Department of Obstetrics and Gynaecology, Antoine Béclère Hospital, 157 Rue de la Porte-de-Trivaux, 92141 Clamart,France
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Abstract |
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Key words: Asherman's syndrome/operative hysteroscopy/placenta accreta/reproductive outcome/severe intrauterine adhesions
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Introduction |
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Materials and methods |
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There was no case of tuberculous endometritis in this series. Of the 31 patients, 16 patients (52%) reported amenorrhoea and 15 (48%) reported pronounced hypomenorrhoea. Twenty-six (84%) patients complained of infertility and five (16%) complained of recurrent pregnancy loss.
Diagnosis was made by hysterosalpingography and confirmed by hysteroscopy in all cases.
Technique
Hysteroscopy was performed under general or epidural anaesthesia in the early proliferative phase of the menstrual cycle in the patients who were menstruating. A 9mm hysteroscope equipped with an hysteroscopic monopolar knife (Karl Storz GmbH, Tuttlingen, Germany) was introduced into the blind reduced cavity, obtained after prudent dilatation of the cervix by Hegar's dilators. Glycine was used as distending medium. Treatment was performed by making several myometrial incisions 4 mm deep: two or three lateral incisions from the fundus to the isthmus on both sides and two or three transversal incisions of the fundus. Procedure was stopped at that point, even if ostial areas were not visible. A simultaneous laparoscopy was performed only in three patients with a past history of pelvic inflammatory disease or ectopic pregnancy, to observe the distal tubal status. Prophylactic antibiotics amoxicillin and clavulanic acid at the dose of 2 g (SmithKline Beecham, Nanterre, France) were given routinely at the induction of anaesthesia. No intrauterine contraceptive device was inserted, since no significant advantage has been noted when compared with hormonal therapy alone (San Fillipo and Fitzgerald, 1982). Postoperative oestrogen therapy (oestradiol 4 mg daily; Laboratoires Cassenne, Puteaux, France) was given to all patients for 2 months. Postoperative hysterosalpingography was not performed routinely. The anatomical result was checked in all patients by an outpatient hysteroscopy without anaesthesia at the end of hormonal therapy. Subsequent fertility was studied by calling all patients by telephone.
The follow-up was defined as immediately after treatment for women who were trying for pregnancy, except in one case.
2 test modified by Yates correction when appropriate was used for statistical evaluation and P < 0.05 was considered to be statistically significant.
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Results |
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A satisfactory anatomical result was observed after the initial procedure by the outpatient control hysteroscopy in 16 patients out of 31 (51.6%), and these patients were allowed to try for pregnancy. Nevertheless, in 10 of these 16 patients (62.5%), filmy adhesions were found and were easily ruptured by the hysteroscope. In the 15 remaining patients, the control hysteroscopy diagnosed the persistence of mild or severe IUA justifying a second operative hysteroscopy. Finally, reconstruction of a functional uterine cavity was realized after one (n = 16), two (n = 7), three (n = 7) or four (n = 1) surgical procedures.
Menstruation improved in all patients. All 16 patients previously amenorrhoeic had resumption of menses after one (n = 11), two (n = 4) or three surgical procedures (n = 1). The 15 patients with hypomenorrhoea had longer and heavier periods.
Three patients were lost to follow-up after the control hysteroscopy.
The mean follow-up time was 31 months (range 284) for the remaining 28 patients. All patients except one had at least a 6 month follow-up period.
Fifteen pregnancies were obtained in 12 patients and the outcomes were the following: two first trimester missed abortions, three second trimester fetal losses, a second trimester termination of pregnancy for multiple fetal abnormalities and nine live births in nine different patients. Pregnancy rate after treatment was 12/28 (42.8%) and live birth rate was 9/28 (32.1%). These results are shown in Table I. All patients conceived spontaneously except one. In this patient only one ostial area was restored, homolateral to a previous salpingectomy for ectopic pregnancy. She successfully underwent a first cycle of in-vitro fertilization (IVF) and embryo transfer.
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Three pregnancies out of 15 (20%) were complicated with a second trimester fetal loss. One patient had a one-step procedure and two patients had undergone three surgical procedures. Two patients out of the three became pregnant again and had an uneventful pregnancy after cervical cerclage performs at 12 weeks gestation.
In nine patients with live births there were four vaginal deliveries at term and five Caesarean sections. Three Caesarean sections were performed for prepartum fetal distress, one was performed for past history of two Caesarean deliveries and the last one was realized at 30 weeks gestation for chorioamnionitis. Severe complications occurred in two cases out of nine (22.2%).
