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Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure
Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure Vanessa K. Dalton, M.D., Natalie A. Saunders, M.D., Lisa H. Harris, M.D., Jennifer A. Williams, M.D., and Dan I. Lebovic, M.D., M.A. University of Michigan Medical School, Department of Obstetrics and Gynecology, Ann Arbor, Michigan
Objective: To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure. Design: Case series. Setting: Tertiary care center. Patient(s): Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure. Intervention(s): Chart review. Main Outcome Measure(s): Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration. Result(s): Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration. Conclusion(s): Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss. (Fertil Steril威 2006;85:1823.e1–3. ©2006 by American Society for Reproductive Medicine.) Key Words: Early pregnancy failure, manual vacuum aspiration, intrauterine adhesions
Early pregnancy failure (EPF) occurs in up to 20% of clinically recognized pregnancies and is commonly managed surgically with suction dilation and curettage (D&C) (1). Although EPF is traditionally treated with electric suction in an operative suite, office-based management with a handheld suction device is an effective alternative. The efficacy of manual vacuum aspiration (MVA) is comparable to traditional electric suction and is an ideal tool for an office-based procedure because of its portability and low cost (1). Since January 2002, almost half of women presenting to the University of Michigan Hospitals with EPF were treated with MVA in an office setting. A known postoperative complication of suction D&C is intrauterine adhesions (IUAs) or Asherman’s syndrome (2). No previous report of IUAs after MVA was identified in the literature. This article describes three women with Asherman’s syndrome after undergoing MVA for EPF. An exemption for full review was obtained from the institutional review board for this project. The same provider utilizing the same techniques and equipment performed all the procedures. Briefly, each procedure was performed in an office setting under a paracervical block using MVA—a Received May 25, 2005; revised and accepted November 1, 2005. Dr. Dalton was supported by the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program, US HHS PHS National Institutes of Health (1 K12 HDO1438-01). Dr. Harris is a consultant for Ipas, a manufacturer of the manual vacuum aspirator, and has received honorarium from Ipas in the past. These funds are in no way related to this manuscript. Reprint requests: Vanessa K. Dalton, M.D., Department of Obstetrics and Gynecology, University of Michigan Medical School, L4000 Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109 (FAX: 734-647-9727; E-mail: [email protected]).
0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2005.11.065
handheld suction device consisting of a 60-cc syringe (Ipas, Chapel Hill, NC). The sharp curette was not utilized in any of the cases. The implications of these cases and a brief review of intrauterine adhesions after surgical management of pregnancy loss are discussed in the concluding section. CASE REPORTS Case 1 A 38-year-old gravida 5 para 1 presented at 10 weeks from her last menstrual period with an ultrasound documenting an EPF corresponding to 6 weeks’ gestation. Before this pregnancy, she reported regular menses, lasting from 4 –5 days. Her previous obstetrical history was significant for an EPF requiring suction D&C, an uncomplicated term vaginal delivery, a midtrimester induction for severe fetal anomalies, and an electric suction D&C for a partial molar pregnancy. Subsequent to these pregnancies and immediately before the index pregnancy, she underwent a hysterosalpingogram during an infertility workup, which was negative for intrauterine adhesions. The patient underwent an office-based MVA that was completed without complication. Subsequently, she presented with a decreased menstrual flow and an inability to conceive 5 months after her procedure. A sonohysterogram revealed a large intracavitary defect that was consistent with intrauterine adhesions. The patient was taken to the operating room for a hysteroscopy and resection of fibrotic bands. Hysteroscopy confirmed the presence of American Fertility Society (AFS) stage 1 intrauterine adhesions (3). These bands were resected sharply without complication. Two
Fertility and Sterility姞 Vol. 85, No. 6, June 2006 1823.e1 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.
