Dissection of intrauterine synechiae. Intrauterine synechiae Classification of intrauterine adhesions


Synechiae are acquired or congenital fusions of adjacent organs or their surfaces. Often synechiae occurs in children, especially in girls - fusion of the labia minora.

And intrauterine synechiae also occurs in adult women. Let's talk about this pathology and treatment methods - separation of synechiae and removal of synechiae.

Intrauterine synechiae is a condition characterized by complete or partial occlusion of the uterine cavity. Intrauterine synechiae are one of the possible causes of infertility.

Mechanical trauma is considered the main factor in their development. of various origins basal layer of the endometrium of the uterus (after abortion or childbirth, uterine surgery), and infection is a secondary factor. The first month after childbirth or abortion is considered the most dangerous in terms of possible trauma to the uterine mucosa.

Symptoms of intrauterine synechiae appear depending on the degree of uterine infection. Most often noted hypomenstrual syndrome with the development of infertility or miscarriage.

Treatment of this disease comes down to dividing the synechiae or removing the synechiae.

Based on the histological structure, there are three types of intrauterine synechiae:

1. Light type- synechiae in the form of a film, usually consisting of the basal endometrium; dissection and separation of synechiae does not cause difficulties.

2. Medium type- synechiae of a fibromuscular structure, covered with endometrium; when cut, the synechiae bleed.

3.Heavy type– dense, connective tissue synechiae. As a rule, when dissected, synechiae do not bleed and are difficult to dissect.

Dissection of synechiae is carried out under visual control of a hysteroscope, which avoids additional trauma to the endometrium and helps restore fertility and the normal menstrual cycle.

The separation and separation of synechiae are carried out using various methods, and the nature of the operation depends on the type of synechiae formed inside the uterine cavity and the degree of occlusion of its cavity.

Separation of centrally located synechiae can be carried out using endoscopic scissors or forceps.

Centrally located synechiae can be divided bluntly using the hysteroscope body. To dissect, spread and remove synechiae of a denser structure, a hysteroresectoscope with an electrode is used - a laser conductor or an “electroknife”. To prevent uterine perforation, surgery is often performed under ultrasonic control or with significant occlusion - under laparoscopic control.

Despite the high efficiency of hysteroscopic removal of intrauterine synechiae, recurrence of the disease cannot be ruled out - especially in the presence of dense widespread synechiae, as well as in patients with tuberculous lesions of the uterus.

In order to reduce the risk of relapses after dissection, separation and removal of synechiae, hormonal therapy is carried out (estrogen-gestagens are prescribed in high doses).

Thus, pregnancy in women with intrauterine synechiae has a high risk of complications, both during pregnancy and during childbirth and the postpartum period.

Intrauterine synechiae (Asherman's syndrome) or so-called adhesions inside the uterus are complete or partial occlusion of the uterine cavity.

Causes of synechiae

Today, several theories of the formation of intrauterine synechiae are known: traumatic, infectious and neurovisceral. According to the traumatic theory, the key trigger that initiates the process of synechiae is traumatic damage to the basal layer of the endometrium. Mechanical trauma is possible due to difficult childbirth or frequent curettage of the uterine cavity, as well as abortion. In this case, infection is a secondary factor in the occurrence of uterine synechiae. Also, synechiae of the uterine cavity can form in women whose gynecological history is burdened by a frozen pregnancy. This is possible because the remaining placental tissue may contribute to the activation of fibroblasts and collagen synthesis even before the process of regeneration of the inner layer of the uterus (endometrium).

The cause of synechiae that forms inside the uterine cavity can be various surgical manipulations and interventions on the uterus: diagnostic and curettage uterine cavity, hysteroscopy, myomectomy, metroplasty. Synechiae are often observed after conization of the cervix or severe endometritis. Frequent provoking factors for the formation of synechiae of the uterine cavity include the introduction or removal of intrauterine contraceptives (spirals), as well as the installation of the Mirena system for therapeutic purposes.

Classification of intrauterine synechiae

In practice, gynecologists use a special classification in which Synechiae are divided according to their prevalence and degree of involvement in the pathological process of the uterus:

  • I degree is characterized by the involvement in the pathological process of no more than 1/4 of the volume of the uterine cavity, intrauterine adhesions of thin diameter, and the fundus of the uterus and the mouth of the fallopian tubes are free.
  • II degree - intrauterine synechiae extends to no less than 1/4 and no more than 3/4 of the volume of the uterine cavity. The walls of the uterus do not stick together; there are only thin adhesions that partially cover the fundus of the uterus and the openings of the fallopian tubes.
  • Stage III is characterized by the involvement of more than 3/4 of the entire uterine cavity in the pathological process.

Clinical manifestations of intrauterine synechiae

The clinical picture of synechiae located inside the uterine cavity depends on the extent of damage to the uterine cavity by the pathological process. The most common clinical manifestations of intrauterine synechiae are amenorrhea or hypomenstrual syndrome. The result of a long and neglected process of synechiae being inside the uterine cavity is infertility, or the inability to bear a child. In cases where there is infection of the lower parts of the uterus with a normally functioning upper sections internal endometrium, a cavity filled with blood (hematometra) can form. With significant occlusion of the uterine cavity and a poorly functioning inner layer of the uterus, the process of implantation of the embryo into the uterine cavity becomes difficult. Also, intrauterine synechiae, even of small diameter, can cause ineffective in vitro fertilization.

Diagnosis of intrauterine synechiae

To remove synechiae, it is necessary to clearly establish their location and the extent of damage to the uterine cavity by synechiae. To diagnose synechiae, the following research methods are used:

  • Hysterosalpingography;
  • Ultrasonography pelvic organs;
  • Hydrosonography;
  • Diagnostic hysteroscopy.

Examination for the presence of intrauterine synechiae begins in cases where there are problems with conception. To date, there is no specific developed plan for examining such women. Many practicing doctors believe that it is better to start diagnosing intrauterine synechiae with hysteroscopy, and if a questionable result is obtained, hysterosalpingography should be performed.

