Re: Hysterosonography protocol
From: Dr Fazeel uz Zaman (fazeel@atd.hazara.net.pk)
Tue Apr 3 12:18:15 2001
i guess air elasticity will give a less painful plug?.......fazeel
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
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