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Intrauterine adhesions in an African population
International Journal of Gynecology & Obstetrics 77 Ž2002. 37᎐38
Brief communication
Intrauterine adhesions in an African population B. OzumbaU , H. Ezegwui Department of Obstetrics and Gynaecology, Uni¨ ersity of Nigeria Teaching Hospital, PMB 01129 Enugu, Nigeria Received 17 April 2001; received in revised form 26 July 2001; accepted 1 August 2001
Keywords: Intrauterine adhesions; Cesarean sections; Nigeria
Intrauterine adhesion is a recognized cause of secondary amenorrhea and consequently, secondary infertility w1᎐4x. This study was undertaken to assess the clinical profile and etiological factors for intrauterine adhesions in an African population with high incidence of induced septic abortion w1x and uterine fibroids. Fifty patients were seen in the gynecological out-patient clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria between January 1995 and December 1997. Every patient presenting with secondary amenorrhea had a pregnancy test and Mantoux test done. Blood levels of follicle stimulating hormone, lutenizing hormone, prolactin, estrogen, progesterone and testosterone were estimated. A hysterosalpingogram using iodipamide meglumine as an aqueous contrast medium was carried out for each patient. Hysteroscopy and
U
Corresponding author. Tel.: q234-42-253496; fax: q23442-252665. E-mail address: [email protected] ŽB. Ozumba..
hysterography, which could lead to a more precise diagnosis, were not available in our hospital during this period. Lysis of adhesion was performed with uterinesound and occasionally with uterine dilators when there was dense fibrosis. A Lippes loop of appropriate size was inserted after lysis of adhesion and left in situ for three cycles. Cyclical estrogen therapy was prescribed for 3 months. Secondary amenorrhea of at least 6 months’ duration was the most common clinical presentation in 32 Ž64%. women, followed by scant periods in 15 Ž30%. and irregular vaginal spotting in three Ž6%.. Most of the cases of intrauterine adhesions were found in nulliparas 26 Ž54%.. There were two high parity women Ž4%. while the rest 22 Ž44%. were found in women with a parity of one to four. The mean age of patients was 29.2 years, with a range of 19᎐48 years. There were very few cases at the extremes of age. Normal menstruation returned in 16 Ž73%. of those who had induced abortion and in 6 Ž55%. of those who had cesarean sections. Four of the
0020-7292r02r$20.00 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 1 . 0 0 5 0 0 - 8
38
B. Ozumba, H. Ezegwui r International Journal of Gynecology & Obstetrics 77 (2002) 37᎐38
Table 1 Etiological factors in intrauterine adhesions Factors
N
Induced abortion Cesarean section Evacuation for spontaneous abortion Myomectomies Dilatation and curettage for postpartum hemorrhage Manual removal of placenta Total
22 11 9
42 22 18
7 2
14 4
1 50
2 100
%
women who previously had myomectomy Ž57%. subsequently regained their menstrual periods while three Ž33%. of those who were evacuated for spontaneous abortion eventually menstruated. As many as 84% of our cases were associated with uterine manipulations in a recent pregnancy. The fact that previous myomectomies in which the uterine cavity was breached was associated with 14% of intrauterine adhesions, suggests that Table 2 Outcome of treatment
Normal menstruation Lost to follow-up Amenorrhea Cyclical spotting Pregnancy
N
%
30 6 6 4 4
60 12 12 8 8
pregnancy may not be ruled out as a causative factor in this condition ŽTable 1.. The proportion of patients who regained normal menstruation Ž60%. after adhesiolysis in this series is low when compared with 74% reported from the United States, possibly because of differences in etiology. The pregnancy rate of 8% after adhesiolysis is even lower than 70% reported from the United States ŽTable 2.. Women from this part of the world are averse to hysterectomy even when the chances of future pregnancy is very low, as in cases of difficult myomectomy. Elimination of the main contributing factors such as septic abortion, prolonged obstructed labor and difficult myomectomy is likely to reduce the incidence of intrauterine adhesions in our community. References w1x Megafu U, Ozumba BC. Morbidity and mortality from induced illegal abortion at the University of Nigeria Teaching Hospital Enugu, a five year review. Int J Obstet Gynecol 1990;34:347᎐352. w2x Sugimoto O. Diagnostic and therapeutic hysteroscopy for traumatic adhesions. Am J Obstet Gynecol 1978; 131:439᎐444. w3x Katz Z, Ben Arie A, Lurie S, Manor M, Luster V. Reproductive outcome following hysteroscopic adhesiolysis in Asherman’s syndrome. Int J Fertil 1996;41Ž5.: 462᎐467. w4x Ozumba BC, Uchegbu H. Incidence and management of obstructed labour in eastern Nigeria. Aust N Z J Obstet Gynaecol 1991;32:213᎐217.
