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Uterine Synechiae

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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).