introduction to hsg instruments indications contraindications preparations steps complications

1. Hysterosalpingography
SITTAL SIMKHADA
18TH M.B.B.S

2. Hysterosalpingography is an operative procedure used to assess
the interior anatomy of the uterus and tube including tubal
patency.
It is radiographic study and a contrast media is used.
The cavity is outlined by the injection of contrast medium
through cervix, shape and contour of uterine cavity is assessed
to detect any abnormalities

4. Indications
• To study the patency of fallopian tubes in infertility and post
operative tuboplasty
• To detect uterine anomalies such as septate and corunate
uterus
• To assess the feasibility of tuboplasty by studying the location
and extent of tubal pathology
• To detect uterine polyp
• To detect uterine synechiae (Asherman’s syndrome)
• To study incompetence of internal OS, recurrent miscarriages

5. Contraindications
• Vaginal bleeding and menses
• Purulent discharge on inspection, diagonsed PID in the last 6
months
• Pre menstrual phase (thick endometrium prevents smooth flow
of dye at cornual end and risk of endometriosis)
• Suspected pregnancy
• Tubal or uterine surgery within last 6 weeks
• Contrast sensitivity
• Genital tuberculosis
• Pelvic tenderness on bimanual examination

6. CONTRAST MEDIA
LIPID SOLUBLE CONTRAST (LIODOL) WATER SOLUBLE CONTRAST
(urographin 60%, ionohexol)
sharp image ampullary rugae clearly visualised
delayed absorption gets absorbed within hours, does not leave
residue
risk of lipogranuloma formation in case of tubal
block or hydrosalpinx
granuloma fromation rare
intravasation of contrast and risk of oil embolism pain after procedure
need of delayed film prompt demostration of tubal patency, delayed
film not needed
less often used widely used and preferred

7. Advantage of water based media Advantage of oil based media
Rapid absorption Better resolution of tubal architecture
Negligible peritoneal irritation Less uterine cramping pain
No risk of embolism when extravasated Higher subsequent pregnancy rates
Lesser allergic reaction

8. INSTRUMENTS
• fluoroscopy unit IITV( image intensifying television)
• contrast
• uterine catheter ( leech wilkinson)
• vaginal speculum
• syringe
• allis forceps
• sponge holding forceps
• local anesthesia

9. INSTRUMENTS

10. Instruments

11. Preliminaries
• History and examination
• irregular menses
• Investigations
• hemogram
• urine b-hcg
• Informed consent

12. Patient Preparation
• Done in between 8th to 12th day of menstrual cycle, following removal of
clots but before ovulation.
• Avoid unprotected intercourse from last menses to the date of
proceudure.
• In case of irregular menses, urine b-hcg to rule out pregnancy.
• Exclude pelvic infections.
• fasting 4 hours prior to procudure, empty the bladder.
• laxative may be given to empty the bowels.
• Antibiotic prophylaxis: doxycycline 100mg per oral BD, from a day before
the procedure till 5 days after.
• Anti spasmodic(atropine) and analgesia given prior to the procedure.

13. Technique & steps
• Placed in lithotomy position, perineal cleaned with betadine and draped
• bimanual examination done to note size and position of uterus
• Posterior vaginal speculum is introduced, anterior lip of cervix is held with Allis
forceps or vulsellum forceps
• Hysterosalpingographic cannula or HSG catheter is fitted into the syringe
containing radiopaque iodinated contrast medium.(water soluble-meglumine
diatrizoate or oil based- ethidol), catheter inserted beyond internal os.
• The dye is introduced slowly, about 5-10ml is introduced. This passage of dye is
visualized by fluoroscopy.

14. Technique & steps
• Uterine cavity and fallopian tubes are visualised as dye passes
through them during fluoroscopy.
• At specific times Xrays are taken
• Instruments are withdrawn.
• Patient observed for half and hour.

15. v

16. Detectable Pathology
UTERINE TUBAL
uterine anomaly tubal block
fibroid (submucosal) tubal spasm
adenomyosis tubal polyp
endometrial polyp hydrosalpinx
intrauterine synaechiae salpingitis isthmic nodosum
endometrial TB peritubal adhesions
cervical incompetence TB salpingitis
The common luminal filling defects are air bubbles, uterine folds, synechiae,
fibroid and polyps*

17. Findings
Hysterosalpingogram
showing radio-opaque
shadow demarcating the
uterine cavity. The radio-
opaque dye is visible in the
lumen of both the tubes.
There is peritoneal spillage
on both sides.
Diagnosis- Normal hysterosalpingogram
(normal cavity) with bilateral patent tubes.

18. Hysterosalpingogram showing a
filling defect in uterine cavity.
The radio-opaque dye is visible in
the lumen of both the tubes. There
is peritoneal spillage on both
sides.
Diagnosis- endometrial polyp

19. Hysterosalpingogram showing radio-
opaque shadow demarcating the
uterine cavity. No radio-opaque
shadow is visible on either tube.
Diagnosis-: Hysterosalpingogram
showing bilateral cornual block.

20. Hysterosalpingogram showing radio-opaque
shadow filling the uterine cavity. The tubes
of both sides are distended with the radio-
opaque dye. There is no evidence of
peritoneal spillage.
Diagnosis-: Bilateral hydrosalpinx

21. Hysterosalpingogram showing a
radio-opaque shadow filling
both the horns of the uterus. The
radio-opaque dye is visible within
the tubes. There is peritoneal
spillage on both the sides.
Diagnosis- Bicornuate uterus
with bilateral patent tubes.

22. Hysterosalpingogram showing
a radio-opaque shadow filling a
single horn of the uterus. There
is peritoneal spillage from the
tube.
Diagnosis- seems to be a
case of unicornuate uterus
with patent tube.

23. Hysterosalpingogram showing irregular
filling of radio-opaque dye.
Diagnosis- Uterine synechiae
(Asherman’s syndrome).

24. False positive results False negative results
Tubal contraction- cornual spasm Excess contrast media in uterus which may
obliterate shadows caused my smaller lesions
Blood clots
Mucus plugs

25. Complications
• Peritoneal irritation and pelvic pain
• Flaring up of pelvic infection
• Allergic reaction to dye
• Intravasation of dye into venous or lymphatic system
• Hemorrhage
• pregnancy irradiation
• uterine perforation
• Pelvic Endometriosis if done premenstrually or while women in
bleeding

26. Refrence
• Howkins & Bourne (2015) shaw’s Textbook of Gynecology
16E,111-113