Special radiographic procedure -Hysterosalpingography.

1. Arba Minch University
College of Medicine and Health Sciences
Department of MRT
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2. Chapter – Three
Hysterosalpingography
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3. OBJECTIVES:
 After completing this chapter, the student will be able
to:
 Identify major components of female genital tract ,to
include their location & function.
 Discuss radiographic examination of female genital
tract, including pre- & post procedural patient care for
hysterosalpingography (HSG).
 List & describe equipment commonly used for HSG.
 Define terminology associated with female genital tract
& special radiographic procedures, to include anatomy,
& pathology.
FEMALE GENITAL TRACT
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4. Uterus Anatomy
 Pear shaped organ.
 Lies anterior to sigmoid colon & posterior to
bladder.
 Average size: 8 x 5 x 3 cm.
 Comprised of 3 layers:
Serosa.
Myometrium.
Endometrium.
 Orientation
 Anteverted, Anteflexed – Normal.
 Retroverted, Retroflexed – Abnormal.
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5. Con…
Pouch of Douglas(arrow)
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6. The Uterus
 The uterus is subdivided into four divisions:
(1) the fundus,
(2) the corpus (body),
(3) the isthmus, and
(4) the cervix (neck).
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7.  Orientation
 The uterine fundus may point anteriorly toward the
navel, anteversion, or posteriorly toward the spine,
retroversion.
 Long axis of the uterus lies horizontally in sagittal
plan at 90 degree with the vagina, Anteverted.
 The fundus is flexed anteriorly in relation to the cervix
with 125 degree, Anteflexed.
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8. 8
 Retroversion & Retroflexion are opposite of
anteverted and anteflexed respectively.

9. Adenexal Anatomy
Fallopian Tubes
 Located below fundus
 Average size: 1- 4 mm in diameter and 10-
12cm long
 Four segments
 Isthmus.
 Ampulla.
Infundibulum.
Fimbriae.
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10. Female Reproductive
System
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11. HYSTEROSALPINGOGRAPHY(HS
G)
 Is radiographic demonstration of female reproductive
tract with a contrast medium.
 Best demonstrates uterine cavity and patency
(degree of openness) of uterine tubes.
 Uterine cavity is outlined by injection of a contrast
medium through the cervix.
 The shape and contour of uterine cavity are
assessed to detect any uterine pathologic process.
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12. INDICATIONS for HSG
 Infertility Assessment - Most Common.
 Demonstration of intrauterine pathology:
 Lesions demonstrated can include endometrial polyps,
uterine fibroids, and intrauterine adhesions.
 HSG is also use to diagnose fistulas and congenital
defects.
 For evaluation of uterine tube after tubal ligation or
reconstructive surgery.
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13. CONTRAINDICATIONS
 HSG is contraindicated with pregnancy.
 To avoid possibility that patient may be pregnant, examination
is typically performed 7 to 10 days after onset of menstruation.
 Acute pelvic inflammatory disease and
 Active uterine bleeding, immediate pre and post menses.
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14. PATIENT PREPARATION
 Proper bowel preparations.
 Abstain from intercourse b/n booking the appointment and
time of exam.
 Take a mild pain reliever before the examination.
 Empty her bladder immediately before the examination.
 Informed consent obtained.
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15. TROLLEY SETTING (HSG SET)
 Upper (sterile) shelf
 Vaginal speculum.
 Vulselum forceps.
 Uterine sound.
 Uterine canula.
 Sterile gauze.
 Sterile drapes.
 Sterile gloves.
 Sponge-holding forceps.
 10-ml syringes.
 Basin.
 Cotton balls.
Lower(unsterile)
shelf
• Antiseptic solution.
• Contrast media.
• Emergency drugs.
• Obstetric cream.
(e.g. Hibitane 1%)
• Masks.
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16.  CONTRAST MEDIA
 Water-soluble iodinated CM.
 DOSAGE
 10-20 ml is used
 Approximately 5ml is necessary to fill uterine cavity &
 An additional 5ml is needed to demonstrate uterine tube
patency.
 If uterine tubes are patent (open), contrast media will
flow from distal ends of the tubes into peritoneal cavity.
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17. PROCEDURE
 Empty bladder immediately before the examination.
 AP scout image may be taken on a 24x30 cm film to
look for calcified masses.
 Central ray: 5cm superior to the symphysis pubis.
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18. 19

