Asherman’s syndrome

 

Asherman’s syndrome usually occurs from intrauterine surgery, most commonly after D&C.

It be the cause of menstrual disturbances, infertility, and placental abnormalities.Risk factors can include:

Myomectomy, Cesarean-section, infections, age, genital tuberculosis, and obesity.

Can develop even if the woman has not had any uterine surgeries, trauma, or pregnancies.

First trimester miscarriages and elective abortions use vacuum aspiration is surgical management that does not result in AS.

AS is often characterized by a decrease in flow and duration of bleeding, little menstrual bleeding, or infrequent menstrual bleeding and infertility.

Menstrual anomalies are often but not always correlated with severity.

Adhesions restricted to only the cervix or lower uterus may block menstruation.

Pain during menstruation and ovulation is sometimes experienced and can be attributed to blockages.

It has been reported that 88% of AS cases occur after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or during an elective termination abortion to remove retained products of conception.

The uterus is lined by the endometrium, which 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.

Dilation and curettage (D&C) performed after a miscarriage, or delivery, or for surgical termination of pregnancy basal layer trauma can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees.

In an advanced case the whole cavity can be scarred and occluded.

With the development of scars, the endometrium may fail to respond to estrogen.

Affects women of all races and ages equally.

There is no underlying genetic predisposition.

Chronic endometritis from genital tuberculosis is a significant cause of in the developing world.

Endometrial/pelvic/genital tuberculosis, is another cause of Asherman’s syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions.

Artificial form can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy.

The history of a pregnancy event followed by a D&C leading to secondary amenorrhea or hypomenorrhea is typical.

Hysteroscopy is the gold standard for diagnosis.

Imaging by sonohysterography or hysterosalpingography will reveal the extent of the scar formation.

Ultrasound is not a reliable method of diagnosing Asherman’s Syndrome.

Hormone studies show normal levels.

A 2013 review concluded there is no link between intrauterine adhesions and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to surgical management (e.g. D&C), medical management or conservative management.

There is no clear evidence of any method of prevention of adverse pregnancy outcomes.

The recently pregnant uterus is particularly soft easily injured.

D&C is a blind, invasive procedure, making it difficult to avoid endometrial trauma.

Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol and mifepristone.

D&C could be performed under ultrasound guidance rather than as a blind procedure, to avoid injury.

The longer the period after fetal death following D&C, the more likely adhesions may occur, so immediate evacuation following fetal death may prevent intrauterine adhesions.

The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative.

Depending on the severity of the initial trauma, fertility may sometimes be restored by removal of adhesions by operative hysteroscopy to visualize the uterine cavity during adhesion dissection.

Intrauterine adhesions frequently reform after surgery (28-42%).

Techniques to prevent recurrence of adhesions include: use of mechanical barriers, gel barriers and sequential hormone therapy to maintain opposing walls apart during healing.

Management depends on extent of disease:

Mild to moderate adhesions can usually be treated successful.

Extensive obliteration of the uterine cavity or fallopian tube openings and deep endometrial or myometrial trauma may require several surgical interventions and/or hormone therapy.

Extensive disease may be uncorrectable.

If the uterus has been irreparably damaged, surrogacy or adoption may be the only options.

It may result in infertility, repeated miscarriages, pain, and future obstetric complications if left untreated.

The obstruction of menstrual flow that may result from adhesions can lead to rarely lead to endometriosis.