Diagnostic hysteroscopy

Hysteroscopy today in practical gynecology is a key method for diagnosing synechiae inside the uterine cavity. In this study, intrauterine synechiae are presented in the form of white cords without vessels of varying lengths. These pathological adhesions of dense consistency, located throughout the entire length between the walls of the uterus, can cause a decrease in its size due to complete or partial obliteration of the uterine cavity. Synechiae can also be localized in the cervical canal, which causes fusion cervical canal and difficulty entering the uterine cavity. Intrauterine synechiae of thin diameter are presented in the form of strands of pale pink color, sometimes they look like a cobweb, in which the vessels passing through it are visible.

Hysterosalpingography

With hysterosalpingography, the signs of synechiae of the uterine cavity clearly depend on their nature and distribution. As a rule, intrauterine synechiae on hysterosalpingography are presented in the form of single or multiple filling defects that have irregular shape. More often, synechiae of the uterine cavity appear as lacunae-shaped defects of various sizes. Intrauterine synechiae have a dense consistency; they divide the uterus into numerous chambers of different sizes, which are connected to each other only by small-diameter ducts. This configuration of the uterine cavity is not completely visualized during diagnostic hysteroscopy, since during this research method only the first few centimeters of the lower part of the uterus are examined. While during hysterosalpingography, a viscous contrast agent bypasses all the complex labyrinths of the uterine cavity affected by synechiae and the non-obliterated spaces of the uterus. This method of radiographic examination has negative qualities. It may give false-positive results due to remnants of the inner layer of the uterus (endometrium), mucus, or deformation of the uterine cavity by synechiae.

Ultrasound examination of the pelvis

At present, even advanced ultrasound equipment, when detecting intrauterine synechiae, does not provide complete information about the state of the uterine cavity and the doctor does not receive an objective picture of what is happening. In some cases, it is possible to visualize unclear contours of the inner layer of the uterus, and in the presence of a hematometra, an anechoic formation is detected that completely fills the uterine cavity. Hydrosonography can detect single synechiae of the uterine cavity when there is no complete obstruction in the lower segment of the uterus. Dense intrauterine synechiae are characterized as white cords of dense consistency, which are often localized along the side walls. They are located very rarely in the central part of the uterus. A large number of transverse synechiae lead to partial or complete closure of the uterine cavity in the form of numerous cavities of different sizes. These cavities are sometimes mistaken for the openings of the fallopian tubes.

Treatment of intrauterine synechiae

Today, the only correct solution for the treatment of synechiae of the uterine cavity is dissection of the synechiae under the careful control of a hysteroscope, which does not injure the remnants of the endometrium, which is important for normalizing the menstrual cycle and maintaining a woman’s reproductive function. The volume of operations to separate synechiae and its effectiveness depend on the type of synechiae and the degree of obstruction of the uterine cavity by synechiae.

Intrauterine synechiae, which are localized in the central part of the uterus, can only be cut in a blunt manner using the body of a hysteroscope. Also, special endoscopic scissors and forceps are used to separate synechiae. In this case, a hysteroresectoscope with an electrode (“electronic knife”) is used to completely dissect the synechiae of the uterine cavity.

In order to prevent uterine perforation, dissection of synechiae is performed under constant and careful monitoring of ultrasound equipment. Such separation of synechiae is possible only with partial obstruction of the uterine cavity. While in case of complete or significant occlusion of the uterine cavity by synechiae, control over the progress of the operation is performed through laparoscopic access using special equipment.

Despite the greater effectiveness of hysteroscopic treatment, relapse is possible pathological process. More often, intrauterine synechiae can recur with compacted adhesions, as well as uterine tuberculosis. After dividing the synechiae, the doctor prescribes hormonal therapy for each patient individually ( oral contraceptives in large dosages). This therapy is prescribed for 3-6 months to restore normal menstrual function.

Prognosis for synechiae inside the uterine cavity

A positive result after hysteroscopic dissection of synechiae depends on the duration and prevalence of intrauterine synechiae. For example, the more the uterine cavity is obstructed by synechiae, the less effective the treatment is. The worst possible results in normalizing menstrual function and restoring a woman’s reproductive function are observed with synechiae of the uterine cavity of a tuberculous nature.

Women who underwent surgical treatment with a history of synechiae, during pregnancy they are at risk for complications during pregnancy, delivery and the early postpartum period. In 35% of pregnant women who have synechiae inside the uterine cavity, spontaneous abortion occurs. In 30%, labor begins before the due date, while the remaining 35% of pregnant women develop placental pathology (solid or partial placenta attachment or placenta previa).

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First, let's define a new term - synechia. Synechiae are pathological fusions of the surfaces of the same organ or the contacting surfaces of different organs.

Frequency of intrauterine synechiae in women with infertility is 55%. More often, this pathology is combined with a tubo-peritoneal factor of infertility.

The mechanism of infertility with uterine synechiae

As we know, the uterine cavity is the abode of the intrauterine developing baby. Therefore, a violation of the anatomical structure of the uterus causes difficulty in the implantation of a fertilized egg and the development of pregnancy.

Causes:

Without endometrial trauma, the formation of synechiae in the uterine cavity, even in the presence of inflammation, is almost impossible. Adhesions in the uterine cavity occur as a result of mechanical impact on the basal layer of the endometrium, which most often occurs during curettage, especially in the early postpartum period. Intrauterine synechiae can be the result of surgical interventions, the presence of foreign bodies in the uterus (intrauterine device, remnants of fetal fragments after abortion), as well as irrational medical manipulations in the uterine cavity (intrauterine administration of various medications for therapeutic purposes).

The second most important factor in the formation of intrauterine synechiae is chronic endometritis. In women with primary infertility and the absence of any previous manipulations in the uterine cavity, intrauterine synechiae are the result of only one specific pathological process - tuberculous endometritis.

