Treatment of synechia in the uterus. Intrauterine synechia. Reasons for the formation of intrauterine synechia

The term "synechia" is derived from the Greek syn-echein, which means "connection", "connection", "continuity". These medical concepts with philosophical overtones in practice denote pathological processes in various organs.

In women of reproductive age, synechia in the uterus leads to severe complications and leaves negative consequences.

About pathology - definition and classification

Synechia that occurs in the uterine cavity are strands and bridges of connective tissue that connect sections of the internal cavity of the reproductive organ. Classification of synechia by morphology and histological structure:

Lungs.

They consist of a thin layer of basal endometrium.

Medium.

They consist of endometrial-covered tissues of the fibrous and muscular layer of the uterine membranes, tightly attached to the endometrium.

Heavy.

Strong strands consist of connective tissue, have a dense structure, and are difficult to dissect during surgical procedures.

Classification of the process according to the degree of involvement of the structures of the uterus:

  • No more than ¼ of the internal area of ​​the organ is involved in the pathological process, the bottom and passages of the fallopian tubes are free;
  • Synechiae occupy 3/4 of the internal cavity of the uterus, the walls of the organ stick together, partial occlusion is observed in the openings of the fallopian tubes;
  • The entire uterine cavity is affected by the pathological process.

International classification according to the degree of damage and the level of cavity filling, used in surgical endoscopic intervention:

  • Thin synechia, easily destroyed during hysteroscopy;
  • Single dense films;
  • 2a. Synechia is localized in the uterine pharynx, the upper part of the uterine cavity is not affected;
  • A large number of dense areas are diagnosed, the mouths of the fallopian tubes are involved in the process;
  • In addition to the above signs, partial occlusion of the uterine cavity is diagnosed;
  • The above symptoms are accompanied by scars on the inner walls of the organ.

In rare cases, single adhesions are diagnosed, located randomly in different parts of the uterus.

The most common symptom that a pathological process has arisen in the uterus is pain. They intensify during exercise, during menstruation and during the adoption of a certain posture.

The pain has a different character, it can be sharp or aching, aggravated by movement or physical inactivity. Additionally, urination and defecation disorders, infertility or problems with carrying a pregnancy in the early stages are diagnosed.

Why do synechias occur

In most cases, synechiae are formed in the uterine cavity as a result of injury to the basal layer of the endometrium. After an injury, a response occurs - the main connective tissue protein collagen is synthesized in large quantities and fibroblasts are activated.

Causes of mechanical or other effects that provoke the formation of synechia:

  • Scraping;
  • The consequences of surgery;
  • The presence of the Navy;
  • Remains of the fetal egg left after an abortion;
  • Intrauterine administration of drugs.

In addition, adhesions and synechia in the uterine cavity occur as a complication of chronic or tuberculous endometritis.

Possible problems

As a result of the formation of synechia, the menstrual and reproductive functions of the female body are disturbed. The following abnormalities of cyclic bleeding from the norm are most often diagnosed:


  • Violation of the intensity and duration of menstruation;
  • Complete absence of menstruation;
  • The formation of a hematometra (accumulation of blood) in the uterus when the opening of the cervical canal is blocked and the endometrium remains active, accompanied by cramping pain and a feeling of heaviness in the lower abdomen;
  • The development of the inflammatory process (pyometra, endometritis).

Reproductive disorders:

  • Difficulties with implantation of the embryo due to a deficiency in the uterine cavity of a normally functioning endometrium;
  • The impossibility of fertilization of the egg by spermatozoa during fusion of the mouths of the fallopian tubes;
  • Obstetric complications during pregnancy: placenta previa, spontaneous abortion, premature birth;
  • Problems during IVF due to changes in the functional layer of the endometrium and a decrease in its area.

Violation of the normal course of pregnancy occurs due to the fact that synechia prevent an increase in the uterine cavity, fixing it in the same position. Since the fetus grows, and the uterus does not stretch, this circumstance leads to the appearance of severe pain, hypertonicity of the uterus.

If these symptoms are ignored, miscarriage occurs, in difficult cases - uterine rupture. In the period before the onset of a miscarriage or before a medical abortion, synechia and adhesions deform the fetal egg, limiting its growth, interfering with full development.

Methods of instrumental diagnostics and removal of synechia


Before starting the treatment of strands and adhesions in the uterine cavity, it is necessary to clarify the diagnosis, because the clinical picture of the pathology does not differ in specific symptoms that are unique to this disease.

For this, the following instrumental methods are used:

Hysterosalpingography.

X-ray of the uterine cavity with contrast, with the disease, defects in the filling of the organ are fixed.

Ultrasound of the uterus.

Not the most reliable method, its information content is only 65%.

echohysterosalpingoscopy.

The accuracy of the method is 96%, synechiae are visualized as hyperechoic inclusions.

Hysteroscopy.