The first case was a Caesarean hysterectomy for placenta accreta in a patient with a history of two previous Caesarean sections with a placenta accreta at the latest delivery. The patient did well after the procedure. The second patient underwent a Caesarean section at 30 weeks gestation because of Candida albicans chorioamnionitis after preterm rupture of membranes. The placenta was abnormally adherent and was partially removed manually. Haemostasis was obtained by hypogastric arteries ligation and placenta accreta was confirmed by histological diagnosis. The mother had an uneventful postoperative course. The infant required respiratory support initially and specific treatments. He is now 2 years old and has a normal development.
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Discussion |
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Different hysteroscopic techniques have been described. Intrauterine adhesions can be divided by hysteroscopic scissors (Valle and Sciarra, 1988) or laser treatment (Chapman and Chapman, 1996
). More recently an innovative technique involving hysteroscopic scissors has been reported: a 5 mm hysteroscope was introduced from the cervix to each cornua, converting the obliterated cavity into a uterine septum (McComb and Wagner, 1997
). Hysteroscopic resection with a monopolar probe is also efficient (Chen et al., 1997
; Protopapas et al., 1998
). In the technique described by Chen et al. (1997), laminaria tents were used to distend the uterine cavity prior to transcervical resectoscopy. No perforation of the uterus occurred in this series of seven patients, and all patients achieved normal menstruation and normal uterine cavity. Similar to our own technique, myometrial scoring has been described (Protopapas et al., 1998
). This technique was proposed to seven patients who had undergone a first inefficient hysteroscopic procedure. Scoring involved making six to eight 4 mm deep longitudinal incisions into the myometrium with a knife electrode, from the uterine fundus to the isthmus and distributed over all the circumference of the endometria. A normal uterine cavity was restored in all patients. Contrary to all these reports, we had no need for laparoscopic guidance and no perforation was noted except during dilatation of the cervix. After a limited number of incisions, systematically realized in the same way (two or three lateral incisions from the fundus to the isthmus on both sides and two or three transversal incisions of the fundus), the procedure was stopped since it was impossible to distinguish denuded myometrium from scar tissue. At that point, further treatment might become inefficient or dangerous, even under laparoscopic control. Therefore, endometrial regrowth was awaited and a second stage hysteroscopy, surprisingly easy relative to the initial step, was performed when necessary.
Debate concerning the abdominal versus the hysteroscopic approach has revived recently (Reddy and Rock, 1997). There are probably very few indications left for laparotomy, even in the treatment of the most severe IUA. Repeated hysteroscopic procedures as described (Chapman and Chapman, 1996
; Protopapas et al., 1998
), and our series allowed the re-establishment of a normal cavity in all cases. Menses improved in all our patients. In any case, patients should be made aware of the possibility of multiple stage surgery.
Many studies fail to present their results according to the severity of the adhesions. Therefore different techniques are difficult to compare. In Table II, the results of the four main series are given, including our own results of subsequent fertility after hysteroscopic treatment of severe Asherman's syndrome. In common with the other authors, we found that almost 50% of patients became pregnant and that almost one third had live births. When the patient's age was considered, we found that 62.5% patients aged
35 years conceived compared with 16.7% patients aged >35 years (P = 0.01). These results confirm that it is worthwhile repeating hysteroscopic treatments until a normal cavity is restored, especially for young women under 35. For women over 35 years, the principal aim of the treatment should be resumption of normal menses, but obstetric outcome remains disappointing.
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Another finding was a high rate of second trimester fetal losses. In three patients with this condition, one patient had a one-step procedure and two had undergone three surgical procedures. Two patients out of three became pregnant again and had an uneventful pregnancy after cervical cerclage at 12 weeks' gestation. Therefore we think that cervical cerclage should be discussed in patients with multiple stage procedures.
Hysteroscopic treatment of severe Asherman's syndrome appeared to be effective for the restoration of a functional uterine cavity. All patients achieved a normal uterine cavity and normal menses. The overall pregnancy rate after treatment was 42.8%, and was 62.5% in women 35 years. Live birth rate was 32.1%. However these pregnancies were at high risk for haemorrhage with abnormal placentation. Because risk factors for IUA and for placenta accreta are similar, and because treatment of severe Asherman's syndrome is probably an added risk factor for abnormal placentation, subsequent pregnancies should be managed appropriately in a tertiary care reproductive centre.
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Notes |
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References |
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Submitted on September 21, 1998; accepted on January 29, 1999.