Post-abortion-hysteroscopy — a method for early diagnosis of congenital and acquired intrauterine causes of abortions

European Journal and Reproductive

of Obstetrics

& Gynecology

Biology 57 (1994) 171-173

Post-abortion-hysteroscopy - a method for early diagnosis of congenital and acquired intrauterine causes of abortions Thomas Department of

R6mer

Obstetrics and Gynaecology,

WollweberstraJe

I, D-17489

Ernsf Morirz

Greifswald,

Arndt University,

Germany

Accepted 29 August 1994

Abstract Objective: A prospective study was conducted on the incidence of intrauterine pathology diagnosed by hysteroscopy. Study DeA hysteroscopy was performed in 53 women 6- 12 weeks after a dilatation and curettage for incomplete abortions or missed abortions. Results: Uterus malformations were found in 11 patients, submucous myoma in two and a corpus polyp in one. The main findings were intrauterine adhesions in 16cases. The incidence of intrauterine adhesions was about the same after incomplete abortions and after missed abortions, but in patients with recurrent abortions the incidence was significantly higher than in patients after first abortion (47.6% versus 18.8%). Conclusion: Post-abortion-hysteroscopy is a simple and useful method for early diagnosis of acquired and congenital intrauterine pathology after abortions.

sign:

Keywords:

Hysteroscopy; Abortion; Intrauterine adhesions; Septum

1. Introduction

Acquired and congenital intrauterine causes of abortions are often overseen and diagnosed too late. Uterus malformations, especially a uterus subseptus/septus, are well known and accepted as a cause of abortions, especially of recurrent abortions [1,2]. If such malformations are diagnosed early, hysteroscopic treatment is possible and prevents further abortions [2]. Most patients with intrauterine adhesions have a history of pregnancy-related curettage [3-61. Curettage after abortion (induced or spontaneous) is the most common etiologic factor for the development of intrauterine adhesions [3-61. In most cases intrauterine adhesions will only be looked for after symptoms such as hypomenorrhea or amenorrhea have occurred [3]. In many studies it was shown that hysteroscopy is the method to be favoured in the diagnosis of uterine cavity in infertility [6-81. 2. Materials and methods From January 1991 to December 1993 post-abortion 0028-2243/94/$07.00 SSDI

0

1994

0028-2243(94)01959-B

hysteroscopies were performed in 53 women who underwent dilatation and curettage for incomplete abortions or missed abortions and who had a desire of further pregnancy. The hysteroscopies were carried out between 6 and 12 weeks after abortions as an outpatient procedure. The patients were on average 27.5 f 5.4 years old. Thirty-two women had had their first abortion and 21 women a recurrent abortion. In most cases the hysteroscopies were performed without anaesthesia or with help of a paracervical block. A 5-mm rigid hysteroscope (Circon GmbH, Taufkirchen, Germany) and isotonic saline solution as distension medium were used. 3. Results A regular uterine cavity was found in 23 patients. Intrauterine changes could be diagnosed in 30 patients. There were 11 cases of uterus malformation (four uterus arcuatus and seven uterus subseptus/bicornis), two submucous myoma and one corpus polyp. The main findings were intrauterine adhesions, which were found in 16 patients and were classified according to the grade ex-

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172

T. Riimrr

Table

(IUA) Grade

sheath

Multiple

Extensive

scarring

of intrauterine

adhesions

( % )

20 10 0

i

n = 32

n = 21 grou P

of the uterine cavity wall or pronounced

171-173

30

firm adhesions

With amenorrhea

c1994)

40

Connecting separate parts of the uterine cavity Unilateral obliteration of ostial areas of the tubes llla

57

50 I/

alone

Occluding adhesions only in the region of the internal cervical 0s Upper uterine cavity normal

Ill

Bid.

extent of

Singular firm adhesions Connecting separate parts of the uterine cavity Visualization of both tubal ostia possible Can not be ruptured by hysteroscope sheath alone

Ila

Rqwotl.

incidence adhesions

Thin or filmy adhesions Easily ruptured by hysteroscope Cornual areas normal

II

Gynrcd.

