Hysteroscopic Management of Asherman syndrome (HMAS)

 

Asherman Syndrome or syndrome Fritsch, is a disorder characterized by adhesion and / or fibrosis of the endometrium, but in precise can also touch the myometrium. It is often related together dilation and curettage of intrauterine cavity. Many other terms used to describe the condition and related conditions, including: Intrauterine adhesions, uterine / cervical atresia, traumatic atrophy of the uterus, endometrial sclera, multiple adhesions and endometrial aspiration. The condition was first defined in 1894 by Heinrich Fritsch and is also characterized by an Israeli gynecologist Joseph Asherman in 1948. It is also identified as Fritsch syndrome, or Asherman's syndrome-Fritsch.

Causes and characteristics

The uterine cavity is lined by the endometrium. This coating comprises two layers, the functional layer (adjacent to the uterus) spilling during menstruation, and underlying base layer (adjacent to the myometrium), which is necessary for regeneration of the functional layer. Trauma to the basal layer, usually after a dilation and curettage (D & C) carried out after a miscarriage or childbirth or surgical termination of pregnancy, can lead to the development of scars resulting from adhesions intrauterine can delete the cavity in varying degrees. In extreme cases, the entire cavity can be cured and occluded. Even with relatively few scars, the endometrium can not respond to estrogen. Often, patients experience side menstrual irregularities characterized by a decrease in the rate and duration of bleeding (amenorrhea, oligomenorrhea or hipomenorrea) and become sterile. Menstrual disorders are often, but not always correlate with the severity: adhesions restricted only to the cervix or uterus can lower block menstruation. Pain during menstruation and ovulation is sometimes known and can be attributed to blockages. It is reported that 88% of those recorded after a D&C is performed in a womb recently pregnant, following a missed call or incomplete miscarriage, birth, or during a voluntary termination (abortion) to remove the retained products of conception.

It affects women of all races and ages, as well, suggesting no underlying genetic predisposition to their development. Depending on the severity, as can result in infertility, recurrent miscarriages, ache from stucked blood, and upcoming obstetric complications. Without treatment, obstruction of menstrual flow resulting from adhesions can lead to endometriosis in some cases.

AS can end-up in other pelvic operations together with Caesarean sections, removal of fibroids (myomectomy) and other causes, such as the IUD, pelvic irradiation, schistosomiasis and genital tuberculosis. Chronic endometritis from genital tuberculosis is a major cause of severe IUA (UIA) in the developing world, often it results in the total destruction of the uterine cavity which is difficult to treat.

Effect

As an incidence of 25% curettage performed 1-4 weeks after birth, up 30.9% curettage made for lost 6.4% false and curettage for incomplete spontaneous abortions performed layers. In another study, 40% of patients who underwent repeated D & C to design products retained after a miscarriage or retained placenta developed AS lost.

In the case of false lost layers, the time period between and curettage stillbirths can increase the likelihood of adhesion formation due to activity remaining tissue fibroblasts.

As risk also increases with the number of procedures: one study estimated that the risk is 16% after a D & C and 32% after 3 or more D & Cs. However, only curettage often underlies the condition.

Predominance

In an attempt to estimate the prevalence of AD in the general population, it was found in 1.5% of women undergoing HSG HSG, and between 5 and 39% of women with recurrent miscarriage.

After a miscarriage, a review found that the prevalence of AD is approximately 20% (confidence interval 95%: 13% to 28%).

Diagnosis

The historical event of pregnancy followed by curettage which leads to secondary amenorrhea or hipomenorrea is typical. Hysteroscopy is the gold standard for diagnosis. Sonohysterography images or hysterosalpingography reveal the degree of healing. Ultrasound is a reliable way to diagnose Asherman syndrome method. Hormonal studies show normal levels compatible with the playback function.

Classification

Various classification systems have been developed to describe Asherman's Syndrome, some considering the operation amount of the residual endometrium, menstrual cycle, reproductive history and other factors is expected to play a role in determining the forecast. With the advent of techniques that allow visualization of the uterus, classification systems have been developed to accept into explanation the location and severity of adhesions inside the uterus. This is useful as mild cases with adhesions limited cervix may present with amenorrhea and infertility, demonstrating that symptoms alone does not necessarily reflect the severity. Other patients may have no adhesions but amenorrhea and infertility due to endometrial atrophy sclera. This latter form has the worst prognosis.

