Hysterosalpingogram (HSG) PRINT

HSG HOSPITAL PROTOCOL (printer friendly version)

I. Equipment (May vary at different sites)

a. HSG tray from sterile processing

• Sterile tongs
• Glass or metal cups x 2

b. Mayo stand
c. Sterile towels
d. Contrast (Isovue or Omnipaque)
e. Betadine
f. Sterile cotton balls
g. 20cc luer lock syringe
h. Sterile KY jelly
i. Disposable speculum
j. Speculum light
k. Hand grips for stirrups (covered with wash cloths)
l. Sanitary napkin + washcloth for bathroom
m. Sterile gloves
n. HSG catheters (size 5 + size 7)
o. Chux
p. Rolled up towel or bump to raise hips

II. Personnel

a. Radiologist or Fluoroscopy Technologist

• Places speculum
• Administers contrast
• Runs fluoroscopy using fluoro pedal

b. Hospital Technologist

• Calls patient > 48 hrs. prior to appointment to review HSG TECH PRE-CALL QUESTIONNAIRE
• Checks patient order, confirms negative blood serum pregnancy test results (scans in EPIC/PACS)
• Assists the radiologist or RA during procedure
• Captures images or takes spot images upon request
• Provides patient with aftercare instructions

III. Procedure

a. Verify negative results of blood serum pregnancy test
b. Patient on table in modified lithotomy position
c. Speculum placed
d. Cervix cleaned w/ betadine x 3
e. Hystero catheter placed

IV. Required Images

a. Scout
b. Minimal fill of uterine cavity
c. Partial fill of uterine cavity
d. Total fill of uterine cavity
e. Oblique views of uterine cornua
f. Contrast filled cervical canal with catheter removed

Indications:

– Infertility
– Confirmation of tubal occlusion

Contraindications:

-Pregnancy or the possibility of pregnancy
– Active pelvic bleeding
– Allergy to iodinated contrast (requires 13-hour premedication & must be performed in a hospital setting)
– Signs or symptoms of active pelvic infection including fever

V. Special Considerations

a. Scheduling/Timing:

• HSG’s are to be scheduled within the first 10 days of the menstrual cycle. Cycle day 1 is considered the first day of menstrual bleeding.
• The patient is instructed to refrain from sexual intercourse from the onset of the menstrual cycle (day 1) until after the procedure is performed.

b. Pregnancy Test Requirement:

• A negative blood serum pregnancy test is required within 24 hours before the exam, for all patients, before HSG is performed. This includes patients who have had a Depo Provera shot for birth control.
• Patients should bring the results of their blood serum pregnancy test to their HSG appointment.
• If the patient arrives without a negative blood serum pregnancy test, or does not meet the 24-hour requirement, she will be sent to the hospital lab (site specific) to have a blood serum pregnancy test before proceeding. The HSG will not begin until a negative test is confirmed.
• Blood serum pregnancy tests will not be performed at Littleton Hospital. (Patient must have results from an outside lab)
• Patients requiring hospital blood serum pregnancy tests should arrive at least 1 hour prior to their scheduled appointment time for lab work.

c. Irregular menstrual cycle or amenorrhea:

• Require a blood serum pregnancy test within 24 hours of the scheduled HSG.

d. IUD (Intrauterine Device)

• If a patient has had an IUD removed recently, they must wait at least 2 weeks before having an HSG exam.
• An HSG may be performed with an IUD present.

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Hysterosalpingogram (HSG) PRINT