{"paper_id":"f4ffa10c-ed74-4a6b-9791-e90b1917360c","body_text":"~ 32 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2019; 3(6): 32-36 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2019; 3(6): 32-36 \nReceived: 18-09-2019 \nAccepted: 22-10-2019 \n \nVidya Gaikwad \nDepartment of Obstetrics and \nGynecology, Dr. D.Y. Patil \nMedical College, Pimpri, Pune, \nMaharashtra, India \n \nPankaj Salvi  \nDepartment of Obstetrics and \nGynecology, Dr. D.Y. Patil \nMedical College, Pimpri, Pune, \nMaharashtra, India \n \nBethu Sruthi \nDepartment of Obstetrics and \nGynecology, Dr. D.Y. Patil \nMedical College, Pimpri, Pune, \nMaharashtra, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nPankaj Salvi  \nDepartment of Obstetrics and \nGynecology, Dr. D.Y. Patil \nMedical College, Pimpri, Pune, \nMaharashtra, India \n \nDiagnostic accuracy of saline infusion sonography as \ncompared to hysteroscopy in premenopausal women \nwith abnormal uterine bleeding \n \nVidya Gaikwad, Pankaj Salvi and Bethu Sruthi \n \nDOI: https://doi.org/10.33545/gynae.2019.v3.i6a.389  \n \nAbstract \nObjective: To diagnose various intrauterine pathologies that causing Abnormal uterine bleeding (AUB) by \nSaline infusion son ography (SIS). To compare diagnostic accuracy of saline infusion sonography to gold \nstandard investigation hysteroscopy in premenopausal women with abnormal uterine bleeding. \nMethods: The study was conducted in the D.Y.  Patil hospital Pune from September 2017 to August 2019. \nA total of 40 premenopausal women with abnormal uterine bleeding were included in the study. All \npatients were subjected to saline infusion sonography followed by hysteroscopy at a later date. \nResults: Sensitivity and specificity of sal ine infusion sonography when compared to hysteroscopy for \nsubmucous fibroids were100% and 100% , for endometrial polyps were 100% and 97.4%, for endometrial \nhyperplasia were 100% and 97.14%, for adenomyosis 77.78% and 100%, for endometritis 0% and 100% \nrespectively. \nConclusion: The diagnostic accuracy of SIS in detecting the lesions like endometrial polyps, submucous \nfibroids, endometrial hyperplasia is almost comparable to hysteroscopy. But early changes of adenomyosis \nand endometritis are better detected on hysteroscopy. Based on results obtained, saline infusion sonography \ncan be used as preliminary investigation before performing hysteroscopy. \n \nKeywords: AUB, SIS, NPV, PPV, hysteroscopy, TVS \n \nIntroduction  \nAbnormal uterine bleeding constitutes one among t he most frequent gynecological complaints \nreferred to outpatient department. It presents as a diagnostic dilemma to the gynaecologist.  \nIncidence of AUB is 25 -30% among women of reproductive age and 50% in perimenopausal \nwomen. Life time chance to have menorrhagia for a woman is 1 in 20  [1]. There are many causes \nof AUB and differentiating whether due to ovulatory abnormalities or anatomic lesions can be \nchallenging. \nInternational Federation of Gynecology and Obstetrics (FIGO) classification system for cause s \nof AUB include 9 categories that follows acronym PALM -COEIN. Structural causes includes \nPolyp, Adenomyosis, leiomyomas, malignancy and hyperplasia, nonstructural causes include \ncoagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified [2]. \nImaging modalities used to assess AUB  are Hysteroscopy, Transvaginal sonography  (TVS), \nSaline infusion sonography, Magnetic resonance imaging (MRI). MRI can be used in women \nwho cannot be imaged properly by ultrasonography. The disadvantage is the cost and therefore it \nis not used routinely. \nHysteroscopy is considered as the “Gold Standard” for the evaluation of uterine cavity as it \nallows direct visualization of uterine cavity  [3]. It has got both diagnostic and therapeutic \nadvantage. It has the advantage of see and treat approach. Any abnormal lesions can be biopsied \nat the same setting. Disadvantages include it is