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1. MAJOR EQUIPMENT * fluoroscope room Table Gynecologic stirrups

2.2.Accessory & Optional Equipment Routinely, a sterile, disposable HSG tray is used.

speculum, cotton balls, cup, gauze, drapes, sponge-holding forceps, 10 ml syringes,

lubricating jelly extension tube.

3.3.In addition to the HSG tray, sterile gloves, an antiseptic solution, a 6 fr foleys or sholkoff

balloon catheter, and contrast media are necessary.

4.4.Contrast Media Two categories of radio-opaque iodinated contrast used.Water-soluble

iodinated CM, e.g. Omnipaque 300. absorbed easily, does not leave a residue within

reproductive tract, provides adequate visualization. however, cause pain &persist for hours

after procedure.

5.5.In the past, oil-based contrast media was used. Allowed maximal visualization of

uterine structures however very slow absorption rate persists in body cavities for extended

time. Introduces risk of oil embolus that could reach lungs.

6.6.Amount of contrast medium to be introduced is variable. On average, approx. 5 ml is

necessary to fill uterine cavity, and additional 5 ml needed to demonstrate uterine tube

patency. Fractional injections may be performed during study.7.7.Patient lies in lithotomy position. Patient is draped & speculum inserted. Vaginal walls &

cervix are cleansed. Catheter is inserted into cervical canal. Dilation of balloon helps to

occlude cervix, preventing contrast medium from flowing out.

8.8.Once placement of catheter obtained, pt put in slight Trendelenburg position. This position

facilitates flow of contrast media into uterine cavity. Contrast filled Syringe attached to

catheter. Using fluoroscopy, contrast slowly injected into uterine cavity.

9.9. The pelvic ring as seen on an AP projection should be centered within the collimation

field. The cannula or balloon catheter should be demonstrated within the cervix. An

opacified uterine cavity and uterine tubes are demonstrated centered to the IR.

10.10.Imaging most commonly acquired with use of spot- film fluoroscopy or, digital

fluoroscopy.Scout image obtained.During injection of contrast, series of images taken

while uterine cavity &tubes are filling.After injection of contrast, additional image taken to

document spillage.

11.11.Pt most commonly remains in supine position during imaging, but additional images may

be taken with pt in an LPO or RPO position to adequately visualize pertinent anatomy. Image

taken at the end for evaluation of lower uterine segment.

12.12.Spot radiograph obtained during the early filling stage of the uterus. Small filling defects

are best seen at this stage.

13.13.On a radiograph obtained with the uterus fully distended with contrast material, portions

of both fallopian tubes are opacified. Like images obtained during the early filling stage of theuterus, images obtained at full uterine distention allow evaluation for filling defects and

contour abnormalities. However, small filling defects may be obscured when the uterus is well

opacified

14.14.Spot radiograph clearly depicts the interstitial, isthmic, and ampullary portions of both

fallopian tubes.

15.15.Spot radiograph shows intraperitoneal contrast material spillage from the fallopian tubes.

In this case, the spillage outlines the convexity of the uterine fundus

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16.16.Conditions which may be detected with HSG include: Uterineuterine congenital

anomalies . 15%submucosal uterine fibroidsuterine malignancyadenomyosis

intrauterine adhesionsuterine (endometrial) polyps

17.17.Unicornuate uterus. Spot radiograph demonstrates a single uterine horn . A single

fallopian tube is also visualized.

18.18.Bicornuate uterus. Spot radiograph shows two markedly splayed uterine horns.

19.19.HSG image shows a bicornuate bicollis uterus with two HSG cannulas due to two

cervices. There is a fundal linear defect (arrow) with filling of two symmetric uterine horns

through the right cannula (arrowhead) due to communication in the lower uterine segment.

20.20.Septate and arcuate uterus. Spot radiograph demonstrates a depression of the uterine

fundus, a finding that may represent a short septum or an arcuate deformity

21.21.Double uterus

22.22.Uterus didelphys. (a, b) HSG images show catheterization of two separate cervices with

opacification of two widely divergent noncommunicating endometrial cavities

23.23.Common finding.Includes : Air bubbles Uterine folds Synechiae

24.24.Flush catheter thoroughlyWell- circumscribed filling defectNon- dependentportion of uterusTransient and mobile

25.25.Air bubbles. Spot radiograph shows air bubbles (arrow) in the left side of the uterus.

