الفهرس 
ABNORMAL HYSTEROGRAMOnly 14 pages are availabe for public view
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Abstract
STUDY OBJECTIVE: To compare between two dimensional transvaginal ultrasound (2D-TVS), three dimensional transvaginal ultrasound (3D-TVS), two dimensional saline infusion sonohysterography (2D-SIS) and diagnostic hysteroscopy (DHS) in the diagnosis of abnormal uterine findings at HSG ; regarding their sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy (DA). Diagnostic hysteroscopy (DHS) was regarded; as the gold standard with which other methods of scanning were compared. DESIGN: A comparative, observational, cross-sectional study. SETTEING: Department of Obstetrics and Gynecology at Benha University Hospital. STUDY DURATION: from June 2009 to December 2010. PATIENTS: Fifty (50) patients were included in the study. Inclusion criteria included patients who a HSG done within 6 months before the study, and showed abnormal uterine finding; regardless their age, complaint and parity. Exclusion criteria included; patients with active uterine bleeding, an evidence of cervical or uterine infection, and suspected pregnancy. The fifty (50) studied patients, were categorized into 4 groups, according to their abnormal uterine finding at HSG; as the following:
• Group I : included 18 patients with HSG suggestive of; congenital uterine anomalies, and were divided into:
o Five (5) patients with HSG suggestive of a fundal septum.
o Four (4) patients with HSG suggestive of a cervico-fundal septum.
o One (1) patient with HSG suggestive of a bicornuate uterus.
o Four (4) patients with HSG suggestive of a bicornuate Vs septate uterus.
o Two (2) patients with HSG suggestive of an unicornuate uterus.
o Two (2) patients with HSG suggestive of an arcuate uterus.
• Group II : included 13 patients with an irregular uterine contour; and were divided into:
o Three (3) patients with a fine irregular uterine contour; suggestive of IUAs.
o Ten (10) patients with a coarse irregular uterine contour; suggestive of either IUAs or SMF.
• Group III : included 15 patients with intrauterine filling defects; and were divided into:
o One (1) patient with 2 irregular intrauterine filling defects; suggestive of thick IUAs.
o Fourteen (14) patients with a regular well-defined intrauterine filling defect; suggestive of an endometrial polypi.
• Group IV : included 4 patients with uterine obliteration, and were divided into:
o 3 patients with a partial uterine contour obliteration, and were divided into:
- 2 patients with HSG suggestive of a large SMF.
- 1 patient with tube-like HSG; suggestive of marginal IUAs.
o 1 patient with a total uterine obliteration (failure of injection of the dye); suggestive of either severe IUAs or uterine hyperkinesia.
Every patient in the 4 groups was subjected to:
• Complete history taking with special emphasis on the present, menstrual and obstetric history.
• Complete general examination.
• Complete abdominal examination.
• Complete pelvic examination including; PV, bimanual examination and speculum examination.
Laboratory investigations were done for every patient in the 4 groups; as pre-operative investigations for DHS. They included:
• Quantitaive B- subunits HCG.
• Fasting and 2 hour postprandial blood glucose.
• Complete blood picture.
• Serum creatinine and blood urea.
• SGPT and SGOT.
• E.C.G.
METHODS: Every patient in the 4 groups was subjected to the following procedures; 2D-TVS, 3D-TVS, 2D-SIS, and DHS in this sequence.
The examination, by 2D-TVS and 3D-TVS was done in the secretory phase (mid- luteal) of the patient’s menstrual cycle. However, re-examination was done in the proliferative phase of the menstrual cycle (6th or 7th day) if any patient was diagnosed with an endometrial polypi.
On the contrary, the examination, by 2D-SIS and DHS was done in the proliferative phase of the patient’s menstrual cycle (6th or 7th day). Patients with menstrual disorders, they received progesterone in the form of norethisterone acetate (Steronate-nor); 1 tab. (5 mg), twice daily, for 7 days. Then, the procedures were performed in the 6th or 7th day of the withdrawal bleeding.
RESULTS: Concerning our 4 groups, the following was recorded:
Diagnostic hysteroscopy (DHS) (gold standard) didn’t show any uterine abnormality in only 1 patient with HSG suggestive of an endometrial polypi. So, HSG had a PPV of 100% in the diagnosis of congenital uterine anomalies, SMF, and IUAs while it had a PPV of 96.6% in the diagnosis of endometrial polyps.
For the 49 diagnosed patients, by DHS, there were only 4 uterine abnormalities; congenital uterine anomalies in 18 patients, SMF in 11 patients, endometrial polyps in 13 patients and IUAs in 7 patients.
• Regarding the diagnosis of congenital uterine anomalies (n=18):
2D-TVS 2D-SIS 3D-TVS
Sensitivity 88.2% 100% 100%
Specificity 100% 100% 100%
+ve predictive value (PPV) 100% 100% 100%
-ve predictive value (NPV) 33.3% 100% 100%
Diagnostic accuracy (DA) 88.8% 100% 100%
• Regarding the diagnosis of submucous fibroids (SMFs) (n=11):
2D-TVS 2D-SIS 3D-TVS
Sensitivity 100% 100% 100%
Specificity 100% 100% 100%
+ve predictive value (PPV) 100% 100% 100%
-ve predictive value (NPV) 100% 100% 100%
Diagnostic accuracy (DA) 100% 100% 100%
- Diagnostic hysteroscopy (DHS) could able to classify SMFs into:
o Type 1: in 2 patients.
o Type 2: in 9 patients.
• Regarding the diagnosis of endometrial polyps (n=13):
2D-TVS 2D-SIS 3D-TVS
Sensitivity 100% 100% 100%
Specificity 50% 50% 50%
+ve predictive value (PPV) 92.8% 92.8% 92.8%
-ve predictive value (NPV) 100% 100% 100%
Diagnostic accuracy (DA) 93.3% 93.3% 93.3%
- DHS was the only method able to differentiate between SMF polyps (4 patients) and other uterine polyps (9 patients).
• Regarding the diagnosis of intrauterine adhesions (IUAs) (n=7):
2D-TVS 2D-SIS 3D-TVS
Sensitivity 14.2% 28.5% 42.8%
Specificity 0% 0% 0%
+ve predictive value (PPV) 100% 100% 100%
-ve predictive value (NPV) 0% 0% 0%
Diagnostic accuracy (DA) 14.2% 28.5% 42.8%
- Diagnostic hysteroscopy (DHS) was the only method able to classify IUAs. It classified them into:
o Grade I: in the 3 patients with HSG showed a fine irregular uterine contour.
o Grade III: in 2 patients (1 patient with HSG showed a coarse irregular uterine contour and in another 1 with HSG showed 2 intrauterine filling defects).
o Grade IV: in the 1 patient with HSG showed a marginal IUAs (tube-like uterine cavity).
oGrade Vb: in the 1 patient with HSG showed total uterine