Brief communication
Intrauterine adhesions in an African population B. OzumbaU , H. Ezegwui Department of Obstetrics and Gynaecology, Uni¨ ersity of Nigeria Teaching Hospital, PMB 01129 Enugu, Nigeria Received 17 April 2001; received in revised form 26 July 2001; accepted 1 August 2001
Keywords: Intrauterine adhesions; Cesarean sections; Nigeria
Intrauterine adhesion is a recognized cause of secondary amenorrhea and consequently, secondary infertility w1᎐4x. This study was undertaken to assess the clinical profile and etiological factors for intrauterine adhesions in an African population with high incidence of induced septic abortion w1x and uterine fibroids. Fifty patients were seen in the gynecological out-patient clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria between January 1995 and December 1997. Every patient presenting with secondary amenorrhea had a pregnancy test and Mantoux test done. Blood levels of follicle stimulating hormone, lutenizing hormone, prolactin, estrogen, progesterone and testosterone were estimated. A hysterosalpingogram using iodipamide meglumine as an aqueous contrast medium was carried out for each patient. Hysteroscopy and
U
Corresponding author. Tel.: q234-42-253496; fax: q23442-252665. E-mail address: [email protected] ŽB. Ozumba..
hysterography, which could lead to a more precise diagnosis, were not available in our hospital during this period. Lysis of adhesion was performed with uterinesound and occasionally with uterine dilators when there was dense fibrosis. A Lippes loop of appropriate size was inserted after lysis of adhesion and left in situ for three cycles. Cyclical estrogen therapy was prescribed for 3 months. Secondary amenorrhea of at least 6 months’ duration was the most common clinical presentation in 32 Ž64%. women, followed by scant periods in 15 Ž30%. and irregular vaginal spotting in three Ž6%.. Most of the cases of intrauterine adhesions were found in nulliparas 26 Ž54%.. There were two high parity women Ž4%. while the rest 22 Ž44%. were found in women with a parity of one to four. The mean age of patients was 29.2 years, with a range of 19᎐48 years. There were very few cases at the extremes of age. Normal menstruation returned in 16 Ž73%. of those who had induced abortion and in 6 Ž55%. of those who had cesarean sections. Four of the
0020-7292r02r$20.00 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 1 . 0 0 5 0 0 - 8
38
B. Ozumba, H. Ezegwui r International Journal of Gynecology & Obstetrics 77 (2002) 37᎐38
Table 1 Etiological factors in intrauterine adhesions Factors
N
Induced abortion Cesarean section Evacuation for spontaneous abortion Myomectomies Dilatation and curettage for postpartum hemorrhage Manual removal of placenta Total
22 11 9
42 22 18
7 2
14 4
1 50
2 100
%
women who previously had myomectomy Ž57%. subsequently regained their menstrual periods while three Ž33%. of those who were evacuated for spontaneous abortion eventually menstruated. As many as 84% of our cases were associated with uterine manipulations in a recent pregnancy. The fact that previous myomectomies in which the uterine cavity was breached was associated with 14% of intrauterine adhesions, suggests that Table 2 Outcome of treatment
Normal menstruation Lost to follow-up Amenorrhea Cyclical spotting Pregnancy
N
%
30 6 6 4 4
60 12 12 8 8
pregnancy may not be ruled out as a causative factor in this condition ŽTable 1.. The proportion of patients who regained normal menstruation Ž60%. after adhesiolysis in this series is low when compared with 74% reported from the United States, possibly because of differences in etiology. The pregnancy rate of 8% after adhesiolysis is even lower than 70% reported from the United States ŽTable 2.. Women from this part of the world are averse to hysterectomy even when the chances of future pregnancy is very low, as in cases of difficult myomectomy. Elimination of the main contributing factors such as septic abortion, prolonged obstructed labor and difficult myomectomy is likely to reduce the incidence of intrauterine adhesions in our community. References w1x Megafu U, Ozumba BC. Morbidity and mortality from induced illegal abortion at the University of Nigeria Teaching Hospital Enugu, a five year review. Int J Obstet Gynecol 1990;34:347᎐352. w2x Sugimoto O. Diagnostic and therapeutic hysteroscopy for traumatic adhesions. Am J Obstet Gynecol 1978; 131:439᎐444. w3x Katz Z, Ben Arie A, Lurie S, Manor M, Luster V. Reproductive outcome following hysteroscopic adhesiolysis in Asherman’s syndrome. Int J Fertil 1996;41Ž5.: 462᎐467. w4x Ozumba BC, Uchegbu H. Incidence and management of obstructed labour in eastern Nigeria. Aust N Z J Obstet Gynaecol 1991;32:213᎐217.