26.26.Spot radiograph no longer depicts the air bubbles seen in the left cornua of the uterus in .

Air bubbles are often mobile or transient when they are expelled into the fallopian tubes.

27.27.Linear filling defectsDue to under-distended uterusParallel to long axis of uterus

May extend into horns

28.28.Uterine folds. 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.

29.29.Intra uterine adhesions

Post curettage and infection

Linear filling defect

Arising

from one wallMultiple+infertility= Asherman syndrome

30.30.Synechiae. Spot radiograph shows a central oval filling defect within the uterus, a finding

that represents a synechia

31.31.Polyps: Endometrial over growths. Sonohysterography.Leiomyoma's: sub-serosal,

intra mural, sub-mucosal. only sub mucosal depicted, early stage filling

32.32.Endometrial polyp. Anteroposterior (left) and oblique (right) hysterosalpingograms

demonstrate a pedunculated filling defect within the uterine cavity (arrows).

33.33.Leiomyomas. Spot radiograph obtained during the early filling stage shows a well-defined

filling defect (arrow) in the fundus

34.34.On a spot radiograph obtained with the uterus more distended with contrast material, thefibroid (arrow) is less apparent

35.35.Spot radiograph obtained in a different patient reveals a large leiomyoma distorting the

endometrial cavity as it drapes over a mass in the left myometrium.

36.36.Submucosal fibroids. Oblique (left) and anteroposterior (right) hysterosalpingograms

demonstrate smooth filling defects distorting the uterine cavity and representing submucosal

fibroids..

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37.37.Endometrium extends into myometrium.Focal or diffuse.Nests of endometrium

connect to uterine cavity.Out pouching of endometrial cavity.

38.38.Diffuse adenomyosis. Spot radiograph shows irregularity of the uterine contour with small

outpunching's of contrast material, findings that represent diffuse adenomyosis.

39.39.Spot radiograph demonstrates an irregular mass-like filling defect in the fundus with small

contrast materialfilled diverticula, findings that represent focal adenomyosis

40.40.Cesarean section scar. 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.

41.41.Tubalobliteration of fallopian tubes : usually secondary to previous pelvic

inflammation. must be differentiated from incomplete tubal opacification due to tubal spasm,

or underfilling of uterus with contrast .tubal polyps .tubal malignancyhydrosalpinx

salpingitis isthmica nodosa (SIN) .tubal spasm : can be physiological

42.42.Out pouchings of isthmusUnilateral or bilateralUnknown causeAssociated withinfertility, PID and ectopic pregnancy

43.43.SIN. Spot radiograph demonstrates SIN as small outpouchings or diverticula from the

isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral.

44.44.Cornual portion encased in myometriumIf msl spasm tube appears occludedHSG

cannot differntiate b/w spasm & true occlusionMsl relaxant can occasionally help.

45.45.Cornual spasm. On an HSG spot radiograph obtained during the early filling stage of the

uterus, the 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 image46.46.On a spot radiograph obtained after the instillation of additional contrast material, the

right fallopian tube opacifies to the ampullary portion. Right-sided SIN and a left- sided

hydrosalpinx are also noted. Amorphous calcifications (arrowheads) are again seen on the

right side of the pelvis

47.47.Occluded fallopian tubes

48.48.Hydrosalpinx. Steep 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

49.49.Spot radiograph shows dilatation of the ampullary portion of the left fallopian tube, afinding 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.

50.50.Peritubal adhesions. Spot radiograph demonstrates 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.

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lpingography-140406072713-phpapp02/95/hysterosalpingography-49-638.jpg?cb=1396769310http://image.slidesharecdn.com/hysterosalpingography-140406072713-phpapp02/95/hysterosalpingography-50-638.jpg?cb=1396769310

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51.51.Spot radiograph demonstrates 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).

52.52.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.

53.53.Radiograph obtained after instillation shows no contrast material filling of the fallopian

tube beyond the microinsert, a finding that helps document tubal occlusion.

54.54.Tubal polyp. Spot radiograph shows a small filling defect (arrow) in the proximal left

fallopian tube, a finding that typically represents a tubal polyp.

55.55.Common but self limiting Abdominal cramping PV spotting Rare but serious pelvic

infection contrast reaction Perforation

56.56.Thank You

http://www.slideshare.net/airwave12/hysterosalpingography-33184676

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