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Successful Intrauterine Pregnancy after Endometrial Ablation
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
Successful Intrauterine Pregnancy after Endometrial Ablation Cheryl P. Pugh, M.D., Joan M. Crane, M.D., FRCSC, and T. Guy Hogan, LRCPSI, FRCSC
Abstract The frequency of pregnancy after endometrial ablation is reported in the literature to be 0.7%, with a variety of complications and adverse outcomes for the fetus. A 30-year-old woman underwent rollerball endometrial ablation for menometrorrhagia. Her menses returned to normal and she conceived 16 months later. The pregnancy was uncomplicated apart from diet-controlled gestational diabetes and cesarean delivery for a transverse lie. To our knowledge, this is the first literature report of a viable pregnancy after rollerball ablation. (J Am Assoc Gynecol Laparosc 7:(3):391–394, 2000)
decided on. Tubal sterilization was advised, but the patient refused. After a course of suppressive therapy of danazol 200 mg orally twice/day for 5 weeks, the patient underwent uncomplicated endometrial ablation. The endometrium was poorly suppressed, and some polypoid lesions seen just below the right uterine cornu were resected with the cutting loop. The uterine cavity was otherwise normal. Ablation was performed with a resectoscope with rollerball electrode and 50 W of coagulating current. Glycine was the distending medium. It was thought that ablation was satisfactory. Menstrual cycles returned with a light flow acceptable to the patient. One year after ablation, at age 30 years, she reported complete amenorrhea. A pregnancy test performed 4 months later was positive and ultrasound confirmed pregnancy at 16.5 weeks’ gestation. A perinatalogist was consulted for antenatal care, given reported increased risks associated with pregnancy after ablation, including premature rupture of membranes, premature labor, growth restriction, abnormal placentation, and fetal death.1–3 Increased
A number of techniques are employed to achieve endometrial ablation for dysfunctional uterine bleeding. As pregnancy is possible after ablation, adequate contraception such as tubal sterilization is recommended. A woman who declined tubal sterilization after endometrial ablation with a rollerball electrode carried pregnancy to term. Case Report A nulliparous woman was seen for secondary amenorrhea and diagnosed with polycystic ovary disease that initially responded well to hormone therapy. Three years later the patient continued to have irregular menses and menorrhagia despite taking oral contraceptives. She was uncertain whether she desired to undergo hysterectomy or attempt pregnancy. A trial of clomiphene citrate was prescribed, however, she was noncompliant. Management options were discussed, and the patient declined medical management and requested surgical correction. Endometrial biopsy revealed an endometrial polyp with no evidence of hyperplasia. A course of endometrial ablation was
From the Department of Obstetrics and Gynecology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada (all authors). Address reprint requests to Cheryl P. Pugh, M.D., Department of Obstetrics and Gynecology, Grace General Hospital, St. John’s, Newfoundland, Canada A1E 1P9; fax 709 7531862. Presented as a poster at the 55th annual clinical meeting of the Society of Obstetricians and Gynecologists of Canada, Ottawa, Ontario, Canada, June 25–29, 1999, and as a video at the American Association of Gynecologic Laparoscopists International Symposium on Diagnostic and Operative Hysteroscopy, Miami Beach, Florida, February 25–27, 1999. Accepted for publication February 23, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
391
Successful Intrauterine Pregnancy after Endometrial Ablation Pugh et al
risks of spontaneous abortion, uterine dehiscence, and complications similar to those in Asherman syndrome also were suggested.3–5 Maternal serum screening was performed. Pregnancy was complicated by gestational diabetes, which was controlled with diet. Biophysical profiles and ultrasound assessments for fetal well-being and growth were performed every 2 weeks beginning at 26 weeks, then weekly after 34 weeks’ gestation. These revealed adequate fetal growth with normal fetal biophysical scores, including normal amniotic fluid volume. The placenta was anterior and fundal, with no evidence of accreta on ultrasound. At 38 weeks 5 days’ gestation the patient experienced brownish vaginal discharge and 2 days later had spontaneous rupture of membranes. Classic cesarean delivery was performed for transverse lie with the back down. Six units of packed red blood cells were made available at the time of delivery in view of reports of placenta accreta and postpartum hemorrhage, and the possibility of hysterectomy was entertained. General anesthesia was given as the patient refused to consider regional anesthesia. She also again refused tubal sterilization. There was no evidence of placenta accreta or placental abnormality at time of cesarean delivery, and the uterine cavity and endometrium appeared normal. A healthy, 3095-g female infant was delivered uneventfully. She was normally developed and of appropriate size for gestational age. The mother’s postoperative course was uneventful. Hemoglobin concentrations preoperatively and postoperatively were 128 and 101 mg/dl, respectively. The patient and baby were discharged on the fifth postoperative day with advice that some means of contraception would be necessary. Review of the placenta for pathology was unremarkable.
