Re: Hysterosonography protocol
From: art fougner, md (evsono@pipeline.com)
Tue Apr 3 08:06:50 2001
Dr. Kumar -
agreed.
art
At Tue, 03 Apr 2001, udaya kumar wrote:
>
>Nice protocol. I wonder why 1cc air should be used to inflate the balloon. Would
>prefer 1cc of water/saline instead for obvious reasons.
>..Udayakumar
>
>Forum List Admin wrote:
>
>> 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
--
art fougner, md
A series of 1000 cases begins with but a single anecdote.
