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.
Adhesions are formed in the body as repair process response to previously incurred surgery, infection and radiological procedures. Adhesions contain fragments of scar tissues that are arranged between previously damaged tissues. Adhesions are often significant post-operative complications, which predominantly occur in the pelvic and cardiac regions. Many cases of obstructive bowel disorders have been reported after pelvic surgeries due to the presence of abdominal adhesions.
Abdominal adhesions are asymptomatic in most but they gradually produce significant symptoms leading to complications. In case of obstructive diseases, abdominal adhesions result in ischemia of the intestines. Along with the abdominal region, adhesions also occur in the uterus, ovaries, fallopian tubes post cesarean sections, hysterectomy and treatments of pelvic inflammatory disease. Adhesions in the heart cause conditions such as rheumatic fever by affecting the pericardial region of the heart. It also causes damage to the valves in decreasing the cardiac activity resulting in ischemic heart disease.
Clinical manifestations of abdominal adhesions
Abdominal adhesions prevent the movement of intestines by adhering to their surfaces. Adherence of these adhesions gradually results in the formation of fiber-like structures along the intestinal region constricting the blood flow leading to the onset of tissue necrosis and inflammation. Abdominal adhesions occur as a result of surgical procedures. Some of the predisposing factors include the handling of the internal organs during surgeries, incisions, preexisting infections, and contacts with surgical instruments and absorbent materials such as gauze and cotton swabs which dry the tissues, remnants of blood clots after the surgical procedure and radiation. Other factors include appendicitis.
Symptoms of abdominal adhesions include vomiting, constipation, improper bowel movement, bloating and abdominal swelling. The classical symptom indicating the presence of abdominal adhesions is chronic abdominal pain followed by gastrointestinal bleeding. These symptoms are further correlated with the patient's history associated with previous surgical procedures.
Diagnosis and prevention
Abdominal adhesions can only be detected using laparoscopic procedure. However, X rays determine the presence of intestinal obstructions. Hence abdominal surgeries are only recommended when it is absolutely necessary. Abdominal adhesions can only be prevented by administering minimal invasive procedures such as laparoscopy. In cases of surgeries that require large incisions, a thin absorbable material called seprafilm is placed between the tissues to prevent the occurrence of adhesions. Seprafilm is gradually digested by the tissue fluids. Many studies indicate that the usage of latex free gloves can prevent adhesions to a greater extent. Tissue rehydration is very important during surgical procedure to prevent abdominal adhesions.
Treating of Abdominal adhesions
Abdominal adhesions are removed surgically followed by analgesic medication. An alternative to surgery in the treatment of these lesions includes the administration of complementary and alternative medicine (CAM). The CAM procedure consists of methodologies such as acupuncture and physical therapy.
Culdoscopy involves insertion of a narrow telescope into the vagina so as to get a good view of the uterus, fallopian tubes and ovaries. Culdoscopy or transvaginal hydrolaparoscopy allows the doctor to check for endometriosis, blockage in fallopian tubes and scar tissues that might affect fertility. It offers a more limited view than a laparoscopy.
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Bibliography / Reference
Collection of Pages - Last revised Date: November 12, 2019