a likely result of scarring of the uterus not allowing it to expand properly, and lack of functioning endometrium resulting in placental insufficiency and abnormal placentation. More than 370 ablations have been performed at our center. This case was the sole instance of pregnancy, for a rate of 0.24%. Before our patient, 35 pregnancies were reported after ablation. Case reports were identified by a MEDLINE search 1966 to September 1998, reviewing published English-language reports involving human subjects, using key words “endometrial ablation” or “endometrial resection” and “pregnancy.” References from the publications were manually searched and cross-referenced to identify additional case reports. Cases that were reported more than once were counted only once. Cases of only partial resection were not included. Combining the six series that determined pregnancy rates (Table 1),3–5,7,8,10 the pregnancy rate after endometrial resection is 0.68%; our rate was 0.24%.6 The total number of postablation pregnancies is 36, including our patient, with seven other viable pregnancies.2,4,10 According to a survey,10 among five viable pregnancies, four infants had growth restriction, with three of these pregnancies being delivered preterm and having placenta accreta or increta. Our current practice is to recommend laparoscopic tubal sterilization at the time of ablation to minimize the risk of future pregnancy and associated problems. Other possible benefits include less fluid loss during the procedure, decreased risk of endometriosis, detection of accidental uterine perforation during the procedure,2 and decreased frequency of pelvic inflammatory disease.9 This case highlights the need to make sure that patients fully understand the issue of possible continuing fertility after ablation if they refuse sterilization. Our patient was provided with printed material that outlined the procedure and risks involved; she also viewed an informed consent videotape on endometrial ablation, and participated in a lengthy discussion to review concerns and reiterate the possibility of pregnancy. All of these interventions are properly documented in the woman’s chart. She was made aware that sterilization is recommended and that precautions against pregnancy would be required if she refused it. The issue of informed consent is no different in this instance than in any other operative procedure;
Discussion Although infrequent, the possibility of pregnancy after endometrial ablation obviously exists and poses potential hazard to the patient. Possible complications include ectopic pregnancy, spontaneous abortion, premature rupture of membranes, preterm labor, growth restriction, abnormal placentation, and fetal death.1–10 Ablation also increases the risk of uterine dehiscence and postpartum hemorrhage. These complications are
392
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Pregnancy after Endometrial Ablation Method Rollerball6 Rollerball3 Rollerball7 Resection1 Resection2 Resection4,a Resection Resection5 Resection8 Resection9 Resection (6), laser (20)10
Outcome
Rate
%
Missed abortion Incomplete abortion PROM at 22 wks, chorioamnionitis, fetal death Cesarean hysterectomy for fetal death at 31 wks PROM at 30 wks Ruptured isthmic ectopic Termination Term cesarean section Termination Termination 5 liveborn: 1 term, appropriately grown 4 with complications: growth restriction (4) preterm birth (3) placenta accreta, increta (3) cesarean hysterectomy (1)
1/? 1/375 1/800
0.266 0.125
1/? 1/? 2/350 1/350 1/234 1/? 25/2585
0.571 0.286 0.427 0.967
PROM = premature rupture of membranes. aOne patient was included in references 4 and 10 and was not counted twice.
however, it is recognized that some physicians may choose not to perform ablation in patients who refuse to undergo concurrent tubal sterilization. Our patient is the fourth reported to become pregnant after endometrial ablation with rollerball electrocoagulation. To our knowledge, this is the first viable term pregnancy after the procedure (Table 2). It is only the third report of term pregnancy not complicated by fetal problems such as growth restriction. Despite the successful pregnancy, one must recognize the potential complications of pregnancy after endometrial ablation or complete resection. The need to recommend termination of pregnancy in women who conceive after ablation remains controversial. For women who continue pregnancy, both they and health care providers should be aware and monitor for antenatal complications, and at delivery be prepared for the possibility of placenta accreta, postpartum hemorrhage requiring transfusion, and need for cesarean hysterectomy.
