Intrauterine adhesions

Are you facing problem to insulate the uterine sound /smallest dilator even after misoprostol primed Cervix?? Are you thinking of perforation of uterus with sound or small dilator or curette? Think of stenosis of os due to an extension of intrauterine adhesions (A syndrome).

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·         The terms “Ashermans syndrome” and IUAs are often used interchangeably, although the term A syndrome requires the constellation of signs and symptoms like dysmenorrhoea, menstrual disturbance, and subfertility in any combination due to the presence of IUAs . The presence of IUAs in the absence of symptoms may be best referred to as asymptomatic IUAs and are of questionable clinical significance. While the presence of IUAs in the absence of symptoms may be best referred to as asymptomatic IUAs and are of questionable clinical significance. The term “IUAs” specifying whether or not they are associated with clinical symptoms.
In women with suspected Ashermans syndrome, physical examination frequently fails to reveal abnormalities Blind, transcervical uterine sounding may reveal cervical obstruction at or near the level of the internal os however, adhesions higher in the cavity or more laterally may not be demonstrated in this manner

Hypomenorrhoea is the commonest symptom. of A syndrome . Additionally there can be dysmenorrhoea, subfertility problem. IUA may also follow CS/ myomectomy and Kochs-and not specific for vigorous D&C procedure.
There are different grades of IUA which has been duly classified by many International academic bodies including AFS(1988). Such different kinds of classification have made a comparative study of efficacy of different treatment options and outcome of treatment ... Both confirmation as well as therapy bestow on Hysteroscopy and that too by a skilled person lest there is a possibility of perforation. One can use Lap /USG concurrently ( for early detection of slightest thinning of uterine musculature) -but even then this threat of perforation remains. Semi flexible scissors is the preferred instrument on which one should bank upon too much for this open.

. Diagnosing IUA?? How?? Choiced method : 1: Hysteroscopy has been established as the criterion standard for diagnosis of IUAs but before that HSG was the most common method for diagnosis. Compared with radiologic investigations(HSG) and provided the endometrial cavity is accessible, hysteroscopy more accurately confirms the presence, extent, and morphological characteristics of adhesions and the quality of the endometrium. It provides a real-time view of the cavity, enabling accurate description of location and degree of adhesions, classification, and concurrent treatment of IUAs
method : 2:: Hysterosalpingography (HSG) using contrast dye has a sensitivity of 75 to 81%, specificity of 80%, and positive predictive value of 50% compared with hysteroscopy for diagnosis of IUAs . The high false-positive rate (up to 39%) limits its use, and it does not detect endometrial fibrosis or the nature and extent of IUAs and therefore, use should be confined to that of a screening test.
method : 3 : Sonohysterography (SHG; also called saline infusion sonography (SIS) or gel infusion sonography (GIS)) was found to be as effective as HSG, with both reported to have a sensitivity of 75% and positive predictive value of 43% for SHG or SIS/GIS and 50% for HSG, compared with hysteroscopy

method : 4: 2-D USG : Imaging techniques do appear to be hierarchical with two-dimensional gray-scale transvaginal ultrasonography having a sensitivity of 52% and specificity of 11% compared with hysteroscopy

Diagnosis of synechiae :: method : 5 : Three-dimensional (3D) ultrasonography may be more helpful in the evaluation of IUAs, with sensitivity reported to be 87% and specificity of 45% when compared with 3D SHG . 3D SHG has a high specificity of 87% although a lower sensitivity of 70% when compared with the standard, hysteroscopy.
method : 6: Power Doppler sonography where studies suggest high resistance flows that are associated with poorer obstetric outcomes and the addition of contrast color power angiography to 3D ultrasonography may have a role in both initial assessment and prognosis for women with Ashermans syndrome

method : 7 : MRI: Initial assessments of magnetic resonance imaging (MRI) for the diagnosis of IUAs show few advantages over less costly alternatives with more recent assessment of gadolinium-enhanced images showing some promise

5. How to prevent adhesion after lysis contemplated ?? Both primary and secondary adhesion prevention including solid and semi-solid barriers, The commonly adopted post op adhesion preventive strategies are 1) Pad Foley Catheter 1 week 2) Two mg Oestradiol valerate oral estrogen for 60 days 3) Along with oral oestrogens some still use IUD-(but I have a feeling that will cause more inflammatory reaction and may lead to re-adhesion and compromise fertility potential.)
4) alginate carboxymethylcellulose hyaluronic acid was compared with carboxycellulose hyaluronic acid. Till date alginate carboxymethylcellulose hyaluronic acid was reported to be a better primary prevention product
Method 5: Bone marrow derived stem cells: Recent human studies documenting successful pregnancy outcomes for bone marrow-derived stem cell (BMDSC) treatments following intermittent hysteroscopy are reported
But no RCT on the above agents are possible as the extent of IUA have been variously classified

1. Conclusion:-- The terms “Asherman syndrome” and IUAs are often used interchangeably, although the syndrome requires the constellation of signs and symptoms (in this case, pain, menstrual disturbance, and subfertility in any combination) related to the presence of IUAs Hysteroscopy is the most accurate method for diagnosis of IUAs and should be the investigation of choice when available. The risk for de novo adhesions during hysteroscopic surgery is impacted by the type of procedure performed with those confined to the endometrium (polypectomy) having the lowest risk and those entering the myometrium or involving opposing surfaces a higher risk. Level B
2. The method of pathology removal may impact the risk of de novo adhesions. The risk appears to be greater when electrosurgery is used in the non-gravid uterus and for blind versus vision-guided removal in the gravid uterus. Level C
The application of an adhesion barrier following surgery that may lead to endometrial damage significantly reduces the development of IUAs in the short term, although limited fertility data are available following this intervention. Level
1. Hysteroscopy is the most accurate method for diagnosis of IUAs and should be the investigation of choice when available. Level B.
2. If hysteroscopy is not available, HSG and SHG are reasonable alternatives. Level B.
3. Magnetic resonance imaging should not be used for diagnosis of IUAs outside of clinical research studies. Level C.
Level B.
1. If hysteroscopy is not available, HSG and SHG are reasonable alternatives. Level B.
2. Magnetic resonance imaging should not be used for diagnosis of IUAs outside of clinical research studies. Level C

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