HSG Case Review - srpeweb.org

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

34

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?

leslie.partridge@osumc.edu

References

Ott, DJ and Fayez, JA. Hysterosalpingograpy. Baltimore: Urban & Schwarzenberg, 1991.