HSG: What we need to remember from time to time?? Point 1: How does a myoma influence the HSG images?? Ans: A) Polyps or fibroids, may cause mechanical obstruction of the proximal fallopian tube. As such, the effect of treatment on tubal patency and preservation or enhancement of fertility must be considered. Point 2 ) Prior to Hysteroscopic myomectomy close to Ostia :-- if hysteroscopic loop resection of a fibroid, the surgeon must be aware of the relationship of the fibroid to the tubal ostium so that no damage is causes by permanent tubal occlusion during the hysteroscopic myomectomy . Point 3: Deviation of tube what may be cause?? Ans: Well, the tube may be patent but clearly deviated by an intramural myoma and myomectomy is planned, the surgeon needs to be careful to approach the fibroid with the goal of removal and preserving the fallopian tube.
What are the kinds of catheters used in HSG procedures?? Ans : Three kids of catheter . 1) Balloon uterine infusion catheter, a more traditional “acorn" catheter, or a suction catheter. These are the three kinds of catheter used . Objective of HSG is to not only to visualize the uterine cavity but F tubes and even details of Cx canal too. When used with optimal technique, the HSG provides an image of the cervix which we seldom achieve to image . However of these three kinds of catheters, the acorn and suction catheters is basically designed to assess the uterine cavity for a woman with abnormal bleeding, since these are placed in the lower cervix and cervical abnormalities can be identified in addition to uterine defects.
Balloon catheter when ?? Ans: The intrauterine balloon catheter is used by placing the catheter in the uterus, holding it in place by inflating a balloon, and then injecting contrast into the cavity. Drawbacks of balloon catheter?? Ans: Inflating the balloon catheter in the uterus can obscure uterine abnormalities such as polyps or fibroids, and since the catheter is placed above the cervix, imaging of the cervix is limited.
Tip 4: To put firm traction on Cervix : In order to accomplish “parallel” imaging for a uterus that is anteverted or retroflexed, it is necessary to obtain traction of the cervix as contrast is slowly filling the cervix and uterus. Traction is accomplished by pulling a cervical tenaculum or the suction device towards the introitus during examination. As this causes cramping, the traction can be stopped after early images of filling of the uterus have been obtained. Cramping is minimized by preprocedural administration of Paracetamol / ibuprofen 600-800 mg 30-60 minutes before the procedure. Occasionally, the uterus is so sharply anteverted or retroflexed that traction causes too much discomfort. When this is the case, the provider can push the cervix away from the introitus to completely invert the uterus.
What is two-triangle” image ?? Ans: The uterine images should always show an elongated uterine cavity that tapers into the lower uterine segment, and not two triangles reflecting the upper uterus and the lower uterine segment. A “two-triangle” image indicates suboptimal assessment of the uterine cavity. Lateral images may help identify an asymmetric flexion of the uterine cavity caused by a large anterior or posterior submucous lesion.
Two simple but important points must be made about optimal performance of HSG: Ans: Constant fluoroscopic visualization and avoidance of any air or bubbles: Any air bubble present anywhere within the catheter system will obliterate the image (distortion) . Air bubbles can be mistaken for anatomic filling defects of the cavity, or may obscure the image of actual defects. If air bubbles are suspected, they will usually follow the flow of contrast and migrate to the upper uterus during the examination, so a filling defect that moves is almost certainly an air bubble. If the provider is still unsure, the patient should roll slightly to the right, left, or both sides, and additional images should be obtained. Air bubbles will move with position changes, whereas polyps and fibroids will not.
Additionally the uterus should be filled slowly under constant fluoroscopic visualization.. The uterus should be filled slowly, since rapid filling causes cramping, and overdistension of the cavity can obscure subtle abnormalities. Fluoroscopy continuously monitors the procedure, and targeted permanent images are captured at key moments during the examination, including early fill of the uterus, tubal fill, and tubal spill.
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