I

ESH Classification of intrauterine intrauterine adhesions [9] I

/ Eur. J. Ohstct

hypomenorrhea Fig. 2. Incidence of intrauterine adhesions dependent on the number of previous abortions. Previous number of abortions: ?? , I abortion; ?, ?;1:2 abortions.

lllb

Combination

IV

Extensive lirm adhesions with agglutination walls At least both tubal ostial areas occluded

of III and III a of uterine

tent of the European Society of Hysteroscopy (Table 1) [9]. There were five cases each of intrauterine adhesions grades 1 and 2, and six cases of intrauterine adhesions grade 3. In 10 cases of grades 1 and 2 the adhesions were dissected by hysteroscope or microscissor. In patients

with grade 3 intrauterine adhesions, adhesiolysis by hysteroscopic surgery with a cutting needle was indicated. The incidence of intrauterine adhesions was about the same in 38 patients after incomplete abortions and 15 patients after missed abortions (Fig. 1). In 21 patients with recurrent abortions the incidence of intrauterine adhesions was 47.6%, significantly higher than in 32 patients after first abortion (Fig. 2). 4. Discussion

incidence

35

/,

of intrauterine

.’

adhesions

( % )

,,,,/ ,’ ‘/ ‘,I!,;,I:/, : l,‘ , ‘3

I

i,‘,,

/

OV n = 38

n = 15

group Fig. I. Incidence of intrauterine adhesions after spontaneous or mlssed abortions. Previous type of abortion: ?? , spontaneous abortion; 0, missed abortion.

In this prospective study we found a high incidence of acquired and congenital intrauterine changes. A general agreement exists regarding the fact that a post-abortal curettage is the principal etiologic factor for intrauterine adhesions formation [3-61. Lancet and Kessler [3] found that approximately twothirds of patients suffering from intrauterine adhesions had previous spontaneous abortions. In a WHOsupported study in Ljubljana an incidence of 22.7% of adhesions was diagnosed after induced abortions by hysterosalpingography [lo]. Adoni et al. [l l] performed a hysterosalpingogramm 6-8 weeks after an abortion in 120 patients. They found intrauterine adhesions in 15% of patients. In a previous study we investigated the value of hysteroscopy in comparison with sonography and hysterosalpingography, and we showed that intrauterine adhesions can be diagnosed by sonography in only 33% and by hysterosalpingography in only 66% of cases [S]. Fayez et al. [7] also confirmed the value of hysteroscopy in intrauterine adhesions. In two different studies in

T. Rdmer / Eur. J. Ohsrr/. Gvwcol. Rcyvd. Bid

Israel the incidence of intrauterine adhesions was investigated by hysteroscopy [ 12,131. Friedler et al. [ 121 found an incidence of 19% in 147 women and Golan et al. [ 131 found 16.7% of adhesions in 60 patients after missed abortion. It is known that the incidence of intrauterine adhesions in Israel is higher than in other areas of the world [4]. In our study we found in 16 patients (30.2%) with intrauterine adhesions. The higher incidence in our study is possibly due to a greater number of women with recurrent abortions and to the inclusion of thin and filmy adhesions, which could be dissected during introducion of the hysteroscope sheath. We did not find any difference in the incidence after missed abortion and incomplete abortion, although we expected a higher incidence after missed abortion, because in these cases a high degree of tissue necrosis and absorption along with inflammation occurs. With an increased number of pregnancy-related curettage, the incidence of intrauterine adhesions also increased [4]. In our prospective study intrauterine adhesions after recurrent abortion were found in 47.6% of patients in comparison with only 18.8% in patients after first abortion. Friedler et al. [12] found a significantly higher incidence of intrauterine adhesions after three or more abortions (32% versus 14% and 16.3% after two or one abortions). The high incidence of intrauterine adhesions diagnosed in this prospective study stresses the need for the preventive treatment and close follow-up of patients with curettage due to spontaneous abortion. Early diagnosis of intrauterine adhesions in most cases makes simultaneous treatment possible [3,5,6]. We could dissect all adhesions in grades 1 and 2 by hysteroscope sheath alone or by microscissors. In severe cases of intrauterine adhesions an operative hysteroscopy with electrosurgical adhesiolysis is necessary. This procedure is the most difficult hysteroscopic surgery [3,5,6]. Pregnancy after this treatment is often accompanied by obstetric complications [14,15]. With the help of post-abortionhysteroscopy, prevention of severe intrauterine adhesions is possible, if the intrauterine adhesion formation is an evolutive process; this remains to be shown in further investigations. The finding of uterus malformation in 11 cases is interesting but only the cases with a uterus septus are clinically important [ 1,2]. A uterus arcuatus is only a physiological variant and there is no correlation to the abortion rate. For the diagnosis of a uterus arcuatus especially, a sufficient distention of uterine cavity is necessary because otherwise a wrong diagnosis will be obtained in normal uterine cavity. Golan et al. [13] found a uterine septum after missed abortion in onequarter of their patients. In our study seven patients (13.2%) had a uterus septus or bicornis. For further differential diagnosis a laparoscopy is necessary since only

