1. Dick Schoot MD PhD Catharina Hospital Eindhoven The Netherlands
Asherman’s syndrome
Dick Schoot MD PhD
Catharina Hospital Eindhoven
The Netherlands

2. Primaire preventie
Secundaire preventie
Behandeling adhaesies

3. cause of adhaesions Curettage Genetic predisposition
Placental characteristics

4. Primaire preventie
Chemische abortus
inductie
Mefigyn
cytotec

5. Primaire preventie door adequate curettage

6. placental remnants

7. remnant placental or trophoblastic tissue
often leads to
infection
repeated curettage
intrauterine adhaesions (Asherman’s syndrome)

8. Wat te doen na incomplete curettage secundaire preventie
Expectatief (>6 weken)
Herhaalde curettage (evt echogeleide)
Hysteroscopisch
Schaar
Cold loop
Truclear

9. prevalence of adhaesions
after secondary or repeated curettage
35% Golan 1996
50% Westendorp 1998

10. patients and procedure
n = 55 (Jan 2005-Jan 2008)
mean age 34 (21-40)
previous curettage = 20 (first trimester and puerperal)
manual placenta removal = 35
median interval first proc. and morc. 8 wks (2-40)
hysteroscopic morcellation (TRUCLEAR Smith&Nephew)
saline distension (max. 120 mm Hg)
antibiotic prophylaxis

11. Studies met cold loop and truclear convincing

12. conclusion the prevalence of intrauterine synechiae is high
(35-50%) after secondary or repeated curettage of placental remnants
hysteroscopic morcellation reduces the risk of these synechiae (5.5%)

13. If prevention failed: Synechiae

14. cause of adhaesions
in most cases only a single uncomplicated pregnancy related intra-uterine procedure
first trimester curettage
puerperal curettage
manual placenta removal
always pregnancy related
never spontaneous
difficult to mimmick in ‘disfunctional bleeders’

15. Intrauterine adhaesions (Asherman’s syndrome)
rare condition (approx. 1:500 pregnancies)
iatrogenic etiology obligatory
postpartem curettage
postabortem curettage
amenorrhea or severe oligomenorrhea
individualized need for treatment
hysteroscopic surgery
technically difficult
centralized treatment

16. Grades of Intrauterine Adhaesions
European Society for Hysteroscopy (1989) ESGE
I - Thin or filmy adhesions easly ruptured by hysteroscope sheath alone, cornual areas normal;
II - Single firm adhesions connecting separate parts of the uterine cavity, visualization of both tubal ostia possible, cannot be ruptured by hysteroscope sheath alone;
IIa - Occluding adhesions only in the region of the internal cervical OS. Upper uterine cavity normal;
III - Multiple firm adhesions connecting separate parts of the uterine cavity, unilateral obliteration of ostial areas of the tubes;
IIIa - Extensive scarring of the uterine cavity wall with amenorrhea or hypomenorrhea;
IIIb - Combination of III and IIIa;
IV - Extensive firm adhesions with agglutination of the uterine walls. Both tubal ostial areas occluded

17. Intrauterine adhaesions (Asherman’s syndrome)
hysteroscopic treatment can result in an 85-95% return to normal menstrual cycles
if no other infertility issues are present, 80% of treated patients have normal pregnancies (ie, 75% of those with mild disease but only 30% with recurrent adhesions)
after hysteroscopic treatment the risk of abnormal placentation (eg, accreta, percreta, increta, previa) is increased
worst prognosis after resectoscopic hot-loop procedures

18. Threrapy Intrauterine adhaesions (Asherman’s syndrome)
hysteroscopic treatment combined with fluoroscopy
50% office
50% OR
IUD
Medical hormonal adjuvant treatment
sequential oestradiol and progesterone for 6 weeks, two withdrawal bleedings
IUD removal during second withdrawal
Second look hysteroscopy after 8-10 wks
Recurrent treatment during menstruation