Had an Hsg Done January 12 2018 Shouldnt I Have My Period Again
Int J Surg Case Rep. 2019; 55: 179–182.
Rupture of an unsuspected ectopic pregnancy following a hysterosalpingography—A case report
P.T. Lim
aDepartment of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
Rohit
bDepartment of Diagnostic Radiology, KK Women'south and Children'south Hospital, Singapore
Observe articles past Rohit
5. Viardot-Foucault
cDepartment of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
Received 2018 October 14; Revised 2019 Jan 7; Accustomed 2019 Jan 19.
Abstract
Introduction
Hysterosalpingography (HSG) is routinely performed in the mid-follicular stage of a woman's menstrual cycle for crenel and tubal patency cess every bit a function of the infertility screening. A pre-procedural pregnancy test is not routinely required unless the patient reports abnormal menstrual bleeding or irregular menstrual design.
Presentation of case
We nowadays the example of a 29 year-old sub fertile woman who had a HSG performed on day 12 of her menstrual cycle. She developed intestinal pain shortly after and was diagnosed with a ruptured ectopic pregnancy, resulting in a correct salpingectomy. The patient was discharged well iii days later.
Word
Based on available guidelines and the rare occurrence of such complication, we observe insufficient evidence to perform universal pre-procedural pregnancy testing. Nonetheless, we strongly recommend doing it for abnormal menstrual cycles (cycles shorter than 21 or longer than 35 days, unreliable menstrual history or unusual menstrual menses design). Furthermore, HSG should be scheduled during the follicular phase after practicing safe sexual practice within the two weeks preceding the exam.
Conclusion
While pre-procedural pregnancy test should not be performed for all, a high alphabetize of suspicion for early pregnancy should be maintained as undetected ectopic and heterotopic pregnancies could lead to serious complications once the HSG is washed.
Keywords: Case study, Hysterosalpingography, Ectopic pregnancy, Subfertility
1. Introduction
Hysterosalpingography (HSG) is a minimally invasive radiographic imaging of the uterine cavity and fallopian tubes involving the injection of contrast media with fluoroscopic visualization. It is ofttimes used as the starting time line of assessment in a context of subfertility, ordinarily performed inside the first v–12 days of the menstrual cycle later the cessation of menstrual catamenia [1]. A pre-procedural pregnancy examination is not routinely required unless the patient reports abnormal menstrual bleeding or irregular menstrual pattern [1]. The incidence of performing HSG in an undetected pregnancy is low hence in that location is limited information bachelor on the long-term adverse pregnancy outcomes related to the exposure to ionizing radiation or the mechanical trauma to the embryo. Nosotros present a instance of a patient managed in a tertiary public hospital for whom a HSG was performed while an unsuspected ectopic pregnancy was ongoing, leading to a rupture. Nosotros will then discuss the role of routine pre-procedural pregnancy exam for patients undergoing HSG.
This case report has been written in line with the SCARE criteria [two].
ii. Presentation of case
A 29 year-sometime Chinese woman, gravida 2 para ane, consulted a public 3rd hospital subsequently viii months of secondary subfertility despite regular sexual intercourse. She had no significant by medical history or family history. She was not on whatever long term medications. Her clinical exam was normal with a torso mass alphabetize of 24.ix kg/m2. Her menstrual cycles were longer than usual but regular (36–twoscore days with five days of menstrual flow).
Hormonal investigations revealed normal gonadotropins and ovulatory cycles (Tabular array one). The baseline transvaginal ultrasound of the pelvis showed a normal uterus, and a correct polycystic ovarian morphology (volume 14cc) (Fig. 1). The semen assay was consequent with an isolated teratozoospermia. She reported a normal menstrual menstruation starting on seventh November 2016 and was scheduled for an HSG on 18th November 2016 (day 12 of menstrual bicycle). The menstrual menses prior to this was on 30th September 2016. No pregnancy exam was done prior to the HSG because the reported menstrual flow was normal and on fourth dimension. The HSG was reported as normal, with both fallopian tubes beingness opacified and showing gratis intraperitoneal spillage (Fig. 2).