Diagnostics

Clinical picture and complaints:

Important information for a gynecologist is the presence of a history of curettage of the uterine cavity due to artificial or spontaneous abortion, as well as other medical intrauterine manipulations. Women with synechiae in the uterine cavity often complain of pain in the lower abdomen, which intensifies during menstruation. The intensity of pain may vary. Greater pain intensity is achieved with synechiae localized in the lower third of the uterus and the cervical canal, which impedes the passage of menstrual flow. If the outflow of menstrual fluid is not impaired, the pain is not expressed.

Many patients with intrauterine synechiae complain about changes in the nature of menstruation. Menstruation becomes less abundant and shorter. With significant damage to the endometrium, they pass in the form of a “daub.” In especially severe cases, when the uterine cavity or cervical canal is completely closed, menstruation disappears (uterine form). In patients with atresia (fusion) of the cervical canal and absence complete defeat endometrium, with normal ovarian function, there are complaints of recurring monthly cyclical pain in the lower abdomen on the days of expected menstruation.

Instrumental methods research:

X-ray methods: performed by hysterosalpingography - with the introduction of contrast into the uterine cavity and a series of X-ray images. Signs of synechiae are filling defects or complete absence of filling of the uterus with contrast.

Ultrasound. The diagnostic value of ultrasound for identifying intrauterine synechiae is 60-70%. For women with amenorrhea and suspected intrauterine synechiae, it is better to have an ultrasound scan on the days of expected menstruation, and if the menstrual cycle is intact, twice: on days 8-12 of the cycle and at the end of the cycle. On ultrasound, synechiae may look like constrictions that deform the uterine cavity.

Echohysterosalpingoscopy. After expansion of the uterine cavity with a liquid medium, intrauterine synechiae are visualized as hyperechoic inclusions, constrictions that deform the cavity. The diagnostic value of the method in identifying intrauterine synechiae reaches 96%.

Magnetic resonance imaging. If necessary, it can be used to diagnose intrauterine synechiae.

Hysteroscopy. If synechia is suspected, it is carried out in a hospital in the first phase of the menstrual cycle. During this period, against the background of a thin endometrium in the uterine cavity, intrauterine synechiae are clearly visible.

Treatment

Medicinal preoperative preparation

Only surgical treatment is effective, but preoperative preparation and postoperative treatment.

Preoperative preparation. Purpose preoperative preparation to hysteroresectoscopy is the creation of reversible endometrial atrophy to ensure optimal conditions for surgical intervention. It is carried out with hormonally active drugs that affect the condition of the endometrium. The growth and maturation of the endometrium is suppressed.

Surgical intervention
A surgical operation to eliminate intrauterine adhesions and restore the patency of the uterine cavity is called hysteroresectoscopy. This operation is performed using special endostotic equipment through transvaginal access.

Postoperative treatment

Early rehabilitation treatment begins from the first day of the postoperative period, using physical and medicinal methods.

Antibacterial therapy is indicated in the early postoperative period.

Physiotherapy improves healing processes, increases local immunity, prevents the formation of new intrauterine synechiae and the development of adhesions in the pelvis. Treatment begins no later than 36 hours after surgery. They use an alternating low-frequency magnetic field, a constant magnetic field, supratonal frequency currents, and laser exposure.

What treatment is prescribed after surgery?

A repeated course of physiotherapy begins on the 5th-7th day of the menstrual cycle following surgery. The number of physiotherapy courses is determined individually. If necessary, up to three courses are carried out with an interval of at least 2 months between them.

Cyclic or hormone replacement therapy (HRT). It is performed in the treatment of women with intrauterine synechiae that arose against the background of chronic inflammatory process. HRT promotes the complete restoration of the uterine mucosa and its complete rejection during menstruation, prevents the re-formation of synechiae in the uterine cavity, improves metabolic processes in the endometrial tissues of the uterus, which creates a favorable environment for pregnancy.

Immunomodulators are selected taking into account indicators of immune and interferon status determined before the start of surgery and drug treatment.

After completion of rehabilitation treatment, an additional examination is carried out, which consists of assessing the condition of the uterine cavity. Based on X-ray examination, echohysterosalpingoscopy or control hysteroscopy, an objective picture of the achieved results is compiled. In cases of incomplete separation of intrauterine synechiae, repeated surgery and subsequent conservative complex treatment.

In the absence of pathological changes in the uterine cavity, the patient is observed for 6 months (waiting period for pregnancy). Dynamic observation involves monitoring ovulation and ultrasound monitoring of the condition of the endometrium during the menstrual cycle.

Waiting tactics for 6 months are indicated provided that ovulation is present, the man is not infertile, and adequate monthly cycle. If the ultrasound parameters of the endometrium do not correspond to the abundance of menstrual flow, it is necessary to repeat the therapeutic effect aimed at improving the trophic processes in the uterus (physiotherapeutic and hormonal treatment).

If ovulation defects are detected, it is stimulated for four consecutive cycles. If pregnancy does not occur within the specified period of time, additional examination is necessary to identify and analyze the reasons for unsuccessful treatment.

Intrauterine synechiae occur in a variety of lengths and densities. Located between the walls of the uterus, they reduce its cavity, in severe cases completely obliterating the uterus (obliteration - overgrowth). In addition, synechiae can appear in the cervical canal, which leads to its fusion. In this case, the entrance to the uterine cavity is closed. There is another name for this disease - Asherman's syndrome. Among patients who suffer from infertility, intrauterine synechiae is diagnosed in almost every second one.

Causes of the disease

Currently, infectious, traumatic and neurovisceral causes of intrauterine synechiae are distinguished. One of the main factors is considered to be previous trauma to the basal layer of the endometrium. This occurs, as a rule, as a result of termination of pregnancy, after diagnostic curettage, operations in the uterine cavity (myomectomy, conization of the cervix). Trauma or inflammation leads to damage to the endometrium, which causes the release of fibrin. As a result, the walls of the uterus “stick together” and adhesions form.

Also, the disease often develops against the background of a frozen pregnancy - the remains of the placenta cause the activity of fibroblasts and the appearance of collagen before the regeneration of the endometrium. In addition, the development of the disease is influenced by the use of an intrauterine contraceptive.