expensive, invasive procedure, it cannot diagnose \nmyometrial and adnexal pathologies, poor visualization when uterine bleeding is pres ent, and it \ncan cause complications like perforation and infection [4]. \nTVS is a non-invasive alternative for imaging uterine and endometrial abnormalities but it has a \ndisadvantage of having high false negative rate in diagnosing focal intra uterine pathol ogy. \nSaline Infusion Sonography (SIS) also known as Sonohysterography is the infusion of saline \ninto the uterine cavity via balloon catheter during TVS to distend uterine cavity and to delineate \nthe endometrium. Saline can be used as a negative contrast agent to improve the imaging in  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 33 ~ \ntransvaginal sonography. Advantage of SIS over hysteroscopy is \nthat myometrial and adnexal pathologies can be detected and in \naddition to this it is cost effective, performed in short duration \nand less painful. Limitations include blood clot can be \nmisinterpreted as polyps  [5]. Because of smaller volume  of \ndistention media used, SIS is generally better tolerated than \nhysteroscopy [6, 7 ]. Saline infusion sonography can become \ncomplementary method to conventional Transvaginal \nsonography in evaluating the cases with Abnormal uterine \nbleeding. \n \nMethods \n40 patients of abnormal uterine bleeding presenting to \ngynaecology outpatient department in Dr . DY Patil medical \ncollege were enrolled to further study. Inclusion criteria include \npremenopausal women, normal cervical cytology, not pregnant. \nExclusion criteria were evidence of pelvic inflammatory disease, \nsexually transmitted disease, suspected or diagnosed cases of \nendometrial cancer, active menstrual bleeding. The consent was \ntaken from the patients who fulfilled inclusion and exclusion \ncriteria. All the patients were explained regarding both SIS and \nhysteroscopy procedures and their complications. \nDetailed history was taken from all participants which includes \nsymptoms, onset, duration, past history, family history, personal  \nhistory. \nHistory was followed by detailed general examination, systemic \nexamination, local examination, per speculum examination and \nbi-manual pelvic examination. \nVenous sample was obtained for regular, routine, relevant \ninvestigations. \nSaline infusion sonography followed by hysteroscopy at later \ndate were performed in all cases \nPatients were examined after the menses, during early -mid \nfollicular phase of menstrual cycle, but before 10 th day of same \nmenstrual cycle [8]. \nFor saline infusion sonography, the patient was positioned in \ndorsal lithotomy position. TVS probe inserted to obtain coronal \nand sagittal views and it is removed. \nSterile speculums are introduced into the vagina. Cervix was \ncleansed with povidone iodine solution for antisepsis. \nAnterior lip of cervix was held with vulsellum forceps. \nA Foley’s catheter no 10 and stiffener were  introduced into \ncervix until it touched fundus. The inflatable balloon of Foley’s  \nwas inflated with 3cc of normal saline in o rder to keep the \ncatheter in place. Traction is given to Foley’s to keep the bulb at \nthe internal os. Speculums are removed.  TVS probe (5MHZ) \nwas introduced into vagina, 10 -20 ml of normal saline was \ninfused until there is clear visualization of uterine ca vity. \nUterine cavity is evaluated in both coronal and sagittal views \nand findings noted. No need for local anaesthesia  and \nprophylactic antibiotics. \nIn hysteroscopic procedure, patient is placed in lithotomy \nposition under general anaesthesia. Painting and  draping done. \nPer vaginal examination done and findings are confirmed. Sims \nspeculum were introduced. Cervix is cleaned with betadine \nsolution. Anterior lip of cervix is held with Vulsellum forceps. A \n5mm rigid endoscope was introduced into vagina, from t here \ninto cervical canal into uterine cavity. Normal saline