hysterosalpingography
Post on 22-Jan-2017
1.833 Views
Preview:
TRANSCRIPT
May 1, 2023
DR. PRADOSH KUMAR SARANGI
HYSTEROSALPINGOGRAPHY
UNDER GUIDANCE OFDR JAYASHREE MOHANTYDR SASMITA PARIDADR B M SWAINDR KALYANI PARIDA
1
May 1, 2023 2
HYSTEROSALPINGOGRAPHY
Hysterosalpingography is the radiographic evaluation of uterus and fallopian tubes under fluoroscopic guidance.
May 1, 2023 3
INDICATION
1. Infertility (main role)2. Recurrent spontaneous abortions3. Congenital anomalies of uterus 4. Postoperative evaluation following (a)tubal
ligation (b) reversal of tubal ligation5. Suspected case of genital tuberculosis6. To prove tubal occlusion after insertion of
transcervival sterilization microinsert (essure)HSG also has a potential therapeutic role in increasing the probability of pregnancy ( especially if oil soluble contrast –lipiodol is used)
May 1, 2023 4
CONTRAINDICATION
• Suspected pregnancy• Acute pelvic infection• Active vaginal bleeding• Recent dilation and curettage• Immediate pre and post menstrual phase• Tubal or uterine surgery within last 6 wks• Contrast sensitivity
May 1, 2023 5
PATIENT PREPARATION• Done in first half of menstrual cycle in proliferative
phase between 8th to 12th day• Patient to avoid unprotected sexual intercourse from
the date of her period until investigation is over to avoid possible risk of pregnancy
• If periods are irregular , do urine b- hcg test to rule out pregnancy
• Exclude active pelvic infection• Prophylactic antibiotics not routinely recommended
(considered in case of bacterial endocarditis)
May 1, 2023 6
PROCEDURE• Informed consent is taken• Antispasmodic (im drotin) given before procedure.• Patient is asked to empty bladder immediately before
procedure• Scot film may be taken.• Patint is placed in lithotomy position• The perineum is cleaned with antiseptic solution (Betadine)and
draped with sterile towel. The cervix is localized and cleansed with povidone-iodine solution. A speculum is inserted into the vagina. Cervix is cannulated with any of available cannulas which is made air free before administration of contrast
May 1, 2023 7
PROCEDURE ....• Tenaculm is used to hold anterior lip of cervix .• Speculum is removed & Patient is placed in slight
trendelenburg position and contrast is slowly given• 3 ml contrast to fill uterine cavity and another 3 ml to fill tube.
( up to 10 ml)• 4 spot films are taken• Additional oblique views may be taken for optimal
visualisation of pelvic pathology and tortuous fallopian tubes( to see retroverted or anteverted)
• After end of the procedure , antibiotic course is given and patient is informed about vaginal spotting for 1-2 days
May 1, 2023 8
COMPLICATION
• Pain (because of dilatation of uterus , spillage into peritonium).
• Infection (pelvic).• Bleeding.• Vascular or lymphatic Intravasation• Vasovagal episode.• Pregnancy irradiation.• Allergic reaction (to iodinated contrast media).• Uterine perforation
May 1, 2023 9
HISTORY OF HSG
• First report on HSG using oil soluble contrast (collargel) published by Carey in 1914.
• Collargel – significant tissue damage and painful
• Because of these serious adverse events, its use was abandoned and a tubal insufflation test was introduced by Rubin in 1920 (Rubin, 1920)
May 1, 2023 10
HISTORY....
• Rubin insufflated oxygen (later carbon dioxide) under pressure through the cervical canal into the uterine cavity. Tubal patency was determined by presence of air under the diaphragm on X-ray, by auscultation of air flow into the abdomen or a drop in pressure during insufflation
• Heuser was the first to report on the use of lipiodol in HSGs (Heuser, 1925)
• Lipiodol- oil soluble, low viscosity, less toxic, became widely accepted
May 1, 2023 11
• Lipiodol was gradually replaced by water soluble contrast media for several reasons
LIPIODOL is 40% iodine in poppy seed oil Manufactured by guerbert ,france
WHY WATER SOLUBLE CONTRAST MEDIA ARE PREFERRED ?