Adhesions also appear with genital tuberculosis, its presence is confirmed by bacteriological examination or by endometrial biopsy. It should be taken into account that unfavorable factor, which increases the risk of developing the disease, there may be intrauterine instillations, radiotherapy for tumors of the uterus or ovaries.

Symptoms of the disease

There are different degrees of severity of the disease.

In mild cases, the disease may be asymptomatic. However, later, depending on the degree of spread, the symptoms of intrauterine synechiae become more varied. The patient experiences pain in the lower abdomen, the intensity of which intensifies as critical days. At the same time, the duration of menstruation decreases, they become scanty, and in severe cases, amenorrhea develops (absence of menstruation in women fertile age). Infection of the lower area in the uterus with a normally functioning endometrium in the upper part leads to a disruption of the outflow of blood, which can result in the development of a hematometra. The clinic resembles a painting acute abdomen, in this situation the patient needs emergency surgical care.

With extensive lesions in the uterine cavity with an insufficiently functioning endometrium, difficulties arise in the implantation of the fertilized egg. By the way, one of the reasons for the ineffectiveness of IVF - in vitro fertilization - is even mildly expressed adhesions. It should be taken into account that intrauterine synechiae are often accompanied by endometriosis (adenomyosis), which negatively affects the prognosis of treatment.

Patients often experience symptoms of intoxication, manifested by weakness, muscle pain, rapid heartbeat, and emotional instability.

Classification

Today there are various classifications intrauterine synechiae, providing complete information about the disease: type histological structure, affected area, etc. Since 1995, the classification proposed by the European Association of Gynecologists (ESH) has been used, which distinguishes five degrees based on hysterography and hysteroscopy data. This takes into account the length of synechiae, the degree of damage to the endometrium, and occlusion of the mouth of the fallopian tubes.

Complications

As a result of a lack of functioning endometrium, as well as the formation of adhesions, the fertilized egg cannot attach to the wall of the uterus. In addition, the fertilization process itself may be disrupted due to overgrowth of the fallopian tubes. In 30% of patients with diagnosed synechiae, spontaneous abortion occurs, in 30% of women premature birth occurs. Pathologies of the placenta often occur. Thus, complications of intrauterine synechiae are very numerous; pregnancy in such women is associated with great risk. But, in addition to miscarriage, there is a possibility of postpartum hemorrhage.

Diagnostics

Currently, there is no uniform examination algorithm. However, according to most doctors, the diagnosis of intrauterine synechiae should begin with hysteroscopy; in case of doubtful results, hystersalpingography is recommended.

  • Hysteroscopy is an examination of the inner surface of the uterus using endoscopic equipment (hysteroscope). The technique allows you to perform not only a visual examination of the cavity and detect pathological changes, but also, if necessary, perform a biopsy or surgical intervention. This minimally invasive procedure is virtually painless and low-traumatic; it can be done under either local anesthesia or general anesthesia. The likelihood of complications after hysteroscopy is minimal.
  • Hysterosalpingography is in some cases more effective than hysteroscopy. With dense, multiple synechiae, dividing the uterine cavity into chambers of various sizes, and connected by ducts, this study is more informative. However, deformation of the uterine cavity, the presence of mucus and endometrial fragments, etc. in some cases can lead to false positive result. Therefore, it is better to entrust the choice of a suitable research method to a specialist.
  • Ultrasound can detect single adhesions if there is no obstruction in the lower part of the cavity.
  • MRI with contrast is a fairly effective diagnostic method that allows you to visualize possible pathology.
  • Negative hormonal tests - when progesterone and estrogens are prescribed, there is no menstrual-like bleeding.

Treatment of intrauterine synechiae

The goal of therapy is to eliminate adhesions in the uterus and restore menstrual and reproductive functions. It must be emphasized that it is possible to decide how to treat intrauterine synechiae only after a thorough examination. Today, the only treatment method is dissection of synechiae. The nature of the operation depends on the type of adhesions, as well as the degree of damage. Weak synechiae are dissected with endoscopic forceps, scissors or the body of a hysteroscope; an electric knife or laser is used to remove denser strands. This intervention is a complex procedure, therefore, to prevent perforation of the uterine wall, it is carried out under visual control.

After surgery, hormone therapy is indicated, the purpose of which is to restore the endometrium. In the case where intrauterine synechiae arose as a result of infection, then after a biopsy and bacteriological examination, antibacterial drugs are prescribed.

Lightweight and average degree The disease is quite treatable. In situations where synechiae are located in a limited area, in vitro fertilization is effective.

Prevention

To reduce the risk of developing pathology, there are several simple rules:

  • Using competent contraceptive methods to prevent abortions
  • Intrauterine manipulations are best performed in clinics where there is modern equipment and qualified specialists
  • Timely treatment genitourinary tract infections

It should be taken into account that in some patients, after treatment, there is a risk of developing a relapse, especially with dense widespread adhesions, as well as with tuberculous lesions. Therefore, the prevention of intrauterine synechiae after surgery plays a huge role. For these purposes, special devices are placed in the uterine cavity: IUD ( intrauterine contraception), Foley catheter. In addition, hormone therapy is performed to restore the endometrium.

You should also remember the existing risk in women with a complicated course of the postpartum period or after an abortion. If there is a suspicion of placental remnants, in case of menstrual irregularities, etc., hysteroscopy should be immediately performed, the purpose of which is to clarify the exact location of the pathology focus and its removal without injuring the normal endometrium.

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Gynecology

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Intrauterine synechiae (IUD) still represent a major medical and social problem with a disappointing prognosis for fertility and quality of life, particularly in female patients reproductive age. The true incidence of IUDs is still unknown, because the range of clinical manifestations is too wide - from menstrual dysfunction to infertility.
The trigger for the formation of an IUD is injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or the postpartum period. Thanks to the development of intrauterine surgery, resectoscopic interventions have recently been increasingly used to treat IUDs: myomectomy, removal of the intrauterine septum, etc. Hysteroscopy is used as the main method of diagnosing and treating IUDs in order to normalize the menstrual cycle and restore fertile function. When pregnancy occurs after treatment of Asherman's syndrome, there remains a high risk of such serious complications as spontaneous miscarriage, premature birth, intrauterine growth restriction, pathology of the placenta, etc. The use of an anti-adhesion gel containing hyaluronic acid and carboxymethylcellulose (Antiadgesin®) helps reduce the risk recurrence of IUDs after their separation.

