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Asherman's syndrome

Asherman's syndrome, also called "uterine synechiae", presents a condition characterized by the presence of scars within the uterine cavity. more...

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Features

The cavity of the uterus is lined by the endometrium. This lining can be traumatized, typically after a dilation and curettage (D&C) done after a miscarriage, abortion, or delivery, and then develops intrauterine scars which can obliterate the cavity to a varying degree. 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. The patient experiences secondary amenorrhea and becomes infertile. An artificial form of Asherman's syndrome can be surgically induced by uterine ablation in women with uterine bleeding problems in lieu of hysterectomy.

Diagnosis

The history of a pregnancy event followed by a D&C leading to seconday amenorrhea is typical. Imaging by gynecologic ultrasonography or hysterosalpingography will reveal the extent of the scar formation. Hormone studies show normal levels consistent with reproductive function.

Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Options include HSG (hysterosalpingography) or SHG (sonohysterography). Hysteroscopy is the most reliable. The website at www.ashermans.org gives more detail.

Treatment

Operative hysteroscopy is used for visual inspection of the uterine cavity and dissection of scar tissue.

Prognosis

The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity may require several surgical interventions or even be uncorrectable. Patients who carry a pregnancy after correction of Asherman's syndrome may have an increased risk of having a placenta that invades the uterus more deeply, leading to complications in placental separation after delivery.

History

It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome per the individuals who described it, Heinrich Fritsch and Joseph G. Asherman.

Read more at Wikipedia.org


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Last 50 years show 10-fold rise in placenta accreta - Behind 50% of Emergency Hysterectomies
From OB/GYN News, 12/15/02 by Kate Johnson

INDIANAPOLIS - Placenta accreta is a growing cause of postpartum hemorrhage and an increasing cause of emergency hysterectomy, according to Dr. Gary Dildy III.

"The incidence of placenta accreta is increasing, and it's thought this may have to do with the increasing rate of cesarean sections since the 1960s," he said at the annual meeting of District V of the American College of Obstetricians and Gynecologists.

Research has shown that the incidence of placenta previa and accreta correlates highly with the number of prior cesarean sections that a woman has had. In addition, while placenta accreta accounted for only about 10% of emergency hysterectomies in the 1950s, it accounted for 50% of these procedures in the mid-1980s.

Currently, the incidence of placenta accreta is about 1 per 2,500 pregnancies and has increased 10-fold in the past 50 years, said Dr. Dildy, professor of ob.gyn. at Louisiana State University New Orleans.

Although placenta accreta remains one of the rarer causes of postpartum hemorrhage, Dr. Dildy urged physicians to be aware of it. Occasionally the condition can be diagnosed prenatally, which can be highly advantageous.

"It is always nice to know ahead of time whether a problem like this exists. Although nothing that we currently have available is exact, including ultrasound or MRI, it can at least give us a heads up in many cases, he said, adding that a combination of the patient's history of a previous cesarean section plus ultrasound imaging is probably the most reliable means of investigating a suspected placenta accreta.

Other risk factors for placenta accreta include placenta previa with or without previous uterine surgery, prior myomectomy, prior cesarean delivery Asherman's syndrome, submucous leiomyomata, and maternal age older than 35 years.

Women who have had at least two cesarean deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta in the future.

"By using ultrasound and assessing risk factors, we can identify patients that require a greater degree of advance preparation," he said in an interview.

The ACOG Committee Opinion No. 266, issued in January 2002, recommends that when placenta accreta is suspected prenatally appropriate measures need to be taken to acquire blood for transfusion, arrange for Cell Saver technology when available, arrange a preoperative anesthesia consultation, and recruit the appropriate backup expertise.

"If you have vascular involvement, you may need a vascular surgeon; if you have urologic involvement, you may need a urologist or a gynecologic oncologist," he explained.

The ACOG committee opinion states that "profuse hemorrhage can occur when attempting to separate the placenta. If the clinician is extremely confident in the diagnosis, it maybe prudent to complete the delivery of the infant and proceed with hysterectomy while the placenta remains attached."

Cell Saver technology is starting to gain popularity in obstetrics and can greatly reduce the need for blood transfusions in the case of placenta accreta. The device suctions blood out of the pelvic cavity filters it, and reinfuses the red cells into the patient.

"It's relatively new to obstetrics, and in the past, we've always been afraid to use it because of concerns about putting amniotic fluid and fetal cells back into the maternal circulation. But the filtration system seems be effective against this, and the cases that are published thus far, although the numbers are small, suggest that Cell Saver is safe in pregnancy and [that] the benefits probably outweigh the risks," he said.

COPYRIGHT 2002 International Medical News Group
COPYRIGHT 2002 Gale Group

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