HSG and FTR Procedure PDF

HSG AND FTR Quick Anatomical Review  The female reproductive organs are divided into: An internal group lies in the true pelvis. An external group lies below& in front of the pubic arch. The internal organs are: Two ovaries. Two uterine (fallopian) tubes. Uterus. Vagina....

HSG AND FTR Quick Anatomical Review  The female reproductive organs are divided into: An internal group lies in the true pelvis. An external group lies below& in front of the pubic arch. The internal organs are: Two ovaries. Two uterine (fallopian) tubes. Uterus. Vagina. The external organs are: Collectively called the The Ovaries: The ovaries are female “Sex Glands”& they lie, one on each side of the uterus. Each is attached to the upper layer of a peritoneal fold, called the broad ligament of the uterus. Each ovary is about 3cm in length, 1.5 cm in width & 1cm thick. The structure of the ovaries: Each ovary is composed of: an outer zone called the cortex. an inner zone called the medulla. The Uterine (Fallopian) Tubes: The uterine tubes lie in the upper margins of the broad ligament of the uterus. They are each about 10cm in length& they serve to transmit the ovum from the ovary to the uterus. Fallopian tubes divided, for descriptive purpose, into four parts: The infundibulum. The ampulla. The isthmus. The uterine portion. Structure of the Uterine Tubes: The uterine tubes are composed of three coats: Outer serous coat. Middle muscular coat. Inner mucous coat. The Uterus: The uterus is a hallow, pear shaped muscular organ, which is approximately 7.5cm in length, 5cm in width& 2.5cm in thick. It’s divided for descriptive purposes, into two parts: Body –corpus- of the uterus. Cervix of the uterus. The structure of the uterus: Uterus is composed of three layers: Outer serous coat. Middle muscular coat. Inner mucous coat. The ligament of the uterus: The uterus is supported by several ligaments: The broad ligament. The round ligament. The anterior& posterior ligament. The vagina: The vagina is a fibromuscular canal, about 7.5cm in length, which extends from the vulva to the uterus. The structure of the vagina: The vagina is composed of three coats: - Outer coat of loose areolar tissue. -Middle coat of smooth muscle. - Inner coat of mucous membrane.  Hysterosalpingography is the radiographic evaluation of uterus and fallopian tubes under fluoroscopic guidance.  Indications 1. Infertility (main role) 2. Recurrent spontaneous abortions 3. Congenital anomalies of uterus 4. Following tubal surgery 5. Migrated IUCD 6. Uterine and tubal lession like tuberculosis, polyps, submucosal fibroids Migrated IUDs  Contraindication  Suspected pregnancy  Acute pelvic infection  Active vaginal bleeding  Recent dilation and curettage  Immediate pre and post menstrualphase  Tubal or uterine surgery within last 6wks  Contrast sensitivity  Severe renal / cardiac diseases  Purulent vaginal discharge  Patients Preparation: -An HSG is usually scheduled within 2-5 days after the period ends (day 7-10 of the menstrual cycle) and before ovulation (day 14 of the cycle) to avoid exposing the uterus to radiation and X-ray dye, if the woman is pregnant. - abstain from intercourse to avoid irradiation. -Fasting for 4 hrs prior to procedure. - Tell your doctor before the test if you: - are allergic to X-ray dye (iodine), any medications or foods. - are asthmatic. - are taking any medications. - have any bleeding disorders.  CONTRAST MEDIA A. Water soluble media UROGRAFFIN 60%, CONRAY 280, TRIVIDEO 280. VOLUME 10-20 ML B. Oily contrast media   Lipiodol was gradually replaced by water soluble contrast media for several reasons Lipiodol is 40% iodine in poppy seedoil manufactured by guerbert ,france  Why water soluble contrast media are preferred?  