Table i
Hormonal investigations revealed normal gonadotropins and ovulatory cycles.
| Investigation | Units | Reference Range | 12/08/2016 | 27/ten/2016 |
|---|---|---|---|---|
| Follicle-stimulating hormone | IU/L | 1.35–17.06 | 4.9 | |
| Luteinizing Hormone | IU/L | 0.38–60.33 | 22.85 | |
| Progesterone | nmol/L | Follicular phase: 2.03–14.1 Mid Luteal phase: 19.i–79.v | 5.69 | 53.69 (24-hour interval 29) |
| Estradiol | pmol/L | 77–2382 | 362 | |
| Testosterone | nmol/50 | 0.5-1.9 | one.half-dozen | |
| Prolactin | mcg/50 | seven.0–32.9 | 5.three | |
| Anti-Mullerian Hormone | ng/ml | 4.0–6.eight | 6.iii | |
| Thyroid Stimulating Hormone | mIU/L | 0.fifty–four.l | – | 0.nine |
| Free Thyroxine | pmol/l | 10.three–25.7 | – | 14 |
Transvaginal ultrasound pelvis images. [A] Sagittal view of the uterus with normal endometrium thickness [B] Right ovary enlarged with polycystic morphology (vol14cc). [C] Left ovary is normal.
Hysterosalpingography [A] Smooth triangular uterine cavity filled with contrast [B] dilated right fallopian tube, filling with contrast but with presence of free spillage.
A few hours after the HSG, she developed intermittent lower abdominal hurting that progressively exacerbated. She consulted the emergency section on 22nd November 2016. She was tachycardic with a centre rate of 106 beats/min and blood force per unit area was stable at 105/69 mmHg. She was given fluid resuscitation and was monitored in the critical intendance area in the emergency department. On examination, in that location was tenderness over the right iliac fossa and suprapubic region with guarding but no rebound tenderness. Vaginal examination revealed tenderness over the right adnexa and blood at the cervix. The urine pregnancy test was found to be positive with a serum beta HCG level of 29,271 mIU/mL. A bedside transvaginal ultrasound showed an empty uterus with a thickened endometrium and costless fluid in the pouch of Douglas. Her hemoglobin level was 11.2 thousand/dL. Renal function and coagulation profile were normal. The diagnosis of a ruptured ectopic pregnancy was suspected and confirmed by laparoscopy when a therapeutic right salpingectomy was performed by a gynecology specialist. Intra-operatively, there was a ruptured right tubal ectopic pregnancy approximately 4 cm in size and hemoperitoneum with an estimated blood loss of 600mls. Her post-operative recovery was unremarkable and she was discharged iii days later. She was well when reviewed in the outpatient clinic three months later on and did non written report any post-operative complication.
3. Discussion
This is a instance of an undetected ectopic pregnancy that ruptured later on a HSG was performed. To date, there accept been very few reports of this kind. A review of 6225 HSG by Justesen et al constitute an incidence of 4 cases (0.06%) of inadvertently performed examinations during early pregnancy [iii]. He reported a case of a 34 twelvemonth-old adult female whose last vaginal bleeding started a few days earlier the expected time and lasted only for 1 mean solar day. She reported this as a menstrual bleeding, just an intrauterine pregnancy was found at HSG. She was initially treated equally per threatened ballgame as she presented with lower abdominal pain and bloody vaginal discharge v days after HSG. 4 weeks afterwards, she was readmitted and a laparotomy revealed a ruptured right ectopic pregnancy [three].