19. Cont .
CANNULA/CATHETER PLACEMENT AND INJECTION PROCESS
 The patient lies supine on the table in the LITHOTOMY position.
 The patient bends her knees and places her feet at the end of the
table.
 The patient is draped with sterile towels.
 With sterile technique a vaginal speculum is inserted.
 The vaginal walls and cervix are cleansed with an antiseptic
solution.
 The anterior lip of the cervix is grasped by vulsellum forceps.
 A uterine sound is inserted to show the length and direction of the
uterus.
 Injection cannula is inserted in to the cervical canal.
 Speculum is removed.
 A syringe filled with CM is attached to the cannula.
 Under fluoroscopic guidance CM is injected. 20

20. Lithotomy position
Trendelenburg position
(15-300 feet raised )
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21. 22

22. Cont.
 A tenaculum (vulsellem forceps) may be necessary to aid in the
insertion and fixation of the cannula or catheter.
 Once cervical placement of the cannula or catheter is obtained, the
speculum is removed.
 The patient is placed in a slight Trendelenburg position. This position
facilitates the flow of contrast media into the uterine cavity.
 A syringe filled with contrast is attached to the cannula or balloon catheter.
 Using fluoroscopy, the gynecologist slowly injects the contrast medium
into the uterine cavity.
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23. Vaginal Speculum
Vaginal Speculum, Forceps & Uterine Sound
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24. Tenaculum (vulsellem forceps)
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25. Uterine Cannula & Syringe
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26. Uterine Dilator
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27. TECHNEQUE
 Fluoroscopy, conventional radiography, or a
combination of both may be used.
FLUOROSCOPY/SPOT FILMING
 During the injection of the CM, a series of AP images
are taken.
 After injection of the CM, an additional image are
taken.
 Slight LPO or RPO may be taken.
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28. CONVENTIONAL RADIOGRAPHY
 If fluoroscopy is unavailable, fractional injection of the
CM is implemented.
 Overhead radiographs are taken after each fraction.
 Additional images may include LPO or RPO.
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29. Fig. HSG demonstrating uterus
and fallopian tube (white arrows)
are normal spillages seen.
Radiographic
Criteria
 The pelvic AP projection
should be centered within
collimation field.
 The cannula or balloon
catheter should be
demonstrated within the cervix.
 An opacified uterine cavity
& uterine tubes are
demonstrated centered to the
image. 30