It can be used as a diagnostic and therapeutic manipulation at the same time, it is carried out in the first phase of the menstrual cycle against the background of a thin endometrium.

The main method by which the pathology is treated radically is the removal of synechiae surgically. The peculiarity of such an operation is that additional trauma to the endometrial mucosa can lead to a deterioration in the patient's condition.

Synechia is removed during hysteroscopy under visual control of the endoscope. The cords are dissected using an electric or laser knife, hystero- or resectoscope, surgical scissors.

After surgical procedures, the endometrium is restored with hormonal preparations based on a combination of progestogen and estrogen. The inflammatory process is treated with antibiotics, selected after diagnosing the sensitivity of microflora to them. Immunomodulators based on interferon are used to increase immunity.

Additional therapeutic methods used in the early stages of the disease and during the recovery postoperative period:

Gynecological massage.

Stretches thin adhesions, eliminating discomfort, not effective for infertility.

Physiotherapy with high frequency currents.

Promotes stretching of medium ligaments and resorption of thin synechiae.

Physiotherapy.

Exercises are mastered under the guidance of a doctor, help stretch thin synechiae and eliminate discomfort.

6 months after the removal of synechiae and a follow-up examination, pregnancy can be planned. In this case, 4 cycles of normal ovulation should be recorded, and ultrasound of the uterus confirms the normal state and functioning of the endometrium.

Intrauterine synechia are fusions of the tissues of the cavity with each other, which entails partial or complete infection of the entire uterus. It is imperative to eliminate such a problem, otherwise a woman is unlikely to be able to become pregnant and bear a healthy fetus. Therefore, the removal of synechia in the uterus must be done promptly and with the help of a qualified doctor.

Reasons for the formation of synechia

There are a number of specific factors that can provoke the formation of synechia in the uterine cavity of any woman.

We list these reasons:

  • Mechanical damage. They can be triggered by abortion (rough curettage of the fetus), severe pregnancy, removal of benign formations, conization of the cervix, metroplasty, surgery on the walls of the uterus, improper placement of the intrauterine device, etc.
  • Infectious and inflammatory processes. Endometritis, the chronic course of the development of chlamydia and other diseases will become a clear reason for the degeneration of the endometrial layer and the formation of synechia.
  • Frozen pregnancy. Remnants of placental tissue cause fibroblast activation and collagen formation to produce synechia in the uterine cavity.

As you can see from the list, there are plenty of reasons for getting such an unpleasant ailment. But most importantly, the initial stage of the formation of synechia is invisible to a woman and it is very important to contact the clinic at the first unpleasant symptoms to provide qualified medical care.

Symptoms of the disease

It is possible to identify the fusion of uterine tissues with the help of a preventive gynecological examination, so every woman should not neglect the golden rule: 2 times a year, you must definitely visit a gynecologist. Also, one of the visible symptoms of the disease is the meager course of menstruation or its complete absence. The cessation of the menstrual cycle threatens with the accumulation of menstrual blood in the uterus, which will lead to disastrous consequences.

Also, the last stages of the course of the disease, a woman may feel unpleasant pain in the abdomen.

Stages of disease development

It is used in the treatment of synechia to identify a varying degree of prevalence and employment of the uterine cavity.

There are 3 stages of the development of the disease:

  • There are thin adhesions, ¼ of the volume of the uterine cavity is involved.
  • Adhesions have a denser structure, but there is no adhesion of the walls yet, up to ¾ of the uterine cavity is involved.
  • Dense adhesions are observed, more than ¾ of the uterine cavity is involved.

The last stage is very dangerous and threatens the woman with infertility.

Diagnostics

It is possible to start treatment of synechia only after their thorough diagnosis. The patient will need to perform an ultrasound, hysterosalpingography (x-ray of the uterus) and hysteroscopy (examination of the uterus with a tiny video camera that is inserted into the woman's vagina). After receiving all the results of the study, the doctor will prescribe the correct and effective treatment.

Treatment

Removal of synechia in the uterus occurs using a hysteroscope or endoscopic instruments. Removal of synechia of the uterine cavity is a painless procedure.

The hysteroscope is used if the synechiae have the first degree of damage to the uterine cavity. The hysteroscope is inserted into the vagina and thin and tender adhesions are carefully dissected with the body of the device. In this case, the procedure is very safe, painless and not accompanied by bleeding.

Endoscopic instruments, such as microscissors, are used by the doctor when removing grade 2 and 3 synechiae. Medical manipulation does not require the use of general anesthesia. The essence of the procedure is as follows: microscissors are passed through the channels of the endoscopic installation and, with special care, so as not to cause additional harm to the uterus, the neoplasms are dissected. Such an operation requires a high qualification of the attending physician, since the dissection of synechia of the 2nd and 3rd degree is fraught with the occurrence of profuse bleeding.