months postoperatively, she conceived and delivered at term after an uncomplicated pregnancy. Case 2 A 36-year-old gravida 1 para 0 presented with an EPF corresponding to a gestational age of 6 weeks. Her obstetrical history before this pregnancy was notable for primary infertility, without history of uterine infection or intracavitary instrumentation. She spontaneously conceived during her infertility workup. Four days after diagnosis of pregnancy failure, she underwent an uncomplicated office MVA. She subsequently presented with secondary amenorrhea at 3 months’ postop. An office hysteroscopy noted dense adhesions obstructing the internal os, and a hematometra was noted upon dilation of the cervix. Additional adhesions were noted in the lower uterine segment (AFS stage 2), which were lysed by the office flexible hysteroscope. Subsequently, menses resumed, and the patient spontaneously conceived 5 months later. She delivered at term after an uncomplicated pregnancy. Case 3 A 35-year-old gravida 1 para 0 who had no prior medical or gynecological problems presented with an EPF measuring approximately 10 weeks’ gestation. At the time of this pregnancy, she had been actively attempting to conceive for approximately 6 months. Before that time, she had regular menses on oral contraceptives for many years. She had no history of uterine infection or surgery. After reviewing treatment options, she had an uncomplicated office MVA 3 days after diagnosis. Three months later, she presented with secondary amenorrhea. At that time, she failed to have withdrawal bleeding with medroxyprogesterone and was noted to have a 2-mm endometrial stripe on transvaginal ultrasound. Office hysteroscopy was attempted but not completed because of dense adhesions at the internal os that prevented cervical dilation. She was taken to the operating room where the cervical adhesions were lysed. Hysteroscopy revealed AFS stage 2 fundal and cornual adhesions, causing significant distortion of the uterine cavity. The adhesions were taken down sharply until the cavity was normalized. Postoperatively, an intrauterine foley catheter (Bard, Covington, GA) was placed for 5 days. Additionally, she was started on 2.5 mg of conjugated estrogens on postoperative days 1–30 and 10 mg of medroxyprogesterone acetate on days 10 –30. Three weeks postoperatively, the follow-up office hysteroscopy revealed a largely normalized cavity. Eight months later, she conceived; however, this pregnancy also ended in a first trimester loss. DISCUSSION Intrauterine adhesions are a known but infrequently addressed complication of D&C (2). The formation of IUAs is 1823.e2 Dalton et al.
thought to occur during processes that destroy the endometrial stratum basalis, with the gravid uterus being particularly vulnerable. Surgical procedures, infection, and retained products of conception are implicated as etiologies (2). Previous studies estimate that adhesion formation occurs in 7%–30% of patients undergoing hysteroscopic examination after D&C for EPF (2, 4 –7). Although hysteroscopy was not performed before their treatment for pregnancy failure, several studies have found both increased incidence of IUAs as well as more significant diseases in patients with a history of multiple D&Cs, as compared with those undergoing a single procedure (5, 8). A case series cannot attribute the IUAs noted among these patients to their previous MVAs with certainty. Although Case 1 had a hysterosalpingogram (HSG) documenting a normal uterus immediately before her MVA, she had numerous other risk factors and procedures. It is possible that these factors placed her at particular risk for the development of IUAs or that her first HSG failed to visualize preexisting adhesions. Even given these limitations, however, the cases described suggest that IUAs may occur after an MVA even in the absence of sharp curettage, and this risk should be considered when assessing treatment options and consenting patients in the face of a pregnancy loss. No studies have been undertaken to examine the risk of IUA after MVA as compared with electric vacuum aspiration (EVA). After 262 office MVAs for first trimester pregnancy losses, we have identified 5 cases of IUAs corresponding to a rate consistent with published rates for EVA (7%–30%) (2, 4 –7) In this article, we present the three cases without obvious alternate etiologies for their IUAs. The other two cases had multiple uterine procedures or infections without documentation of a normal cavity before the index pregnancy. Based on our experience to date, we have not noted a higher rate of IUAs among those patients undergoing MVA as compared with traditional electric suction D&C and continue to offer either technique to patients with EPF. Although we have not established causation, the possibility of IUAs after MVA does warrant attention. Many patients present to us with a perception that office-based MVA is “less invasive” than traditional electric suction and, presumably, would result in fewer complications such as uterine scarring. There is insufficient information to suggest that either procedure offers an advantage when it comes to the prevention of IUAs. Advantages of office MVA make it a favorable option for some women who desire surgical completion of EPF, such as avoidance of general anesthesia, less noise, improved privacy, the presence of their partners, and less time spent overall on the part of the patient and her family. Intrauterine adhesions are a possible complication of office MVA, even in the absence of sharp curettage, and should be considered when discussing treatment options
Adhesions after manual vacuum aspiration
Vol. 85, No. 6, June 2006
for EPF with patients. Further studies are needed to determine the incidence of IUAs associated with MVA. REFERENCES 1. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure— current management concepts. Obstet Gynecol Surv 2001;56: 105–13. 2. Al-Inany H. Intrauterine adhesions. An update. Acta Obstet Gynecol Scand 2001;80:986 –93. 3. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944 –55.
Fertility and Sterility姞
4. Tam WH, Lau WC, Cheung LP, Pong MY, Chung TK. Intrauterine adhesions after conservative and surgical management of spontaneous abortion. J Am Assoc Gynecol Laparosc 2002;9:182–5. 5. Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of post-abortion intrauterine adhesions evaluated by hysteroscopy—a prospective study. Hum Reprod 1993;8:442– 4. 6. March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995;22:491–505. 7. Adoni A, Palti Z, Milwidsky A, Dolberg M. The incidence of intrauterine adhesions following spontaneous abortion. Int J Fertil 1982;27: 117– 8. 8. Romer T. Post-abortion-hysteroscopy—a method for early diagnosis of congenital and acquired intrauterine causes of abortions. Eur J Obstet Gynecol Reprod Biol 1994;57:171–3.
