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Ashermans Syndrome
be informed about D&C risks and alternatives


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#1 aphraell

Posted 04 October 2012 - 10:18 PM

Mods - if this is not the right section, please move


My main reasons for this post are that I wished this information had been available to me before I elected to have a D&C or when I was looking for answers afterwards. I hope that by this post I can provide other women with the information to make an informed decision or to help someone find answers. In no way am I saying that women should never have a D&C – not only are there medical circumstances where it the best/only option but the emotional and psychological factors also contribute and every situation will be different.

It took me almost 5 months to get a diagnosis of severe AS (including cervical scarring, large sections of scarring in my uterus and blockage of one tube) after a MMC and D&C at 8 weeks.  I had to refuse to leave my GPs office (after the 4th visit) until I was given a referral to an AS specialist.

I was extremely fortunate that I had access to Prof V (one of the worlds leading specialist in Ashermans diagnosis and treatment) and that I only required one surgery before being given the all clear to TTC. We were even more blessed to get our BFP that month and our wonderful DD joined us almost exactly a year after my AS diagnosis.

One of the things I found hardest to deal with during the process was my anger at not being fully informed about the risks and options to having a D&C. Although I may have still made the same decision it would have been an informed decision. I also struggled with the medical worlds denial of AS - The lack of awareness and willingness of many doctors to even consider the possibility of Ashermans Syndrome is one of the major issues in diagnosis and treatment and one that I encountered. This is even though some research suggest up to 40% of women who have had a D&C due to retained products of conception may have some for of AS and it  is thought to be one of the causes of unexplained infertility,


I am more than happy to answer any questions (via post or PM) of my experience.


The following information comes from http://www.ashermans.org/

What is Asherman's Syndrome?
Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus stick to one another. In other cases, adhesions only occur in a small portion of the uterus. The extent of the adhesions defines whether the case is mild, moderate, or severe. The adhesions can be thin or thick, spotty in location, or confluent. They are usually not vascular, which is an important attribute that helps in treatment.

Symptoms
Most patients with Asherman's Syndrome have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time that their period would normally arrive each month. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be symptoms (1).

Causes
Asherman's syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together. Most commonly, intrauterine adhesions occur after a dilation and curettage (D&C) that was performed because of a missed or incomplete miscarriage, retained placenta with or without hemorrhage after a delivery, or elective abortion. Pregnancy-related D&Cs have been shown to account for 90% of Asherman's Syndrome cases(2). Sometimes adhesions also occur following other pelvic surgeries such as Cesarean section, surgery to remove fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis(3) and schistosomiasis(4).

There is a 25% risk of developing Asherman's Syndrome from a D&C that is performed 2 to 4 weeks after delivery(5-8).  Dilation and Curettages may also lead to Asherman's Syndrome in 30.9% of procedures for missed miscarriages(17) and 6.4% of procedures for incomplete miscarriages(2). The risk of Asherman's Syndrome increases with the number of D&Cs performed; after a single termination the risk is 16%, however, after 3 or more D&Cs, the risk increases to 32%(9).

Each case of Asherman's Syndrome is different, and the cause must be determined on a case-by-case basis. In some cases, Asherman's Syndrome may have been caused by an "overly aggressive" D&C. However, this is not often considered to be the case. The placenta may have attached very deeply in the endometrium or fibrotic activity of retained products of conception could have occurred, both of which make it difficult to remove retained tissue. For the most comprehensive information about D&Cs and Asherman's Syndrome, please click here to visit DandCnow.info.

There is a variant of Asherman's Syndrome called "Unstuck Asherman's or endometrial sclerosis that is more difficult to treat. In this condition, which may coexist with the presence of adhesions, the uterine walls are not stuck together. Instead, the endometrium has been denuded. Although curettage can cause this condition, it is more likely after uterine surgery, such as myomectomy. In these cases the endometrium, or at least its basal layer, has been removed or destroyed.

Incidence
Asherman's Syndrome is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as an ultrasound scan. The condition is estimated to affect 1.5% of women undergoing a hysterosalpingogram (HSG) (10), between 5 and 39% of women with recurrent miscarriage (11-13), and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion (14) (see Causes above).

Diagnosis
Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

Prevention
Ideally, prevention is the best solution. It was suggested as early as in 1993 (9) that the incidence of intrauterine adhesions (IUA) might be lower following medical evacuation (eg., misprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did(15). The advantage of misoprostol is that is can be used for evacuation not only following miscarriage, but also for retained placenta or hemorrhaging following birth. Alternatively, D&C could be performed under ultrasound guidance rather than blindly. This would ensure that the surgeon stops scraping the lining when all retained tissue has been removed, thereby avoiding injury. Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurrence of Asherman's Syndrome as adhesions are more likely to occur after a D&C the longer the period after fetal death (2). Therefore, immediate evacuation following fetal death may prevent IUA. There is no evidence to suggest that suction D&C is less likely to result in adhesions than sharp D&C. Cases of Asherman's Syndrome have been reported even following manual vacuum aspiration, (16) and the rate of Asherman's Syndrome has not dropped since the introduction of suction D&C.