In order to avoid recurrences at the end of the procedure, a special gel-like filler is injected into the uterine cavity of women. It will help to avoid re-growth of the walls and the formation of adhesions. Hysteroresectoscopy of synechia in the uterine cavity is performed on the eve of menstruation.

Postoperative period

In the postoperative period, it is mandatory to take antimicrobial drugs to prevent the onset of an inflammatory and infectious process. Also, the attending physician, in addition to antibiotics, will prescribe hormonal therapy for the fastest recovery of the female body without the appearance of unwanted side effects.

After a short time after the procedure, a woman will need to visit a gynecologist without fail for a second hysteroscopy. It will help determine the condition of the uterine cavity after removal of synechiae, evaluate the results of treatment and avoid recurrence.

Do I need to remove intrauterine synechia? Of course yes! And the faster the better. In whom synechia of the uterine cavity was found, reviews after the treatment always turn into two strips on the gavidar test!

Intrauterine adhesions (IUDs) are still a major medical and social problem with a poor prognosis in terms of fertility and quality of life, in particular in patients of 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 mechanism for the formation of the IUD is an injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or in the postpartum period. Due to the development of intrauterine surgery, resectoscopic interventions are increasingly used for the treatment of IUDs: myomectomy, removal of the intrauterine septum, etc. Hysteroscopy is used as the main method for diagnosing and treating IUDs in order to normalize the menstrual cycle and restore fertile function. When pregnancy occurs after the treatment of Asherman's syndrome, there remains a high risk of such terrible complications as spontaneous miscarriage, premature birth, intrauterine growth retardation of the fetus, placental pathology, etc. The use of an anti-adhesion gel containing hyaluronic acid and carboxymethylcellulose (Antiadgesin®) helps to reduce recurrence of the IUD after their separation.

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

For citation: Popov A.A., Manannikova T.N., Alieva A.S., Fedorov A.A., Bespalova A.G. Intrauterine synechia: a century later // RMJ. 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 quote: 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 synechia

Introduction

For the first time, intrauterine synechia (IUD) was described in 1894 by Fritsch H. in a patient with secondary amenorrhea that developed after curettage in the postpartum period. After 33 years, Bass B. diagnosed cervical atresia in 20 out of 1500 women examined after a medical abortion. In 1946, Stamer S. added 24 cases from his own experience to the 37 cases described in the literature. In 1948, Joseph Asherman published a number of articles in which he first indicated the frequency of the IUD, described in detail the etiology, symptoms, and also presented the X-ray picture of the IUD. After his publications, the term "Asherman's syndrome" has been used to describe the IUD until the present day. Despite the fact that synechia has been known for more than a century, the problem still remains unresolved, and work is currently underway to find measures for the prevention, diagnosis and treatment of this pathology.
The trigger for the formation of the IUD is an injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or in the postpartum period. Despite the fact that Asherman's syndrome has been described after curettage for obstetric conditions, other causes of IUD have now been established. Thus, an increase in the number of intrauterine interventions for submucosal myomatous nodes, anomalies in the development of the uterus, etc., gave another group of patients predisposed to the formation of an IUD.
The role of infection in the development of the IUD is controversial. While some authors believe that infections are not involved in the formation of the IUD, 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 IUDs, the picture during hysteroscopy (HS) can be different: from loose, single adhesions to complete obliteration of the uterine cavity with dense synechiae. A number of authors claim that the critical 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 may involve different layers of both the endometrium and the myometrium. Adhesions of these tissues are hysteroscopically manifested by a characteristic picture: endometrial adhesions are similar to the surrounding healthy tissue, myofibral adhesions are the most common, characterized by a superficial thin layer of the endometrium with multiple glands.
Menstrual dysfunction, including hypomenorrhea and amenorrhea, remain common clinical manifestations of IUDs. With IUD, amenorrhea can be caused by various etiological factors: endocervical adhesions leading to obstruction of the cervical canal, extensive adhesions in the uterine cavity due to destruction of the basal layer of the endometrium. With obstructive amenorrhea, patients experience cyclic discomfort or pain in the lower abdomen, hematometer, and even hematosalpinx. Dysmenorrhea and infertility are also noted. Compared with amenorrhea and infertility, miscarriage is a milder complication of the IUD. Possible etiological factors include: reduction of the uterine cavity, lack of sufficient normal endometrial tissue for implantation and support of the placenta, inadequate vascularization of the functioning endometrium due to fibrosis, etc. In a study by Schenker J.G., Margalioth E.J. 165 pregnancies were observed in women with untreated Asherman's syndrome. The frequency of spontaneous miscarriage was 40%, premature birth 23%, timely delivery 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 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 detected above the adhesions, 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 synechia 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 a central IUD 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 cavity of the uterine body.

