|Year : 2016 | Volume
| Issue : 1 | Page : 36-38
Intravasation of water-soluble contrast agent during hysterosalpingography: A potential pitfall in diagnosis
Japleen Kaur1, Shalini Gainder1, Marpalli Vasudeva Karthik2, Tulika Singh2
1 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||2-Jun-2016|
Department of Obstetrics and Gynaecology, 3rd Floor, F Block, Nehru Hospital, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Hysterosalpingography (HSG) is an integral component of infertility investigation. Certain technical artifacts can lead to misdiagnosis. Intravasation of contrast is seen in 0.4-6.9% cases. Radiologists as well as gynecologists should be aware of this phenomenon as it can potentially be misinterpreted as free intraperitoneal spillage. Venous intravasation was seen during HSG in a 33-year-old woman with primary infertility and initially misdiagnosed. No serious systemic complications were noted. The tubal block was later confirmed on laparoscopy and chromopertubation. A review of literature was performed to identify potential risk factors, for example, tuberculosis, recent endometrial curettage, uterine anomalies, etc. Certain measures such as slow instillation of contrast have also been proposed for prevention of this phenomenon.
Keywords: Contrast agent, hysterosalpingography, intravasation, tubal block, water soluble
|How to cite this article:|
Kaur J, Gainder S, Karthik MV, Singh T. Intravasation of water-soluble contrast agent during hysterosalpingography: A potential pitfall in diagnosis. IVF Lite 2016;3:36-8
|How to cite this URL:|
Kaur J, Gainder S, Karthik MV, Singh T. Intravasation of water-soluble contrast agent during hysterosalpingography: A potential pitfall in diagnosis. IVF Lite [serial online] 2016 [cited 2022 Jan 18];3:36-8. Available from: http://www.ivflite.org/text.asp?2016/3/1/36/183445
| Introduction|| |
Hysterosalpingography (HSG) is a fluoroscopic imaging procedure with numerous diagnostic as well as therapeutic applications.  It is most frequently used to evaluate uterine morphology and tubal patency in cases of infertility. Some artifacts such as air bubbles, corneal spasms, and intravasation of the contrast agent can be misinterpreted as space occupying lesions, tubal block, and free intraperitoneal spill, respectively. Intravasation of contrast refers to the passage of contrast directly into the myometrial-parametrial venous plexus and subsequently pelvic veins. The prevalence of this phenomenon ranges from 0.4% to 6.9%.  There is a dearth of literature recognizing this entity. This case report and review is an attempt to highlight the potential pitfall in diagnosis due to contrast intravasation in HSG.
| Case report|| |
A 33-year-old female with primary infertility of 8 years presented to our institute in October 2014. She had a history of delayed cycles and scanty flow for the past 3 years. There was no history of tuberculosis, medical disorder, or surgical intervention. There was no record of seeking treatment for infertility in the past. Clinical examination was unremarkable. Baseline investigations in the form of husband semen analysis, ultrasound pelvis, and hormone analysis were within normal limits. She underwent an endometrial biopsy on the 1 st day of menstrual cycle in November 2014. Histopathology report was suggestive of fragmented endometrial glands and negative for tuberculosis.
Thereafter, she was planned for HSG. Informed and written consent was taken after explaining the procedure to the patient. Premedication with antispasmodic and analgesic (hyoscine/mefenamic acid tablet) was given. Under aseptic precautions, Sims speculum inserted and anterior lip of the cervix held with vulsellum and contrast instilled using Leech-Wilkinson cannula. A high osmolality, water-soluble contrast agent (urografin 76%, diatrizoate sodium, and diatrizoate meglumine, Bayer Zydus Pharma Pvt. Ltd., Maharashtra, India) was used for the study. The plain film was recorded first [Figure 1]. Instillation of 2 ml of contrast outlined the uterus [Figure 2]. Further instillation of 5 ml of contrast agent resulted in immediate opacification of thin reticulate channels bilaterally.