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Objective: To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure. Design: Case series. Setting: Tertiary care center. Patient(s): Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure. Intervention(s): Chart review. Main Outcome Measure(s): Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration. Result(s): Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration. Conclusion(s): Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss. (Fertil Steril威 2006;85:1823.e1–3. ©2006 by American Society for Reproductive Medicine.) Key Words: Early pregnancy failure, manual vacuum aspiration, intrauterine adhesions
Early pregnancy failure (EPF) occurs in up to 20% of clinically recognized pregnancies and is commonly managed surgically with suction dilation and curettage (D&C) (1). Although EPF is traditionally treated with electric suction in an operative suite, office-based management with a handheld suction device is an effective alternative. The efficacy of manual vacuum aspiration (MVA) is comparable to traditional electric suction and is an ideal tool for an office-based procedure because of its portability and low cost (1). Since January 2002, almost half of women presenting to the University of Michigan Hospitals with EPF were treated with MVA in an office setting. A known postoperative complication of suction D&C is intrauterine adhesions (IUAs) or Asherman’s syndrome (2). No previous report of IUAs after MVA was identified in the literature. This article describes three women with Asherman’s syndrome after undergoing MVA for EPF. An exemption for full review was obtained from the institutional review board for this project. The same provider utilizing the same techniques and equipment performed all the procedures. Briefly, each procedure was performed in an office setting under a paracervical block using MVA—a Received May 25, 2005; revised and accepted November 1, 2005. Dr. Dalton was supported by the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program, US HHS PHS National Institutes of Health (1 K12 HDO1438-01). Dr. Harris is a consultant for Ipas, a manufacturer of the manual vacuum aspirator, and has received honorarium from Ipas in the past. These funds are in no way related to this manuscript. Reprint requests: Vanessa K. Dalton, M.D., Department of Obstetrics and Gynecology, University of Michigan Medical School, L4000 Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109 (FAX: 734-647-9727; E-mail: [email protected]).
0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2005.11.065
handheld suction device consisting of a 60-cc syringe (Ipas, Chapel Hill, NC). The sharp curette was not utilized in any of the cases. The implications of these cases and a brief review of intrauterine adhesions after surgical management of pregnancy loss are discussed in the concluding section. CASE REPORTS Case 1 A 38-year-old gravida 5 para 1 presented at 10 weeks from her last menstrual period with an ultrasound documenting an EPF corresponding to 6 weeks’ gestation. Before this pregnancy, she reported regular menses, lasting from 4 –5 days. Her previous obstetrical history was significant for an EPF requiring suction D&C, an uncomplicated term vaginal delivery, a midtrimester induction for severe fetal anomalies, and an electric suction D&C for a partial molar pregnancy. Subsequent to these pregnancies and immediately before the index pregnancy, she underwent a hysterosalpingogram during an infertility workup, which was negative for intrauterine adhesions. The patient underwent an office-based MVA that was completed without complication. Subsequently, she presented with a decreased menstrual flow and an inability to conceive 5 months after her procedure. A sonohysterogram revealed a large intracavitary defect that was consistent with intrauterine adhesions. The patient was taken to the operating room for a hysteroscopy and resection of fibrotic bands. Hysteroscopy confirmed the presence of American Fertility Society (AFS) stage 1 intrauterine adhesions (3). These bands were resected sharply without complication. Two
Fertility and Sterility姞 Vol. 85, No. 6, June 2006 1823.e1 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.
months postoperatively, she conceived and delivered at term after an uncomplicated pregnancy. Case 2 A 36-year-old gravida 1 para 0 presented with an EPF corresponding to a gestational age of 6 weeks. Her obstetrical history before this pregnancy was notable for primary infertility, without history of uterine infection or intracavitary instrumentation. She spontaneously conceived during her infertility workup. Four days after diagnosis of pregnancy failure, she underwent an uncomplicated office MVA. She subsequently presented with secondary amenorrhea at 3 months’ postop. An office hysteroscopy noted dense adhesions obstructing the internal os, and a hematometra was noted upon dilation of the cervix. Additional adhesions were noted in the lower uterine segment (AFS stage 2), which were lysed by the office flexible hysteroscope. Subsequently, menses resumed, and the patient spontaneously conceived 5 months later. She delivered at term after an uncomplicated pregnancy. Case 3 A 35-year-old gravida 1 para 0 who had no prior medical or gynecological problems presented with an EPF measuring approximately 10 weeks’ gestation. At the time of this pregnancy, she had been actively attempting to conceive for approximately 6 months. Before that time, she had regular menses on oral contraceptives for many years. She had no history of uterine infection or surgery. After reviewing treatment options, she had an uncomplicated office MVA 3 days after diagnosis. Three months later, she presented with secondary amenorrhea. At that time, she failed to have withdrawal bleeding with medroxyprogesterone and was noted to have a 2-mm endometrial stripe on transvaginal ultrasound. Office hysteroscopy was attempted but not completed because of dense adhesions at the internal os that prevented cervical dilation. She was taken to the operating room where the cervical adhesions were lysed. Hysteroscopy revealed AFS stage 2 fundal and cornual adhesions, causing significant distortion of the uterine cavity. The adhesions were taken down sharply until the cavity was normalized. Postoperatively, an intrauterine foley catheter (Bard, Covington, GA) was placed for 5 days. Additionally, she was started on 2.5 mg of conjugated estrogens on postoperative days 1–30 and 10 mg of medroxyprogesterone acetate on days 10 –30. Three weeks postoperatively, the follow-up office hysteroscopy revealed a largely normalized cavity. Eight months later, she conceived; however, this pregnancy also ended in a first trimester loss. DISCUSSION Intrauterine adhesions are a known but infrequently addressed complication of D&C (2). The formation of IUAs is 1823.e2 Dalton et al.