TABLE 2. Viable Pregnancies after Ablation Method Resection2 Resection5 Laser10
Outcome PROM at 30 wks, healthy neonate Cesarean section, elective repeat at 39 wks Cesarean section at 39 wks, complicated by PIH, breech presentation, IUGR Cesarean section at term; compound breech presentation Cesarean section at 31 wks, severe IUGR, placenta increta Cesarean section at 34 wks; severe fetal bradycardia, placenta accreta; hysterectomy Cesarean section at 29 wks, premature labor; IUGR, severe oligohydramnios
PROM = premature rupture of membranes; PIH = pregnancy-induced hypertension; IUGR = intrauterine growth retardation.
393
Successful Intrauterine Pregnancy after Endometrial Ablation Pugh et al
References
6. Goldberg JM: Intrauterine pregnancy following endometrial ablation. Obstet Gynecol 83:836–837, 1994
1. Hopkisson JF: Caesarean hysterectomy for intrauterine death after failed endometrial resection. Br J Obstet Gynaecol 101:810–811, 1994
7. Vilos GA: Intrauterine pregnancy following rollerball endometrial ablation. J Soc Obstet Gynaecol Can 17:479–480, 1995
2. Maouris P: Letter to the editor. Aust NZ J Obstet Gynaecol 34(1):122, 1994 3. McLucas B: Pregnancy after endometrial ablation. J Reprod Med 40:237–239, 1995
8. Magos AL, Baumann R, Lockwood GM, et al: Experience with the first 250 endometrial resections for menorrhagia. Lancet 337:1074–1078, 1991
4. Lam AM, Al-Jumaily RY, Holt EM: Ruptured ectopic pregnancy in an amenorrheic woman after transcervical resection of the endometrium. Aust NZ J Obstet Gynaecol 32(1):81–82, 1992
9. Mongelli JM, Evans AJ: Pregnancy after transcervical endometrial resection. Lancet 338:578–579, 1991 10. Whitelaw NL, Garry R, Sutton CG: Pregnancy following endometrial ablation: 2 case reports. Gynaecol Endosc 1:129–132, 1992
5. Hill DJ, Maher PJ: Pregnancy following endometrial ablation. Gynaecol Endosc 1:47–49, 1992
394
The Journal of the American Association of Gynecologic Laparoscopists
Successful Intrauterine Pregnancy after Endometrial Ablation Cheryl P. Pugh, M.D., Joan M. Crane, M.D., FRCSC, and T. Guy Hogan, LRCPSI, FRCSC
Abstract The frequency of pregnancy after endometrial ablation is reported in the literature to be 0.7%, with a variety of complications and adverse outcomes for the fetus. A 30-year-old woman underwent rollerball endometrial ablation for menometrorrhagia. Her menses returned to normal and she conceived 16 months later. The pregnancy was uncomplicated apart from diet-controlled gestational diabetes and cesarean delivery for a transverse lie. To our knowledge, this is the first literature report of a viable pregnancy after rollerball ablation. (J Am Assoc Gynecol Laparosc 7:(3):391–394, 2000)
decided on. Tubal sterilization was advised, but the patient refused. After a course of suppressive therapy of danazol 200 mg orally twice/day for 5 weeks, the patient underwent uncomplicated endometrial ablation. The endometrium was poorly suppressed, and some polypoid lesions seen just below the right uterine cornu were resected with the cutting loop. The uterine cavity was otherwise normal. Ablation was performed with a resectoscope with rollerball electrode and 50 W of coagulating current. Glycine was the distending medium. It was thought that ablation was satisfactory. Menstrual cycles returned with a light flow acceptable to the patient. One year after ablation, at age 30 years, she reported complete amenorrhea. A pregnancy test performed 4 months later was positive and ultrasound confirmed pregnancy at 16.5 weeks’ gestation. A perinatalogist was consulted for antenatal care, given reported increased risks associated with pregnancy after ablation, including premature rupture of membranes, premature labor, growth restriction, abnormal placentation, and fetal death.1–3 Increased
A number of techniques are employed to achieve endometrial ablation for dysfunctional uterine bleeding. As pregnancy is possible after ablation, adequate contraception such as tubal sterilization is recommended. A woman who declined tubal sterilization after endometrial ablation with a rollerball electrode carried pregnancy to term. Case Report A nulliparous woman was seen for secondary amenorrhea and diagnosed with polycystic ovary disease that initially responded well to hormone therapy. Three years later the patient continued to have irregular menses and menorrhagia despite taking oral contraceptives. She was uncertain whether she desired to undergo hysterectomy or attempt pregnancy. A trial of clomiphene citrate was prescribed, however, she was noncompliant. Management options were discussed, and the patient declined medical management and requested surgical correction. Endometrial biopsy revealed an endometrial polyp with no evidence of hyperplasia. A course of endometrial ablation was