IUD Diagnostics

Hysterosalpingography (HSG) before the invention of the hysteroscope was and still is the method of choice for many gynecologists. HSG is able to assess the shape of the uterine cavity and the condition of the fallopian tubes. Wamsteker K. described the HSG picture in IUD as filling defects with sharply defined boundaries, with a centralized and / or parietal location.
Due to its non-invasiveness, ultrasound is widely used both for diagnostic and, intraoperatively, with an auxiliary purpose.
Sonohysterography combines ultrasound with intrauterine administration of isotonic saline. If one or more echogenic areas are identified between the anterior and posterior walls of the uterine cavity, an IUD can be suspected.
The main advantage of MRI is the visualization of proximal adhesions in the uterine cavity and the assessment of the state of the endometrium, which is necessary to resolve the issue of further management of the patient. MRI plays a supporting role in diagnosing complete obliteration of the uterine cavity when hysteroscopic imaging is not possible.
Thanks to direct imaging in HS, it is possible to more accurately confirm the presence and assess the degree of adhesions in the uterine cavity. Al-Inany H. described various types of intrauterine adhesions that are visualized with a hysteroscope: 1) central adhesions look like columns with expanded ends and connect 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 asymmetric shape; 3) multiple adhesions that divide the uterine cavity into several smaller cavities.
None of the IUD classifications take into account clinical manifestations, features of menstrual function. Of all the known classifications, the classification of the American Fertility Society (AFS) of 1988 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 the recurrence of adhesions. Over the past century, various treatments have been described.
1. Expectant tactics. Schenker and Margalioth followed up 23 women with amenorrhea who did not receive surgical treatment, 18 of them recovered a regular menstrual cycle in the period from 1 to 7 years.
2. Blind dilation 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, D. Asherman proposed hysterotomy to separate the IUD. In the analysis of 31 cases of hysterotomy, 16 women (52%) became pregnant, 8 (25.8%) of whom delivered safely. However, this treatment method 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 synechia, there is a lower risk of perforation of the uterus and destruction of the basal layer of the endometrium compared with the use of various types of energy. However, energy-assisted intrauterine surgery can enable efficient and precise cutting as well as guarantee hemostasis by providing optical transparency to the operating field.
The efficacy and safety of surgical treatment of Asherman's syndrome can be improved if GS 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 control 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 being used for hysteroscopic separation of intrauterine adhesions and significantly reduces the risk of uterine perforation.
Surgical success can be judged by the restoration of the normal anatomy of the uterine cavity, the restoration of menstrual function, the onset of pregnancy and live birth. It is noted that the restoration of the normal uterine cavity after the first procedure is 57.8–97.5%. However, the reproductive outcome depends not only on the state of the uterine cavity, but also on the state 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 frequency of relapses in the range of 3.1–28.7% is typical for all cases of adhesions and 20–62.5% for widespread adhesions.
Since IUD recurrence occurs in the early postoperative period, prophylaxis after surgery is important and is carried out by various methods.

Prevention of IUD recurrence

Intrauterine contraceptives have been widely used as a method to prevent recurrence of the IUD. In a literature review March C.M. concluded that T-shaped intrauterine devices have too little surface area to prevent adhesion of the walls of the uterine cavity. There is evidence in the literature on the use of a Foley catheter inserted into the uterine cavity for several days after adhesion lysis to prevent recurrence. In a prospective controlled study, Amer M.I. et al. evaluated the effectiveness of this method by leaving the Foley catheter in the uterine cavity for one week after surgery in 32 patients. Diagnostic HS was performed within 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 non-balloon group (9 of 18; 50%). However, the use of 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 reduced blood flow to the uterine wall and adverse effects on endometrial regeneration. In addition, this method can create significant discomfort for the patient.
J. Wood and G. Pena proposed the use of estrogen to stimulate the regeneration of the endometrium on injured surfaces. In a randomized trial, 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 vs. 0.67 cm; P1/4.02) and endometrial volume (3.85 cm2 vs. 1.97 cm2) were statistically significantly greater than in the control group. These data suggest that hormone replacement therapy significantly increases the thickness and volume of the endometrium, stimulating repair and cyclic transformation.
In the recommendations of the Royal College of Obstetricians and Gynecologists on the prevention of adhesions, it is noted that any surgical intervention on the organs of the abdomen and pelvis leads to the formation of adhesions and related complications in the long-term period. To avoid such risks, the use of anti-adhesion barrier agents is necessary. Hyaluronic acid (HA) derivatives are recognized as the most effective antiadhesion agents in obstetrics and gynecology. The American Association of Laparoscopic Gynecological Surgeons recommends the use of barrier antiadhesions (gels), which include HA, after any intrauterine interventions, since it has been proven that these agents significantly reduce the risk of adhesions in the uterine cavity.
The use of gel forms of antiadhesion agents is most preferred in intrauterine surgery, since the gel is evenly distributed over the entire sphere, filling congruent surfaces and hard-to-reach areas in the uterine cavity. The gels are easy to use, they form a thin film on the surface of the organ, which acts as an anti-adhesion barrier during intensive tissue healing. Therefore, to prevent recurrence after adhesiolysis, gel-like fillers are introduced into the uterine cavity, preventing the contact of its walls, thus preventing the formation of an IUD. The most widely used barriers are made of biodegradable materials, which are completely excreted 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 shown beneficial biological properties for the body. The mechanism of action of HA 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 the formation of fibrin and creating a protective barrier on the damaged tissue area. The half-life of HA is about 1-3 days. Completely split in the body within 4 days with the help of the enzyme hyaluronidase.
Another anti-adhesive component called carboxymethyl cellulose (CMC) is a high molecular weight polysaccharide that also serves as an effective anti-adhesion agent. CMC is non-toxic, non-carcinogenic. In the food industry, it is used as a thickener, filler and food additive. In surgery, CMC is used as a substrate for fixing and prolonging 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 adhesion formation after any operations on organs and tissues where there is a risk of adhesion formation, 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 Antiadhesin than in the control group: 13% versus 26%, respectively. The anti-adhesion gel has favorable characteristics: convenience and ease of use, the possibility of using it for intrauterine, open and laparoscopic intervention, the duration of the anti-adhesion effect (up to 7 days), the ability to resolve (biodegradation), safety, immunocompatibility, inertness (the gel is not a focus of infection, fibrosis, angiogenesis, etc.), has a barrier (delimiting) 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 normal regeneration processes and meets all established quality standards.
It should be remembered that IUD prevention is always more useful and easier than treatment. To this end, it is important to avoid any injury to the uterus, especially during pregnancy and the postpartum period. In the presence of changes in the uterine cavity in the postpartum period or after abortion, GS should be considered as an effective method for diagnosis and treatment control, since it is preferable to conventional uncontrolled, blind curettage.

