Spontaneous abortion occurs when there is loss of fetus during fetus. Spontaneous abortion or miscarriage happens due to natural events and must not be confused with an elective abortion. Typically, most spontaneous abortions take place during the first trimester. Usually a miscarriage occurs anywhere between 7 - 12 weeks of pregnancy. It can even occur before a woman realizes that she is pregnant. Spontaneous abortion can occur due to infection, trauma, immune response by the body or other conditions such as diabetes. The risk of such miscarriage is higher in women who are above 35 years or suffering from systemic conditions such as thyroid or diabetes. Endocrine factors such as Hypothyroidism, hypoprolactinemia or Polycystic ovarian syndrome can bring on a spontaneous abortion. Chromosomal abnormalities, sexually transmitted diseases or immunological reactions can trigger a miscarriage.
A woman may experience vaginal bleeding that may contain tissue or clots. There is low back pain or abdominal cramps. Other symptoms of impending miscarriage are fever, headache and high blood pressure. Blood tests to check levels of HCG (human chorionic gonadotropin) are done. An ultrasound helps in confirming whether there has been a spontaneous abortion or not. It can detect the presence of a live fetus and fetal heart beat. It is essential to consult the health worker when such symptoms are noticed. Not all bleeding in the first trimester leads to spontaneous abortion.
In cases of threatened abortion, the expectant mother will be advised complete bed rest. In some women, an incompetent cervix can lead to a threatened abortion. In such cases, a suture is placed around the cervix to close the cervical canal. But this has to be closely monitored. Environmental factors such as smoking or contracting rubella can threaten a pregnancy. Women who have had repeated miscarriages need to be tested to identify the cause. This may involve genetic testing of the partners and inspection of the uterus and cervix.
Dilation and Curettage
Dilation and curettage or D&C is a procedure that involves widening of the cervix and removing of the uterine lining and contents by scraping and scooping. Dilation and curettage is used as a diagnostic procedure for fibroids or uterine cancer and often as an abortion procedure during the first trimester. A hysteroscope is used to look inside the womb for abnormalities such as fibroids or polyps. D&C is also done when there is endometrial abnormality or menstrual bleeding irregularity. D&C is done under anesthesia. The procedure doesn't take much time but the woman needs to rest for the day. A D&C is not done on women who have an infection of the uterus or fallopian tubes.
Asherman's syndrome refers to the formation of adhesions or scar tissues on the endometrium (uterine lining). Most often endometrial scarring occurs as a result of scraping of tissue from the uterine wall while performing dilation and curettage (D& C). Though D&C is mainly responsible for adhesions, uterine surgery and severe infections of the endometrium such as genital tuberculosis are some of the other factors that cause Asherman's syndrome. Normally, Asherman's syndrome shows up with decreased menstrual flow or even amenorrhea, cramping, abdominal pain and is even associated with infertility and recurrent miscarriages.
Causes of Asherman's syndrome
D&C procedure is performed for miscarriages, excess bleeding, elective abortion or to remove the retained products of conception. Some gynecological disorders call for uterine surgery. Sometimes trauma occurs to the uterine lining while performing D&C procedure or other surgery. In case of damage, the wound begins to heal and in the process, fuses with the affected portion causing adhesions. The risk of Asherman's syndrome increases with repeated D&Cs.
Diagnosis and treatment of Asherman's syndrome
Hysteroscopy is the widely used method to diagnose the Asherman's syndrome as it allows the doctor to have a complete view of the uterus directly. However other methods such as sonohysterography (SHG), hysterosalpingogram (HSG) and transvaginal ultrasound examination are also used to evaluate adhesions. Blood tests are done to detect tuberculosis or schistosomiasis.
Asherman's syndrome is normally treated with surgery to remove the adhesions or scar tissue. The surgery involves hysteroscopy procedure wherein scar tissue is removed by using small instruments, micro scissors and a camera. Once the scar tissue is removed, an intra uterine balloon is placed inside the uterus to keep the uterine cavity open. This procedure aids the healing process and prevents adhesions from returning. Patient may also be prescribed oral estrogen medications for promoting growth of regular uterine lining. Patient may be called in for review hysteroscopy after two weeks of the procedure to make sure that there is no reformation of adhesions.
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Bibliography / Reference
Collection of Pages - Last revised Date: September 18, 2021