In another instance series by Cheung et al., a 23 year old woman with regular menstrual cycles underwent a HSG five days after her reported menstrual flow [four]. The radiology report showed no abnormalities and tubes were patent. A calendar week after, she presented with lower abdominal pain and bleeding that was assumed as beingness part of an endometritis and was treated with antibiotics. She was then readmitted for increasing lower abdominal pain a calendar week later and the diagnosis of a right ectopic pregnancy was suspected (urine pregnancy test positive, empty uterus with a correct adnexal mass on pelvic ultrasound). A diagnostic laparoscopy was performed confirming the presence of a right tubal ectopic pregnancy and a right salpingectomy was performed.
Cheung et al also reported two other cases – one with a spontaneous abortion and some other with an intrauterine pregnancy which resulted in a good for you live birth at 39 weeks gestation. The child was followed-up and was reported to have normal growth and development at 7 years of historic period [5].
While our patient reported a "normal menstrual flow", information technology is not uncommon to accept bleeding from a decidualized cycle which may be easily mistaken as a menstrual flow [half-dozen]. Moreover, her history of long menstrual cycles and scan findings of unilateral polycystic ovarian morphology are suggestive of polycystic ovarian syndrome even though one of her cycle was proven to be ovulatory (adequate luteal phase progesterone level). Indeed, a normal menstrual cycle length is divers as being between 21 to 35 days and the extension of her cycles' length across 35 days could accept been considered as abnormal and a pre-procedural pregnancy exam washed. The positivity of the test would take immune early detection and treatment of this ectopic pregnancy and therefore a possible preservation of her full fertility potential. The early treatment of an ectopic pregnancy is often conservative and consists of either medical treatment with Methotrexate or surgery with salpingotomy instead of salpingectomy. The overall success rate of methotrexate for tubal ectopic pregnancy was quoted as 65–95% with three–27% of women requiring a second dose [7]. In patients with fertility – reducing factors such equally previous pelvic inflammatory disease, it is plant that in that location are college rates of subsequent intrauterine pregnancy in patients with salpingotomy performed rather than salpingectomy [7]. In this case, though methotrexate would be unsuitable in view of the high beta HCG level, a salpingotomy, rather than a salpingectomy could have been performed if the ectopic pregnancy was detected earlier and the rupture probably avoided.
In order to avoid performing a HSG during early pregnancy, the American Higher of Radiology advocates that HSG should be scheduled between mean solar day seven–10 of the menstrual cycle and a pregnancy examination should exist done if there is whatsoever suspicion of pregnancy [1]. Similarly, the American College of Obstetricians and Gynecologists does not advocate a routine pre-procedural pregnancy test, and advise performing HSG within the first 14 days of the menstrual cycle. In our institution, HSG is scheduled betwixt Twenty-four hours 5–12 of the menstrual cycle, and only after cessation of menstrual menstruation. Patients are also advised to avoid sexual intercourse during that menstrual cycle. They are required to fill in a pre-procedural questionnaire which includes questions about their menstrual cycle pattern, abnormal bleeding or irregular menstruation. A pregnancy exam is performed if at that place is a positive answer.
As nosotros review the literature for cases of undiagnosed pregnancies which take undergone HSG, we raise the question of whether a pre-procedural pregnancy test should be adopted for all.
In a prospective report performed by Herr et al, which implemented a mandatory point-of-intendance urine pregnancy testing before HSG, only 1 out of 410 (0.025%) women were plant to accept unsuspected early on pregnancy [eight]. In our institution where approximately 1800 HSGs were performed in 2016, merely one example was performed during an unsuspected pregnancy. Upon reviewing our hospital data, no other instance was reported previously.
About of the studies focused on the cost-effectiveness of routine pre-procedural pregnancy test to prevent an extremely rare complication. However, due to the astringent complications that can possibly ascend from a misdiagnosis, the cost of the pregnancy test is not the but financial component to consider but also the additional cost derived from unnecessary hospitalization, surgical process and treatment of iatrogenic infertility.