Case Study #1

Patient Ya., 28 years old. Complaints of cyclic pain in the lower abdomen, secondary amenorrhea during the year. From the anamnesis: in February 2014 - urgent spontaneous delivery, manual separation of the placenta. In March 2014, curettage of the walls of the uterine cavity was performed due to uterine bleeding and remnants of placental tissue. After 2 weeks ultrasound revealed the remains of placental tissue, in connection with which the repeated curettage of the walls of the uterine cavity was performed. After 5 months there were cyclic pains in the lower abdomen, menstruation was absent. Ultrasound revealed massive synechia of the uterine cavity, signs of hematometra. In March 2015, HS was performed under endotracheal anesthesia, resection of extensive intracervical and intrauterine synechiae. The procedure was performed under ultrasound guidance. During the restoration of the uterine cavity, a section of the functioning endometrium was identified in the region of the left tubal angle. During the period of the expected menstruation, the patient noted the appearance of spotting spotting. With the control office HS after 2 months. a recurrence of synechiae was revealed only in the uterine cavity, and they were dissected. In order to prevent the formation of synechia, cyclic hormone therapy was prescribed using drugs for menopausal hormone therapy (dydrogesterone + estradiol, 2/10). In a subsequent patient, 3 office HSs were performed with an interval of 2 months, during which the adhesions of the uterine cavity were dissected using endoscopic scissors. Upon completion of the operation, Antiadhesin® 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 found. During the control office GS, the uterine cavity had a normal shape, the mouth of the left fallopian tube was visualized without 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 an office HS, a spontaneous pregnancy occurred, which ended with a planned caesarean section at the 38th week due to complete placenta previa.

Case Study #2

Patient A., 34 years old , was admitted to the clinic with complaints of hypomenorrhea, recurrent miscarriage. From the anamnesis: in 2010 - urgent spontaneous delivery. The postpartum period was complicated by endometritis, in connection with which the walls of the uterine cavity were scraped. The menstrual cycle was restored after 2 months. 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 synechia of the cervical canal and uterine cavity. Performed hysteroresectoscopy (HRS), dissection of synechia of the cervical canal and uterine cavity. Subsequently, two office HSs were made with an interval of 1 month, during which the IUD was dissected. A month later, a spontaneous pregnancy occurred, but in the period of 7-8 weeks. was again diagnosed as non-developing, in connection with which 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 anti-adhesion gel Antiadhesin®. After 2 months spontaneous pregnancy occurred, which at full term ended in a planned caesarean section due to the transverse position of the fetus and the low location of the placenta.

Case Study #3

Patient T., 37 years old, was admitted to the clinic with complaints of pain in the lower abdomen, lack of menstruation. From the anamnesis: the patient underwent 2 emergency caesarean sections for pregnancies that occurred through IVF (male factor). The postpartum period of the last pregnancy was complicated by hematometra, suspected endometritis, in connection with which diagnostic curettage was performed. Menstrual function was not restored, there were cyclic pains in the lower abdomen. The patient underwent HRS, excision of the synechia of the uterine cavity and cervical canal with the appointment of hormone therapy for 3 months. Restored menstruation - meager, within 1-2 days. At the next 2 control office GS after excision of recurrent synechiae, antiadhesion gel Antiadhesin® was introduced into the uterine cavity. Currently, the patient has no complaints, menstruation is regular for 4 days, pregnancy is not planned.

