Hysterosalpingogram Periprocedural Care

Elements of informed consent

Key points to be reviewed during informed consent include the risks of infection, contrast reaction, hemorrhage, uterine perforation, radiation exposure, the theoretical risk of harm to an undiagnosed pregnancy, and oil embolism after extravasation of an oil-based media. Significant contrast reactions are rare and more common in patients with a history of hypersensitivity to iodinated contrast agents, recurring in approximately 8-25% of cases. ^{[5, 6]} Other recognized risks include a history of asthma or ectopic allergic reaction. The age-old practice of inquiring about seafood allergies has no predictive value of contrast reaction. ^[7]

The radiation dose to the ovaries during HSG varies from 0.4t-5.5 mGy. ^[8] This compares to other procedures such as fluoroscopic tubal cannulation (8.5 mGy), barium enema (6.5 mGy), and pelvic CT (1-19 mGy). ^[9] One rad, or 10 mGy, at a rate of 1 rad/min for up to 10 minutes (100 mGy total) has been suggested as the threshold below which the added incidence of teratogenicity is exceedingly low. ^[8] Thus, conventional HSG is considered safe. Even so, equipment should be properly calibrated, repetitive procedures should be avoided, and the radiation exposure time during each procedure should be minimized. ^[8]

Diagnostic considerations

Even with proper technique, radiographic artifact is not an uncommon phenomenon. These filling defects include those caused by inspissated air, intrauterine mucous, broken fragments of endometrium, and extravasation of contrast. An inadvertent air bubble can be confused for a polyp or myoma but is distinguished by its tendency to migrate and settle in the nondependent portion of the cavity, especially as the patient moves. ^[10]

Significant extravasation of dye into the myometrial venous plexus and surrounding pelvic vasculature may be caused by excessive instillation pressure that usually occurs while attempting to overcome proximal tubal occlusion, or in the setting of recent uterine surgery. ^[10] Extravasation fills venous and lymphatic channels, appearing as multiple thin lines in a reticular pattern that usually dissipates once injection of dye stops (see the image below). ^[10] The procedure should be halted with the onset of extravasation.

Dramatic extravasation of contrast media is seen in the myometrial and uterine veins.

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The diagnostic accuracy of HSG has been widely investigated. Although hysteroscopy is very sensitive and specific for detecting uterine cavity pathology, no optimal standard of reference exits for assessing tubal patency. The criterion standard for tubal patency evaluation is generally considered to be laparoscopy with chromotubation. But this procedure has suboptimal sensitivity, specificity, and positive and negative predictive values. ^[11] Nevertheless, comparisons between HSG and laparoscopy with chromotubation are prevalent and have demonstrated discrepancies of up to 45%. ^[12]

Furthermore, a large Dutch meta-analysis reported HSG sensitivity and specificity of only 65% and 85%, respectively, for fallopian tube assessment. ^[13] Studies that have compared hysteroscopy to HSG have reported HSG sensitivity and specificity of approximately 80% in correctly identifying uterine cavity pathology with both false-positive and false-negative rates approximately 10-20%. ^{[4, 14]} In light of such figures, some authors have advocated that HSG be replaced by hysteroscopy as the first-line diagnostic procedure. ^[15]

Methods to determine tubal patency with ultrasound have been proposed for years. A medium of galactose microparticle granules (Echovist 200, Schering Co.) provides ultrasound contrast and is quickly metabolized. An analysis of 3 clinical trials showed a 68.3% agreement with HSG. Compared to HSG, ultrasound showed false occlusion in 12.8% of tubes and false patency in 3.9%. Compared to laparoscopic examination, ultrasound showed 10.3% false occlusion and 6.7% false patency rates. ^[16] An alternate ultrasound medium containing air-filled albumin microspheres has also been used. ^[17] Concomitant instillation of normal saline with air has been advocated for determination of tubal patency. In one study, this technique showed a 89.6% concordance with HSG. ^[18]

The role of antibiotic use in HSG is not standardized. In 1980, Stumpf et al reported an incidence of serious pelvic infection after HSG of 3.1%, most commonly occurring in women with a history of infertility or prior or current pelvic infection or adnexal mass. ^[19] The American College of Obstetricians and Gynecologists recommends empiric treatment for women with a history of pelvic infection or when hydrosalpinx is diagnosed at the time of the study. A common and effective regimen is doxycycline, 100 mg orally twice daily for 5 days. ^[20] Other situations in which treatment is common include when tubal blockage is suspected, unexpected distal occlusion is encountered, or significant vascular extravasation occurs.

A 2010 Cochrane review of antibiotic prophylaxis for transcervical procedures concluded that insufficient evidence existed to recommend for or against the routine use of antibiotics in such procedures. ^[21] Therefore, prophylaxis in HSG should be limited to patients deemed to be at higher risk of infection.

Unfortunately, many women have preconceptions that HSG is a painful test. Mild-to-moderate cramps are common but most often temporary. Unquestionably, patient discomfort is influenced by operator technique. Pain associated with HSG is generally related to cervical manipulation, uterine cavity distention with the instillation of the contrast media, and peritoneal irritation from dye that has spilled into the pelvis. Discomfort typically peaks at the time of dye injection until 5 minutes after the procedure and then begins to fall precipitously, so that 30 minutes after the procedure most patients report significant relief ^[22] .

A cross-sectional questionnaire study by Handelzalts et al suggested that HSG is associated with a higher degree of fear, anxiety, and pain than colposcopy, with women in the HSG group reporting significantly higher preprocedural anxiety and fear of pain and retrospectively reporting the procedure to be more painful than did the colposcopy group. ^[23]

Multiple trials have been conducted to assess the effect of analgesics on pain from HSG. A 2010 Cochrane meta-analysis reviewed investigations of opioid and nonopioid oral analgesics as well as paracervical block and local analgesics on reported pain during and after HSG. No overall benefit existed from any type of prophylactic analgesia for pain during or up to 30 minutes after HSG, but local analgesia (10 mL of 1% lidocaine injected into the uterine cavity before the contrast) may reduce delayed pain. ^[24]

Arnau et al conducted a randomized, double-blind, controlled study to investigate the efficacy of 5% lidocaine/prilocaine 25 mg/g cream applied to the uterine cervix for reducing pain during hysterosalpingography. One hundred successive patients scheduled to undergo hysterosalpingography were randomly assigned to receive either 3 ml of lidocaine-prilocaine cream or 3 ml of placebo, applied endocervically and exocervically, 10 minues before hysterosalpingography. Patients' intensity of pain was assessed at baseline (speculum application), after application of Pozzi tenaculum and cannula on the uterine cervix, during cervical traction, and after contrast medium injection, using a 10-cm visual analogue scale immediately after the procedure. The most painful step was also identified. The visual analogue scale was administered again at the 1-month follow-up visit. For both cohorts, the injection of contrast medium was the most painful step of hysterosalpingography. No differences were found between thetwogroupsduring this step. When comparing the pain scale after the application of Pozzi tenaculum and cannula and after cervical traction, significantly less pain was experienced by the group treated with lidocaine-prilocaine cream than by the group receiving placebo group. The invesgtigators concluded that endocervical and exocervical topical application of lidocaine-prilocaine cream 10 minutes before performing hysterosalpingography significantly reduced pain during cervical manipulation with tenaculum and cannula and during cervical traction. It did not reduce pain during injection of contrast, which was was the most painful step of the procedure. ^[25]