Intravasation of water-soluble contrast agent into the internal iliac vein during hysterosaplingography.
Intravasation of contrast agent during hysterosalpingography is a rare event. Most complications of hysteroscopy happen when oil-soluble contrast agent is used and the commonly reported cases are cramping lower abdominal pain, vaso-vagal attack, embolic phenomenon or uterine perforation. During the procedure of hysterosalpingography in a young woman with primary subfertility, using water-based, low osmolar contrast agent, intravasation of contrast into the parametrial vessels and internal iliac veins was noted. There was no major consequence except intense pain that was managed with analgesia and hours of observation. Although no major adverse reaction was noted yet safety profile of such type of contrast agent need to be evaluated further in controlled trials.
KEY WORDS: Hysterosalpingography, Contrast agent, Intravasation, Water-soluble.
Hysterosalpingography is a procedure that is mostly carried out as a part of subfertility investigations, although it has other diagnostic and therapeutic uses too. Complications of hysterosalpingography are mostly theoretical except for transient abdominal cramping or bleeding. Other rare complications include infection, embolic phenomenon, vaso-vagal attack, uterine perforation, granuloma formation, pelvic peritonitis and dye intravasation.1
There are different types of contrast media used for the procedure. Either they are oil based or water based depending on their specific formulation, activity and side effects. The debate between which media to use is still on going and water based contrast media is preferred by majority because of the better image quality it gives, earlier dissipation that remove the need of delayed films and avoidance of side effects like embolism and granuloma formation that is known with oil-based contrast agents.2 There are few reported side effects of these contrast media verifying rarity of adverse effects and most of these are not confirmed in randomized trials. Despite all the debate being carried out, which medium to use remains the choice of physician or institute.
Iobitriol, Xenetix, is iodinated, low osmolar; water-based contrast media that is less toxic and more soluble then previously used high osmolar agents. Iobitriol, being used now in many radiological procedures, was tested in a large study and it was shown to be 99.04% safe for the general population though the group had not studied its use in hysterosalpingography specifically.3 Moreover Iobitriol has been evaluated for pharmacologic4 and toxicology5 profile in studies which have shown its protection by excellent pharmacological profile and favorability due to safe toxic profile like other water-based contrast agents.
We did literature search to review the previously published complications of hysterosalpingography. Coming specifically across the intravasation of contrast medium during hysterosalpingography, few reported cases were found. In one study from Nepal that was done to detect prevalence of tubal blockage found during hysterosalpingography as a part of infertility work-up percentage of dye intravasation was 1.2% and 1.7% in primary and secondary subfertility respectively.6
A 32 years old young Saudi lady presented at Reproductive Endocrine and Infertility Medicine Department, Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia on March, 2010. She had primary subfertility of seven years duration. She was asymptomatic with no medical or surgical illness. She had irregular cycle and was previously diagnosed to have polycystic ovaries. Clinically she was obese with BMI of 36.6. Her husband was 33 year old healthy man with normal semen analysis.
She was planned for routine baseline subfertility work-up which included hysterosalpingography. She was next seen in radiology department on the day when she was booked for HSG in the follicular phase of her cycle. The procedure was first explained to the patient in detail and her language. Procedure was started using aseptic technique; cervix was held with forceps and catheter was easily introduced and its placement inside the uterine cavity was confirmed by fluoroscopic image.
In our unit, iobitridol (Xenetix) is used as contrast medium. It is water-soluble, nonionic, low-osmolar iodinated agent. After taking initial image of the pelvis, (Fig.1) the contrast (Xenetix) was injected slowly through the catheter. When 5ml of contrast was injected, the patient complained of sudden and severe lower abdominal pain. After abandoning the procedure temporarily the radiologist informed that the contrast is seen entering the parametrial vessels and internal iliac vein (Fig.2). Procedure was stopped completely. Patient was in pain, but she was oriented and hemodynamically stable. She was immediately shifted to the recovery room, on IV fluids. She was expectantly managed and pain settled down using simple analgesia. There were no symptoms/signs of hypersensitivity or any system involvement.
No abnormality detected on general and systemic examination of cardiovascular, respiratory and central nervous system. Her blood count, liver, kidney function tests, blood sugar and electrolytes all returned normal. Patient was kept under observation for almost six hours during which time she was well and stable. She was discharged home in stable condition.