Conclusion

During the century, great progress has been made in the diagnosis and treatment of IUDs, as a result of which HS has become 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 with the desired result. The use of an anti-adhesion gel based on hyaluronic acid and carboxymethylcellulose in combination with hormonal treatment is a modern innovative method for preventing intrauterine adhesion formation with a high success rate. Women who become pregnant after IUD treatment are subject to close monitoring due to the high risk of a number of obstetric complications. Future research should focus on the cellular and molecular aspects of endometrial regeneration, as well as measures to prevent primary and recurrent postoperative IUDs.

Literature

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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.
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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.
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16. The Use of Adhesion Prevention Agents in Obstetrics and Gynaecology, RCOG // Scient Impact Paper. 2013. Vol.39. P.6.
17. AAGL Practice Report: Practice Guidelines for the Management of Intrauterine Synechiae. 2013. P. 8.
18. Directory of drugs RLS. Sterile absorbable anti-adhesion gel // 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.


Intrauterine synechia are found 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 infection. 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 synechia is diagnosed in almost every second.

Causes of the disease

Currently, infectious, traumatic and neurovisceral causes of intrauterine synechia are distinguished. One of the main factors is the previous traumatization of the basal layer of the endometrium. This occurs, as a rule, due to 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", adhesions are formed.

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 in genital tuberculosis, its presence is confirmed by bacteriological examination or endometrial biopsy. It should be borne in mind that intrauterine instillations, radiotherapy for tumors of the uterus or ovaries can be an unfavorable factor that increases the risk of developing the disease.

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 synechia become more diverse. The patient has pain in the lower abdomen, the intensity of which increases on critical days. At the same time, the duration of menstruation decreases, they become scarce, in severe cases, amenorrhea develops (absence of menstruation in women of childbearing age). Infection of the lower section in the uterus with a normally functioning endometrium in the upper part leads to a violation of the outflow of blood, as a result of which a hematometer may develop. The clinic at the same time resembles a picture of an acute abdomen, in this situation the patient needs emergency surgical care.

With extensive lesions in the uterine cavity with insufficiently functioning endometrium, difficulties arise in the implantation of the fetal egg. By the way, one of the reasons for the ineffectiveness of IVF - in vitro fertilization - are even mild adhesions. It should be borne in mind that intrauterine synechia is often accompanied by endometriosis (adenomyosis), which negatively affects the prognosis of treatment.

Often, patients experience symptoms of intoxication, manifested by weakness, muscle pain, heart palpitations, and emotional instability.

Classification

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

Complications

As a result of the lack of a functioning endometrium, as well as the resulting adhesions, the fetal egg cannot attach to the wall of the uterus. In addition, the fertilization process itself can be disrupted due to overgrowth of the fallopian tubes. In 30% of patients with diagnosed synechia, spontaneous abortion occurs, and in 30% of women, premature birth occurs. Often there are pathologies of the placenta. Thus, the complications of intrauterine synechia are very numerous, and pregnancy in such women is associated with a high risk. But, in addition to miscarriage, there is a possibility of postpartum hemorrhage.

Diagnostics

Currently, there is no unified survey algorithm. However, according to most doctors, the diagnosis of intrauterine synechia should begin with hysteroscopy; in case of a doubtful result, hystersalpingography is recommended.

  • Hysteroscopy - 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 to conduct, if necessary, a biopsy or surgical intervention. This minimally invasive procedure is virtually painless and less traumatic and can be done under local or general anesthesia. The likelihood of complications after hysteroscopy is minimal.
  • Hysterosalpingography - in some cases more effective than hysteroscopy. With dense, multiple synechia, dividing the uterine cavity into chambers of various sizes, and interconnected by ducts, it is this study that is more informative. However, deformation of the uterine cavity, the presence of mucus and fragments of the endometrium, etc., in some cases can lead to a 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 a possible pathology.
  • Negative hormonal tests - when prescribing progesterone and estrogen, there is no menstrual bleeding.

Treatment of intrauterine synechia

The goal of therapy is the elimination of adhesions in the uterus, the restoration of menstrual and reproductive functions. It must be emphasized that it is possible to decide how to treat intrauterine synechia only after a thorough examination. Today, the only method of treatment is the dissection of synechiae. The nature of the operation depends on the type of adhesions, as well as on the degree of damage. Weak synechiae are dissected with endoscopic forceps, scissors or a hysteroscope body; an electric knife or a 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 the operation, hormone therapy is indicated, the task of which is to restore the endometrium. In the event that intrauterine synechia arose as a result of an infection, then after a biopsy and bacteriological examination, antibacterial drugs are prescribed.

