Article References: Placental Fragments

PLACENTAL FRAGMENTS

5. AUTHOR	Chapman-K, Chapman-R.
TITLE	Asherman's syndrome: a review of the literature, and a husband and wife's 20-year world-wide experience.
SOURCE	J-R-Soc-Med 1990 Sep, VOL: 83 (9), P: 576-80, ISSN: 0141-0768.

ABSTRACT

Asherman's syndrome is reviewed, and 27 cases treated by us in Iran, England, New Zealand and Australia over a 20-year period are analysed. Aetiological factors and treatment are discussed. In view of the high incidence of complications in subsequent pregnancies, the need for prevention is stressed. Although more common in some countries, it is, nevertheless, of world-wide distribution and, unless looked for, will be missed. Author.

1. (Page 576) Review...Most authorities believe that, if the decidua basalis is severely damaged, it may be replaced by granulation tissue. Should this happen, the opposing uterine walls will adhere to form scar tissue which, later, may be infiltrated by myometrial cells and covered by endometrium. A somewhat similar explanation may account for cervical synechiae...

2. ...The most common complaint is infertility. Amenorrhoea is usually present...Dysmenorrhea sometimes occurs...Should pregnancy occur, there is a high incidence of recurrent abortion, premature rupture of membranes, abnormal fetal presentation, placenta accreta and placenta praevia.

3. (Page 578) Discussion...whereas isthmic (upper cervical) synechiae are comparatively easily cured, corporeal adhesions are not only diffuclt to treat, but are likely to recur. Fertility, too, even in the apparently adequately treated case, is still likely to be impaired.

4. Jewelewicz et al...Columbia University, New York, in 1976, diagnosed 36 patients a having Asherman's syndrome. Treatment was followed by a 50% conception rate, but only 17% had uncomplicated full-term deliveries. Lancet and Mass, in 1981...Of 56 patients treated, 53 were subsequently found to have a regular uterine cavity and they claimed that the obstetric performance was improved from 31.9%, with the old blind method of separation of adhesions, to 64.9% by using the hysteroscope. Valle and Sciarra of Northwestern University Medical School, in 1988...of 187 pateitns, 76.4% subsequently achieved pregnancy and 79.9% of them went to term...the reproductive outcome correlated with thickness of the adhesions and the extent of the uterine cavity occlusion, ranging from a term pregnancy rate of 81.3% in patients with mild disease, to 31.9% in patients with severe disease.

5. (Page 579)...In our previous paper we suggested that Asherman's syndrome is more prevalent in Iran than Britain, because gynaecologists there use a sharp curette for puerperal and post-abortal evacuations, whereas in Britain a blunt curette was normally used. A secondary factor, possibly, is the higher incidence of puerperal infection.

6. ...Intrauterine infection might have been a contributing factor in three of the 13 Australian cases. Almost certainly, however, the sharp curette, which appears to be commonly employed in both countries [Australia and New Zealand], is more likely to be primarily incriminated. One must also note that the suction curette is capable of causing synechiae, usually, however, in the region of the internal os. It goes without saying that, in view of the seriousness of the sequelae, the best management is prevention, and all hospital dilatation and curettage sets should include two or three blunt curettes of different sizes.

7. The suggestion that a pack be inserted through the cervix after puerperal and post-abortal curettage...and left in situ for 24 yours to discourage the formation of synechiae, does not commend iself to use. Such a procedure would increase the risk of adhesion formation from trauma and infection.