From the Department of Obstetrics and Gynecology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada (all authors). Address reprint requests to Cheryl P. Pugh, M.D., Department of Obstetrics and Gynecology, Grace General Hospital, St. John’s, Newfoundland, Canada A1E 1P9; fax 709 7531862. Presented as a poster at the 55th annual clinical meeting of the Society of Obstetricians and Gynecologists of Canada, Ottawa, Ontario, Canada, June 25–29, 1999, and as a video at the American Association of Gynecologic Laparoscopists International Symposium on Diagnostic and Operative Hysteroscopy, Miami Beach, Florida, February 25–27, 1999. Accepted for publication February 23, 2000. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2000, Vol. 7 No. 3 © 2000 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
391
Successful Intrauterine Pregnancy after Endometrial Ablation Pugh et al
risks of spontaneous abortion, uterine dehiscence, and complications similar to those in Asherman syndrome also were suggested.3–5 Maternal serum screening was performed. Pregnancy was complicated by gestational diabetes, which was controlled with diet. Biophysical profiles and ultrasound assessments for fetal well-being and growth were performed every 2 weeks beginning at 26 weeks, then weekly after 34 weeks’ gestation. These revealed adequate fetal growth with normal fetal biophysical scores, including normal amniotic fluid volume. The placenta was anterior and fundal, with no evidence of accreta on ultrasound. At 38 weeks 5 days’ gestation the patient experienced brownish vaginal discharge and 2 days later had spontaneous rupture of membranes. Classic cesarean delivery was performed for transverse lie with the back down. Six units of packed red blood cells were made available at the time of delivery in view of reports of placenta accreta and postpartum hemorrhage, and the possibility of hysterectomy was entertained. General anesthesia was given as the patient refused to consider regional anesthesia. She also again refused tubal sterilization. There was no evidence of placenta accreta or placental abnormality at time of cesarean delivery, and the uterine cavity and endometrium appeared normal. A healthy, 3095-g female infant was delivered uneventfully. She was normally developed and of appropriate size for gestational age. The mother’s postoperative course was uneventful. Hemoglobin concentrations preoperatively and postoperatively were 128 and 101 mg/dl, respectively. The patient and baby were discharged on the fifth postoperative day with advice that some means of contraception would be necessary. Review of the placenta for pathology was unremarkable.
a likely result of scarring of the uterus not allowing it to expand properly, and lack of functioning endometrium resulting in placental insufficiency and abnormal placentation. More than 370 ablations have been performed at our center. This case was the sole instance of pregnancy, for a rate of 0.24%. Before our patient, 35 pregnancies were reported after ablation. Case reports were identified by a MEDLINE search 1966 to September 1998, reviewing published English-language reports involving human subjects, using key words “endometrial ablation” or “endometrial resection” and “pregnancy.” References from the publications were manually searched and cross-referenced to identify additional case reports. Cases that were reported more than once were counted only once. Cases of only partial resection were not included. Combining the six series that determined pregnancy rates (Table 1),3–5,7,8,10 the pregnancy rate after endometrial resection is 0.68%; our rate was 0.24%.6 The total number of postablation pregnancies is 36, including our patient, with seven other viable pregnancies.2,4,10 According to a survey,10 among five viable pregnancies, four infants had growth restriction, with three of these pregnancies being delivered preterm and having placenta accreta or increta. Our current practice is to recommend laparoscopic tubal sterilization at the time of ablation to minimize the risk of future pregnancy and associated problems. Other possible benefits include less fluid loss during the procedure, decreased risk of endometriosis, detection of accidental uterine perforation during the procedure,2 and decreased frequency of pelvic inflammatory disease.9 This case highlights the need to make sure that patients fully understand the issue of possible continuing fertility after ablation if they refuse sterilization. Our patient was provided with printed material that outlined the procedure and risks involved; she also viewed an informed consent videotape on endometrial ablation, and participated in a lengthy discussion to review concerns and reiterate the possibility of pregnancy. All of these interventions are properly documented in the woman’s chart. She was made aware that sterilization is recommended and that precautions against pregnancy would be required if she refused it. The issue of informed consent is no different in this instance than in any other operative procedure;