Mild to moderate disease responds well to treatment. 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 a few simple rules:

  • Use of competent methods of contraception to prevent abortions
  • Intrauterine manipulations are best done in clinics with modern equipment and qualified specialists.
  • Timely treatment of urinary tract infections

It should be borne in mind that in some patients, after the treatment, there is a risk of relapse, especially with dense widespread adhesions, as well as with tuberculous lesions. Therefore, the prevention of intrauterine synechia 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 be aware of the existing risk in women with a complicated postpartum period or after an abortion. If placental remnants are suspected, if the menstrual cycle is disturbed, etc., hysteroscopy should be performed immediately, the purpose of which is to clarify the exact localization of the pathology focus and remove it without injuring the normal endometrium.

Expert advice

Gynecology

Types of services provided

Various pathological processes in the organs, even after their complete cure, can leave some complications and consequences. It is these unpleasant complications of inflammatory (most often) processes that include synechia, which can form in the uterine cavity. About what it is, and how they affect the quality of life and reproductive function, is described in this material.

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Definition

What is synechia in the uterine cavity? Synechia is the medical name for adhesions, which are neoplasms of inextensible connective tissue that are formed as a result of inflammatory processes and are able to tighten organs, deform them, block their lumen, etc.

You can often hear that in the context of this topic, such a diagnosis as Asherman's Syndrome is mentioned. What it is? This is a disease that occurs only in women and is an adhesive process (the presence of synechia in the uterus).

Structure

The reasons

Most often, this condition develops as complications after pathological and even medical processes. Among them:

  1. Inflammatory processes;
  2. infectious processes;
  3. Processes with the formation of exudate;
  4. Surgical interventions, cleanings, abortions (if we are talking about the uterus, etc.).

From a technical point of view, the process of formation of adhesions is associated with the fact that the tissue affected during the pathological process or surgical intervention begins to be replaced by another. In such processes, fibrous connective tissue is always formed (it also forms, for example, scars and scars), which does not have any functions.

Classification

This pathological process can be classified in different ways. There are several types of classifications depending on the tissue composition of synechiae, their location, and the degree of development of the process. Such a system of classifications allows doctors to better navigate the process, and is also important for determining the optimal method of treatment.

Histology

There are three types of synechia according to tissue composition. They correspond to the three stages of the syndrome.

  1. The mild stage is characterized by the presence of adhesions from the epithelial tissue. They are thin and easily dissected;
  2. The middle stage is characterized by the presence of more dense, fibromuscular neoplasms, densely germinated to the endometrium. They are more difficult to dissect, they bleed when damaged;
  3. The severe stage is distinguished when the synechiae are dense, consist of connective tissue and are difficult to dissect.

In principle, any stage can be cured surgically, but the volume and complexity of the intervention will be different.

By prevalence

In this case, we are talking about how much of the cavity is involved in the process.

  • The first type is characterized by the involvement of up to 25% of the uterine cavity, the orifices of the tubes are not affected;
  • The second type is distinguished when from 25 to 75% of the cavity is involved, the mouths are slightly affected, there is no adhesion of the walls;
  • The third type - more than 75% of the cavity is involved, the mouths are affected, there may be sticking of the walls and deformation of the organ.

From the point of view of pregnancy, any type of pathology is undesirable, however, with the third type, conception is also very unlikely.

According to the degree of damage and closure of cavities and gaps

This is an international classification used by the Association of Gynecologists-Endoscopists. According to her, 6 stages of the syndrome are distinguished.

  • I - thin films that are destroyed upon contact with the hysteroscope;
  • II - denser films, often single;
  • II-a - localization inside the uterine os, when the upper sections are not affected;
  • III - dense multiple areas, mouths are affected;
  • IV - signs of the third stage are supplemented by partial occlusion of the cavity;
  • V - signs of all other stages, as well as the presence of scars on the walls.

This classification is used only in the context of surgery.

Symptoms

Signs that synechia has formed in the uterus may be different. But most often it is a stable pain syndrome, which occurs mainly during physical exertion or placing the body in a certain position. In addition, this is possible with a full bladder and during menstruation. The pains are sharp and sharp, of high intensity, or aching. Usually, they increase with physical inactivity - in this case, they can begin to appear even at rest.

Depending on the location of the formations, there may be problems with conception, up to infertility, urination disorders. Possible violation of the outflow of menstrual blood /. Violation of defecation, etc.

Diagnostics

Synechiae have a density different from other uterine tissues, therefore they are easily visualized during ultrasound examination. During the ultrasound, it is possible to determine both the actual location of their location, and the degree of closeness of the organ by them, how deformed it is, etc.

If it is necessary for diagnostic purposes to take tissues of synechia for histology, then this is done during hysteroscopy. The same method can also be used to examine the uterine cavity for diagnostic purposes (if there are no obstacles to the penetration of equipment into its cavity).