Keywords: intrauterine synechiae, Asherman's syndrome, infertility, hysteroscopy, amenorrhea.

For quotation: Popov A.A., Manannikova T.N., Alieva A.S., Fedorov A.A., Bespalova A.G. Intrauterine synechiae: a century later // Breast cancer. Mother and child. 2017. No. 12. pp. 895-899

Intrauterine synechiae: a century later
Popov A.A., Manannikova T.N., Alieva A.S., Fedorov A.A., Bespalov A.G.

Moscow Regional Research Institute of Obstetrics and Gynecology

Intrauterine synechia is still a major medical and social problem with a disappointing prognosis of fertility and quality of life, particularly in women of reproductive age. The true frequency of the occurrence of the IUS is not known up to the present time, as the range of its clinical manifestations is too wide - from the violation of menstrual function to infertility. Any triggers of intrauterine synechia lead to the emergence of this condition by a common mechanism involving injury of the basal layer of the endometrium and trauma of the pregnant uterus, which cause IUS. In connection with the development of intrauterine surgery, intrauterine synechia has been increasingly associated with resectoscopic interventions such as myomectomy, removal of the intrauterine septum, and others. Hysteroscopy is used as the main method of diagnosis and treatment of the IUS aiming at normalizing the menstrual cycle and restoring fertility. At the onset of pregnancy after the treatment of Asherman's syndrome there remains a high risk of such severe complications as spontaneous abortion, premature birth, intrauterine growth retardation, placental pathology, etc.The use of an anti-adhesive gel containing hyaluronic acid and carboxymethyl cellulose (Antiadhesin) helps to reduce the risk of recurrence of intrauterine synechia after separation.

Key words: intrauterine synechia, Asherman's syndrome, infertility, hysteroscopy, amenorrhea.
For citation: Popov A.A., Manannikova T.N., Alieva A.S. et al. Intrauterine synechiae: a century later // RMJ. 2017. No. 12. P. 895–899.

The article is devoted to the problem of intrauterine synechiae

Introduction

Intrauterine synechiae (IUD) were first described in 1894 by Fritsch H. in a patient with secondary amenorrhea that developed after curettage in the postpartum period. After 33 years, Bass V. diagnosed 20 out of 1,500 women examined with cervical atresia that arose after medical abortion. In 1946, Stamer S. added 24 cases from 37 cases described in the literature own experience. In 1948, Joseph Asherman published a number of articles in which he first indicated the frequency of IUDs, described in detail the etiology, symptoms, and also presented a radiological picture of IUDs. Following his publications, the term "Asherman's syndrome" is used to describe IUDs to this day. Despite the fact that synechiae has been known for more than a century, the problem still remains unsolved, and work is currently underway aimed at finding measures for the prevention, diagnosis and treatment of this pathology.
The trigger for the formation of an IUD is injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or the postpartum period. Although Asherman's syndrome has been described after curettage for obstetric conditions, other causes of IUDs have now been identified. Thus, an increase in the number of intrauterine interventions for submucosal myomatous nodes, uterine development anomalies, etc. has provided another group of patients predisposed to the formation of an IUD.
The role of infection in the development of IUDs is controversial. While some authors believe that infections are not involved in the formation of IUDs, others argue that the main cause of this pathology is infection, especially with histologically confirmed chronic or subacute endometritis, even without a clinical picture (fever, leukocytosis, purulent discharge).
In patients with IUD, the picture during hysteroscopy (HS) can be different: from loose, single adhesions to complete obliteration of the uterine cavity by dense synechiae. A number of authors argue that critical period The period during which adhesions appear is from 3 to 5 days after surgery. This process is enhanced by a number of factors that disrupt physiological fibrinolysis: ischemia, post-traumatic inflammation, the presence of blood, foreign bodies. Adhesions can involve different layers of both the endometrium and myometrium. The adhesions of these tissues hysteroscopically manifest themselves in a characteristic pattern: endometrial adhesions are similar to the surrounding healthy tissue, myofibrial adhesions are the most common and are characterized by a superficial thin layer of the endometrium with multiple glands.
Menstrual irregularities, including hypomenorrhea and amenorrhea, remain common clinical manifestations of IUD. With IUD, amenorrhea can be caused by various etiological factors: endocervical adhesions leading to obstruction of the cervical canal, extensive adhesions in the uterine body cavity due to destruction of the basal layer of the endometrium. With obstructive amenorrhea, patients experience cyclic discomfort or pain in the lower abdomen, hematometra, and even hematosalpinx. Dysmenorrhea and infertility are also noted. Compared with amenorrhea and infertility, miscarriage is more mild complications Navy. Possible etiological factors include: reduction of the uterine cavity, lack of a sufficient amount of normal endometrial tissue for implantation and support of the placenta, inadequate vascularization of the functioning endometrium due to fibrosis, etc. In the study, Schenker J.G., Margalioth E.J. 165 pregnancies were observed in women with an untreated form of Asherman's syndrome. The frequency of spontaneous miscarriage was 40%, premature birth 23%, timely birth occurred in 30% of cases, pathological attachment of the placenta was observed in 13% of women, ectopic pregnancy - in 12% of patients.
Clinical manifestations are closely related to such pathological changes, such as the depth of fibrosis, the location of adhesions (Fig. 1), and are divided into 3 types.

Type 1. Amenorrhea develops due to adhesions or stenosis of the cervical canal. In such cases, as a rule, a normal uterine cavity is revealed above the adhesions, and the prognosis is quite favorable.
Type 2. Adhesions are detected in the uterine cavity. This most common form of IUD has 3 degrees of severity: central intrauterine synechiae without narrowing of the cavity, partial obliteration with reduction and complete obliteration of the uterine cavity. The prognosis after treatment directly depends on the degree of damage. In patients with central IUDs and preserved normal endometrium and uterine cavity, the treatment prognosis is quite favorable. The prognosis of treatment is often unsatisfactory in patients with partial or complete atresia of the uterine cavity.
Type 3. Adhesions can be detected both in the cervical canal and in the uterine body cavity.