was \nintroduced for distension of uterine cavity and allows adequate  \nand direct visualization of endometrial cavity. Biopsy of \nsuspected lesions were done at the same sitting. Prophylactic \nantibiotic therapy is required. \nAfter the both procedures, findings obtained in SIS were\ncompared to hysteroscopy and diagnostic accuracy was \nexpressed in terms of sensitivity, specificity, positive predictive \nvalue, and negative predictive value. \n \nResults \nThe study was conducted from September 2017 to August 2019. \nA total of 40 patients who attended to gynecological OPD with \nabnormal uterine bleeding were enrolled to study.  \n \nTable 1: Show the Age \n \nMean age 44.725 \nStd. Dev 2.98704 \nRange of age 40-50 years \n \nTable 2: Distribution of study population according to age \n \nAge distribution No of cases N=40 Percentage \n40-42 years 10 25% \n43-45 years 13 32.50% \n46-48 years 11 27.50% \n49-50 years 6 15% \n \nMean age at presentation is 44.725 years with standard deviation \nof 2.98704 years with majority of women in the age distribution \nbetween 43-45years (32.50%). AUB was commonest in the age \ngroup of 40-50 years. \n \n \n \nFig 1: Pie chart showing parity status of study population. \n \nMajority of patients were para 3 which constitutes 45%. \nMultiparous women constitutes 95%. \n \n \n \nFig 2: Bar diagram of presenting complaints in the patients \n  \nMost common presenting complaint among the patients is \nmenorrhagia which is present in 57.50% of cases followed by \nPolymenorrhagia which is present in 12.5% of cases.  \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 34 ~ \n \n \nFig 3: Bar diagram showing abnormal findings in saline infusion sonography \n \nIn saline infusion sonography, leiomyomas are present in \n10(25%) patients, hyperplasia of endometrium is present in \n6(15%), polyps present in 3(7.50%), adenomyosis presen t in 7 \n(17.50%), adnexal mass is present in 6(15%)  cases. Among \nLeiomyomas out of 10, 2 were submucosal fibroids, 6 were \nintramural fibroids, 2 were subserosal fibroids. \n \nTable 3: Hysteroscopic findings \n \n Hysteroscopic findings N=40 Percentage \nPolyp present 2 5% \nFibroid present 2 5% \nIntrauterine adhesions (Asherman’s syndrome) 5 12.50% \nAdenomyosis present 9 22.5% \nEndometritis present 1 2.5% \nEndometrial hyperplasia 5 12.50% \n \nIn hysteroscopy, adenomyosis was present in 9(22.5%)  patients, \nendometrial hyperplasia in 5(12.50%)  patients, submucous \nfibroid present in 2(5%) patients, polyps present in 2(5%)  \npatients, adhesions are present in 5(12.50%) patients, \nendometritis is present in 1patient(2.5%). \n \nTable 4: Diagnostic accuracy of saline infusion sonography with hysteroscopy as gold standard. \n \n Submucous fibroid Endometrial polyp Endometrial hyperplasia adenomyosis endometritis \nsensitivity 100% 100% 100% 77.78% 0% \nspecificity 100% 97.4% 97.14% 100% 100% \nPositive predictive value (PPV) 100% 66.7% 83.33% 100% 0% \nNegative predictive value (NPV) 100% 100% 100% 93.93% 97.5% \n \nDiscussion \nAmong premenopausal women with age group of  40-50 years, \nthe average age of presentation was 44.72 years with standard \ndeviation of 2.98. In present study, AUB was commo nest in age \ngroup of 40-45 years. In the study performed by Indman P D et \nal. [9]. Study of AUB demonstrated 43.2% of patients from age \ngroup of 40 -49years. In the present study,  18 patients (45%) \nwere found to be para 3 followed by para 2 who were 16 (40%). \n95% were multiparous. In the study conducted by Dasgupta et \nal. [10]. 88.5% were found to be multiparous. \nIn the present study, most common presenting symptom includes \nmenorrhagia which is present in 23 patients  (57.50%), followed \nby polymenorrhagia which is present in 5(12.50%) patients. This \nis similar to study conducted by Finikiotis et al . [11]. where \nmenorrhagia was reported in 62% cases of AUB. In the study \nconducted by Tabassum Kotagasti et al. [12]. also most common \npresenting symptom was menorrhagia which accounts for 33%.  \nIn present study, Endometrial hyperplasia was present in 6 \n(15%) patients when Saline infusion sonography was performed, \nwhereas it is present in 5(12.5%)  patients on hysteroscopy. The \nsensitivity and specificity of saline infusio n sonography when \ncompared to gold standard procedure hysteroscopy to detect \nendometrial hyperplasia are 100% and 97.14% respectively. \nThis is similar to the study conducted by Rudra et al. [13]. where \nsensitivity and specificity of SIS when compared to \nhysteroscopy in detecting endometrial hyperplasia were 100% \nand 97.9% respectively. In the  study conducted by Wildrich et \nal. [14]. Sensitivity and specificity of SIS when compared to \nhysteroscopy for detecting endometrial hyperplasia were 100% \nand 95% respect ively. In present study in one case with normal \nendometrium SIS detected falsely as endometrial hyperplasia.  \nIn present study, Saline infusion sonography diagnosed \nendometrial polyps in 3(7.50%)  patients with abnormal uterine \nbleeding, whereas hysteroscopy diagnosed endometrial polyps in \n2(5%) patients with abnormal uterine bleeding. The sensitivity \nand specificity of SIS when compared to gold standard \nprocedure hysteroscopy in detecting endometrial polyps were \n100% and 97.4% respectively. This is similar to the study \nconducted by Pawel Radwan et al . [15]. where sensitivity and \nspecificity of SIS  when compared to hysteroscopy in detecting \nendometrial polyps were 97.3% and 95.8% respectively. \nAnother study conducted by Nallapati et al . [16] the sensitivity \nand s pecificity of SIS when compared to hysteroscopy in \nimaging polyps were 90.9% and 92.68% respectively. The \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 35 ~ \ndiagnostic accuracy of SIS for detecting endometrial polyps is \nmore than TVS but when compared to Hysteroscopy it is equally \nsensitive but less specif ic because blood clots in endometrial \ncavity were falsely interpreted as endometrial polyps.  \nIn the present study, adenomyosis was diagnosed in 7(17.50%) \npatients by using transvaginal sonography with Saline infusion \nsonography, whereas, adenomyosis was d iagnosed in 9(22.5%) \npatients by using Hysteroscopy In current study, The sensitivity \nand specificity of SIS in diagnosing adenomyosis when \ncompared to hysteroscopy were 77.78% and 100% respectively. \nAnother advantage of hysteroscopy in diagnosing adenomyo sis \nis that early changes of adenomyosis can be made out in \nhysteroscopy which are not seen with SIS. Positive predictive \nvalue of SIS in diagnosing adenomyosis in the present study was \n100%. In the study conducted by T Usha et al. [17] where PPV of \nSIS in diagnosing adenomyosis was 90%. \nIn the present study submucous fibroids were diagnosed in \n2(5%) patients by using Saline infusion sonography whereas by \nhysteroscopy, 2(5%) patients were found to have submucous \nfibroid. The sensitivity and specificity of su bmucous fibroid \nwhen compared to hysteroscopy in patients with AUB were \n100% and 100% respectively. It is similar to  study conducted by \nB Bingol et al . [18] which showed sensitivity and PPV of SIS \nwhen compared to gold standard hysteroscopy were found to be \n99% and 96% respectively. Anothe r study conducted by M \nKamel et al. [19] shown that sensitivity and specificity of SIS in \ndetecting submucous myomas were found to be 94.3% and \n97.6% respectively. The advantage of SIS is it can measure \ndepth and size of leiomyom as and by using color doppler \nsimultaneously we can measure vascularity also, but during \nhysteroscopy only protruding part  can be visualized  Chronic \nEndometritis which is one of cause of AUB is present in 1 \npatient which is best visualized in hysteroscopy than Saline \ninfusion sonography. It was identified by the presence of micro \npolyps during hysteroscopy and later confirmed by \nhistopathological examination. Hysteroscopy has the advantage \nof taking a biopsy in the same setting and to be sent for \nHistopathological examination and TB PCR if required which is \nnot possible with Saline infusion sonography. Endometrial \nsampling devices like Pipelle are not helpful for focal lesions.  \nTransvaginal sonography with saline infusion sonography have \nthe advantage of di agnosing adnexal pathologies which are \nfound in 15% of patients in present study and intramural fibroids \nwhich are found in 15% of patients and sub serosal fibroids \nwhich are present in 5% of patients but these lesions cannot be \nseen during hysteroscopy. I ntra uterine abnormalities like \nadhesions which were detected in 5 patients  (12.5%) were better \nvisualized in hysteroscopy than SIS. Myometrial cysts were best \nvisualized in saline infusion sonography but not in hysteroscopy. \nPost procedure pain was less fo llowing SIS than hysteroscopy. \nNo other complications were seen in either procedures. \nAnesthesia and antibiotic coverage were required in \nhysteroscopy but not in SIS. \nThus advantage of SIS is that, uterine cavity pathologies like \npolyp, submucous fibroid c an be detected in addition to adnexal \nmasses and myometrial pathologies like intramural fibroids, \nmyometrial hyperplasia and adenomyosis. This can be done \nconveniently in an OPD setup. The advantage of hysteroscopy is \ndetection of uterine cavity pathologie s, taking a biopsy for HPE \nand TB PCR. Besides this it can also detect early changes of \nadenomyosis and chronic endometritis. Hysteroscopy has dual \nadvantage of see and treat approach in the same setting. \nTherefore it is considered as Gold standard procedu re in woman \nwith AUB. \nThe limitation of our study is the small sample size. More \nstudies with more number of patients are required to know the \nexact diagnostic accuracy of Saline infusion sonography in \nrelation to hysteroscopy. \n \nConclusion \nSaline infusion sonography is simple, less painful, causes little \ndiscomfort, better tolerated, cheap, noninvasive, shorter \nduration, and associated with less complications. Sensitivity and \nspecificity of SIS in detecting intracavitary pathologies is more \nthan Transvaginal sonography. The disadvantage is not able to \nidentify endometritis which is also a cause of AUB.  \nHysteroscopy is considered as gold standard because it allows \ndirect visualization of uterine cavity. It is more sensitive in \ndiagnosing intrauterine patholo gies compared to other \nprocedures, and has the advantage of see and treat approach and \nthe lesions can be biopsied at same time  but the disadvantage is \ncost of the procedure, requires anesthesia, causes discomfort. \nHowever all these disadvantages can be ov ercome by doing \noffice hysteroscopy instead of conventional hysteroscopy.  \n \nTo conclude \nThe diagnostic accuracy of SIS in detecting the lesions like \nendometrial polyps, submucous fibroids, endometrial \nhyperplasia is almost comparable to hysteroscopy. But ea rly \nchanges of adenomyosis and endometritis are better detected on \nhysteroscopy whereas, adnexal masses and myometrial lesions \nare detected in SIS not on hysteroscopy. \nHysteroscopy allows direct visualization of endometrial cavity \nwith see and treat advan tage. So, it is considered as a gold \nstandard procedure in evaluation and management of AUB.  \nThus, based on the results obtained, saline infusion sonography \ncan be used as a preliminary investigation in the women with \nabnormal uterine bleeding before performing hysteroscopy.  \nHowever, our study has limitation of small sample size. More \nstudies with large number of patients are required to know the \nexact diagnostic accuracy of Saline infusion sonography in \nrelation to hysteroscopy. \n \nReferences \n1. Schorge, John  O, Williams, J. Whitrid ge. Williams \nGynecology. The Mc Graw Hill Company,  China, Press. \n2008; 175. \n2. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO \nclassification system (PALMCOEIN) for causes of \nabnormal uterine bleeding in non -gravid women of \nreproductive age. Int. J Gynaecol Obstet. 2011; 113(1):3-13. \n3. Manoj Kumar Tangri, Ajay Krishna Srivastava. Diagnostic \naccuracy of saline infusion sonography as compared to \nhysteroscopy in premenopausal women with abnormal \nuterine bleeding. Int J of Repord, Contrace pt Obstet and \nGynecol. 2017; 6(2):682-687. \n4. Marc A  Fritz, Leon Speroff. Clinical Gynecologic \nEndocrinology and Infertility: Abnormal Uterine Bleeding. \nEighth Edition, 2018, 605.  \n5. Sandra J, Allison, Mindy M Horrow, Han Y Kim, Anna S \nLev-Toaff. Saline -infused sonohysterography: Tip s for \nachieving greater success, 2011. Online published. \n6. Brown SE, Coddington C C, Schnorr J. Evaluation of \noutpatient hysteroscopy, saline infusion hysterosonography \nand hysterosalpingography in infertile women: a \nprospective, randomized study. Fertile Steril. 2000; \n74:1029-1034. \n7. Tur-Kaspa I, Gal M, Hartman M. A prospective evaluation \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 36 ~ \nof uterine abnormalities by  saline infusion \nsonohysterography in 1,009 women with infertility or \nabnormal uterine bleeding. Fertile Steril. 206 ; 86:1731 -\n1735. \n8. Mohamed Helmy Draz, Tarek Mohammed El -Sabaa, \nShahinaz Hamdy El Shorbagy. Saline infusion sonography \nversus hysteroscopy in the evaluation of uterine cavity in \nwomen with unexplained infertility. Tanta Medical Journal. \n20178; 45:155-159. \n9. Indman PD. Abnormal uterine bleeding: Accuracy of \nvaginal probe ultrasound in predicting abnormal \nhysteroscopic findings. J Reprod Med. 1995; 40:545-548. \n10. Subhankar Dasgupta, Barunoday Chakraborty,  Rejaul \nKarim, Ranen Kanti Aich,  Pradip Kumar Mitra,  Tarun \nKumar Ghosh. Abnormal uterine bleeding in peri -\nmenopausal age: Diagnostic options and accuracy. J Obstet \nGynaecol India. 2011; 61(2):189-194. \n11. Finikiotis G. Hyateroscopy an analysis of 523 patients. Aust \nNz J Obst Gyn. 1989; 29:253-258. \n12. Tabassum Kotagasti. Prev alence of different menstrual \nirregularities in women with abnormal uterine bleeding \n(AUB) - An observational study. Int J Cur Res Rev. 2015; \n7(10):66-70. \n13. Rudra S, Duggal BS, Bharadwaj D. Prospective study of \nsaline infusion sonography and office hysterosc opy. Med J \nArmed Forces India. 2009; 65:332-335. \n14. Wildrich T, Bradley LD, Mitchinson A. Comparison of \nsaline infusion sonography with office hysteroscopy for the \nevaluation of the endometrium. Am J Obstet Gynecol. 1996; \n174:1327-1334. \n15. Paweł Radwan, Michał R adwan, Marek Kozarzewski, \nIreneusz Polac, Jacek Wilczyński. Evaluation of \nsonohysterography in detecting endometrial polyps – 241 \ncases followed with office hysteroscopies combined with \nhistopathological examination. Videosurgery Miniinv. \n2014; 9(3):344–350. \n16. Sowjanya N, Pallavee P. Comparative study of saline \ninfusion sonography and hysteroscopy for evaluation of \nuterine cavity in abnormal uterine bleeding. Int J  Reprod \nContracept Obstet Gynecol. 2015; 4(3):8258-832 \n17.  TH Usha, M Gayathiri. Efficacy of saline  infusion \nsonography in diagnosing intrauterine pathology in patients \nwith abnormal uterine bleeding: An observational study. \nInternational Journal of Scientific Study.  2016; 4(4):118 -\n121. \n18. Bingol B, Gunenc MZ, Gediknasi A, Guner H, Tasdemir S, \nTiras B. Com parison of diagnostic accuracy of saline \ninfusion sonohysterography, transvaginal sonography and \nhysteroscopy in postmenopausal bleeding. Arch gynecol \nObstet. 2011; 284(1):111-117 \n19. Kamel M. Comparison of saline infusion sonography with \ndiagnostic hysterosco py for the evaluation of the uterine \ncavity in patients with abnormal uterine bleeding. \nUltrasound in Obstet Gynec. 2003; 22(S1):3.","source_license":"CC0","license_restricted":false}