30. Cont.
 Contrast medium is seen within peritoneum if one or
both uterine tubes are patent.
 Appropriate density & short-scale contrast demonstrate
anatomy & contrast medium.
 The patient ID marker should be clear, and
 R or L marker should be visualized without superimposing
anatomy.
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31. AFTER CARE OF THE PATIENT
 A recovery room should be available.
Make sure that:
 There is no serious discomfort.
 No significant bleeding.
Advise the patient that:
 She may have bleeding for 1-2 days.
 Pain may persist for 2 weeks.
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32. - Normal hysterosalpingogram
picture.
- A smooth triangular uterine
cavity and spill from both tubes.
- The bones of the pelvis are seen
on the x-ray around edges of
image
- HSG showing a normal uterus and
blocked tubes.
- No "spill" of dye is seen at the ends
of the tubes.
- Both tubes are slightly dilated and
fluid filled - Hydrosalpinx
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33. Complications associated with a HSG are rare.
Possible risks include:
 Allergic reaction to the dye, which is uncommon. This usually
causes a rash, but can rarely be more serious.
 Endometrial (uterine lining) or fallopian tube infection.
 Injury to the uterus, such as perforation.
 If a woman has multiple sexual partners or is otherwise at
risk for sexually transmitted diseases, she might be screened
with cervical cultures before doing an HSG.
 Some physicians prescribe several days of antibiotics to
reduce risk of infection after HSG.
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34. HSG on assessment of Infertility
 Infertility may be caused by:
 Structural abnormalities in the uterus, which may be
congenital or acquired.
 Blockage of the fallopian tubes.
 Scar tissue in the uterus.
 Uterine fibroids.
 Uterine tumors or polyps.
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35. - HSG showing multiple "filling
defects" in uterine cavity.
- These represent numerous
endometrial polyps.
- The polyps were then removed
by hysteroscopic resection.
- Abnormal study with a collection of
dye in a "pocket" at the end of the
left tube.
- Scar tissue (adhesions) are
holding the dye in the pocket.
- Right tube was previously
removed at surgery for a tubal
pregnancy.
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36. - HSG picture showing uterus with a fibroid that is pushing in to the
cavity &
Another fibroid on the outside of uterus is circumscribed by dye
along red line.
- Fibroids inside the cavity can cause infertility, miscarriage or
preterm birth.
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37. Sample Report
Name: Age: yr Sex: Female
Examination: – HSG under Fluoroscopy
 Findings
- Cervix is normal and no erosion seen (speculum examination).
- Uterine cavity is normal.
- No filling defect.
- Both tubes are visualized with peritoneal spillage.
CONCLUSION:- Normal HSG.
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38. INFERTILITY
DEFINITION
 Infertility is defined as the inability of couples to
conceive after 12 or more months of regular
intercourse without contraception.
Classification
 Primary Infertility - applies to those who have never
conceived.
 Secondary Infertility - designates those who have conceived
at some time in the past.
 Infertility affects about 10% to 15% of reproductive–age
couples.
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39. Factors Essential for Conception
 Healthy spermatozoa should be deposited high
in the vagina at or near the cervix (male factor).
 Spermatozoa should undergo changes
(capacitation, acrosome reaction) and acquire
motility(cervical factor).
 Motile spermatozoa should ascend through the
cervix into the uterine cavity and the fallopian
tubes.
 There should be ovulation (ovarian factor).
 The fallopian tubes should be patent and the
oocyte should be picked up by the fimbriae end
of the tube (tubal factor).
 The spermatozoa should fertilize the oocyte at
the ampulla of the tube.
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40.  The embryo should reach the uterine cavity.
 The endometrium should be receptive (by
estrogen, progesterone, IGF-l, cytokines, integrins)
for implantation, and the corpus luteum should
function adequately.
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Factors Essential for Conception

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42. Etiology of Infertility
 Successful pregnancy requires a complex
sequence of events including ovulation,
ovum pick-up by a fallopian tube,
fertilization, transport of a fertilized ovum
into the uterus, and implantation into a
receptive uterine cavity.
 With male infertility, sperm of adequate
number and quality must be deposited at the
cervix near the time of ovulation.
 Remembering these critical events can help
direct a clinician to develop an appropriate
evaluation and treatment strategy.
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43. Causes
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44. Faults in the Male
 Defective spermatogenesis.
 Obstruction of the efferent duct system.
 Failure to deposit sperm high in the
vagina.
 Errors in the seminal fluid.
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45. Female Causes
Ovulatory
 Premature Ovarian Failure.
 Viral infection of the Ovary.
 Chemotherapy.
 Surgery.
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46. Tubal Causes
 Symptoms such as chronic pelvic pain or
dysmenorrhea may suggest the presence of tubal
obstruction or pelvic adhesions or both.
 Adhesions can prevent normal tubal movement, ovum
pick-up, and transport of the fertilized egg into the uterus.
 A wide variety of etiologies may contribute to tubal
disease, including pelvic infection, endometriosis, and
prior pelvic surgery.
 A history of pelvic inflammatory disease (PID) is
highly suspicious for damage to the fallopian tubes or the
presence of pelvic adhesions.
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47.  The most common causes of tubal
disease are infection with Chlamydia
trachomatis or Neisseria gonorrhoeae,
whereas tuberculosis is a common
cause of both tubal and intrauterine
disease in countries with endemic
infection and should be considered in
immigrant populations.
 Tubal infertility has been estimated to
follow in 12 percent, 23 percent, and 54
percent of women following one, two, or
three cases of PID, respectively.
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48. Uterine Abnormalities
 Congenital Anomalies.
 Endometrial polps.
 Myoma.
 Asherman’s syndrome (The presence of
intrauterine adhesions).
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49. The End !!!
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