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Asherman's syndrome
Classification and external resources
ICD-10 N85.6
ICD-9 621.5
DiseasesDB 946
MedlinePlus 001483
MeSH D006175
Ultrasound view.
Ultrasound view. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings N00-N39 - Diseases of the Genitourinary system: urinary system (N00-N08 Glomerular diseases Prefixes. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books

Asherman's syndrome, also called "uterine synechiae" or intrauterine adhesions, presents a condition characterized by the presence of scars within the uterine cavity. In medicine synechia refers to an adhesion, usually involving the iris (see article below but also within the uterus as in Asherman's syndrome. Adhesions are fibrous bands that form between tissues and organs often as a result of injury during surgery

Contents

Causes and features

HSG view.
HSG view.
Hysteroscopic view.
Hysteroscopic view.

The cavity of the uterus is lined by the endometrium. The uterus (from the Latin word for womb) is the major Female reproductive organ of most Mammals including Humans One end the The endometrium is the inner membrane of the Mammalian Uterus. This lining is composed of two layers, the functional layer which is shed during menstruation and an underlying basal layer which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or for elective abortion can lead to the development of intrauterine scars resulting in adhesions which can obliterate the cavity to varying degrees. Dilation (dilatation and curettage literally refers to the dilation (opening of the Cervix and surgical removal of the contents of the Uterus. Miscarriage or spontaneous abortion is the natural or spontaneous end of a Pregnancy at a stage where the embryo or fetus is incapable of surviving generally defined Childbirth (also called labour, birth, partus or parturition) is the culmination of a Human Pregnancy or An In the extreme, the whole cavity has been scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogens and rests. Estrogens (US otherwise oestrogens or œstrogens) are a group of Steroid compounds named for their importance in the Estrous cycle, Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding (amenorrhea, hypomenorrhea, or oligomenorrhea) [1] and becomes infertile. Amenorrhoea ( BE) amenorrhea ( AmE) or amenorrhœa, is the absence of a Menstrual period in a woman of reproductive age Hypomenorrhea also known as or related to hypomenorrhoea scanty periods and spotting at periods is Menstrual blood flow that is extremely light Oligomenorrhea is the medical term for infrequent uterine bleeding episodes with intervals of more than 35 days Menstrual anomlies are often but not always correlated with severity: adhesions restricted to only the cervix or lower uterus may block menstruation. The cervix (from Latin "neck" is the lower narrow portion of the Uterus where it joins with the top end of the Vagina. Pain during menstruation and ovulation are also sometimes experienced, and can be attributed to blockages.

Asherman's syndrome occurs most frequently after a d&c is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or elective termination (abortion) to remove retained products of conception/placental remains. An As the same procedure is used in all three situations, Asherman's can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related curettage [2]. It is estimated that up to 5% of d&cs result in Asherman's. More conservative estimates put this rate at 1%. Asherman's results from 25% of d&cs performed 1-4 weeks post-partum [3][4][5], 30. 9% of d&cs performed for missed miscarriages and 6. 4% of d&cs performed for incomplete miscarriages. [6] In the case of missed miscarriages, the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30. 9% [2][7]The risk of Asherman's also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs [8].

Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies [9](see Prognoses below). There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to endometriosis[5]. Endometriosis (from endo, "inside" and metra, " Womb " is a common medical condition characterized by growth beyond or outside the uterus

Asherman's can also result from other pelvic surgeries including Cesarean sections[2], removal of fibroid tumours (myomectomy) and from other causes such as IUDs, pelvic irradiation, schistosomiasis[10] and genital tuberculosis[11]. A Caesarean section (or Cesarean section in American English) also known as C-section, is a form of Childbirth in which a surgical Myomectomy refers to the surgical removal of Uterine fibroids also known as Myomas. Irradiation is the process by which an item is exposed to Radiation. Schistosomiasis (also known as bilharzia, bilharziosis or snail fever) is a Parasitic disease caused by several species of fluke Tuberculosis (abbreviated as TB for tubercle bacillus or T u' b' erculosis Bacillus --> is a common Chronic endometritis from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat [12]. Endometritis refers to Inflammation of the Endometrium, the inner lining of the Uterus.

An artificial form of Asherman's syndrome can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy. Endometrial ablation is a Medical procedure that is used to remove ( ablate) or destroy the endometrial lining of a woman's Uterus. A hysterectomy (from Greek hystera "womb" is the surgical removal of the Uterus, usually performed by a gynecologist.

Incidence

The condition is estimated to affect 1. 5% of women undergoing HSG [13], between 5 and 39% of women with recurrent miscarriage [14][15][16] and up to 40% of patients who have undergone D&C for retained products of conception [17]. The true prevalence of Asherman’s syndrome is unclear as many doctors are unaware of the symptoms or diagnosis. Increased awareness about the condition and its diagnosis is also expected to reveal a higher frequency than previously reported.