CONTRAST MEDIA  LIPID SOLUBLECONTRAST  WATER SOLUBLECONTRAST  (lipiodol)  (iohexol-omnipaque,meglumine  Sharp image  diatrizoate-urograffin  Minimal pain  Ampullary rugae clearly  Delayed absorption visualised  Risk of lipogranuloma  Gets absorbed within hours, formatation in case of tubal does not leave residue block or hydrosalpinx  Granuloma formation rare  Intravasation of contrastand  Pain persists after procedure  Prompt demonstration of tubal  possible risk of oil embolism patency, delayed film not  Need of delayed film needed.  Pregnancy rate doubled Widely used andpreferred  Less oftenused Contrast media, 20 cc syringe, canula- leech wilkinson, jarcho type, spackman, uterine sound and dilator, sims speculum, vulsellum forceps, fluoroscope machine. CONTAINS: Inner Tray for Povidone - Iodine Solution Disposable Speculum Povidone-Iodine Solution (2 packets) Disposable Cervical Dilator 36" Extension Tube Three Swab Sticks 20cc Syringe with 18-Gauge Needle One Wide Swab Lubricating Jelly Packet Sterile Wrap Two 3" x 3" Pads  Patient Position:  Lithotomy Position:  “A recumbent (supine) position knees and hip flexed and thighs abducted and rotated externally, supported by ankle supports.”  Technique  Using a canula  Using foley’s catheter Using canula:  Patient is positioned in lithotomy position.  A speculum is introduced into vagina and anterior lip of cervix is held with tenaculum and traction is applied  Canula is inserted into cervical canal  Now speculum is removed  Inject contrast media 2ml under fluoroscopy to outline uterine cavity  CM can be injected slowly govern by patient’s tolerance until the oviduct is outlined, and free intra peritoneal spill of dye is visible Using foley’s catheter a method using 8 F Foley's catheter. The cervix is exposed with a vaginal speculum and swabbed with an antiseptic solution with the patient in lithotomy position. After the lumen of the catheter is filled with the contrast (to prevent air bubbles) the catheter is inserted through the cervical os using a cervical forceps to guide it when the ballon lies within the uterine cavity, it is gently inflated with water (2-3 ml). Before the injection of contrast, the ballon is pulled downwards against the internal os. The speculum is withdrawn and the catheter is attached to the syringe. The patient assumes a more relaxed supine position. Contrast injection and filming is same as with using a canula.  Radiation protection  Max. screening must not exceed 30 sec.  Exposure level should be kept as low as possible(Alara)  70-90 kVp range  Four films are taken 1.Early filling 2. Uterus fully phase distended 3.Tubalfilling phase 4.Peritoneal spillage  AFTER CARE  Check that the patient is not serious discomfort before she leaves  Patient must be cautioned that she might have mild bleeding per vaginal for 1-2 days  For mild pain analgesic may be given  Complications  Pain (because of dilatation ofuterus , spillage into peritonium).  Infection (pelvic).  Bleeding.  Vascular or lymphatic intravasation  Vasovagal episode.  Pregnancy irradiation.  Allergic reaction (to iodinated contrastmedia).  Uterine perforation  DETECTABLE PATHOLOGY  UTERINE  TUBAL 1. Uterine anomaly 1. tubal block 2. Fibroid ( 2. Tubal spasm submucosal) 3. Tubal polyp 3. Adenomyosis 4. Endometrial polyp 4. Hydrosalpinx 5. Intrauterine 5. Salpingitis adhesions/synaec isthmic hiae nodosum (SIN) 6. Endometrial TB 6. Peritubal 7. Cervical adhesions incompetence 7. TB salpingitis  NON PATHOLOGIC FINDINGS Air bubble- round, often multiple,welldefined mobile filling defect ,usually displaced to fallopian tubes if additional contrastsgiven Normal myometrial folds-longitudinal folds with parallel orientation touterine cavity Prominent cervical glands-tubular structure with their origin in both cervical walls Previous caeserean sectionscar  Luminal filling defects  Common finding.  