POST PROCEDURAL SEPSIS FOLLOWING HYSTEROSALPINGOGRAPHY BY FOLEY CATHETER TECHNIQUE

Introduction and literature review

• Hysterosalpingography (HSG) has become a commonly performed examination due to recent advances and improvements in, as well as the increasing popularity of, reproductive medicine.

• The prevalence of infertility ranges from 7-28% depending on the age of the woman.

• Globally 10-15% of the couples are subfertile.
• Hysterosalpingography ( HSG) is a recognized method of evaluating fallopian tube patency.
   
• With the use of Hysterosalpingography (HSG) as a basic radiologic tool there is a high probability of making accurate diagnoses of infertility which will lead to prompt treatment.

A normal hysterosalpingogram. Note the catheter entering at the bottom of the screen, and the contrast medium filling the uterine cavity (small triangle in the center).

In our practice, the number of HSG examinations has increased dramatically over the past few years.
This increase is likely due to
(a) advances in reproductive medicine, resulting in more successful in vitro fertilization procedures and
(b) the trend toward women delaying pregnancy until later in life.

• Uterine abnormalities that can be detected at HSG include congenital anomalies, polyps, leiomyomas, surgical changes, synechiae, and adenomyosis.

• Tubal abnormalities that can be detected include tubal occlusion, salpingitis isthmica nodosum, polyps, hydrosalpinx, and peritubal adhesions. 

The procedure can be used to investigate repeated miscarriages that result from congenital abnormalities of the uterus and to determine the presence and severity of these abnormalities, including, tumor masses, adhesions, uterine fibroids. Hysterosalpingography is also used to evaluate the openness of the fallopian tubes, and to monitor the effects of tubal surgery, including:

• blockage of the fallopian tubes due to infection or scarring

• tubal ligation

• the closure of the fallopian tubes in a sterilization procedure and a sterilization reversal

• the re-opening of the fallopian tubes following a sterilization or disease-related blockage 

It is a known and undisputable fact that hysterosapingography has both therapeutic and diagnostic value.
Following hysterosalpingography, certain minor/mild uterine adhesion and partial tubal occlusion are lysed and a hitherto infertile woman have conceived months after HSG without any other gynaecological intervention. Interestingly, an increase in pregnancy rate has been observed in the months after hysterosalpingography. The vagina is an area of the body that is abundant with normal bacterial flora. Any procedure through the vagina may, therefore, be considered to have added potential for resulting in post procedure infection. Some complications can occur with HSG—most notably, bleeding and infection—and awareness of the possible complications of HSG is essential. Nevertheless, HSG remains a valuable tool in the evaluation of the uterus and fallopian tubes. Radiologists should become familiar with HSG technique. The most severe complication of hysterosalpingography is pelvic infection which occurs in 2 to 4% of cases and may require prophylactic antibiotic thereapy. Prophylactic antibiotics may play a role in the prevention of post procedural sepsis. This study was designed to find out the incidence of post procedural sepsis  following hysterosalpingography. The gynecologist often considers prophylactic antibiotics for patients having a history of pelvic inflammatory disease (PID) and those who require systemic bacterial endocarditis (SBE) prophylaxis.

While the risk of infection is rare and has been reported to be less than 1%, if the study results are suggestive of previous PID, antibiotic prophylaxis should be considered; some have even suggested routine prophylaxis in all infertile women. Alternatively, if prophylaxis was not given but the tubes are shown to be dilated at HSG, 200 mg of doxycycline is given after the procedure, followed by 100 mg twice a day for 5 days. An increasing number of clinicians are using catheters typically reserved for SIS for the HSG procedure. Balloon catheters  are advantageous in that they typically do not require tenaculum placement for cervical traction except in cases of cervical stenosis.