Diagnosis of IUD

Before the invention of the hysteroscope, hysterosalpingography (HSG) was and still remains the method of choice for many gynecologists. HSG is able to evaluate the shape of the uterine cavity and the condition of the fallopian tubes. Wamsteker K. described the HSG picture with IUD as filling defects with sharply defined boundaries, with a centralized and/or parietal location.
Ultrasound, due to its non-invasiveness, is widely used both for diagnostic and, intraoperatively, for auxiliary purposes.
Sonohysterography combines ultrasound with intrauterine injection of isotonic saline solution. If one or more echogenic areas are identified between the anterior and back walls the uterine cavity can be suspected of an IUD.
The main advantages of MRI are visualization of proximal adhesions in the uterine cavity and assessment of the condition of the endometrium, which is necessary to decide on further tactics for patient management. MRI plays a supporting role in the diagnosis of complete obliteration of the uterine cavity when hysteroscopic visualization is not possible.
Thanks to direct visualization during HS, it is possible to more accurately confirm the presence and assess the degree of adhesions in the uterine cavity. Al-Inany N. described various types of intrauterine adhesions, which are visualized using a hysteroscope: 1) central adhesions look like columns with widened ends and connect the opposite walls of the uterine cavity; 2) parietal adhesions look like a crescent and a curtain, hiding the bottom or side walls, they can give the uterine cavity an asymmetrical shape; 3) multiple adhesions that divide the uterine cavity into several smaller cavities.
IUDs are not taken into account in any of the classifications clinical manifestations, features of menstrual function. Of all the known classifications, the 1988 classification of the American Fertility Society (AFS) is currently considered the most objective, although it is somewhat complex and cumbersome (Table 1).

According to this classification, the stage of the IUD is determined by the sum of points:
1) stage I – 1–4 points;
2) stage II – 5–8 points;
3) stage III – 9–12 points.

Treatment

Treatment of Asherman's syndrome is aimed at restoring the size and shape of the uterine cavity, menstrual and reproductive function, and preventing relapse of adhesions. Various treatment methods have been described over the last century.
1. Waiting tactics. Schenker and Margalioth observed 23 women with amenorrhea who did not receive surgical treatment; 18 of them regained a regular menstrual cycle within a period of 1 to 7 years.
2. Blind dilatation and curettage. It is known that this method is fraught with a high risk of complications and is ineffective.
3. Hysterotomy. For the first time, hysterotomy to separate the IUD was proposed by D. Asherman. When analyzing 31 cases of hysterotomy, 16 women (52%) became pregnant, 8 (25.8%) of whom were successfully delivered. However, this treatment should only be considered in the most extreme situations.
4. Hysteroscopy(GS) is currently the method of choice for Asherman's syndrome due to its low invasiveness and the possibility of repeated execution in case of relapse. When using scissors or forceps to destroy synechiae, there is a lower risk of uterine perforation and destruction of the basal layer of the endometrium compared with the use of various types of energy. However, energy-assisted intrauterine surgery can create conditions for efficient and precise cutting and also guarantee hemostasis by ensuring optical clarity of the surgical field.
The effectiveness and safety of surgical treatment of Asherman's syndrome can be improved if HS is combined with one of the control methods: fluoroscopy, laparoscopy, transabdominal ultrasound. The disadvantage of fluoroscopy is the radiation exposure. Laparoscopy is widely used to monitor hysteroscopic adhesiolysis and makes it possible to assess the condition of the pelvic organs and perform surgical treatment for various pathologies. Transabdominal ultrasound is increasingly used for hysteroscopic separation of intrauterine adhesions and significantly reduces the risk of uterine perforation.
Surgical success can be judged by restoration of normal anatomy of the uterine cavity, restoration of menstrual function, pregnancy and live birth rates. It is noted that restoration of the normal uterine cavity after the first procedure is 57.8–97.5%. However, reproductive outcome depends not only on the condition of the uterine cavity, but also on the condition of the endometrium.
According to the literature, the pregnancy rate after hysteroscopic lysis of intrauterine adhesions in women was about 74% (468 out of 632), which is much higher than in non-operated women. IUD recurrence is the main factor in the failure of the operation and is directly related to the prevalence of adhesions. It was noted that the relapse rate in the range of 3.1–28.7% is typical for all cases of adhesions and 20–62.5% for common adhesions.
Since IUD relapse occurs in the early postoperative period, prevention after surgery is important and is carried out using various methods.

