HSG 1.pdf

HYSTEROSALPINGOGRAPHY HSG The student should learn -the indications of HSG -contraindications of HSG Also the procedure indication 1. Infertility—to assess tubal patency 2. Recurrent miscarriages—investigation of suspected incompetent cervix, suspected congeni...

HYSTEROSALPINGOGRAPHY HSG The student should learn -the indications of HSG -contraindications of HSG Also the procedure indication 1. Infertility—to assess tubal patency 2. Recurrent miscarriages—investigation of suspected incompetent cervix, suspected congenital anomaly of uterus 3. Following tubal surgery to establish tubal patency, post sterilization to confirm obstruction and prior to reversal of sterilization 4. Assessment of the integrity of a cesarean uterine scar (rare) Contraindications 1. During menstruation 2. Pregnancy or unprotected intercourse during the cycle 3. A purulent discharge on inspection of the vulva or cervix, or diagnosed pelvic inflammatory disease (PID) in the preceding 6 months 4. Contrast sensitivity (relative) Contrast Medium High osmolar iodinated contrast material (HOCM) or low osmolar iodinated contrast material (LOCM) 270/300 mg I mL−1 10–20 mL. The contrast medium Equipment should be pre warmed to body temperature to avoid tubal spasm Equipment 1. Fluoroscopy unit with spot film device 2. Vaginal speculum 3. Vulsellum forceps 4. Hysterosalpingography balloon catheter 5-F to 7-F. In patients with narrow cervix or stenosis of cervical os, Margolin hysterosalphingography (HSG) cannula may be used. It has a silicone tip and provides tight occlusion of the cervix for contrast injection. Patient Preparation 1. The appointment is made before day 21, or the examination can be booked between the 4th and 10th days in a patient with a regular 28-day cycle. 2. The patient should abstain from unprotected intercourse between booking the appointment and the time of the examination. 3. Apprehensive patients may need premedication. Analgesics before procedure may also help. 4. Informed consent should be obtained. Technique 1. The patient lies supine on the table with knees flexed, legs abducted. 2. The vulva can be cleaned with chlorhexidine or saline. A disposable speculum is then placed using sterile jelly, and the cervix is exposed. 3. The cervical is identified using a bright light, and the HSG catheter is inserted into the cervical canal. It is usually not necessary to use a Vulsellum forceps to hold the cervix with forceps, but occasionally this may be necessary. The catheter should be left within the lower cervical canal if cervical incompetence is suspected. 4. Care must be taken to expel all air bubbles from the syringe and cannula, as these would otherwise cause confusion in interpretation. Contrast medium is injected slowly into the uterine cavity under intermittent fluoroscopic observation. Spasm of the uterine cornu may be relieved by intravenous (i.v.) Buscopan or glucagon if there is no tubal spill bilaterally. Prewarming the contrast medium to body temperature and injecting slowly may also help avoid tubal spasm. Note: Opiates increase pain by stimulating smooth muscle contraction. Images The radiation dose should be kept as low as possible. Intermittent screening should be performed to the minimal requirement. Images should demonstrate the following: 1. Endometrial cavity, demonstrating or excluding congenital abnormalities or filling defects. 2. Full view of the tubes demonstrating spill. If occluded, show the extent and level of block. 3. If there is abnormal loculation of contrast, a delayed view may be useful Aftercare 1. It must be ensured that the patient is in no serious discomfort nor has significant bleeding before she leaves. 2. The patient must be advised that she may have spotting or occasional vaginal bleeding for 1–2 days and pain which may persist for up to 2 weeks. 3. Prophylactic broad-spectrum antibiotics are routinely given in several centres and are good practice. Complications Due to the contrast medium Allergic phenomena—especially if contrast medium is forced into the circulation. Due to the technique 1. Pain may occur at the following times: (a) When using the speculum (b) During insertion of the cannula or inflation of balloon, some patients may have developed vasovagal syncope—’cervical shock’. (c) Uterine or tubal distension proximal to a block or spasm (d) With peritoneal irritation during the following day, and up to 2 weeks 2. Bleeding from trauma to the uterus or cervix 3. Transient nausea, vomiting and headache 4. Intravasation of contrast medium into the venous system of the uterus results in a fine lace-like pattern within the uterine wall. It is of little significance when watersoluble contrast medium is used. Intravasation may be precipitated by direct trauma to the endometrium, timing of the procedure near to menstruation or curettage, tubal occlusion or congenital abnormalities. 5. Infection—which may be delayed. Occurs in up to 2% of patients and is more likely when there is a previous history of pelvic infection. Thank you for listening