57 ( 1994) 171-173

173

a uterus septus must be treated. A high rate of spontaneous abortions is reported in pregnancies in septate uterus [1,2]. After hysteroscopic metroplasty the rate of term pregnancy is significantly higher [ 1,2]. An early diagnosis of these uterus malformations can contribute to the prevention of further abortions. 5. Conclusions Post-abortion-hysteroscopy is a simple and useful method for the early diagnosis of acquired and congenital intrauterine pathology after abortions in patients who desire a further pregnancy. References Ill

Buttram VC. Mullerian anomalies and their management. Fertil Steril 1983; 40: 159-16. 121March CM, Israel R, March AD. Hysteroscopic management of recurrent abortions caused by septate uterus. Am J Obstet Gynecol 1977; 156: 834-840 131 Lancet M, Kessler I. A review of Asherman’s syndrome, and results of modern treatment. Int J Fertil 1988; 33: 14-24. EJ. Intrauterine adhesions: an upI41 Schenker JG, Margalioth dated appraisal. Fertil Steril 1982; 37: 593-610. 151 Sugimoto 0. Diagnostic and therapeutic hysteroscopy for traumatic intrauterine adhesions. Am J Obstet Gynecol 1978; 131: 539-547. adhesions: Hysteroscopic 161 Valle RF, Sciarra JJ. Intrauterine diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158: 1459- 1470. value of 171 Fayez JA, Mutie G, Schneider PJ. The diagnostic hysterosalpingography and hysteroscopy in infertility investigation. Am J Obstet Gynecol 1987; 156: 558-560 181 Romer Th, Bojahr B, Lober R, Grabow D. The investigation of the uterine cavity in infertility-comparison of three diagnostic methods. J Assisted Reprod Genetics 1993; IO: Suppl (6) 201. K. ESH Classification of intrauterine adhesions 191 Wamsteker (IUA) - grade extent of intrauterine adhesions. In: European Society of Hysteroscopy - Membership Directory 1990-1991; 60. 1101 Martius G. Prophylaxe und Therapie des Asherman Syndroms (Posttraumatic intrauterine adhesions, Amenorrhea traumatiCal). In: Martius G, ed. Gynakologische Operationen: Ein Lehrbuch fur die facharztliche Aus- und Weiterbildung, 2. Stuttgart, New York: Thieme, 1989: 30-31. 1111Adoni A, Palti 2, Milwidsky A. The incidence of intrauterine adhesions following spontaneous abortion. Int J Fertil 1982; 27: 117-118. 1121 Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of postabortion intrauterine adhesions evaluated by hysteroscopy - a prospective study. Hum Reprod 1993; 8: 442-424. 1131 Golan A, Raziel A, Schneider D, Bukovsky I, Aurech 0, Caspi E. Hysteroscopic findings after missed abortion. Fertil Steril 1992; 58: 508-510. uterine rupture I141 Deaton JL, Maier D, Andreoli J. Spontaneous during pregnancy after treatment of Asherman’s syndrome. Am J Obstet Gynecol 1989; 160: 1053-1054. A, De Fazio J, De Cherney A. Severe obstetric 1151 Friedemann complications after aggressive treatment of Asherman’s syndrome. Obstet Gynecol 1986; 67: 864-865