Hysterosalpingography

Which of the following would be a contraindication to hysterosalpingography

Active Uterine Bleeding

which of the following position is used most frequently during hysterosalpingography?

AnterioPosterior

At which point in the female menstrual cycle is hysterosonography usually performed

Between the 3rd and 7th day of the cycle

CM: Choice of use made by physician or department protocol

Effectiveness of CM depends on: 1. Rapid absorption and excretion 2. Sufficient radiographic density or opacity 3. Adequate viscosity 4. Low reaction response 5. Ability to delineate anatomic structures.

The patient is asked to empty her bladder prior to hysterosalpingography in order to

Eliminate the possibility that the bladder would displace the uterus or uterine tubes.

Which of the following is (are) not a part of the uterine tube (oviduct)

Fimbrae

Two groups of Female Anatomy

Internal and external groups Hysterosalpingography focuses on on *Internal groups: Ovaries, uterus, uterine and vagina.*

Septate Uterus

Malformation which a thin membrane called the septum divides the uterus either partially or completely. Born with but can be treated surgically, if needed to improve successful pregnancy.

Vagina

Muscular tube 3" long forms lower portion of birth canal -*Extends upward and posteriorly into pelvic cavity, lies posterior to the urinary bladder.* -extends from cervix to outside of the body.

The patient would be required to return for a 24-hour film when the following type of contrast agent is used

Oil-based compound

Diethylstilbestrol (DES): Exposed uterus

Pathology: most common associated abnormality from DES exposure, seen in 31% of exposed women. *classified as a class VII Mullerian duct anomaly* Background: *Des synthetic(man made) oestrogen intro 1948*, for women having recurrent spontaneous abortions, premature deliveries, and other pregnancy complication. by increasing the synthesis of placental steroidal hormones, was thought DES decrease the frequency of pregnancy loss. Radiographic Features: (Hysterosalpingogram (HSG)): Shows typically a narrowed irregular endocvervical canal. *cavity space appears small, shortened upper uterine segment, resulting in a T-Shaped.* *CAUSED BY MYOMETRIAL HYPERTROPHY*

Uterine (Fallopian or Oviducts) tubes

Provide pathway for ova into uterus -*Fertilization usually occurs in oviducts (tube)* 3 parts make up the tubes *1-Isthmus*-Medial/thicker part attached to uterus, thinner as it goes to ovaries *2-Ampulla*-Longest/widest lumen, thin walls. *3-Infundibulum*-terminates into *Fimbriae (Finger like) make physical connection to ovary.

QA program

QA deals with people and process used to complete tasks. QA training and record keeping State of California department of radiologic health established the standards of good practice that is foundation of QA and QC in radiology.

Uterine Fistula on HSG

Rectovaginal Fistula

When used in hysterosalpingography, the low osmolaity contrast agents can

Reduce the burning sensation felt by the patient during the procedure

HSG Procedure

Room: Fluoro room or Radiographic room w/urologic table similar to Cysto OR room Position: *Lithotomy position* Cervix: exposed with bivalve speculum and specialized catheter with anchoring balloon tip, placed in transcervical area. Balloon: seals the passageway from cervix to inferior uterus, CM intro slowly. Transcervical Catheter: provides route for introduction to uterine catheters for *selective salpingography* Size 5 French catheters that are pre-shaped can be easily slide over the guidewire which provides access into the proximal uterine tubes. this exams can be therapeutic dislodging an intraluminal blockage to demonstrating cause of stenosis by spasm - this small catheters can also be advanced up to examine the distal uterine tube - these catheters have reduced the need for laparoscopic surgery to establish tube patency - sterile asepsis is following in an HSG procedure to avoid introduction to infection - the transcervical catheter remains in place throughout the entire HSG procedure - if oily contrast median is used, the patient must come back in 24 hrs. for delay films to show whether the contrast medium has reached the free peritoneal cavity or is still in the pathologic uterine tube

Which of the following is not a therapeutic use of hysteroslapingography

Treat Cystic stenosis

Contrast Media: in HSG

Two Types: 1. Water soluble: Advantage: dissolves quickly and do not leave a residual along the genital tract. 2. Oil based: Advantage: Highly opaque. -(24 hour delay films must be acquired to demonstrate patency -Non-Ionic (low osmolarity)- Don't dissipate, thus unlike the ionic or high osmolarity agents will not burn or irritate the mucosal lining the reproductive tract.

Unicornuate uterus

Uterus with single horn and banana shape. -65% of women with unicornuate uterus have a second smaller or rudimentary uterine horn; can be solid or small cavity with functioning endometrium.