Prevention of IUD recurrence

Intrauterine devices have been widely used as a method to prevent IUD recurrence. In a literature review, March C.M. concluded that T-shaped IUDs have too little surface area to prevent adhesion to the walls of the uterine cavity. There is evidence in the literature about the use of a Foley catheter inserted into the uterine cavity for several days after lysis of adhesions to prevent relapse. In a prospective controlled study, Amer M.I. et al. evaluated the effectiveness of this method by leaving a Foley catheter in the uterine cavity for one week after surgery in 32 patients. Diagnostic HS was performed at 6 to 8 weeks. after operation. IUDs were found in 7 patients in the balloon group (7 of 32; 21.9%) compared with 9 patients in the no-balloon group (9 of 18; 50%). However, using a balloon creates an “open gate” into the uterine cavity for infection from the vagina. A large balloon increases intrauterine pressure, which can lead to a decrease in blood flow to the walls of the uterus and a negative effect on endometrial regeneration. In addition, this method can create significant discomfort for the patient.
J. Wood and G. Pena proposed the use of estrogens to stimulate endometrial regeneration on injured surfaces. In a randomized study, 60 women underwent uterine curettage during the first trimester of pregnancy and estrogen-progestin therapy after adhesiolysis. In this group of patients, the thickness (0.84 cm versus 0.67 cm; P1/4.02) and volume of the endometrium (3.85 cm2 versus 1.97 cm2) were statistically significantly greater than in the control group. These data suggest that hormone replacement therapy significantly increases endometrial thickness and volume, promoting repair and cyclic transformation.
The recommendations of the Royal College of Obstetrics and Gynecology on the prevention of adhesions note that any surgical intervention on the abdominal and pelvic organs leads to the formation of adhesions and associated complications in long term. To avoid such risks, the use of anti-adhesion barrier agents is necessary. Derivatives are recognized as the most effective anti-adhesive agents in obstetrics and gynecology. hyaluronic acid(GK). The American Association of Laparoscopic Gynecological Surgeons recommends the use of barrier anti-adhesion agents (gels), which include HA, after any intrauterine interventions, since these agents have been proven to significantly reduce the risk of adhesions in the uterine cavity.
The use of gel forms of anti-adhesive agents is most preferable during intrauterine surgery, since the gel is evenly distributed throughout the entire sphere, filling congruent surfaces and hard-to-reach areas in the uterine cavity. The gels are easy to use and form a thin film on the surface of the organ, which acts as an anti-adhesion barrier during intensive tissue healing. Therefore, to prevent relapse after adhesiolysis, gel-like fillers are introduced into the uterine cavity to prevent contact between its walls, thus preventing the formation of an IUD. The most widely used barriers are made from biodegradable materials that are completely eliminated from the body.
The main component of such barriers is HA (a disaccharide molecule); it is present in the body as a natural component of the extracellular matrix. HA has been proposed as a barrier agent to prevent adhesion and has demonstrated beneficial biological properties. The mechanism of action of GC is realized at a very early stage of tissue healing (the first 3–4 days) by suppressing the adhesion of fibroblasts and platelets, the activity of macrophages, as well as by inhibiting fibrin formation and creating a protective barrier on the damaged tissue area. The half-life of HA is about 1–3 days. It is completely broken down in the body within 4 days using the enzyme hyaluronidase.
Another anti-adhesive component called carboxymethylcellulose (CMC) is a high molecular weight polysaccharide that also serves as an effective anti-adhesive agent. CMC is non-toxic and non-carcinogenic. In the food industry it is used as a thickener, filler and food additive. In surgery, CMC is used as a substrate to fix and prolong the action of HA on the tissue surface. Acts as a mechanical barrier.
The combination of highly purified sodium salt of HA with CMC in the form of a gel (Antiadgesin® (Genuel Co., Ltd., Korea)) is intended for the prevention of adhesions after any operations on organs and tissues where there is a risk of adhesions, including after intrauterine operations. According to a prospective randomized study by J.W. Do et al., development of intrauterine adhesions after 4 weeks. after interventions, it was noted 2 times less often in the group with postoperative use of Antiadgesin than in the control group: 13% versus 26%, respectively. The anti-adhesive gel has favorable characteristics: convenience and ease of use, the possibility of use during intrauterine, open and laparoscopic interventions, the duration of the anti-adhesive effect (up to 7 days), the ability to be absorbed (biodegradable), safety, immunocompatibility, inertness (the gel is not a source of infection, fibrosis, angiogenesis, etc.), has a barrier (discriminating) effect. In addition, Antiadhesin® gel has an optimal degree of fluidity and viscosity, which allows it to envelop anatomical formations of any shape, creating a gel film fixed to the wound surface, and also does not affect the normally occurring regeneration processes and meets all established quality standards.
It should be remembered that prevention of IUDs is always more useful and easier than treatment. To this end, it is important to avoid any trauma to the uterus, especially during pregnancy and the postpartum period. If there are changes in the uterine cavity in the postpartum period or after an abortion, GS should be considered as an effective method for diagnosing and monitoring treatment, since it is preferable to conventional uncontrolled, blind curettage.

Clinical example No. 1

Patient Ya., 28 years old. Complaints of cyclical pain in the lower abdomen, secondary amenorrhea throughout the year. From the anamnesis: in February 2014 - urgent spontaneous birth, manual separation of the placenta. In March 2014, due to uterine bleeding and remnants of placental tissue, curettage of the walls of the uterine cavity was performed. After 2 weeks Ultrasound revealed the remains of placental tissue, and therefore repeated curettage of the walls of the uterine cavity was performed. After 5 months cyclical pain appeared in the lower abdomen, menstruation was absent. Ultrasound data revealed massive synechiae of the uterine cavity and signs of hematometra. In March 2015, HS and resection of extensive intracervical and intrauterine synechiae were performed under endotracheal anesthesia. The procedure was carried out under ultrasound control. When restoring the uterine cavity, a section of functioning endometrium was identified in the area of ​​the left tubal angle. During the period of expected menstruation, the patient noted the appearance of spotting. At control office HS after 2 months. A recurrence of synechiae was detected only in the uterine cavity, and they were dissected. In order to prevent the formation of synechiae, cyclic hormonal therapy was prescribed using drugs for menopausal hormone therapy(dydrogesterone + estradiol, 2/10). Subsequently, the patient underwent 3 office HSs at an interval of 2 months, during which the adhesions of the uterine cavity were dissected using endoscopic scissors. Upon completion of the operation, Antiadgesin® gel was injected into the uterine cavity. The patient noted the restoration of the normal menstrual cycle. According to ultrasound, no pathology of the uterine cavity was detected. During the control office HS, the uterine cavity had normal shape, the mouth of the left fallopian tube was visualized without any features, the mouth of the right fallopian tube was not clearly visualized. The endometrium corresponded to the phase of the menstrual cycle. After 6 months after office HS, a spontaneous pregnancy occurred, which ended with a planned cesarean section at 38 weeks due to complete placenta previa.