Treatment

Fertility can sometimes be restored by removing the adhesions, depending on the severity of the initial trauma and other individual patient factors. Hysteroscopy is used for visual inspection of the uterine cavity during dissection adhesion (adhesion). However, hysteroscopy has not yet become a routine gynecological procedure and only 15% of American gynecologists perform hysteroscopy Isaacson (2002). adhesion dissection can be technically difficult and should be done carefully in order not to create new scars and even worsen the condition. In severe cases, additional features such as laparoscopy in conjunction with hysteroscopy as a protective measure against uterine perforation measures are used. Microscissors are known to relief of adhesions. Electricity is not recommended. As IUA frequently reform after operation, practices have been established to prevent recurrence of adhesions. Methods to prevent adhesion reformation together with the use of automatic blockades (Foley catheter, filled with ball medical saline Cook uterine stent, IUDs) and barriers gel (Seprafilm, SprayGel autocrosslinked hyaluronic acid gel Hyalobarrier) to maintain the opposite walls separated during healing (2002) Tsapanos; (2004) Guida; (2004) Abbott, thereby preventing adhesion reformation. Antibiotic prophylaxis is necessary in the presence of mechanical obstacles to reduce the risk of infection. A common method for pharmacological prevention of adhesions is reforming sequential hormonal therapy with estrogen followed by progestin to stimulate endometrial growth and prevent opposing walls (1996) merge Roge. However, there have been no randomized controlled trials (RCTs) comparing the reformation of post-surgical adhesions with and without hormonal treatment and the ideal regimen or duration of estrogen therapy is not known. The lack of randomized controlled trials comparing treatment methods, it is difficult to recommend optimal treatment protocols. In addition, the severity of diagnosis and the results are evaluated according to different criteria (Examples includes: menstrual cycle, adhesion reformation rate, conception rate, live birth rate). Clearly, more comparable studies in which the results of breeding can be analyzed systematically needed.

Continuation tests are needed to ensure that adhesions have not reformed. In addition, surgery may be necessary to restore normal uterine cavity. A recent study of 61 patients, the overall rate of recurrence membership was 27.9% and in severe cases, it was 41.9%. Another study found that postoperative adhesions are reproduced in almost 50% of severe aortic stenosis and in 21.6% of cases moderate. Mild IUA, unlike moderate to severe synechiae, it seems that reform.

Prognosis

The extent of adhesion formation is essential. Mild to moderate adhesions can be successfully treated. extensive obliteration of the uterine cavity or Fallopian tube openings (ostia) and deep myometrial trauma or endometrium may require surgical treatment and / or hormonal several or even be uncorrectable. If the uterine cavity is free member but the ostia remain obliterated, IVF remains an option. If the uterus has been irreparably damaged, surrogacy or adoption may be the only options.

Patients with a pregnancy even after treatment of IUA may have an increased risk of abnormal Placentation including: the placenta invades the uterus more deeply, placenta accrete, leading to complications in the separation of the placenta after birth. Premature birth, loss of the second trimester of pregnancy and uterine rupture are also reported difficulties. They can also develop cervical insufficiency in the cervix and cannot bear the weight gain of the fetus, the pressure causes the placenta to rupture and the mother puts Preterm birth. Banding is a surgical point that helps support the cervix if necessary.

Pregnancy and live birth rate to be related to the initial severity of adhesions with 93, 78 and 57% of pregnancies achieved after adhesions treatment, respectively mild, moderate and severe were reported, resulting in 81, 66 and 32% in rate of live births, respectively. The overall rate of pregnancy after adhesions was 60% and the live birth rate was 38.9%, according to a study.

Age is another factor contributing to fertility outcomes after treatment of AD. For women under 35 years treated for severe adhesions, pregnancy rates were 66.6% compared with 23.5% among women aged 35 years.