May 1, 2023 12
CONTRAST MEDIALIPID SOLUBLE CONTRAST (lipiodol)
• Sharp image • Minimal pain• Delayed absorption • Risk of lipogranuloma
formatation in case of tubal block or hydrosalpinx
• Intravasation of contrast and possible risk of oil embolism
• Need of delayed film• Pregnancy rate doubled • Less often used
WATER SOLUBLE CONTRAST (iohexol-omnipaque,meglumine diatrizoate-urograffin
• Ampullary rugae clearly visualised
• Gets absorbed within hours, does not leave residue
• Granuloma formation rare• Pain persists after procedure• Prompt demonstration of
tubal patency, delayed film not needed.
• Widely used and preferred
May 1, 2023 13
INSTRUMENTS
tenaculum Hegar dilator
Speculum
leech wilkinson cannula
Sponge holder
May 1, 2023 14
Different types of cannula used
1. leech wilkinson cannula 2. acorn tip metallic cannula 3.cervical vaccum cup 4. balloon catheter or pediatric foley’s catheter
6F
May 1, 2023 15
WHICH ONE IS BETTER??
• Cervical vacuum cup vs metal cannula: Shorter length of time less fluoroscopic time small amount of contrast needed less pain ( no need to grasp cervix) Easier for physician to use Uterus cant be easily manipulated Need to reapply cannula Superior to metal cannula
Cervical vacuum cup
Cohen et al (British Journal of Obstetrics and GynaecologyOctober 2001, Vol. 108, pp. 1031–1035)
May 1, 2023 16
BALLOON CATHETER VS METAL CANNULA
Less fluoroscopic timeSmall amount of contrastLess painEasier for physician to useGood seal at cervixSingle use/disposable(costly)Superior to metal cannula
BALLOON CATHETER
Tur-kaspa et al (Human Reproduction vol.13 no.1 pp.75–77, 1998)
May 1, 2023 17
• Balloon catheter obscures lower uterine segment. Need to be deflated to visualise lower segment
• Balloon catheter better tolerated over cervical cup
May 1, 2023 18
Cervical vacuum cup cannula
May 1, 2023 19
Acorn tip metal cannula
May 1, 2023 20
BALLOON CATHETER
May 1, 2023 21
NORMAL HSG• The uterine cavity is shown
during HSG as a triangular contrast-filled structure, with its base on top and the apex caudally (inverted triangle) and the uterine fundus on top, which can be flattened, concave or slightly convex . -free spillage of the contrast to the peritoneum noted
May 1, 2023 22
At least 4 spot films taken
4.Peritoneal spillage
2. Uterus fully distended
1.Early filling phase
3.Tubal filling phase
NORMAL HSG
May 1, 2023 23
DETECTABLE PATHOLOGY
UTERINE1. Uterine anomaly2. Fibroid ( submucosal)3. Adenomyosis4. Endometrial polyp5. Intrauterine
adhesions/synaechiae6. Endometrial TB7. Cervical incompetence
TUBAL1. tubal block2. Tubal spasm3. Tubal polyp4. Hydrosalpinx5. Salpingitis isthmic
nodosum (SIN)6. Peritubal adhesions7. TB salpingitis
May 1, 2023 24
NON PATHOLOGIC FINDINGS
• Air bubble- round, often multiple, welldefined mobile filling defect ,usually displaced to fallopian tubes if additional contrasts given
• Normal myometrial folds-longitudinal folds with parallel orientation to uterine cavity
• Prominent cervical glands-tubular structure with their origin in both cervical walls
• Previous caeserean section scar
May 1, 2023 25
Luminal filling defects
• Common finding.• Includes : Air bubbles Uterine folds Synechiae endometrial polyp submucosal fibroid
May 1, 2023 26
Spot radiograph shows air bubbles (arrow) in the left side of the uterus.
AIR BUBBLE
May 1, 2023 27
Filling defects on consecutive images at the uterine fundus, that disappearprogressively after the administration of contrast, compatible with air bubbles.
DISAPPEARS
May 1, 2023 28
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.
UTERINE FOLDS
May 1, 2023 29
PROMINENT CERVICAL GLANDS
May 1, 2023 30
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.
CESAREAN SECTION SCAR
May 1, 2023 31
UTERINE ANOMALIESclass anomalyi Partial / complete agenesisii Unicornuateiii Didelphysiv BicornuateV SeptateVi Arcuatevii DES-associated anomalies
AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE
May 1, 2023 32
May 1, 2023 33
Diagnosis: unicornuate uterus. Description: one cornua , one tube , one spillage.
