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Re: Hysterosonography protocolFrom: DuboseTerryJ@uams.eduMon Apr 2 12:14:37 2001
Dear ?, this appears to be good information. Thanks. Terry J. DuBose, M.S., RDMS, Assistant Professor Director, Diagnostic Medical Sonography Program CHRP, University of Arkansas for Medical Sciences Little Rock, Arkansas, USA 501-686-6510 http://www.io.com/~dubose/ http://www.uams.edu/CHRP/dmshome.htm http://www.obgyn.net/us/panel/panel.htm -----Original Message----- From: Forum List Admin [mailto:ob-gyn-l-request@medispecialty.com] Sent: Monday, April 02, 2001 11:58 AM To: Multiple recipients of list ULTRASOUND Subject: Re: Hysterosonography protocol Some comments on the protocol for sonohysterography that was submitted (below), as far as changes from it that I use. To outline my background, I am an OB/Gyn and MFM, and have practiced general OB/Gyn in the past, but now have a practice restricted to sonology in OB/Gyn. My partner and I do all our own scans in their entirety (at least at present). I have been doing sonohysterography for at least 4 or 5 years, and am currently doing about 15 to 20 of them each month on referral from other OB/Gyn physicians. For anyone who is not doing these procedures, you will be amazed at how often you find polyps (or less commonly submucous fibroids) in patients with recurrent intermenstrual bleeding, postmenopausal bleeding, or sometimes in patients just with menorrhagia and dysmenorrhea. I agree with the timing of the procedure (I try for Day 4 to 7) but will do them at other times of the cycle on occasion. In my case it is the physician sonologist being assisted by a medical assistant. Re equipment: I don't use a tray or barrier drape, and don't usually use a specimen container. I usually use a prepackaged Betadine swabstick, but always ask first if the patient is allergic to shellfish or Iodine. If they are I then use Zephiran (in a sterile specimen container). I use 20 cc syringes. Occasionally I'll need to use more than one syringe, but usually 20 cc is enough. I like to use the Ackrad H/S catheter, or alternatively the Cook Silicone Balloon HSG catheters. Both are latex-free. One nice thing about the Ackrad catheter is its introducer system and cover, which enhances the ease to maintain sterility and to introduce the catheter without needing ring forceps or a tenaculum. Indeed I don't use sterile gloves (just exam gloves -- as long as you maintain a no-touch technique, where the inserted part of the catheter is never touched, sterile gloves are not essential (similar to inserting an IUD or doing an endometrial biopsy). Side opening speculums make it easier, but in some patients I need to use the narrow Pederson speculums. I have ring forceps available, but only occasionally need them so I don't have them opened. I almost never need a tenaculum, but again have one available. I also have a # 1 / # 2 Hegar dilator available, for the occasional postmenopausal patient who needs some minimal dilation to be able to insert the (smaller) Cook catheter. Re Procedure: As mentioned, I don't use sterile gloves, but regular exam gloves with a no-touch technique. I no longer have the patient take Ibuprofen before the procedure. I have found that patients rarely need to have it afterwards either, as long as (and this is key) the fluid is injected very slowly. If the fluid is injected quickly the rapid distension causes a lot of cramping. If it is injected slowly, they usually have minimal if any cramping. My assistant draws up the sterile saline into a 20 cc syringe, and then passes the catheter to me once the speculum has been inserted and the cervix prepped, so no separate sterile field is required beyond the opened package. As mentioned, I use Betadine swabsticks or Zephiran solution, but any all-purpose antiseptic that can be used on skin and mucus membranes should be fine. My goal is not to have the catheter in the endometrial cavity, but instead to have the balloon of the catheter within the cervix (which I usually inflate with about 1 cc of air). The advantage to inflating the balloon in the cervical canal is that you get a better seal (less leakage) and so need less fluid injection and get better images, and sometimes if the catheter has been inserted into the endometrial cavity you may lift up some endometrium with the tip of the catheter and have to decide if that it is tiny polyp of just from catheter tip trauma. Other tips: In the past, some people have suggested that a sonohysterogram is unnecessary if the endometrial thickness is less than 4 mm. While pathology is unlikely at < 4mm, it can occur, so consider a patient's symptoms. I have found polyps of 2 mm thickness within a 3 mm endometrium. In the uncommon situation that a patient does get cramping that isn't immediately relieved by removal of the catheter, check by ultrasound to see if the fluid has drained out. If not, the patient may have cervical stenosis, and you can relieve the cramping by opening the cervix with anothet catheter or a dilator to allow the fluid out. If a patient has cervical stenosis with fluid retention, or if they have a hydrosalpinx, I give them 24 to 48 hours of prophylactic antibiotics following the procedure if I didn't already know about the situation. If I already knew about their problems then I give them one dose of antibiotic (e.g. doxycycline 200 mg) just before the procedure. Simplistically, my protocol for Technique of Sonohysterography is: Following a baseline transvaginal ultrasound: *Cervix is visualized (and cleansed, e.g. with Betadine) using a speculum in the vagina - using a side opening speculum makes removal of the speculum (with the SHG catheter in place) easier *Prefill the catheter with saline to lessen air bubbles *The catheter is inserted through the cervix, so that the balloon will be able to inflate either within the cervix (my preference), or in the uterine cavity *The catheter balloon is inflated with air (usually < 1 cc), the speculum is removed, and the transvaginal ultrasound probe (re)inserted *Saline is then slowly injected through the catheter into the endometrial cavity (a 20 cc syringe is usually as much as or more than needed) *The endometrial cavity is imaged in the longitudinal and transverse planes while the endometrial cavity is being distended *Especially if the balloon is in the lower uterine segment, the balloon is deflated and removed under ultrasound observation
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