Asherman syndrome

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Classification according to ICD-10
N85.6 Intrauterine synechiae
ICD-10 online (WHO version 2019)

The Asherman syndrome , also known as Fritsch syndrome or Fritsch-Asherman syndrome , describes adhesions or adhesions ( synechiae ) of the anterior and posterior walls of the uterus, which are often traumatic , usually due to curettage . The consequences can be amenorrhea , hypomenorrhea , habitual abortions and secondary sterility .

The clinical picture was named after the first person to describe it, Joseph Gustav Asherman (1889–1968), a Czech - Israeli gynecologist, and Heinrich Fritsch (1844–1915), a German gynecologist. Individual cases have been described earlier by Ernst Wertheim (1864–1920), Otto Ernst Küstner (1849–1931), Gustav Veit (1824–1903) and others.

hysteroscopic picture of synechiae

causes

Adhesions (synechiae) and scar tissue (fibroids) can develop if the basal layer of the uterine lining has been damaged in depth during an operation. Since the uterine lining is particularly sensitive during and after pregnancy, there is an increased risk here.
Inflammation of the uterine lining ( endometritis ) alone , such as genital tuberculosis, is discussed as a further cause .
After uterine interventions outside of pregnancy, intrauterine adhesions are much less common and occur especially after hysteroscopic interventions.

consequences

Ultrasound longitudinal section through the uterus with evidence of adhesions in the uterine cavity
Adhesions in hysterosalpingography

Asherman's syndrome is less common with slight adhesions, but more often the cause of infertility with severe adhesions , but often leads to amenorrhea , hypomenorrhea, as well as dysmenorrhea and habitual abortions . After hysteroscopic transection of mild to moderate synechiae, there is a relapse in 3–4% of cases. With severe intrauterine adhesions, a recurrence rate of up to 63% must be expected.

Diagnosis

The ultrasound can provide clues to the clinical picture. The endometrium can usually only be identified with difficulty. Depending on the location of the adhesions, it may also be possible to visualize a hematomaetra.
Compared to hysteroscopy , which is the standard diagnostic method today, transvaginal sonography only has a sensitivity of 52% and a specificity of 11% for the detection of intrauterine adhesions. The three-dimensional ultrasound examination (3D sonography) shows a reduced endometrial volume in the affected areas.
Transvaginal sonography still plays an important role before an operation. Patients in whom ultrasonography can detect endometrium behind an obstructive area are more likely to be treated successfully. The hysteroscopy can compared to all other methods much more accurate and precise presence, extent and degree of intrauterine adhesions represent and allows a good assessment of the quality of the rest of the endometrium. It is therefore the method of choice for the diagnosis of intrauterine adhesions. It has thus practically completely replaced hysterosalpingography , in which filling defects of the uterine cavity, the tube ends or the tube ostia, depending on the extent and location of the adhesions, can be visualized. However, it did not make it possible to make a clear statement about the cause of these filling defects.

prophylaxis

When scraping during or after pregnancy, only blunt instruments (curettes) are used and only gentle pressure is used. Suction bears a little less risk, so suction curettage should be preferred if possible.
When determining the indications for intrauterine interventions, such as hysteroscopic myoma resections, the risk of Asherman's syndrome should always be included.

therapy

The hysterotomy (opening of the uterus) with loosening of the adhesions by incision in the abdomen ( laparotomy ) is only justified in exceptional cases today and has been almost completely replaced by hysteroscopic therapy.
The adhesions are loosened instrumentally, sometimes using electrosurgical methods. Using a laser does not seem to have any advantages.
Hormonal treatments to stimulate the lining of the uterus, as well as barrier methods such as hyaluronic acid or intrauterine devices, are used to prevent new adhesions .
There is also research in the field of stem cell therapy, in which remaining endometrial (mesenchymal) stem cells from the basalis or hematopoietic stem cells are extracted from the bone marrow, multiplied and used. The stem cells ensure the growth of the overlying uterine lining.

literature

  • JG Asherman: Syndrome d'Asherman. In: Rev Fr Gynecol Obstet. 61 (1966), pp. 542-544, PMID 5940503
  • JG Asherman: Intrauterine adhesions. In: Bull Fed Soc Gynecol Obstet Land Fr. 4 (1952), pp. 807-814.
  • S. Friedler, EJ Margalioth, I. Kafka, H. Yaffe: Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy - a prospective study. In: Hum Reprod. 8: 442-444 (1993).
  • W. Pschyrembel , G. Strauss, E. Petri: Practical gynecology. 5th edition. Walter de Gruyter, Berlin 1991, ISBN 3-11-003735-1 , pp. 517-519.
  • Rebecca Deans, Jason Abbott: Review of Intrauterine Adhesions. In: J Minim Invasive Gynecol. 17 (2010), pp. 555-569, PMID 20656564 , doi : 10.1016 / j.jmig.2010.04.016
  • Collin Smikle, Shailesh Khetarpal: Asherman Syndrome. StatPearls Publishing, Treasure Island (Florida) 2019, PMID 28846336

Web links

Individual evidence

  1. ↑ a b Baltzer among others: Practice of gynecology and obstetrics. Thieme, Stuttgart 2004, pp. 406f.
  2. ^ JG Asherman: Amenorrhoea traumatica (atretica). In: J Obstet Gynecol Br Emp. 1948, pp. 23-30.
  3. ↑ H. Fritsch: A case of complete disappearance of the uterine cavity after scratching it out. In: Zentralbl Gynäkol. 1894; 18, pp. 1337-1342.
  4. ↑ a b c d e f g h Michael D. Mueller: Asherman syndrome: causes and treatment. Frauenheilkunde aktuell 23/2/2014, pp. 4–12, online
  5. ^ Joachim W. Dudenhausen: gynecology and obstetrics. Walter de Gruyter, 2002, ISBN 3110165627 , p. 47
  6. ↑ Orhan Bukulmez, Hakan Yarali, Timur Gurgan: Total corporal synechiae due to tuberculosis carry a poor prognosis following hysteroscopic synechiolysis. Hum Reprod 14 (1999), pp. 1960-1961, doi: 10.1093 / humrep / August 14, 1960
  7. ↑ Werner Schmidt: Color Doppler sonography in gynecology and obstetrics. Georg Thieme Verlag, 2000, ISBN 3131176210 , pp. 47-48
  8. ↑ a b c Alessandro Conforti, Carlo Alviggi, Antonio Mollo, Giuseppe De Placido, Adam Magos: The management of Asherman syndrome: a review of literature. Reprod Biol Endocrinol 11 (2013), PMID 24373209 , doi: 10.1186 / 1477-7827-11-118 , pp. 118-128
  9. ↑ Sapna Jain, Mayank Jain, Astha Gupta, Mannan Gupta, Poonam Verma: Role of Autologous Stem Cell Therapy in Asherman's Syndrome and Thin Endometrium: A Case Series. Sch J Med Case Rep 5 (2017), doi: 10.21276 / sjmcr , pp. 305-308
  10. ↑ Caroline E. Gargett, David L. Healy: Generating receptive endometrium in Asherman's Syndrome. J Hum Reprod Sci 4 (2011), pp. 49-52, PMID 21772741