Clinical example No. 2

Patient A., 34 years old , was admitted to the clinic with complaints of hypomenorrhea and recurrent miscarriage. From the anamnesis: in 2010 - urgent spontaneous birth. The postpartum period was complicated by endometritis, and therefore the walls of the uterine cavity were curetted. The menstrual cycle was restored after 2 months. according to the type of hypomenorrhea. In 2015, for a period of 5–6 weeks. A non-developing pregnancy was diagnosed, for which curettage of the walls of the uterine cavity was performed. After 2 months Ultrasound revealed synechiae of the cervical canal and uterine cavity. Hysteroresectoscopy (HRS), dissection of synechiae of the cervical canal and uterine cavity was performed. Subsequently, two office GPs were performed with an interval of 1 month, during which the IUD was dissected. A month later, spontaneous pregnancy occurred, but at 7–8 weeks. was again diagnosed as non-developing, and therefore the patient underwent another curettage of the walls of the uterine cavity. In our clinic, the patient underwent office HS, dissection of the IUD, followed by the introduction of Antiadgesin® anti-adhesion gel. After 2 months a spontaneous pregnancy occurred, which at full term ended in a planned cesarean section due to the transverse position of the fetus and the low location of the placenta.

Clinical example No. 3

Patient T., 37 years old, was admitted to the clinic with complaints of pain in the lower abdomen and lack of menstruation. From the anamnesis: the patient underwent 2 emergency caesarean sections due to pregnancies achieved through IVF ( male factor). The postpartum period of the last pregnancy was complicated by hematometra, suspected endometritis, and therefore a diagnostic curettage. Menstrual function was not restored, and cyclic pain in the lower abdomen was observed. The patient underwent GRS, excision of synechiae of the uterine cavity and cervical canal with the prescription of hormonal therapy for 3 months. Menstruation has returned - scanty, within 1-2 days. During the subsequent 2 control office GS, after excision of recurrent synechiae, the anti-adhesion gel Antiadgesin® was introduced into the uterine cavity. Currently, the patient has no complaints, menstruation is regular for 4 days, and she does not plan pregnancy.

Conclusion

Over the course of a century, great progress has been made in the diagnosis and treatment of IUDs, resulting in HS becoming the “gold standard” for the diagnosis and treatment of IUDs. In other cases, repeated (third, fourth, etc.) interventions may be required, which do not always end desired result. The use of anti-adhesion gel based on hyaluronic acid and carboxymethylcellulose in combination with hormonal treatment is a modern innovative method for the prevention of intrauterine adhesions with high percentage success. Women who become pregnant after IUD treatment are subject to careful monitoring due to the high risk of a number of obstetric complications. Future studies should be aimed at studying the cellular and molecular aspects of endometrial regeneration, as well as prevention measures for primary and recurrent postoperative IUDs.

Literature

1. Fritsch H. Ein Fall von volligen Schwund der Gebaumutterhohle nach Auskratzung // Zentralbl Gynaekol. 1894. Vol. 18. P. 1337–1342.
2. Bass B. Ueber die Verwachsungen in der cervix uterinach curettage // Zentralbl Gynakol. 1927. Vol. 51. P. 223.
3. Stamer S. Partial and total atresia of the uterus after excochleation // ActaObstet Gynecol Scand. 1946. Vol. 26. P. 263–297.
4. Renier D., Bellato P., Bellini D. et al. Pharmacokinetic behavior of ACP gel, an autocrosslinked hyaluronan derivative, after intraperitoneal administration // Biomaterials. 2005. Vol. 26(26). P. 5368.
5. Pellicano M., Guida M., Zullo F. et al. Carbon dioxide versus normal saline as a uterine distension medium for diagnostic vaginiscopie hysteroscopy in infertile patients: a prospective, randomized, multicenter study // Fertil Steril. 2003. Vol. 79. P. 418–421.
6. Schenker J.G., Margalioth E.J. Intrauterine adhesions: an updated appraisal // Fertil Steril. 1982. Vol. 37. P. 593–610.
7. Wamsteker K. Intrauterine adhesions (synechiae). In: Brosens I,Wamsteker K, eds. Diagnostic imaging and endoscopy in gynecology: a practical guide. London: WB Saunders, 1997, pp. 171–184.
8. Al-Inany H. Intrauterine adhesions. An update // Acta Obstet Gynecol Scand. 2001. Vol. 80. P. 986–993.
9. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, M€ ullerian anomalies and intrauterine adhesions // Fertil Steril. 1988. Vol. 49. P. 944–955.
10. Pace S., Stentella P., Catania R. et al. Endoscopic treatment of intrauterine adhesions // Clin Exp Obstet Gynecol. 2003. Vol. 30. P. 26–28.
11. Yu D., Wong Y., Cheong, Y. et al. Asherman syndrome – one century later // Fertility and Sterility. 2008. Vol. 89(4). P. 759–779.
12. Zupi E., Centini G., Lazzeri L. Asherman syndrome: an unsolved clinical definition and management // Fertil Steril. 2015. Vol. 104. P. 1561–1568.
13. March C.M. Intrauterine adhesions // Obstet Gynecol Clin North Am. 1995. Vol. 22. P. 491–505.
14. Amer M.I., El Nadim A., Hassanein K. The role of intrauterine balloon after operative hysteroscopy in the prevention of intrauterine adhesion: a prospective controlled study // MEFS J. 2005. Vol. 10. P. 125–129.
15. Wood J., Pena G. Treatment of traumatic uterine synechias // Int J Fertil. 1964. Vol. 9. P. 405–410.
16. The Use of Adhesion Prevention Agents in Obstetrics and Gynaecology, RCOG // Scientific Impact Paper. 2013. Vol.39. P. 6.
17. AAGL Practice Report: Practice Guidelines for Management of Intrauterine Synechiae. 2013. P. 8.
18. Directory of drugs RLS. Anti-adhesin gel, absorbable, sterile, anti-adhesion // Internet resource: http://www.rlsnet.ru/pcr_tn_id_81752.htm.
19. Do J.W. The effectiveness of Hyaluronic acid + Sodium Carboxymethyl Cellulose in the prevention of intrauterine adhesion after intrauterine surgery // J of Korean Gynecologic Endoscopy and Minimally Invasive Surgery. 2005. Vol. 17. P. 2.


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