Treatment
Asherman's Syndrome must be treated by a very experienced surgeon via hysteroscopy (sometimes assisted by laparoscopy) Those few surgeons experienced enough in treating severe Asherman's Syndrome recommend the avoidance of energy sources inside the uterus (this means removing scars with scissors rather than with energy-generating instruments such as resectoscopes or lasers, although not all surgeons agree with this). Adhesions have a tendency to reform, especially in more severe cases. There are different methods to prevent re-scarring after surgery for Asherman´s Syndrome. Many surgeons prescribe estrogen supplementation to stimulate uterine healing and place a splint or balloon to prevent apposition of the walls during the immediate post-operative healing phase. Other surgeons recommend weekly in-office hysteroscopy after the main surgery to cut away any newly formed adhesions. As of yet, studies have not confirmed the method of treatment that is most likely to have a successful outcome, which would be one where the uterus/cervix remains scar-free and fertility is restored.

Non Reproductive Consequences of Asherman’s Syndrome
The reproductive consequences of Asherman’s Syndrome, including infertility, recurrent miscarriage, intrauterine growth restriction, placenta accreta and others, are well known.  However, for all women with intrauterine scarring and amenorrhea, including those who may have completed childbearing, there are other concerns.  Although the lack of menstrual periods could be secondary to hormonal abnormalities, it is more likely caused by either complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus; thus, menses are either retained in the uterus (leading to pelvic pain and a condition called hematometra) or flow into the abdominal cavity leading to endometriosis.  Women with Asherman’s Syndrome may develop uterine cancer, either before or after menopause.  This risk is NOT increased and may be lower than in the general population.  However, the usual warning sign of uterine cancer is excessive uterine bleeding:  those with obstructed menstrual flow cannot have that symptom even if they harbor a uterine growth.   Therefore, pelvic ultrasound should be a routine part of their annual gynecologic visit.

Edited by aphraell, 13 October 2012 - 03:38 PM.


#2 Hedgoth

Posted 06 October 2012 - 04:46 PM

Great post. Should definitely be made a sticky!

#3 caroldiem

Posted 07 October 2012 - 10:18 PM

Mods, Freckles can you please make this post a sticky. I am going to message Freckles about this aphraell brilliant post i am also passionate about raising awareness.

#4 caroldiem

Posted 07 October 2012 - 10:22 PM

I have just messaged freckles

#5 caad

Posted 09 October 2012 - 09:31 PM

Is this raising awareness or alarm?

#6 ubermum

Posted 09 October 2012 - 09:35 PM

QUOTE (cad2 @ 09/10/2012, 10:31 PM) <{POST_SNAPBACK}>
Is this raising awareness or alarm?

Either/ Or. Does it matter? So many people seem to think a d&c is a straitforward thing with risks only related to anaesthetic. I know someone who ended up with this after a d&c, it made me think long and hard before having one.

#7 EffiesMum172

Posted 09 October 2012 - 09:38 PM

.

Edited by EffiesMum172, 03 November 2012 - 09:18 PM.


#8 F.E.B.E

Posted 09 October 2012 - 10:06 PM

Sticking as per request. Thank you for sharing your story OP, I am so sorry. I have never come across this complication before while working on EB so I think it is important to raise awareness.

#9 aphraell

Posted 10 October 2012 - 01:17 PM

QUOTE (cad2 @ 09/10/2012, 10:31 PM) <{POST_SNAPBACK}>
Is this raising awareness or alarm?


It was definitely meant as raising awareness. I was very aware of trying NOT to raise alarm as I know that a women considering a D&C is often already in a highly emotional and potentially vulnerable state.

As I said in my post, sometimes a D&C is the best/only option and there are many factors to consider - physical, emotional and physchological well being that will impact the decision. This post was meant to provide information to better allow women to make an informed decision or worse case to help try and find answers if issues are experienced after a D&C.



#10 caad

Posted 13 October 2012 - 05:37 AM

Hi aphraell, obviously your intentions are good but I think some of the language in your OP is off the mark for a sticky.

You ask, 'why is a D&C so risky?' but the point is, for most women offered one it is not risky at all. It is a routine procedure with a risk of complications. That is not picky word games but a fundamental difference.

The 40% stat is not really useful to the lay reader as it plays into the perception that an 'everyday' D&C is extremely risky but I can tell you from experience with my partner when a woman is in these high risk groups for complications the doctors do not 'offer' a D&C. Quite the opposite they were clear that there was a high risk and they would give every other treatment the maximum possible chance to work. Only if it got to the stage where my partners life was in immediate danger would they do the D&C. So yes 40% of the high risk group might have complications, but *why* were they given a D&C? RPOC is no joke.


Anyway, I won't labour the point any futher. I imagine everyone on this board knows something about complications and I wish you well and am glad to hear yours are behind you.

#11 aphraell

Posted 13 October 2012 - 03:40 PM

Hi cad2

Sounds like out partner had a knowledgeable doctor - sadly not all of them are aware or acknowledge the risks.

I've modified the post slightly based on your feedback.

Mods - if there is anything else you think is "alarmist" about my post please modify




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