|Figure 1: Plain hysterosalpingography film before instillation of contrast|
Click here to view
|Figure 2: Hysterosalpingogram showing opacification of uterus after instillation of 2 ml of contrast agent|
Click here to view
It was initially interpreted as a bilateral free spill. However, careful reconsideration revealed ascendant course of vessels and washout of contrast suggestive of intravasation [Figure 3]. As the Fallopian tube More Detailss were not opacified, a provisional diagnosis of intravasation of contrast with possibility of blocked fallopian tubes was made. The procedure was abandoned. The patient experienced transient pain abdomen but remained hemodynamically stable. She was kept under observation for a few hours and discharged in stable condition. She underwent diagnostic laparoscopy and chromopertubation under general anesthesia in June 2015. Methylene blue dye was instilled slowly with Leech-Wilkinson cannula. No visualization of dye was in the peritoneal cavity either as spill or intra- or extra-vasation. There was no evidence of tuberculosis. Hysteroscopic cornual cannulation was attempted. A final diagnosis of mid-segment tubal block was made and the patient has been counseled for in vitro fertilization.
|Figure 3: Hysterosalpingogram: Venous intravasation of contrast into the parametrial veins, with ascendant course of contrast seen up to the common iliac vein|
Click here to view
| Discussion|| |
The prevalence of contrast intravasation during HSG varies from 0.4% to 6.9% in the available literature.  After observation of contrast intravasation, we reviewed 120 randomly selected HSG films at our center from January 2014 to June 2015 and found two more cases of the same (approximate prevalence - 2.5%).
The clinical relevance of contrast intravasation lies in its potential misinterpretation as free intraperitoneal spillage, thereby giving false positive results. The diagnosis of contrast intravasation is based upon the following radiographic features - filling up of thin beaded channels and ascendant course followed by washout. This is a major differentiating point between the free spill and intravasation. Delayed films may show contrast in the urinary bladder.
The patient may experience acute pain abdomen, which can also be attributed to cervical fixation and contrast instillation. Persistent pelvic discomfort may signify intravasation. 
The possible predisposing factors for contrast intravasation mentioned in the literature are HSG performed in early postmenstrual or late preovulatory phase, application of increased intrauterine pressure during instillation of dye, tubal occlusion, tuberculosis, recent uterine or endometrial intervention, menometrorrhagia, and uterine anomalies. 
The complications of contrast intravasation include embolism of oil-based contrasts.  However, with the use of water-soluble agents, this complication is averted.
Recently, an intravasation severity score has been proposed ranging from none (level zero) to severe (level three) intravasation based on loss of contrast media, systemic reactions, misinterpretation, peritoneal spillage, occurrence, extension of zonal location, and visualized urine bladder.  Severe intravasation is more likely to be associated with pathological blocked tubes as also seen in our case.
Proposed measures for prevention of intravasation include scheduling HSG in the mid-follicular period (6 th -10 th day of cycle), use of hydrosoluble contrast media, and avoidance of exerting excessive instillation pressure. 
| Conclusion|| |
Although a rare event, knowledge of contrast intravasation can prevent potential misinterpretation of hysterosalpingogram as free peritoneal spill.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Roma Dalf A, Ubeda B, Ubeda A, MonzMo M, Rotger R, Ramos R, et al.
Diagnostic value of hysterosalpingography in the detection of intrauterine abnormalities: A comparison with hysteroscopy. AJR Am J Roentgenol 2004;183:1405-9.
Dusak A, Soydinc HE, Onder H, Ekinci F, GF, G NY, Hamidi C, et al.
Venous intravasation as a complication and potential pitfall during hysterosalpingography: Re-emerging study with a novel classification. J Clin Imaging Sci 2013;3:67.
Simpson WL Jr., Beitia LG, Mester J. Hysterosalpingography: A reemerging study. Radiographics 2006;26:419-31.
Uzun O, Findik S, Danaci M, Katar D, Erkan L. Pulmonary and cerebral oil embolism after hysterosalpingography with oil soluble contrast medium. Respirology 2004;9:134-6.
| Authors|| |
Dr. Japleen Kaur is currently working as Senior Resident in the Department of Obstetrics and Gynecology at the Postgraduate Institute of Medical Education and Research, Chandigarh. She is an alumnus of the All India Institute of Medical Sciences, New Delhi. She has keen interest in the fields of infertility, assisted reproduction and gynecologic endocrinology. A gold medalist, she has numerous awards to her credit for paper presentations in National conferences.
[Figure 1], [Figure 2], [Figure 3]