May 1, 2023 34
UNICORNUATE UTERUS
Single right uterine horn with single right fallopian tube. Right side spillage seen
May 1, 2023 35
UTERUS DIDELPHYS 2 Uterine cavities, 2 cervical canals, 2 vagina..(nonfusion of the two Müllerian ducts.)
VAGINAL SEPTUM
May 1, 2023 36
UTERUS DIDELPHYS
May 1, 2023 37
BICORNUATE UNICOLLIS
2 uterine cavities, 1 cervical canalIncomplete fusion of the cephalad extent of the uterovaginal horns with resorption of the uterovaginal septum.
1 CERVIX
May 1, 2023 38
BICORNUATE UNICOLLIS UTERUS
May 1, 2023 39
BICORNUATE BICOLLIS
May 1, 2023 40
Spot radiograph shows two markedly splayed uterine horns. BICORNUATE UTERUS
May 1, 2023 41
BICORNUATE UNICOLLIS
> 100 degree
May 1, 2023 42
UTERUS DIDELPHYS2 uterus2 cervix2 vagina
UTERUS BICORNIS BICOLLIS2 uterus2 cervix1 vagina
May 1, 2023 43
DES-related uterine anomaly. Hysterosalpingogram demonstrates a hypoplastic T-shaped uterus. The patient had been exposed to DES while in utero.
May 1, 2023 44
ARCUATE UTERUS
Depression of uterine fundus
May 1, 2023 45
SEPTATE UTERUS: PARTIAL AND COMPLETE
There is incomplete resorption of the final fibrous septum between the two uterine horns.
SEPTUM
PARTIAL COMPLETE
May 1, 2023 46
SEPTATE UTERUS
May 1, 2023 47
slight separation (forming acute angle). SEPTATE UTERUS
May 1, 2023 48
Bicornuate and Septate Uteri• Bicornuate:– Fundus indented– Cavities widely
separated( > 100 degree)– Partial fusion of
mullerian ducts
• Septate:– Normal external surface– Cavities are close
together– Defect in canalization or
resorption of midline septum between mullerian ducts.
HSG cant differentiate these two. Definite diagnosis by MRIIntervening cleft > 1 cm & intercornual distance > 5cm in bicornuate uterus
May 1, 2023 49
ADENOMYOSIS
Irregular outline, multiple diverticulum (arrows)
May 1, 2023 50
FIBROID UTERUS
Multiple filling defects
May 1, 2023 51
RIGHT SUBMUCOSAL MYOMA
May 1, 2023 52
SALPINGITIS ISTHMICA NODOSA
• Out pouchings of isthmus• Unilateral or bilateral• Unknown cause• Associated with infertility, PID and ectopic
pregnancy
May 1, 2023 53
SALPINGITIS ISTHMIC NODOSUM (SIN)
small outpouchings or diverticula from the isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral.
May 1, 2023 54
LEFT SALPINGITIS ISTHIMICA NODOSUM
Multiple outpouchings from isthmus ( arrow)
May 1, 2023 55
RIGHT HYDROSALPINXSteep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes
May 1, 2023 56
BILATERAL HYDROSALPINX
May 1, 2023 57
TUBAL POLYP
small filling defect (arrow) in the proximal left fallopian tube, a finding that typically represents a tubal polyp
May 1, 2023 58
TUBAL POLYP . (FILLING DEFECT)
May 1, 2023 59
Dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation.
LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION
May 1, 2023 60
Cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation).
TUBAL LIGATION
May 1, 2023 61
A round collection of contrast material adjacent to the left fallopian tube, a finding that suggests peritubal adhesions. Note the free contrast material spillage on the right side.
LEFT PERITUBAL ADHESION
May 1, 2023 62
SYNECHIAE
• Intra uterine adhesions• Post curettage and infection• Linear filling defect • Arising from one of the uterine walls• Multiple+infertility= Asherman syndrome
May 1, 2023 63
Central oval filling defect within the uterus SYNECHIAE
May 1, 2023 64
SYNECHIAEMultiple irregular filling defects in uterine cavity
May 1, 2023 65
Right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image
CORNUAL SPASM
May 1, 2023 66
LEFT CORNUAL SPASM
May 1, 2023 67
B/L FALLOPIAN TUBE LIGATION
No peritoneal spillage of contrast
May 1, 2023 68
VASCULAR INTRAVASATION
May 1, 2023 69
Irreversible tubal occlusion with a microinsert. Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube.
SCOUT FILM
May 1, 2023 70
Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion.
