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Asherman’s syndrome

Asherman’s syndrome. Dick Schoot MD PhD Catharina Hospital Eindhoven The Netherlands. Primaire preventie Secundaire preventie Behandeling adhaesies. cause of adhaesions. Curettage Genetic predisposition Placental characteristics. Primaire preventie. Chemische abortus inductie

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Asherman’s syndrome

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  1. Asherman’s syndrome Dick Schoot MD PhD Catharina Hospital Eindhoven The Netherlands

  2. Primaire preventie • Secundaire preventie • Behandeling adhaesies

  3. cause of adhaesions Curettage Genetic predisposition Placental characteristics

  4. Primaire preventie • Chemische abortus • inductie • Mefigyn • cytotec

  5. Primaire preventie door adequate curettage

  6. placental remnants

  7. remnant placental or trophoblastic tissue often leads to • infection • repeated curettage • intrauterine adhaesions (Asherman’s syndrome)

  8. Wattedoenna incomplete curettagesecundairepreventie • Expectatief (>6 weken) • Herhaalde curettage (evtechogeleide) • Hysteroscopisch • Schaar • Cold loop • Truclear

  9. prevalence of adhaesions after secondary or repeated curettage 35% Golan 1996 50% Westendorp 1998

  10. patients and procedure • n = 55 (Jan 2005-Jan 2008) • meanage 34 (21-40) • previous curettage = 20 (first trimester and puerperal) • manual placenta removal = 35 • median interval firstproc. and morc. 8 wks (2-40) • hysteroscopicmorcellation (TRUCLEAR Smith&Nephew) • saline distension (max. 120 mm Hg) • antibioticprophylaxis

  11. Studies met cold loop and truclear convincing

  12. conclusion the prevalence of intrauterine synechiae is high (35-50%) after secondary or repeated curettage of placental remnants hysteroscopic morcellation reduces the risk of these synechiae (5.5%)

  13. If prevention failed:Synechiae

  14. cause of adhaesions • in most cases only a single uncomplicated pregnancy related intra-uterine procedure • first trimester curettage • puerperal curettage • manual placenta removal • always pregnancy related • never spontaneous • difficult to mimmick in ‘disfunctional bleeders’

  15. Intrauterineadhaesions(Asherman’ssyndrome) • rare condition (approx. 1:500 pregnancies) • iatrogenic etiology obligatory • postpartem curettage • postabortem curettage • amenorrhea or severe oligomenorrhea • individualized need for treatment • hysteroscopic surgery • technically difficult • centralized treatment

  16. Gradesof IntrauterineAdhaesions EuropeanSociety forHysteroscopy (1989) ESGE I - Thinorfilmyadhesionseaslyrupturedbyhysteroscopesheathalone, cornual areas normal; II - Single firmadhesionsconnecting separate parts of the uterinecavity, visualization of bothtubalostiapossible, cannotberupturedbyhysteroscopesheathalone; IIa -Occludingadhesionsonly in the region of the internalcervical OS. Upper uterinecavitynormal; III - Multiple firmadhesionsconnecting separate parts of the uterinecavity, unilateralobliteration of ostial areas of the tubes; IIIa- Extensivescarring of the uterinecavitywallwithamenorrheaorhypomenorrhea; IIIb - Combination of III and IIIa; IV - Extensivefirmadhesionswithagglutination of the uterinewalls. Both tubalostial areas occluded

  17. Intrauterine adhaesions (Asherman’s syndrome) • hysteroscopic treatment can result in an 85-95% return to normal menstrual cycles • if no other infertility issues are present, 80% of treated patients have normal pregnancies (ie, 75% of those with mild disease but only 30% with recurrent adhesions) • after hysteroscopic treatment the risk of abnormal placentation (eg, accreta, percreta, increta, previa) is increased • worst prognosis after resectoscopic hot-loop procedures

  18. ThrerapyIntrauterineadhaesions(Asherman’ssyndrome) • hysteroscopic treatment combined with fluoroscopy • 50% office • 50% OR • IUD • Medical hormonal adjuvant treatment • sequential oestradiol and progesterone for 6 weeks, two withdrawal bleedings • IUD removal during second withdrawal • Second look hysteroscopy after 8-10 wks • Recurrent treatment during menstruation

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