para>Previously, although that modern contraceptive IUDs, such as Mirena IUD or ParaGard copper IUD, were not appropriate for IUA postoperative management. More recent systematic review suggests IUDs are safe, effective adjunct in postoperative management of synechiae (5)[A]
ISSUES FOR REFERRAL
Offer referral to gynecologist with expertise in hysteroscopy (2)[A].
SURGERY/OTHER PROCEDURES
Hysteroscopy with lysis of adhesions is gold standard. Various techniques exist; however, no RCTs to compare them.
- Hysteroscopy with myometrial scoring: for severe IUAs when hysteroscopic adhesiolysis cannot be safely performed
- Cold loop hysteroscopic myomectomy (6)[B]
- Open laparotomy followed by hysterotomy and subsequent blunt dissection of adhesions with finger or curette (used rarely in severe cases)
- Alternative visualizing methods such as fluoroscopy, transabdominal US, and laparoscopy: higher rates of uterine perforation and expense (1)[C]
INPATIENT CONSIDERATIONS
Typically managed as outpatient same-day surgical procedure in absence of complications
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Routine visits at 2 and 6 weeks after surgery
- Repeat hysteroscopy or second-line hysterosalpingography at 2 to 3 menstrual cycles postsurgery to assess for adhesion recurrence (1)[C].
DIET
Routine same-day surgery care: Advance diet as tolerated to preoperative baseline.
PATIENT EDUCATION
Resources for patients may include the following:
- American Academy of Family Physicians (www.familydoctor.org)
- American Congress of Obstetricians and Gynecologists (www.acog.org/For_Patients)
- American Society for Reproductive Medicine (www.asrm.org)
PROGNOSIS
- Mild to moderate disease: Adhesion recurrence rate after lysis of adhesions is 1 of 3 women.
- Severe disease: Adhesion recurrence rate is 2 of 3 women.
COMPLICATIONS
Of hysteroscopy:
- Uterine perforation
- Recurrence of adhesions
- Visceral organ injury
- Bleeding
- Infection
REFERENCES
11 American Association of Gynecologic Laparoscopists Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for management of intrauterine synechiae. J Minim Invasive Gynecol. 2010;17(1):1 " 7.22 Hooker AB, Lemmers M, Thurkow AL, et al. Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome. Hum Reprod Update. 2014;20(2):262 " 278.33 Johary J, Xue M, Zhu X, et al. Efficacy of estrogen therapy in patients with intrauterine adhesions: systematic review. J Minim Invasive Gynecol. 2014;21(1):44 " 54.44 Fuchs N, Smorgick N, Ben Ami I, et al. Intercoat (Oxiplex/AP gel) for preventing intrauterine adhesions after operative hysteroscopy for suspected retained products of conception: double-blind, prospective, randomized pilot study. J Minim Invasive Gynecol. 2014;21(1):126 " 130.55 Salma U, Xue M, Md Sayed AS, et al. Efficacy of intrauterine device in the treatment of intrauterine adhesions. Biomed Res Int. 2014;2014:589296.66 Mazzon I, Favilli A, Cocco P, et al. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril. 2014;101(1):294.e3 " 298.e3.
ADDITIONAL READING
- Deans R, Abbott J. Review of intrauterine adhesions. J Minim Invasive Gynecol. 2010;17(5):555 " 556.
- Liu X, Duan H, Wang Y. Clinical characteristics and reproductive outcome following hysteroscopic adhesiolysis of patients with intrauterine adhesion " a retrospective study. Clin Exp Obstet Gynecol. 2014;41(2):144 " 148.
- March CM. Asherman 's syndrome. Semin Reprod Med. 2011;29(2):83 " 94.
- Myers EM, Hurst BS. Comprehensive management of severe Asherman syndrome and amenorrhea. Fertil Steril. 2012;97(1):160 " 164.
- Xiao S, Wan Y, Xue M, et al. Etiology, treatment, and reproductive prognosis of women with moderate-to-severe intrauterine adhesions. Int J Gynaecol Obstet. 2014;125(2):121 " 124.
SEE ALSO
Algorithm: Amenorrhea, Secondary; Infertility; Pelvic Pain
CODES
ICD10
N85.6 Intrauterine synechiae
ICD9
621.5 Intrauterine synechiae
SNOMED
- Intrauterine adhesions (disorder)
- Asherman syndrome (disorder)
CLINICAL PEARLS
- Typical symptoms: secondary amenorrhea, infertility, recurrent SABs, and/or cyclic pelvic pain
- Prevention of adhesions is key: Minimize intrauterine operative interventions while women are fertile and desire pregnancy.
- Hysteroscopy is the gold standard for both diagnosis (adhesion visualization) and therapy (adhesion lysis).