Diagnosis

The history of a pregnancy event followed by a D&C leading to secondary amenorrhea is typical. Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female Hysteroscopy is the gold standard for diagnosis [9]. Imaging by sonohysterography or hysterosalpingography will reveal the extent of the scar formation. Hysterosalpingography ( HSG) is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the Fallopian tubes. Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Hormone studies show normal levels consistent with reproductive function.

Treatment

Fertility can be restored by removal of adhesions. Fluoroscopically guided operative hysteroscopy is used for visual inspection of the uterine cavity and dissection of scar tissue (adhesiolysis). Hysteroscopy is the inspection of the uterine cavity by Endoscopy. In more severe cases, laparoscopy is used in addition to hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended [18]. Sometimes a balloon stent (Foley catheter or Cook stent) filled with saline is inserted in the uterus for up to 3 weeks to keep the walls of the uterus apart as they heal to prevent the reformation of adhesions. Foley Catheters are flexible (usually Latex) tubes that are passed through the Urethra during Urinary catheterization and into the bladder

Hormonal therapy with synthetic or conjugated estrogen is usually prescribed following surgery to stimulate endometrial growth thereby preventing the walls of the uterus from re-adhering. Estrogens (US otherwise oestrogens or œstrogens) are a group of Steroid compounds named for their importance in the Estrous cycle,

More studies are needed to evaluate which method of treatment is most likely to have a successful outcome.

Follow-up tests (HSG, hysteroscopy or SHG) are necessary to ensure that scars have not reformed. Further surgery may be necessary to restore a normal uterine cavity. According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27. 9% and in severe cases this was 41. 9%. [19] Another study found that postoperative adhesions reoccur in close to 50% of severe Asherman's and in 21. 6% of moederate cases [9]. Mild IUA unlike moderate to severe synechiae do not appear to reform.

Prognosis

The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) may require several surgical interventions or even be uncorrectable. Ostia may refer to Ostia Antica, a township and port of ancient Rome Ostia (town, a modern township (also called Ostia Lido or In this case surrogacy, IVF or adoption may be advised. Surrogacy is a method of Reproduction whereby a woman agrees to become pregnant and deliver a child for a contracted party In vitro fertilisation ( IVF) is a process by which Adoption is the act of legally placing a child with a Parent or parents other than those to whom they were born

Patients who carry a pregnancy after correction of Asherman's syndrome may have an increased risk of having abnormal placentation including placenta accreta [20]where the placenta invades the uterus more deeply, leading to complications in placental separation after delivery. Pregnancy ( Latin graviditas) is the carrying of one or more offspring known as a Fetus or Embryo, inside the Uterus of a Female Placenta accreta is a severe obstetric complication involving an abnormal superficial attachment of the Placenta to the Myometrium (the middle layer of The uterus (from the Latin word for womb) is the major Female reproductive organ of most Mammals including Humans One end the Premature delivery[21], second-trimester pregnancy loss[22], and uterine rupture[23] are other reported complcations. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed[22]. Cervical cerclage ( tracheloplasty) also known as a cervical stitch, is used for the treatment of Cervical incompetence, a condition where the cervix has

The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38. 9% according to one study [24]. Success is related to the severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively [9].

Age is another factor contributing to fertility outcomes after treatment of Asherman's. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66. 6% compared to 23. 5% in women older than 35 [20].

Prevention

Asherman's is not usually caused by an 'over-aggressive' D&C:a properly performed D&C can lead to Asherman’s. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol methotrexate and mifepristone. Misoprostol is a drug that is FDA -approved in the United States for the prevention of non-steroidal anti-inflammatory drug ( NSAID)-induced Studies show this less invasive and cheaper method to be to be efficacious, safe and an acceptable alternative to surgical management for most women. [25] [26]. It was suggested as early as in 1993 [8] that the incidence of IUA might be lower following medical evacuation (eg. Misoprostol) of the uterus, thus avoiding any intra-uterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7. 7% of those undergoing D&C did [27]. The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging.

Alternatively, D&C could be performed under ultrasound guidance rather than blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.

Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurence of Asherman’s as adhesions are more likely to occur after a D&C the longer the period after fetal death [2]. Therefore immediate evacuation following fetal death may prevent IUA.

The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative, although it could be ineffective if a lot of tissue is present. Also, hysteroscopy is not a widely or routinely-used technique and requires expertise.

There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration. [28]

History

It was first described in 1894 by Heinrich Fritsch (Fritsch, 1894)[29] and further characterized by the gynecologist Joseph Asherman in 1948 [30].

It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.

TV series with Asherman's Syndrome

References

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  29. ^ >synd/1521 at Who Named ItFritsch H, Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung. Who Named It? is an English-language dictionary of medical eponyms and the People associated with their identification Zentralbl Gynaekol 1894; 18:1337-1342.
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