pregnancy
Tubal irregularity
– Salpingitis isthmicanodosa
– Tubal diverticula
– Tuberculosis
– Endometriosis
– Postoperative
Considerations forTubal Abnormalities
Congenital abnormalities
DES exposure
PID
Salpingitis isthmica nodosa
Endometriosis
Polyps/neoplasms
Ectopic pregnancy
Postoperative changes
Ovarian disease
Endometriosis
R salpingectomy after ectopic pregnancy L tubal occlusion
Case 1History:
amenorrhea, infertility,
abnormal ultrasound
Case 1 Continued
Case 2History: Infertility, endometriosis
Pre-op note: HSG with L unicornuate uterus, suspect noncommunicating uterine
horn
Ex Lap results: Complete uterine duplication with 2 separate cervices, R uterus
had a blind vaginal pouch, R ovary present, L ovary and kidney absent = Didelphys
Case 3
History: Infertility, endometriosis, dysmenorrhea, pelvic pain
Follow up: Laparoscopy revealed adhesions of L adnexa and posterior broad
ligament to the sigmoid colon with L tube encased in dense adhesions.
Case 4
History: infertility, 3
pregnancies with 1
surviving child,
normal menstruation
Case 5History: Infertility, amenorrhea
Additional history: Recent immigration from India, prior treatment for TB in the
sacral spine region
Follow up: Hysteroscopy performed for diagnosis and treatment. Adhesions too
dense for adhesiolysis and dilation. Procedure terminated. Biopsies negative but
presumed cause of genital tract TB based on HSG and hysteroscopy findings.
Asherman’s Syndrome = infertility + amenorrhea + severe uterine synechiae
Case 6History: multiple spontaneous
abortions
Follow up: Prior treatment for HPV.
Hysteroscopy with lysis of adhesions
followed by successful pregnancy.
Case 7
History: infertility, abdominal
pain, dysmenorrhea
Case 7 CT
Follow up: Laparoscopy, lysis of adhesions, and multiple
partial myomectomies performed.
Path = leiomyomata and a benign serous cyst
Case 8
History: 4 second term
miscarraiges, 1 full-term
C-cection, 1 (maybe
more) D & Cs
Findings?
Right free spill
Left tube obstructed
Intravasation
Likely fibroid in fundus
Duplication cyst or
other congenital cyst
communicating with
vagina; vesicovaginal
fistula could be
considered in proper
clinical setting
Case 8 Continued
Case 8 Continued
Case 9History:
Oligomenorrhea,
infertility
Case 10
History: Infertility
Case 10 Continued
Case 11
History: Infertility
Case 11 Continued
Case 11 Continued
History: Post resection of uterine
septum, miscarriage
Case 12
History: Infertility, dysmenorrhea, pelvic pain
Case 13
Case 14
75% septated uterus, prior R cornuostomy for cornual pregnancy
HSG For Essure Confirmation
Prelim– Include calibration device for measurements
– R or L marker
Minimal filling of uterine cavity
Partial filling of uterine cavity
Full distention of uterine cavity– Induces mild cramping
– True AP uterus
Magnified Left cornu
Magnified Right cornu
HSG For Essure Confirmation
Essure Micro-inserts
http://www.obgmanagement.com/images/supplements/Oct08/SupplOBG_1008_CON-O-1-fig1.jpg
1
2
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HSG Results
Tube occluded
Rely on
Device spans UTJ with 2nd
marker in cornu
Less than 50% of device is intrauterine
Device in tube & 2nd marker is
<30mm from UTJ
Do not rely on
More than 50% of
device is intrauterine
Device in tube & 2nd marker is
>30mm from UTJ
Tube patent
Do not rely on
Acceptable placement
Repeat HSG in 6 months
Tube occluded
Rely on
Tube patent
Do not rely on
Explore alternatives
Unacceptable placement
Explore alternatives
Essure Fails
Essure Fails
Questions?
References
Ott, DJ and Fayez, JA. Hysterosalpingograpy. Baltimore: Urban & Schwarzenberg, 1991.