Scarred Uterus and Asherman’s Syndrome
Synonyms/Description
Intrauterine adhesions or synechiae
Etiology
Most cases of intrauterine adhesions result from trauma to the endometrium, primarily from dilation and curettage (D&C) procedures. Patients most at risk for developing Asherman’s syndrome are those undergoing D&C postpartum for retained products of conception, incomplete spontaneous abortion (SAB), or therapeutic abortion (TAB). Intrauterine synechiae can occur after any procedure or process that causes trauma to the normal endometrium. Examples in addition to those discussed include abdominal or hysteroscopic myomectomy, hysteroscopic septoplasty, and previous placenta accreta, among others. Synechiae are connective tissue bands that disrupt the endometrium, causing a lack of distention of the uterine cavity. They are associated with recurrent pregnancy loss and infertility.
Schenker and Margalioth studied 1856 cases of Asherman’s syndrome and showed that pregnancy was the main predisposing factor in 90.8% of the patients, with 66.7% of cases occurring after D&C for SAB or TAB, 21.5% after postpartum D&C, 2% after Cesarean section, and 0.6% after evacuation of trophoblastic disease.
These results appear to show that the endometrium is most vulnerable to developing Asherman’s syndrome during the hypoestrogenic state immediately after pregnancy.
Asherman’s syndrome may also occur after endometrial ablation. These procedures aim to destroy the basalis layer of the endometrium to decrease menstrual bleeding. If synechiae occur, it makes subsequent evaluation of any abnormal bleeding extremely difficult.
Ultrasound Findings
In patients with Asherman’s syndrome, the endometrial echo is difficult to see, with irregular borders and disruptions of the endometrial lining in multiple areas. There may also be small, focal, cystic-like areas containing blood within the endometrial cavity, trapped by the adhesions. Using 3-D ultrasound, the outline of the endometrial cavity is irregular, shaggy, and distorted. Linear adhesions are usually seen, traversing the endometrium, leaving small islands of endometrial echo.
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