The X-ray films were again reviewed by the radiologists. It is reported that intravasation of contrast was noted in the venous plexus of myometrium and is seen draining into the internal iliac veins. No spillage of dye was noted into the peritoneal cavity as the procedure hysterosalpingography was not completed.
There are few published case reports of dye intravasation during hysterosalpingography but generally it is a rare event.2 From Israel in 1990, a case of contrast intravasation and cerebral embolism was reported where oil-based media was used.7 Another case was reported in Japan, in 1991 where a 25 year old lady, with previous history of uterine curettage had pulmonary edema and shock due to contrast extravasation.8 And there are similar case reports of contrast intravasation followed by cerebral and pulmonary emboli from Turkey.9
Almost all previously reported cases of intravasation had happened when oil-soluble contrast medium was used. There are studies that have compared oil-soluble with water-soluble contrast agents in their achievement to enhance fertility.10 Some authors have reported better image quality with water-based medium but its relation to intravasation per-se has not been evaluated.
Intravasation of water-soluble contrast agents is extremely rare event and being a retrospective complication, it cannot be evaluated properly in prospective studies. However in our case, no adverse outcome was encountered and yet we do not know much about the safety profile of water-soluble contrast agents for diagnostic hysterosalpingography.
1. William L, Sipmpson FR, Laura G, Mester F. Hysterosalpingography: A re-emerging study. Radiographics 2006;26:419-431.
2. Goldberg JM. Clinical reproductive medicine and surgery. 1st ed. Falcone, 2007.
3. Thomas J. Honold E, Wolf M, Mohajeri H. Hammerstringl R. Safety of Iobitriol in the general population and at risk patients. Eur Radiol 2006;16:1288-1297.
4. Idee GM, Bault C, Beaufils H, Berthommier C, Cambar J, Corot C, et al. Pharmacologic profile of iobitridol, a nonionic iodinated contrast medium. Acta Radoiol Supplementum 1996;400:35-38.
5. Donandieu AM, Idee JM, Doucet D, Legros A, Penati S, Nain-Dit-Ducret M, et al. Toxicology profile of iobitridol, a nonionic low-osmolality contrast medium. Acta Radiol Suppl 1996;400:17-24.
6. Shrivastva VR, Rijal B, Shrestha HK, Tuladhar AS. Detection of tubal abnormalities by HSG in Nepalese subfertile women. Nepal Med Coll J 2009;11:42-45.
7. Dan U, Oelsner G, Gruberg L, Ezra D, Menczer J. Cerebral embolization and coma after hysterosalpingography with oil-based contrast medium. Fertil Steril 1990;53:939-940.
8. Ogihara T, Miyao H, Katoh H, Ikenaga H, Michikawa N, Ohkubo N, et al. Adverse reactions to lipiodol ultra fluid: report of an accidental case. Keio J Med 1991;40:94-96.
9. Uzun O, Findik S, Danaci M, Katar D, Erkan L. Pulmonary and oil embolism after hysterosalpingography with oil soluble contrast medium. Respirology 2004;9:134-136.
10. Schwabe MG, Shapiro SS, Haning RV. Hysterosalpingography with oil contrast medium enhances fertility in patients with fertility of unknown etiology. Fertile Steril 1983;40:604-606.
Hussain TZ was directly involved in the procedure of hysteroscopy and noticing its rare occurrence, decided to report it. The report was written by Hussain TZ and reviewed by Agdi M, who also happens to be the treating consultant of the said patient.
1. Tasnim Zahid Hussain, MRCOG; Obstetrics and Gynecology Department, Kingdom Hospital, PO Box 331745, Riyadh 11373, Kingdom of Saudi Arabia.
2. Mohammed Agdi, MD, Reproductive Endocrine and Infertility Medicine Department, Women's Specialized Hospital, King Fahad Medical City, PO Box 220028, Riyadh 11311, Kingdom of Saudi Arabia.
Tasnim Zahid Hussain, MRCOG; Obstetrics and Gynecology Department, Kingdom Hospital, PO Box 331745, Riyadh 11373, Kingdom of Saudi Arabia., E-mail: firstname.lastname@example.org, * Received for Publication: April 11, 2012, * Accepted for Publication: July 24, 2012
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|Author:||Hussain, Tasnim Zahid; Agdi, Mohammed|
|Publication:||Pakistan Journal of Medical Sciences|
|Date:||Dec 31, 2012|
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