Discussion Although infrequent, the possibility of pregnancy after endometrial ablation obviously exists and poses potential hazard to the patient. Possible complications include ectopic pregnancy, spontaneous abortion, premature rupture of membranes, preterm labor, growth restriction, abnormal placentation, and fetal death.1–10 Ablation also increases the risk of uterine dehiscence and postpartum hemorrhage. These complications are
392
August 2000, Vol. 7, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Pregnancy after Endometrial Ablation Method Rollerball6 Rollerball3 Rollerball7 Resection1 Resection2 Resection4,a Resection Resection5 Resection8 Resection9 Resection (6), laser (20)10
Outcome
Rate
%
Missed abortion Incomplete abortion PROM at 22 wks, chorioamnionitis, fetal death Cesarean hysterectomy for fetal death at 31 wks PROM at 30 wks Ruptured isthmic ectopic Termination Term cesarean section Termination Termination 5 liveborn: 1 term, appropriately grown 4 with complications: growth restriction (4) preterm birth (3) placenta accreta, increta (3) cesarean hysterectomy (1)
1/? 1/375 1/800
0.266 0.125
1/? 1/? 2/350 1/350 1/234 1/? 25/2585
0.571 0.286 0.427 0.967
PROM = premature rupture of membranes. aOne patient was included in references 4 and 10 and was not counted twice.
however, it is recognized that some physicians may choose not to perform ablation in patients who refuse to undergo concurrent tubal sterilization. Our patient is the fourth reported to become pregnant after endometrial ablation with rollerball electrocoagulation. To our knowledge, this is the first viable term pregnancy after the procedure (Table 2). It is only the third report of term pregnancy not complicated by fetal problems such as growth restriction. Despite the successful pregnancy, one must recognize the potential complications of pregnancy after endometrial ablation or complete resection. The need to recommend termination of pregnancy in women who conceive after ablation remains controversial. For women who continue pregnancy, both they and health care providers should be aware and monitor for antenatal complications, and at delivery be prepared for the possibility of placenta accreta, postpartum hemorrhage requiring transfusion, and need for cesarean hysterectomy.
TABLE 2. Viable Pregnancies after Ablation Method Resection2 Resection5 Laser10
Outcome PROM at 30 wks, healthy neonate Cesarean section, elective repeat at 39 wks Cesarean section at 39 wks, complicated by PIH, breech presentation, IUGR Cesarean section at term; compound breech presentation Cesarean section at 31 wks, severe IUGR, placenta increta Cesarean section at 34 wks; severe fetal bradycardia, placenta accreta; hysterectomy Cesarean section at 29 wks, premature labor; IUGR, severe oligohydramnios
PROM = premature rupture of membranes; PIH = pregnancy-induced hypertension; IUGR = intrauterine growth retardation.
393
Successful Intrauterine Pregnancy after Endometrial Ablation Pugh et al
References
6. Goldberg JM: Intrauterine pregnancy following endometrial ablation. Obstet Gynecol 83:836–837, 1994
1. Hopkisson JF: Caesarean hysterectomy for intrauterine death after failed endometrial resection. Br J Obstet Gynaecol 101:810–811, 1994
7. Vilos GA: Intrauterine pregnancy following rollerball endometrial ablation. J Soc Obstet Gynaecol Can 17:479–480, 1995
2. Maouris P: Letter to the editor. Aust NZ J Obstet Gynaecol 34(1):122, 1994 3. McLucas B: Pregnancy after endometrial ablation. J Reprod Med 40:237–239, 1995
8. Magos AL, Baumann R, Lockwood GM, et al: Experience with the first 250 endometrial resections for menorrhagia. Lancet 337:1074–1078, 1991
4. Lam AM, Al-Jumaily RY, Holt EM: Ruptured ectopic pregnancy in an amenorrheic woman after transcervical resection of the endometrium. Aust NZ J Obstet Gynaecol 32(1):81–82, 1992
9. Mongelli JM, Evans AJ: Pregnancy after transcervical endometrial resection. Lancet 338:578–579, 1991 10. Whitelaw NL, Garry R, Sutton CG: Pregnancy following endometrial ablation: 2 case reports. Gynaecol Endosc 1:129–132, 1992
5. Hill DJ, Maher PJ: Pregnancy following endometrial ablation. Gynaecol Endosc 1:47–49, 1992
394