The lower portion of the birth canal is formed by the

Vagina

Bicornuate uterus

associated with increased adverse reproductive outcomes. -Recurrent pregnancy loss, -preterm birth at 15%-25%. Pregnancy may not reach full term when baby begins to grow on either horns.

The procedure that is currently used a screening procedure for female reproductive system pathology is

hysterosalpingography

Mullerian ducts

precursors to the female's oviducts, uterus, and upper vagina The müllerian ducts are the primordial anlage of the female reproductive tract. *They differentiate to form the fallopian tubes, uterus, the uterine cervix, and the superior aspect of the vagina*. A wide variety of malformations can occur when this system is disrupted

QA/QC requirement

varies by state, but CA and NY more strict.

CM: Misc info

when *oil based contrasts* are used, *24 hour delay films must be acquired to demonstrate patency* - *negative contrasts such carbon dioxide (aprox. 100ml) can be used after positive contrast injection* - to provide a double contrast effect (*carbon dioxide is usually absorbed within 25 to 30 minutes and causes minimal discomfort*, demonstrates uterine tube patency - it takes approx. *4 ml of contrast to fill a normal uterine cavity and an additional 4 ml may be required to demonstrate both uterine tubes*, -more contrast might be need to demonstrate significate pathological changes

Various Conditions diagnosed by Hysterosalpingography (HSG)

-Habitual Abortion -Amenorrhea-No active period -Dysmenorrhea- Painful menstrual period -Preoperative Evaluation for localization -Locate ectopic pregnancy/ lost contraceptive device -Pelvic masses (Fibroids, ovarian cysts- dermoid cyst) -Fistulas -Cervical Stenosis -Endometrial polyps -Leiomyoma-Are benign tumors that arise from the overgrowth of smooth muscle and connective tissue in the uterus

Arcuate Uterus

-Mildly variant shape of the uterus. -*Mullerian Duct anomalies*, sometimes classfied as normal variant. -Least commonly associated with reproductive failure.

HSG List of Views

*AP/AP oblique Most common* *Prone/Lateral: Pathologies* CR: 2" (5cm) above symphysis pubis.

Quality Control/ Assurance

*Quality Assurance*: deal with people *Quality Control*: Deal with instrumentation and equipment Both designed to ensure the best possible image quality with lowest possible exposure and cost.

Didelphys Uterus

*aka as Uterus Didelphis*

HSG positioning

- *almost all imaging is taken in AP or AP oblique projections* - occasionally to *demonstrate specific pathology the woman may be put into the prone or lateral positions* - fluoro spot films are taken throughout the procedure, if *IR cassette is done it is done on 10x12* size plate and the CR is perpendicular and the entry point is *2" (5 cm) superior to the symphysis pubis - if oblique views are done it is determine by the OBG to demonstrate specific pathology

Equipment

- fluoroscopic rooms with tables equipped with stirrup's for the lithotomy positions are preferred, the exam can be done without fluoro, with more risk to patient - if oil based contrast is used, fluoroscopy aids in the avoidance of perforating a vein or artery or lymph vessel leading to a possible emboli - a disposable or reused sterile Hysterosalpingogram tray should be setup prior to the exam - items specific to the tray include: vaginal speculum, dilators, sponge holding forceps, various sizes of cannulas, including a Malmstrum Westerman vacuum cannula etc.

Ovaries

-Almond shaped -Size fluctuates depending on age and stage of ovarian cycle. -size *average 2.5-5 cm long*, 2 cm wide and 1 cm thick *-Location: Lateral walls of pelvis* *Before pregnancy at level of ASIS lateral to uterus* *During pregnancy they are pulled away by raising uterus* Attached to the uterus by ovarian ligament *Function*: produce Ova and Female sex hormones.

Hysterosalpingography

-Demonstrates/investigate Female reproductive system -Main and Second modality: Main: Fluoroscopy: Surgical Aseptic Technique Secondary: Ultrasound *Function*: investigate Infertility, or structures of the female reproductive: Uterus, Vagina, and uterine (Fallopian tubes)

Patient Prep

-Preform proper bowel cleansing -Non gas forming laxative should be used -intake restrictions should be followed in certain cases -Empty bladder: prevents displacement of uterus and uterine tubes during the procedure. -Emptying bladder encourage to irrigate vagina and clean the perineal region -Sedatives are not usually required. -Written consent and history are taken -Prothrolatic treatment: ex. steroids, antihistamines if they have previous contrast reaction in their history.