thought to occur during processes that destroy the endometrial stratum basalis, with the gravid uterus being particularly vulnerable. Surgical procedures, infection, and retained products of conception are implicated as etiologies (2). Previous studies estimate that adhesion formation occurs in 7%–30% of patients undergoing hysteroscopic examination after D&C for EPF (2, 4 –7). Although hysteroscopy was not performed before their treatment for pregnancy failure, several studies have found both increased incidence of IUAs as well as more significant diseases in patients with a history of multiple D&Cs, as compared with those undergoing a single procedure (5, 8). A case series cannot attribute the IUAs noted among these patients to their previous MVAs with certainty. Although Case 1 had a hysterosalpingogram (HSG) documenting a normal uterus immediately before her MVA, she had numerous other risk factors and procedures. It is possible that these factors placed her at particular risk for the development of IUAs or that her first HSG failed to visualize preexisting adhesions. Even given these limitations, however, the cases described suggest that IUAs may occur after an MVA even in the absence of sharp curettage, and this risk should be considered when assessing treatment options and consenting patients in the face of a pregnancy loss. No studies have been undertaken to examine the risk of IUA after MVA as compared with electric vacuum aspiration (EVA). After 262 office MVAs for first trimester pregnancy losses, we have identified 5 cases of IUAs corresponding to a rate consistent with published rates for EVA (7%–30%) (2, 4 –7) In this article, we present the three cases without obvious alternate etiologies for their IUAs. The other two cases had multiple uterine procedures or infections without documentation of a normal cavity before the index pregnancy. Based on our experience to date, we have not noted a higher rate of IUAs among those patients undergoing MVA as compared with traditional electric suction D&C and continue to offer either technique to patients with EPF. Although we have not established causation, the possibility of IUAs after MVA does warrant attention. Many patients present to us with a perception that office-based MVA is “less invasive” than traditional electric suction and, presumably, would result in fewer complications such as uterine scarring. There is insufficient information to suggest that either procedure offers an advantage when it comes to the prevention of IUAs. Advantages of office MVA make it a favorable option for some women who desire surgical completion of EPF, such as avoidance of general anesthesia, less noise, improved privacy, the presence of their partners, and less time spent overall on the part of the patient and her family. Intrauterine adhesions are a possible complication of office MVA, even in the absence of sharp curettage, and should be considered when discussing treatment options
Adhesions after manual vacuum aspiration
Vol. 85, No. 6, June 2006
for EPF with patients. Further studies are needed to determine the incidence of IUAs associated with MVA. REFERENCES 1. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure— current management concepts. Obstet Gynecol Surv 2001;56: 105–13. 2. Al-Inany H. Intrauterine adhesions. An update. Acta Obstet Gynecol Scand 2001;80:986 –93. 3. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944 –55.
Fertility and Sterility姞
4. Tam WH, Lau WC, Cheung LP, Pong MY, Chung TK. Intrauterine adhesions after conservative and surgical management of spontaneous abortion. J Am Assoc Gynecol Laparosc 2002;9:182–5. 5. Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of post-abortion intrauterine adhesions evaluated by hysteroscopy—a prospective study. Hum Reprod 1993;8:442– 4. 6. March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995;22:491–505. 7. Adoni A, Palti Z, Milwidsky A, Dolberg M. The incidence of intrauterine adhesions following spontaneous abortion. Int J Fertil 1982;27: 117– 8. 8. Romer T. Post-abortion-hysteroscopy—a method for early diagnosis of congenital and acquired intrauterine causes of abortions. Eur J Obstet Gynecol Reprod Biol 1994;57:171–3.
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