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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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COMPLICATIONS
Damage to uterine vasculature is a risk of suture placement. Minor bleeding will often stop after tying of the suture. If
bleeding persists, the broad ligament must be opened to permit vessel isolation and hemostasis with electrocautery, suture
placement, or clip.
After delivery, the cerclage may be left in place if still intact and in the proper location. It is recommended that after
childbearing is complete, the cerclage be removed. Vaginal erosion has been reported as a risk of long-term presence.
6
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KEY REFERENCES
1. American College of Obstetricians and Gynecologists. Cerclage for the management of cervical insufficiency. ACOG
Practice Bulletin, 142. 2014.
2. Merck Manual. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-
pregnancy/cervical-insufficiency. Accessed on September 15, 2016.
3. Ades A, Dobromilsky KC, Cheung KT, et al. Transabdominal cervical cerclage: laparoscopy versus laparotomy. J Minim
Invasive Gynecol. 2015;22(6):968–973.
4. Tulandi T, Alghanaim N, Hakeem G, et al. Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J
Minim Invasive Gynecol. 2014;21(6):987–993.
5. Tusheva OA, Cohen SL, McElrath TF, et al. Laparoscopic placement of cervical cerclage. Rev Obstet Gynecol.
2012;5(3–4):e158–e165.
6. Hawkins E, Nimaroff M. Vaginal erosion of an abdominal cerclage 7 years after laparoscopic placement. Obstet
Gynecol. 2014;123(2 Pt 2 Suppl 2):420–423.
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Uterine
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Chapter 3.1
Correction of Asherman Syndrome
John Pres ton Parry, M azin I. Abdullah, Maher A. Abdallah, Steve n T. Nak ajima
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GENERAL PRINCIPLES
Definition
Intrauterine synechiae, commonly known as Asherman syndrome, is a condition where the uterine cavity is completely or
partially obliterated by adhesions. Though described as early as 1894,
1
it was Joseph Asherman’s 1948 paper,
“Amenorrhoea traumatica (atretica)”
2
detailing a series of 29 cases that was pivotal for medical awareness about this
condition. Though this first paper focused on adhesions involving the cervix and internal os creating hematometra, his
subsequent 1950 paper addressed “regional obliteration of the uterine cavity,” which is more commonly seen.
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Etiology
Endometrial surgical trauma to the stratum basalis is the primary source of Asherman syndrome. Though endometritis can
also contribute, without surgical trauma, infection of the stratum functionale is less likely to extend to the basalis and may be
sloughed with menses.
In societies with limited access to healthcare, nonsurgical infections such as tuberculosis and schistosomiasis can result in
intrauterine adhesions. However, in setting with more developed healthcare systems, pregnancy associated curettage is the
primary cause and can be associated with upward of 90% of cases.
4
The reporting for postsurgical incidence of Asherman syndrome is highly heterogeneous, with one group finding an
incidence of 0% with metroplasty
5
where as another can find 37.5%.
6
Since the incidence of Asherman syndrome is
practice dependent, it is probably easier to focus on broader principles:
The greater the width and depth of endometrial trauma, the more likely intrauterine synechiae will occur.
Particularly with hysteroscopic myomectomy, “kissing” fibroids with a submucosal component are more likely to result in
adhesions than single fibroids that do not result in concurrent trauma to the opposite endometrial surface.
Inflammation at the time of surgery promotes adhesions, such as with curettage for septic abortion.
Hindrance of postoperative endometrial proliferation can increase adhesions, as can be found with postpartum lactational
amenorrhea.
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Symptoms
Menstrual disturbance is the most common complaint, though the extent of adhesions may not always correlate with
symptoms.
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Dysmenorrhea is more likely when hematometra occurs and may occur as cyclical pelvic pain with amenorrhea if outflow is
completely obstructed.
Subfertility and recurrent pregnancy loss can also be sequelae, affecting up to half of women diagnosed with Asherman
syndrome, though diagnostic bias may be present.
8,9
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IMAGING AND OTHER DIAGNOSTICS
Ultrasound imaging can have multiple findings. These can include a thin atrophic endometrium, with hyperechoic adhesive
regions. One can also see asymmetry in endometrial thickness, particularly after estrogen therapy, where endometrial
stricture occurs at synechiae, but is more robust in other regions. With saline infusion sonography, mechanical disruption
with the catheter can be attempted to lyse adhesions.
10
This has been called “PLUG” for pressure lavage under ultrasound
guidance.
11
Three-dimensional ultrasound imaging can be preferred to saline infusion sonography, particularly with
obliteration of the lower uterine segment where balloon inflation for saline infusion is difficult. Hysteroscopy remains the
gold standard for diagnosis, picking up a third more cases relative to even three-dimensional ultrasound.
12
Flexible office
hysteroscopy also has meaningful advantages, including closely reflecting intraoperative findings as well as allowing for lysis
of more filmy adhesions in advance.
Numerous classification systems have been proposed, but the one published by March
13
is frequently used owing to its
simplicity in designating adhesions as minimal, moderate, or severe. The classification system is as follows: Minimal when
<1/4 of the uterine cavity involved with adhesions; moderate when 1/4 to 3/4 of the uterine cavity involved with adhesions
and no agglutination of the uterine walls; severe when >3/4 of the uterine cavity involved with presence of agglutination of
the uterine walls or thick bands present.
Heterogeneity in classifying adhesions is one of the reasons comparisons within the literature are so challenging.
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PREOPERATIVE PLANNING
Expectations are one of the most important aspects of preoperative management. Though patients can do well with a single
surgery for minimal synechiae, with severe adhesions only half will be resolved with a single surgery and rarely will require
as many as four.
14,15
Even then, restoration of the cavity cannot guarantee that the stratum basalis will regrow and for
preoperative amenorrheic patients, live birth rates may be only 27%.
14
Similarly, when endometrium is very thin prior to
therapy, postoperative outcomes tend to be poor.
16
Imaging and particularly office hysteroscopy are particularly useful for
informed consent regarding the extent of disease.
Preoperative estrogen promotes endometrial proliferation, providing “safe windows” for dissection. Typical protocols involve
oral estradiol 4 to 6 mg total daily starting 4 to 8 weeks prior to surgery.
Of note, when endometritis (including genital tuberculosis) causes intrauterine adhesions, these can extend to the cornual
regions, potentially causing greater obliteration, which should shift expectations downward. Postsurgical Asherman
syndrome is more likely to be in the midline of the endometrium.
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SURGICAL MANAGEMENT
Adhesiolysis for Asherman syndrome typically occurs in patients who want to preserve fertility. When performing
hysteroscopic adhesiolysis for pain associated indications in patients with no future procreative goals (as can happen after
endometrial ablation), the balance of risk versus benefit can often lean toward hysterectomy. There are, however, surgeons
who possess advanced hysteroscopic skills who can perform a lysis of intrauterine adhesions in an office-based surgery
setting. However, sonographic guidance and an operating room setting may be preferable for severe Asherman syndrome
owing to the higher risk for uterine perforation.
Prophylactic antibiotics are not indicated for lysis of intrauterine adhesions according to the American Congress of
Obstetricians and Gynecologists (ACOG).
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