While there is bereft evidence at the moment to support the utilise of a universal mandatory pregnancy tests prior to HSG, we propose an individualized approach whereby clinicians would perform a pregnancy test for selected women based on the post-obit stricter criteria defining abnormal menstrual cycles: bike length shorter than 21 days or longer than 35 days; unusual menstrual flow pattern and unreliable menstrual history. A menstrual diary may improve the accuracy of cocky-reported symptoms and as well assist from a medico legal standpoint.
4. Conclusion
In conclusion, we hold with international guidelines that there is at present, insufficient prove to recommend performing a pre-procedural pregnancy test for all. Even so, we should e'er maintain a high alphabetize of suspicion for early on pregnancy in general as undetected ectopic and heterotopic pregnancies could lead to serious complications once the HSG is washed.
This tin can be improved by scheduling the HSG during the follicular phase and advising patient to practice safety-sexual activity during the cycle when the examination has been planned. A pre-procedural pregnancy examination should be performed for women with irregular cycles and for women with unreliable menstrual history or unusual menstrual menstruum pattern.
Conflict of interest
At that place is no conflict of interest to disclose.
Sources of funding
No funding is required for this manuscript.
Ethical blessing
This study is exempt from ethical approval in our institution.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is bachelor for review past the Editor-in-Main of this journal on asking.
Author contribution
Dr PT Lim is the corresponding author who is likewise the chief writer of the manuscript. Dr Veronique is the specialist in reproductive medicine involved in the intendance of the patient during her outpatient dispensary visits. She was as well the principal writer who conceptualised, supervised and edited this instance report. Dr Rohit is the radiologist who reported the hysterosalpingogram and was too involved in editing of the case report.
Registration of research studies
UIN: Researchregistry4439.
Guarantor
Dr Veronique Celine Viardot-Foucault.
Senior Consultant.
KK Women's and Children'south Hospital.
Section of Reproductive Medicine.
Provenance and peer review
Non deputed, externally peer-reviewed.
Boosted data
There is no conflict of interest to disclose and there is no funding required for this study. This written report is exempt from upstanding blessing in our institution.
References
2. Agha R.A., Fowler A.J., Saeta A., Barai I., Rajmohan Southward., Orgill D.P., Afifi R., Al-Ahmadi R., Albrecht J., Alsawadi A., Aronson J. The SCARE statement: consensus-based surgical case report guidelines. Int. J. Surg. 2016;1(Oct (34)):180–186. [PubMed] [Google Scholar]
3. Justesen P., Rasmussen F., Andersen P.E., Jr. Inadvertently performed hysterosalpingography during early pregnancy. Acta Radiol. Diagn. 1986;27(six):711–713. [PubMed] [Google Scholar]
4. Cheung G.W.Y. Unsuspected pregnancy at hysterosalpingography: a report of iii cases with different outcomes. Hum. Reprod. 2003;18(12):2608–2609. [PubMed] [Google Scholar]
5. Kuo Chung-Hai, Lin Haung-Chi, Chang Ming-Hao. Upshot of inadvertently performed hysterosalpingography during early pregnancy—7 years afterward birth. Taiwan. J. Obstet. Gynecol. 2008;47(iv):463–465. [PubMed] [Google Scholar]
6. Albers J.R., Hull S.K., Wesley R.M. Abnormal uterine bleeding. Am. Fam. Phys. 2004;69(Apr (eight)):1915–1934. [PubMed] [Google Scholar]
7. No Chiliad.T. 2016. Diagnosis and Management of Ectopic Pregnancy. [Google Scholar]
viii. Herr Keith. Charge per unit of detection of unsuspected pregnancies after implementation of mandatory point-of-care urine pregnancy testing prior to hysterosalpingography. J. Am. Coll. Radiol. 2013;x(7):533–537. [PubMed] [Google Scholar]
Articles from International Journal of Surgery Case Reports are provided hither courtesy of Elsevier
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6369134/
0 Response to "Had an Hsg Done January 12 2018 Shouldnt I Have My Period Again"
Publicar un comentario