Includes :  Air bubbles  Uterine folds  Synechiae  endometrial polyp  submucosal fibroid Spot radiograph shows air bubbles (arrow) in the left side of theuterus.  Filling defects on consecutive images at the uterine fundus, that disappear progressively after the administration of contrast, compatible with air bubbles. HSG spot radiograph demonstrates uterine folds (arrows) as linear filling defects that parallel the longitudinal axis of the uterus. Uterine folds are normal findings that are occasionally seen at HSG. PROMINENT CERVICAL GLANDS Spot radiograph shows the uterine incision from a cesarean section (arrows) in the typical location (i.e., oriented transverse in the lower uterine segment in the region of the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum. RIGHT SUBMUCOSAL MYOMA RIGHT SUBMUCOSALMYOMA  HSG FINDINDS IN GENITAL TUBERCULOSIS  FALLOPIAN TUBES ❖ SPECIFIC Beaded UTERUS tube Golf club tube ❖SPECIFIC Pipestem tube T shaped uterus  Cobblestone tube Pseudounicornuateuterus  Leopard skin tube Trifoliate uterus T –SHAPED TB UTERUS Cobblestone tube TRIFOLIATE SHAPED UTERUS FTR  Fillopian tube recanalisation  Fallopian tube recanalization (FTR) is a nonsurgical procedure to clear blockages in the fallopian tubes, part of a woman's reproductive system  A guide wire is passed through a catheter to recannulate the tube and to restore its potency.  Indications  Unilateral/ bilateral cornual block proved by HSG(especially if the blockage is close to the entrance to the uterus (proximal).  laparoscopy with chromotubation Contra indications 1) Tubal blockage distal to the cornual end 2) Patient with tubal pathology- hydrosalpinx, abdominal fimbriae. 3) History with tubal surgery 4) With history of PID causing dense adhesions and scarring Timings of study  Follicular phase between 8th and 10th day after onset of menstruation is selected Instrumentation  X ray machine with fluoroscopy advantage  Fallopian tube catheterization set: - Double ballon canula - Catheter - 0.0028 F terumo guide wire  Contrast media- triovideo 280/ conray 280 Preperation  Bladder should be emptied before procedure  Abstain from intercourse between booking appointment Premedications  Atropine – half an hour before procedure  suitable antibiotic- doxycyclin  5-10 mg i.v diazapam is given to remove the anxiety Procedure  Canula is inserted through the cervix into the uterus and inflation of the two bulb, one at the level of internal Os and other at the level of cervical canal.  CM is injected to detect the blockage  Under fluro guide a catheter is advanced through the canula into the opening of fallopian tube  A guidewire is introduced through the catheter till it comes at the fimbrial end thereby dislodging the obstruction  2-3 ml of CM is injected to verify the recanalisation  The process is repeated if there is a block in the bilateral side Over view of FTR by guidewire ,  No controlled studies were identified.  In one study, successful recanalisation was reported in 77% (321/417) of the tubes of 302 patients. Thirty (10%) of these 302 patients became pregnant without further infertility treatment within 12 months of undergoing the procedure. In another study, successful recanalisation was reported in 75% (176/234) of patients. Of these, 22% (39/176) had subsequent live births. By- Interventional procedures overview of fallopian tube recanalisation by guidewire , NATIONAL INSTITUTE FOR CLINEXCELLEN ICAL CE INTERVENTIONAL PROCEDURES PROGRAMME. Bazian Ltd in May 2003  Other methods  Hysteroscopic placement of catheters with laproscopic guidance  Sonologically guided transvaginal fallopian tube catheterisation Post procedure follow up  Admit the patient and observe for 12hrs for signs of perforation leading to peritonitis  Antibiotic cover Complications  Ectopic pregnancy (10%) in history of tubal disease  Perforation and fistula formation  Early tubal reocclusion and strictures THANK YOU