Nancy D. Gaba and Gaby Moawad
History of present illness
A 29-year-old gravida 3, para 1-0-2-1 woman presents to your office reporting no menses since her second spontaneous abortion, which she experienced 6 months prior. She has a history of regular menstrual cycles preceding her two recent spontaneous abortions, and one uneventful normal spontan- eous vaginal delivery four years ago. Her first spontaneous abortion was diagnosed at 11 weeks’gestation, and was treated with dilation and curettage. The most recent spontaneous abortion was diagnosed at nine weeks’ gestation, when she presented to the emergency department with five days of heavy bleeding per vagina. A dilation and sharp curettage was performed; however, the patient returned 3 days later with a fever to 39.4°C, a tender uterus, leucocytosis, and retained products of conception identified on ultrasound.
Another dilation and sharp curettage was performed and the patient received postoperative antibiotics as an outpatient for seven days. The remainder of her postoperative course was unremarkable thereafter but she continues to report cyclic pelvic pain since that event. Her medical history is otherwise unremarkable. She is sexually active with one partner, with whom she desires another pregnancy. She has not been using any contraception. She smokes socially and works as a sales associate.
Physical examination
General appearance: Well-developed, well-nourished young woman
Vital signs:
Temperature: 37.1°C Pulse: 80 beats/min
Blood pressure: 110/70 mmHg Respiratory rate: 16 breaths/min BMI: 24 kg/m2
Breasts: No masses, adenopathy, or nipple discharge Abdomen: Soft, nontender, no masses
External genitalia: Normal
Vagina: Normal mucosa, no lesions, scant discharge Cervix: Parous, no lesions
Uterus: Normal size, minimally tender, retroflexed, mobile
Adnexa: Nontender, no masses
Laboratory studies: Urine pregnancy test: Negative
How would you manage this patient?
This patient has secondary amenorrhea, and given the context of her recent obstetrical history, the differential diagnosis places Asherman syndrome (also known as intrauterine adhesions [IUAs]), which developed as a result of her septic abortion in combination with the repeated instrumentation of her uterus, high on the list of concerns.
Once pregnancy had been excluded, an attempt to pass a small dilator and uterine sound in the office was performed to determine if any cervical or uterine obstruction was present.
The uterus sounded to 8 cm and was easily measured. In this case, where the suspicion for IUAs was high, a hysteroscopy was performed (Fig. 70.1).
Intraoperative findings were consistent with dense IUAs and a hysteroscopic resection of the adhesions was performed with the resectoscope. There were no complications at the time of surgery.
At the completion of the procedure, a normal uterine cavity was visualized (Fig. 70.2).
Six weeks after the hysteroscopic procedure, the patient resumed a light menses. Since then her menses have become
Fig. 70.1 Before hysteroscopic resection of the adhesions.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
more normal, lasting three to four days every month. She continues to attempt conception.
Asherman syndrome
The initial description of intrauterine adhesions (IUAs) was first published by Heinrich Frisch in 1894, but the problem was not studied in detail until Joseph Asherman published his work on the topic in 1949. Asherman syndrome is typically manifested by the formation offibrous adhesions involving the uterine cavity, and sometimes, the internal cervical os and the cervical canal. These adhesions can lead to amenorrhea. It was later recognized that IUAs may result from any trauma to the endometrium, and can also have a significant impact on future fertility. IUAs occur most commonly after surgical manage- ment of incomplete abortion (50%), as in the patient described here, postpartum hemorrhage (24%), and surgically performed elective abortion (17.5%) [1]. Other etiologic factors that can lead to IUAs include myomectomy (especially hysteroscopic removal of opposingfibroids, or when the endometrial cavity is breached via laparoscopy/laparotomy), hysterotomy, Cesar- ean delivery, tuberculosis, caustic abortifacients, and post- pregnancy instrumentation of the endometrium including uterine packing or balloon tamponade.
The presumed mechanism by which the adhesions are formed is trauma to the basalis layer of the endometrium.
Although a Cochrane review [2] concluded that medical and surgical abortion have equal pregnancy rates afterfive years, the specific complication of IUAs was not addressed. It is commonly assumed that IUAs are more prevalent following instrumentation of the uterus, particularly if there are retained
products or repeat instrumentation. Several investigators have attempted to address the question of the likelihood of develop- ing IUAs after a secondary procedure becomes necessary for the removal of placental remnants, as in the patient in this case. Westendorp and colleagues reported on a prospective analysis of 50 women undergoing surgical management for retained placental tissue [3]. Among these women, 40% were found to have IUAs on hysteroscopy conducted 3 months after the instrumentation, and of these, 75% had moderate to severe IUAs [3]. Other studies, which examined only women having one primary surgical evacuation in the case of a spontaneous abortion, have found the rate of IUAs to be as low as 8% in comparative prospective trials [4]. The patient described here desires future fertility and, given her concerning obstetric history, all efforts should be made to accurately determine if her secondary amenorrhea is due to Asherman syndrome and, if so, to restore normal anatomy.