May 1, 2023
HSG FINDINDS IN GENITAL TUBERCULOSIS
FALLOPIAN TUBES UTERUS SPECIFICBeaded tubeGolf club tubePipestem tubeCobblestone tubeLeopard skin tube NON SPECIFICHydrosalpinxMucosal thickeningPeritubal adhesion
SPECIFICT shaped uterusPseudounicornuate uterusTrifoliate uterusNONSPECIFICendometritisSyneciaedistortion of uterine
contourVenous, lymphatic
intravasation71
May 1, 2023 72
TUFTED TUBE Multiple small diverticular like appearance surrounding the ampulla produced by caseous ulceration gives the tubal outline a Rosette-like appearance
May 1, 2023 73
TB SIN-likePenetration of contrast medium between the mucosal folds produces small diverticular-like outpouchings with a bizarre pattern. Entire of both tube involved (arrows).
May 1, 2023 74
cotton-wool plug appearanceDistribution of contrast medium in a reticular pattern producing a " cotton-wool plug" appearance [arrow]
May 1, 2023 75
BEADED TUBE
Multiple constrictions along the fallopian tube giving rise to a " beaded" appearance [arrows]
May 1, 2023 76
GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an associated hydrosalpinx giving a Golf club-like appearance (arrows).
May 1, 2023 77
PIPE STEM APPEARANCE
Absence of normal tortuosity and a curved or straight pipe like appearance show fibrotic stage of tuberculous salpingitis. Irregular contour of the uterine cavity with diminished capacity in the fundual portion resembling a septate uterus.
May 1, 2023 78
FLORAL APPEARANCE
Twisted hydrosalpinx resembles a floral appearance of left side tube (arrow).
May 1, 2023 79
LEOPARD SKIN APPEARANCEMultiple rounded filling defects following intraluminal granuloma formations within the hydrosalpinx, resembling a " leopard skin" appearance [arrows]
May 1, 2023 80
COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone like appearance which is an effective radiographic sign of intraluminal adhesions
May 1, 2023 81
CORK SCREW APPREANCE
Vertically fixed tubes secondary to dense peritubal adhesions. Dense connective tissue causes the lack of tubal mobility. The hyperconvulated right tube and manifests a " cork screw" like appearance [arrows]
May 1, 2023 82
PERITUBAL HALO
Thickening of the tubal walls due to peritubal adhesions (arrows) represents a cloudy sign on hysterosalpingograms. This finding is a non-specific feature of tubal tuberculosis.
May 1, 2023 83
TOBACCO POUCH APPREANCE
Terminal hydrosalpinx with the conical narrowing is seen in the right tube (arrow). Eversion of the fimbria secondary to adhesions, with a patent orifice produces the tobacco pouch appearance in the left terminal.
May 1, 2023 84
A.Uterine cavity is normal in shape and size. Terminal sacculation are seenin both tubes. B. Irregularity, multiple filling defects and obliteration of right ostium secondary to extensive synechiae formation in this site. Obstruction of left tube is also seen.
A B
INTRAUTERINE ADHESION AND DISTORTION
May 1, 2023 85
A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an asymmetric intrauterine obliteration, resembling a unicornuate uterus. the irregular contour and vertical orientation of long axis. B. True unicornuate uterus. the smooth contour, more horizontal orientation of long axis and normal ipsilateral fallopian tube.
May 1, 2023 86
T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
T-shaped configuration in two different patients. A. " T-shaped" tuberculosis uterus. Irregular contour of the uterine cavity with diminished capacity resembling a T-shaped uterus. Both tubes are obstructed from isthmic portion.B. T-shaped uterus due to DES exposure. Narrow endocervical canal and small uterine cavity. Note both tubes are normal.
May 1, 2023 87
TRIFOLIATE SHAPED UTERUS
Synechiae formation at the uterine borders and partial obliteration in the fundus produce a trifoliate like appearance. Both tubes are obstructed in the isthmic portion
May 1, 2023 88
DIAGNOSTIC ACCURACY(Hsg vs laparoscopy)
• Hsg-minimally invasive -superior to laparoscopy for detecting intrinsic
tubal and uterine pathology. - false negative rate due to undected
peritubal adhesion,incomplete filling of a dilated hydrosalpinx
- false positive rate due to tubal spasm, inadequate contrast injection
both are complementary methods in evaluation of infertility
May 1, 2023 89
Thank
You
top related