Hysterosalpingogram (HSG)

 The hysterosalpingogram or HSG is a simple x-ray procedure performed using fluoroscopy with intermittent still images for documentation in general the actual procedure takes three to five minutes the hsg is a relatively low-risk procedure but does result in ovarian radiation exposure greater than a pelvic CT scan thus repetitive 8 sets hsg procedures should be avoided and the radiation exposure time 

Demonstrates performance of an HSG notice the slow filling of the uterine cavity with radio-opaque dye while the uterus is positioned perpendicular to the x-ray beam subsequent fill of the fallopian tubes are visualized with a free spill into the peritoneal cavity unfortunately many women have preconceptions that the HSG is a very painful test there is no question that the discomfort is influenced by the experience of the operator an HSG is performed with the installation of a radio-opaque contrast into the uterine cavity installation devices include instruments that fit into the cervix such as a Cohen cannula or catheters placed into the uterine cavity using a balloon to prevent flow out of the servings very few instruments are necessary for an HSG an open-sided speculum is optimal since it is easier to remove with instruments in place the cervix is prepared with an antiseptic and grass with a single tooth tenaculum gentle slow placement of the tenaculum grasping only enough tissue for adequate stabilization of the cannula is recommended distress experienced by the patient because of poor tenaculum placement is often a predictor of an overall negative experience with the procedure cohen cameo has come with a narrow acorn tip for use in nonparis patients or a wider acorn tip for pairs patients all errors should be removed from the cannula by injecting contrast with the cannula in the vertical position holding the cohen and applied tenaculum in one hand to occlude the cervix is preferable to attach the cannula to the baculum since it usually will cause less pain a balloon catheter maybe more suitable for patients with cervical stenosis since it has a smaller diameter than the tip of the Cohen cannula a tenaculum is still necessary in order to straighten the uterus during the procedure some patients experience discomfort during inflation of the balloon though water-soluble and oil-based iodine-containing contrast is used for hsg the advantages and disadvantages have been debated for years water-soluble dye attends to give better detail of the mucosal folds of ample a portion of the two and is more quickly eliminated oil-based I may have consequences of the granulomatous formation in the pelvic peritoneum an escape of oil into the vasculature has been noted complication from either of these observations have not been reported over reports suggested an increased post

the procedure pregnancy rate with oil media but this appears to be more an opinion than an evidence-based observation the risk of hsg include infection and a theoretical risk of contrast reactions.

Women who were suspected of tubal blockage should receive broad-spectrum antibiotics such as doxycycline for five to seven days starting two days prior to the procedure women with unexpected distal tubule occlusion should receive antibiotics after the procedure prophylactic antibiotics and women with normal tubule fill and spill are not usually necessary women with mitral valve prolapse do not require additional antibiotics except in the case of significant intravascular extravasated a theoretical risk of oil embolism exist with extravasation of an oil-based media.

The consent form includes the risk of infection theoretical damage to an undiagnosed pregnancy contrast our reaction and uterine perforation to avoid a possible exposure of early pregnancy the procedures should be performed in the follicular phase after normal menses.

 Inject it slowly the speculum should be removed both for patient comfort and to prevent non-visualization of portions of the pelvis gentle traction on the cervix is necessary so that the uterine body is perpendicular to the x-ray beam failure to remove the speculum is one of the most common errors made during the HSG as in this film a portion of the lower uterine segment and all of the cervix cannot be evaluated leaving the speculum in place also increases the discomfort of the procedure another very common mistake during the hsg is failure to position the uterus perpendicular to the x-ray beam in film an x-ray is directed through the top of a very anterior flex uterus precluding adequate evaluation this film could easily miss an intrauterine filling defect or fundal contour abnormality the cervix is perpendicular to the x-ray revealing an indiscernible feeling defect most likely

Traction these four images of sequential filling of an anterior flex uterus would suggest a normal uterine cavity yet once proper traction is applied to bring the uterus perpendicular to the x-ray beam a significant uterine abnormality is realized after further evaluation this proved to be a uterine septum when using a balloon catheter it is very important to deflate the balloon at the end of the procedure and continue injecting dye to visualize the lower uterine segment and servings this normal hsg delineates the landmarks of the uterus the lower error shows the in desertic scare to rise by a serrated appearance from the crypts into cervical glands the broken line arrows shows the internal cervical Haas while the upper arrow shows the lower uterine segment there may be substantial differences in the normal variations of the shape of the endometrial cavity this image shows a normal uterus with a concave appearance to the upper fundus, in contrast, this normal uterus shows a convex appearance to the upper fundus the cause of such variations in the shape of the endometrial cavity is not known a shallow and smooth convexity to the upper fundus is classified as an r q 8 uterus this is defined as an angle of greater than 90 degrees from the lowest point of the fundus to the tubal hosta most studies have not shown any significant change in pregnancy outcome with an RQ a uterus although some analyses have suggested a possible.

 HSG shows a complete uterine septum speculum examination shows a single cervix with to cervical openings to surgical options are possible for this anomaly the classic procedure involves connecting the two cavities above the level of the internal us this leaves a residual serve septum preventing and competent servings but usually necessitating a cesarean delivery the second option is to incise the entire septum including the cervical portion and then perform a prophylactic cerclage in this case we use the first approach of uniting the cavities above the internal Oz is performed by inflating a small pediatric Foley balloon in one uterine cavity and applying gentle traction to bring it down to the level of the internal us a30-degree operative history scope is placed on the other side with the angle toward the balloon and the septum incised with scissors into the balloon.