QA evaluate include

-Scheduling patient -instructions to pt -wait times -interpretation of films -retake analysis -record accuracy

Uterus

-Thick walled, muscular organ within pelvis. -Sits *Antegrade superior to urinary bladder and rectum*. -position changes with filled bladder. 4 parts of Uterus. 1-Fundus: rounded upper portion, above the uterine tubes joint the uterus, *makes superior boarder of the "horns of the uterus"* 2-Body: Triangular area, btw uterine walls, extends down to isthmus, *main part of uterus.* 3-Isthmus-which is a narrow constricted, very short segment *about 1 cm long* 4-Cervix-Most inferior portion of the uterus, communicates and extends into vagina.

Congenital Abnormalities

-Unicornuated uterus, -Didelphys uterus (duplicate uterus and cervix without connection), -Bicornuate uterus -Septate uterus (uterine duplication anomaly) -Arcuate uterus (Mild indentation of endometrium) -Diethylstilbestrol-Exposed uterus (T shaped fundus)

Acceptance Testing (QC)

-xray machine, cassettes and film processor or digital system are largest expenses. -economically makes sense to make sure equipment meets performance standards. -recommended 3rd party such as health physicist test. -Tests on X-ray Machine: Shielding of room, focal spot size, calibration of mA, timer or mAs, Calibration of kVp, Linearity of exposure, Beam Alignment, Grid Centering, Collimation, Filtration (HVL) -Tests on Cassettes Screen contact, screen speed, light leaks, and light spectrum matching. -Tests on Film Processor Developer temperature, Replenishment rates, travel time, water flow, hypo retention. *With exception of film processing most testing is annual or semiannual*

Quality Control (Equipment)

1-Acceptance testing 2-Routine Performance monitoring 3-Maintenance

Radiographic Criteria

1-Pelvic rim in AP should be centered within collimated field. 2-Cannula or balloon catheter should be demonstrated within cervix 3-opacified uterine cavity and tube are demonstrated centered of IR 4-CM is seen within peritoneum if one or both uterine tubes are patent. 5-Appropriate density and short-scale (low kvp,) contrast demonstrate anatomy and CM 6-patient ID marker should be clear and R/L marker should be visualized without superimposition of anatomy.

Two main functions of Hysterosalpingography

1. *Diagnostic Tool:* Thru contrast injection demonstrate pathologies and conditions. 2. *Therapeutic Tool:* Same contrast can relieve certain conditions affecting the reproductive system. ex *Restoring patency of uterine tubes, dilation of tubes, stretching tubal adhesions, and straightening out kinks.* -Demonstrate other things like; Abnormal uterine bleeding, patency of uterine tubes, and congenital uterine abnormalities; such as: -Unicornuated uterus, -Didelphys uterus (duplicate uterus and cervix without connection), -Bicornuate uterus -Septate uterus (uterine duplication anomaly) -Arcuate uterus (Mild indentation of endometrium) -Diethylstilbestrol-Exposed uterus (T shaped fundus)

Hystereosalpingogram Contraindications

1. Acute or Subacute pelvic inflammation 2. Vaginal or cervical infection accompanied with purulent discharge 3. During immediate premenstrual or postmenstrual phase 4. Active uterine bleeding- due to seepage of contrast media into general circulation 5. Pregnancy

Ten Steps for Quality Assurance

1. Assign responsibility 2. Delineate scope of care 3. Identify aspects of care 4. Identify outcomes that effect the aspects of care 5. Establish limits of the scope of assessment 6. collect and organize data. 7. Evaluate care when outcomes are reached. 8. Take action to improve care 9. Assess and document actions 10. Communicate information to organization-wide QA program

Things to know

1. Gravida - refers to pregnant women 2. Gravidity - refers to the number of pregnancies 3. Nulligravida - refers to a woman who has never been pregnant 4. Primigravida - is a woman who is pregnant for the first time 5. Multigravida - is a woman in at least her second pregnancy B. Parity 1. Parity - is the number of births (not number of fetus' ie. Twins) carried past 20 weeks gestation whether not fetus was born alive 2. -Nullipara: No Births, not births after 20 weeks. 3. *Primipara* is a woman who has had one birth that occurred after the 20th week of gestation 4. Multipara is a woman who has had two or more pregnancies to the stage of fetal viability -Sialogram: *Sialadenitis infection of the salivary glands not inflammation*.

Uterine Wall 3 layers

1. Perimetrium: *External layer* communicates with peritoneal cavity, has *serosa layer for it's outside.* 2. Myometrium- *Middle Layer* muscle layer 3.Endometrium-*Inner layer* communicates with uterine cavity and has *muchosal layer*

HSG: Order of Procedure for Techs

1. Take the patient's history 2. Ask patient if they have allergy 3. Explain procedure for cooperation 4. Have the pt empty bladder 5. Check if pt has taken Ibuprofen *(Prothoraxes for pain)* 6. Make sure pt understand benefits and risk associated with procedure. 7. Have pt sign consent form.