Heinrich Fritsch 1927 Stamen 1946 1948 Joseph GAshenman The focus of research in the initial Prevalence E tiology and Pathology The focus of research has now Diagnosis Treatment and Reproductive Outcomes ID: 1032035
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1. Asherman SyndromeHormoz Dabirashrafi M.D.
2. Heinrich Fritsch (1927) Stamen (1946)1948 (Joseph G.Ashenman)The focus of research in the initial:Prevalence, Etiology and PathologyThe focus of research has now:Diagnosis, Treatment and Reproductive Outcomes
3. DefinitionAsherman.Sy: curettage of the gravid uterusSyndrome: a group of symptoms…Asymptomatic intrauterine adhesionsIntrauterine fibrosis
4. PrevalenceIsrael, Greece, South America1- Degree of awareness2- The number of therapeutic or illegal – ab 3- Sharp, blunt or suction curettage…4- Incidence of G.Tub5- Criteria Used for diagnosis of…
5. EtiologyA- Truma:1- Truma to a gravid uterine cavity 66.7% post abortion /miscarriage curettage – 21.5% postpartum curettage 2% after CS - 0.6% after mole…Explanation: a) low estrogen statusb) The uterus could be in a vulnerable state 2- Truma to non-gravid uterus Diagnostic curettage (1.6%) – abdominal myomectomy (1.3%)Cervical biopsy or Polypectomy (0.5%) - UseOf radium (0.02%) - Insertion of IUD (0.2%)
6. B- Post Hysteroscopy6.7% resection of septa 31.3% resection of solitary fibroid and multiple fibromas.A case of adhesion after UAE.After endometrial ablation (with thermal balloon) 36.4%
7. C- Infection:Uterine truma and subsequent inflammation in conjunction with a low estrogen status may potentially lead to fibrosis. 1856 case – 74 case TB D- Congenital anomaly of the uterus 43 malformations 7 had Ashenman.Synd (16%)E- Genetic predisposition:Gentle suction curettageNo apparent reason
8. SymptomatologyAtretic amenorrhea. 43% infertility (lack of sufficient amount of normal end – defective vascularization). spontaneous miscarriage 40%, preterm-d 23%, placenta accrete 13%, ectopic p 12%, IUGR.No limb amputation
9. Endometrial Ablation70 pregnancies:1.4% EP - 21% Spontaneous miscarriage. 18.6% premature D 4%IUGR - adherent placenta 14.3%- A case of fetal malformations(limbs abnormality, Scoliosis….)Endometrial malignancyAsherman.Sy and end adenocarcinoma can exist simultaneously….
10. InvestigationsHSG: Prospective study: HSG was comparable with Hysteroscopy It remains an important screening procedureLimitations: not detect end fibrosis –limitation in defining the nature of identified intrauterine adhesions-minor filmy adhesions- air bubbles- differential diagnosis
11. Ultrasonography: Uterine cavity (not possible by HSG or hysteroscopy)Sensitivity and specificity is low Ultrasonography before hysteroscopy SonohysterographyAs accurate as HSG – The sensitivity of SHG 100% - HSG 100% - TVS=52%MRISupplementary role cannot visualize by hysteroscopy
12. TreatmentRestoring the size and shape –preventing recurrence-promoting the repair-restoring normal reproductive functions1)Expectant management (23-18 regular mense)292-133 conserved spontaneously 2) Blind D&C, high incidence of uterine perforation +low success3) Hysterotomy nowadays –very severe cases.3 cases-most extreme of situations
13. 4) Hysteroscopy Adhesiolysis:Method of choice (minimally invasive under vision)Scissors, Unipolar, Bipolar, LaserNo diff in outcome between Scissors, resectoscope and laser. Guide: laparoscopy (often too late…) fluoroscopy, Gynecoradiologic uterine resection, Transabdominal ultrasound.laminaria tent. Sonohysterography.Conversion to septum division-repeat surgery.Genital TBTotal uterine synechia – poor prognosis –surrogacy.
14. ComplicationPerforation, Hemorrhage, Pelvic infection
15. Prevention of recurrence (1.3% - 23.5%)1) IUD (the loop IUD the best choice)No randomized study?2) Foley balloon catheter Foley cath (for 10 days) safer, more effective than IUD (3 month)Prospective controlled study (balloon & no splint)Stem not coming out of the cervix3.5 c.c very important 3) Amnion graft 4) Hyaluronic acid (very effective)Seprafilm - auto – cross – linked HA (ACP)
16. 5)Hormone Treatment: No objective evidence, on the reduction of reformation of adhesion.
17. Prevention1) Curettage in the postpartum or post abortion period should be avoided – hysteroscopy 2) Perform gentle curettage (suction or blunt curette)3) Select medical management
18. Conclusion- The management of moderate to severe Disease still poses a challenge, and the prognosis of severe disease remains poor- repeat surgery may be necessary without desired out come- In pregnancy after treatment, careful surveillance…-future research: cellular and molecular aspects of endometrial tissue regeneration, prevention of postsurgical adhesion formation
19. END