Hysterosalpingography

HISTEROSALPINGOGRAPHY

Lesson objectives

• Defination
• Anatomy
• Indication
• Contraindication
• Patient preparation
• Equipment
• Procedure
• Complications
• Radiographic anatomy
• Common pathology

reference

defination

Hysterosalpingography is a radiological examination of the uterine cavity and the fallopian tubes following injection of a suitable contrast agent through the cervical canal under fluoroscopy.

Anatomy

Uterus

The uterus is located inside the pelvis immediately dorsal to the urinary bladder and ventral to the rectum. The human uterus is pear-shaped and is about 3 in. (7.6 cm) long. The uterus can be divided anatomically into four segments: The fundus, body, cervix and the vaginal canal.

The layers of the uterus from innermost to outermost include the endometrium,myometrium and the parametrium The endometrium is the inner most layer and it consist of the outer layer which is the basal layer known as the stratum basalis and the inner layer is the functional layer which is the stratum functionalis made up of stratum compactum and stratum spongiosum. The functional layer is shade of during menses and damage to the basal endometrium results in adhesion formation and/or fibrosis (Asherman's syndrome).

Hysterosalpingography

The uterus mostly consists of smooth muscle, known as "myometrium." The innermost layer of myometrium is known as the junctional zone, which becomes thickened in adenomyosis.

Parametrium is the outermost layer which is the loose connective tissue around the uterus.

• Perimetrium

The peritoneum covering of the fundus and ventral and dorsal aspects of the uterus

The fallopian tubes

The fallopian tubes are uterine appendages located bilaterally at the superior portion of the uterine cavity. These tubes exit the uterus through an area referred to as the cornua, forming a connection between the endometrial and peritoneal cavities.

Each uterine tube is approximately 10 cm in length and 1 cm in diameter and is situated within the mesosalpinx

Hysterosalpingography

A uterine tube contains 3 parts. The first segment, closest to the uterus, is called the isthmus. The second segment is the ampulla; it is more dilated in diameter and is the most common site for fertilization.

The final segment, located farthest from the uterus, is the infundibulum. The infundibulum gives rise to the fimbriae, fingerlike projections that are responsible for picking up the egg released by the ovary (Marieb, 2010).

Indications

• Congenital abnormalities.
• Primary infertility
• Recurrent spontaneous abortions
• Previous ectopic pregnancy
• ?Presence of mass
• -intraluminal mass
• -intrauterine mass
• -polyps

To monitor the effects of tubal surgery

Contra indications

• Suspected pregnancy, ectopic pregnancy
• Recent birth
• Known ruptured tube
• Inflammation- salpingitis, vagnitis, cervitis

Acute vaginal bleeding

Recent gyneological surgery Immediate pre and post ovulation phase- the examination is best performed at about the mid menstrual cycle

Patient preparations

Performed in the first half of the menstrual cycle following cessation of bleeding ,on the 10th day from the onset of menses,proliferation phase Patient should do ultrasound examinations and lab test before the examination.

• Explanation of the procedure to the pt.
• Pt asked to refrain from unprotected sex from onset of menses to before investigation
• Pt is asked to shave the pubic region if necessary
• Upon arrival patient should sign consent form
• Premedication in anxious pts; 5-10 mg of Diazepan given 30min before examination.

Ask pt to empty bladder immediately before exam and change into hospital gown

Contrast medium

• Isovue 200 mg/mls
• Optiray 320 / 350mg/mls

Urografin 76% – (10-20ml)

Equipment

• UPPERSHELF (sterile)
• Casco-vaginal speculum (Duck-bill / sims speculum )
• Vulsellum forceps
• Uterine sound
• Uterine cannula (Lisch Wilkinson cannula)
• Sponge holding forceps /Tissue forceps
• Syringes (10-20ml) and needle
• Gallipot
• Gauze swabs

Surgical gloves

LOWERSHELF (unsterile)

• Antiseptic solution e.g hibitane
• lubricating gel/ cream
• Ampoules of contrast media in warm water
• File for opening ampoules
• Pads/ tampon
• Emergency drugs

Torch

procedure

The patient should empty the bladder immediately prior to the investigation as a full bladder elevates the fallopian tubes and causes spurious appearance of tubal blockage.

The patient is placed in lithotomy position on the screening table before the examination.

• A prelimary ap film is taken
• The vulva is cleaned with antiseptic solution
• Vaginal speculum lubricated with gel is inserted, vagina and cervix are swabbed
• Anterior cervical lip is grasped using valsellum forceps

A uterine sound is then inserted to check for direction and depth of uterine cavity A uterine cannula is placed within the cervical canal and 10-20ml of contrast media is injected to outline the uterine cavity and tubes under fluoroscopy. Care must be taken to expel all air bubbles from the syringe and cannula.

Hysterosalpingography

Between 15-20mls of water soluble contrast media is introduced into the uterine cavity via a metallic canula and spot films taken.

An AP view of the pelvis is taken after 5-10mls was injected, during uterine filling, before the contrast opacification becomes too dense, in order to demonstrate small uterine filling defects and abnormalities

Hysterosalpingography

A second film is taken after another 5mls of contrast media was injected when the uterus and fallopian tubes are delineated and peritoneal spill is just occurring from the fimbrial ends. A further radiograph can be taken to show the pattern of peritoneal spillage after another 5mls of water soluble contrast media.

Additional views are done when necessary including oblique’s or lateral

aftercare

Tell patient that exam is over and give them a pad/ tampoon Insure pt is in no serious discomfort nor has significant bleeding before she leaves the department Patient is advised that she may have PV bleeding 1-2 days & pain may persist for upto 2weeks.

Ensure that patient recieves there results

complications

Slight risk of pelvic inflammatory disease (PID) resulting from bacteria introduced into the body through the procedure itself.

Uncommon risk of allergic reaction to contrast medium (hives, itching, low blood pressure) and very uncommon risk of uterine perforation.

Venous intravasation: this is a common complication. May be due to too forceful injection or performing the examination too soon after menstruation.

Infection – especially cross infection if instruments are not sterilised properly between patients.Pain – this can be severe on spillage of the contrast medium into the peritoneal cavity, occasionally causing fainting (Sutton 1998

Venous intravasation

The myometrial plexus is shown with drainage into the ovarian veins (arrowheads).

Radiographic anatomy

fibroids

Septated uterus

Polyposis,left hydrosalpinx

Bicornute uterus

Normal Uterine folds

Synechiae

Uniconuate uterus

Uterus bicornis bicollis

Production