Impact on pregnancy

Synechia in the uterine cavity is a serious problem during pregnancy. This is due to the fact that these inextensible ties actually fix the organ in a static state. Thus, the walls of the uterus are at a fixed distance from each other. As the fetus grows, the organ enlarges and stretches, with adhesions this leads to severe pain, hypertonicity of the organ, and as a result, miscarriage or abortion for medical reasons. If such a recommendation is neglected, then theoretically even a rupture of the organ can occur.

In addition, adhesions can be placed in such a way that they deform the fetus, allow it to grow, and put pressure on it. The resolution of pregnancy in this case will be the same as described above. Although most often in the presence of adhesions, the onset of pregnancy is difficult. If they are present in the uterus, then the fetus is poorly attached, and if it is attached, then miscarriages occur in the early stages. But more often there are problems even at the stage of conception - the cervical canal or fallopian tubes can be closed by adhesions.

However, after the removal of synechia, pregnancy can be planned. Usually, depending on the individual characteristics of the body and the volume of the operation, the doctor recommends starting attempts at conception six months to a year after removal.

Therapy

Treatment of this condition is carried out in several ways and, most often, in a complex way, that is, several of them are used at once. All methods can be divided into two large groups - radical and conservative. Much in the choice of treatment depends on where the adhesions are located, how thick they are, and what histological composition they have.

conservative

The following conservative methods of influence are most often used:

  • Gynecological massage. The method is especially good for thin adhesions, which have minimal elasticity and are small in size. During the massage, they are mechanically stretched, as a result of which the organ and / or its parts return to their normal physiological positions, the organ lumens open. That is, in fact, the spike remains in place, but no longer causes discomfort. The method is not suitable for those who are going to give birth in the future, and is also ineffective when adhesions are located in the mouths of the fallopian tubes, cervical canal, etc .;
  • Physiotherapy by methods of microwave and / or UHF exposure is indicated in the same cases as gynecological massage. Often these two methods are used together. Exposure to microwaves leads to the fact that small adhesions dissolve, those that are larger become more elastic and stretch more during the massage. The method is used as an additional method for both radical and conservative treatment;
  • Therapeutic gymnastics is a special set of physical exercises that is developed by a physiotherapy doctor and is aimed at gradually stretching small adhesions so that they no longer cause discomfort. That is, this method, according to the principle of action, is similar to gynecological massage. In addition, it has the same indications, contraindications and scope. Most often, physiotherapy, gymnastics and massage are prescribed together with a slight degree of development of the pathology.

All methods of conservative therapy are used in combination with a mild severity of the process. They are not suitable for those who are planning a pregnancy after the removal of synechiae in the uterus, since they do not actually remove adhesions, but only make them so that they do not cause discomfort for a given organ size. But with an increase in the uterus, they will again make themselves felt. An exception can be called physiotherapy - in rare cases, this method contributes to the complete resorption of small adhesions, but often its effectiveness is not enough to completely cure.

Radical

The radical method of treatment involves surgical intervention. It involves the introduction of a scalpel into the uterus and direct dissection of the adhesions. In some cases, their complete removal is also necessary. Such an intervention may have a different level of severity depending on which method it was performed, and the choice of method, in turn, depends on the structural features of the uterus, the location of adhesions in it, their size, etc.

Such an intervention is almost never performed laparotomically, since in most cases it is pointless, because as a result of such an operation, new adhesions can form. Sometimes it is performed laparoscopically, when micro-instruments and a camera are inserted through punctures in the abdominal wall and the wall of the uterus with a diameter of 1.5 cm, and with the help of them, an operation is performed on the image from the camera that appears on the screen.

The least traumatic and most desirable method is hysteroscopic incision, during which the hysteroscope tube is inserted into the uterine cavity through the cervical canal. Instruments and a camera are inserted through the tube and an intervention is performed. While this method is preferred, it may not be suitable for all adhesion locations.

Such a dissection of synechia in the uterus is usually supplemented by a course of physiotherapy. Also, therapeutic exercises and gynecological massage can be used during the recovery period and after it. This is done in order to prevent the formation of new, postoperative adhesions, and to stimulate the resorption of those small ones that could remain after the operation.

Effects

What happens if treatment is not carried out? The following consequences are possible:

  1. Persistent pain syndrome;
  2. Violation of the work of organs and systems located nearby;
  3. Deformation of the organ;
  4. His injuries and injuries;
  5. Synechia in the uterus during pregnancy leads to miscarriage or abortion for medical reasons;
  6. Infertility.

Not all adhesions lead to such problems, however, if there are indications for removal, then they cannot be neglected even if the patient does not plan to have children.

Conclusion

Synechia of the uterus is a serious enough problem, and this is a condition that requires treatment. Therefore, it is advisable to consult a doctor in a timely manner if you detect symptoms of its presence.

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