The gold standard for diagnosis of IUAs is hysteroscopy.
Although traditional ultrasound, three-dimensional ultra- sound, saline infusion ultrasound, and hysterosalpingography (HSG) have all been utilized for evaluation of the uterine cavity, hysteroscopy provides an accurate “real-time” oppor- tunity to examine the extent of the IUAs. Hysteroscopy also enables the physician to not only accurately diagnose and classify the uterine adhesions, but provides the opportunity for simultaneous therapeutic intervention. There can be some benefit to performing a preoperative ultrasound, as the thick- ness of the endometrium can be used to evaluate improvement after treatment. Conversely, MRI has not been found to be useful, and is considerably more expensive than other diagnos- tic modalities [5]. Several authors have tried to create classifi- cation systems for IUAs, although none of these have received unanimous endorsement. All of these systems rely on hystero- scopy, although in some cases other diagnostic tests such as HSG are used. The goal of these efforts are to help advise the patients regarding the severity of their adhesive disease and the prognosis or likelihood of pregnancy following treatment [6].
The management of severe IUAs and the resulting amen- orrhea has been well studied, although there is currently no single approach that has been shown to create significantly superior outcomes. In a small retrospective review of 12 cases, Myers and Hurst found that a comprehensive approach, including preoperative oral estradiol, intraoperative hystero- scopic synechiolysis, placement of a triangular balloon cath- eter, and subsequent placement of a copper intrauterine device (IUD), resulted in resumption of menses in all patients and a 67% pregnancy rate [7]. Robinson and colleagues reported that serial postoperative blunt adhesiolysis of recurrent synechiae resulted in an improvement in menstrual flow in 95% of women and pregnancy in 46% of women over their 2-year study period [8]. Other studies have evaluated expectant management, cervical probing, and dilation and curettage; however, these are all associated with higher rates of failure and/or complications and, thus, should not be used [5].
Fig. 70.2 After hysteroscopic resection of the adhesions.
Case 70: A 29-year-old woman with secondary amenorrhea after a septic abortion
Ancillary treatments to hysteroscopic adhesiolysis includ- ing physical barriers; (IUDs, Foley catheters, Cook balloons, amnion grafts, hyaluronic acid); hormone therapy (estrogen, estrogen plus progesterone); vascularflow modifiers (nitrogly- cerin, sildenafil); and antibiotic therapy have all been studied.
Although they all have shown some benefit in preventing the reformation of adhesions, no single therapy stands out as significantly better than the others [5,6,9]. Several recommen- dations to prevent Asherman syndrome and IUAs are typically recommended. The general principle is to avoid any trauma to the basalis layer, especially in patients who are pregnant or immediately postpartum. Post-abortal curettage should be avoided whenever possible. Medical management of elective and spontaneous abortion should be offered whenever feasible.
Consideration to treat retained products of conception with agents such as misoprostol should be considered in an effort to avoid unnecessary uterine instrumentation. Finally, hystero- scopic evacuation of retained products, using a resecting loop under direct visualization instead of blind curettage, can also be considered depending on the surgical skill of the clinician [10].
The patient described here might have avoided the initial curettage if alternative management of her incomplete
abortion, such as misoprostol, had been provided. Short- interval office hysteroscopy, given the clinical suspicion of IUAs, could have also been helpful, with early interventions such as blunt lysis of adhesions possibly preventing the devel- opment of the dense IUAs pictured above.
Key teaching points
Asherman syndrome is manifested by the formation of fibrous adhesions involving the uterine cavity, and possibly the internal cervical os and/or cervical canal, which may lead to amenorrhea and infertility.
Intrauterine adhesions (IUAs) occur most commonly after surgical management of an
incomplete abortion, postpartum hemorrhage, elective abortion, or other surgical procedure that involves the endometrial cavity and disrupts the endometrial basalis layer.
The gold standard for the diagnosis of IUAs is hysteroscopy.
Hysteroscopic adhesiolysis is the preferred treatment for IUAs.
References
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