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CASE PRESENTATION

CASE PRESENTATION. Zshari Zxilka T. Tanggol Medical Intern Department of Obstetrics and Gynecology July 2010. General Data. 35 y/o G1P1 (1001) Female Married Roman Catholic Tuguegarao , Cagayan. Chief Complaint. Scanty menses ( Hypomenorrhea ). Past Medical History.

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CASE PRESENTATION

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  1. CASE PRESENTATION ZshariZxilka T. Tanggol Medical Intern Department of Obstetrics and Gynecology July 2010

  2. General Data • 35 y/o G1P1 (1001) • Female • Married • Roman Catholic • Tuguegarao, Cagayan

  3. Chief Complaint • Scanty menses (Hypomenorrhea)

  4. Past Medical History • Patient denied any major medical illnesses • Operation/s: s/p Primary CS for CPD (2008, Spain) s/p endometrial curettage (2008, Spain) • No known allergies • No history of blood transfusions • No use of exogenous hormones

  5. Family History (+) Diabetes mellitus – mother (-) Hypertension, bronchial asthma, heart disease, cancer, thyroid abnormalities

  6. Personal and Social History • Patient claimed good interpersonal relationships • Nonsmoker • Non-alcoholic beverage drinker

  7. Menstrual History • Menarche: 12 y/o • Regular • 2-3 days • 2-3 pads per day, moderately soaked • (-) pain • LMP: June 28, 2010 • PMP: May 2010

  8. Obstetric History • G1P1 (1001)

  9. Gynecologic History • Coitarche: 25 • Sexual Partner: 1 • Family Planning Method: None • Last Pap smear (Nov 2009): Normal • (-) use of OCPs • (-) abnormal vaginal discharge

  10. History of Present Illness 2 years PTA • (+) Patient underwent primary caesarian section for CPD • (+) post-op fever • (-) nausea, vomiting • (-) difficulty in breathing • Patient given unrecalled IV antibiotics • USG done which showed an intrauterine mass (infection?): advised endometrial curettage

  11. History of Present Illness Within the same year (August 26, 2008) (+) Patient underwent endometrial curettage  Discharged after 6 days with an improved condition

  12. History of Present Illness 1 year PTA (5 months after giving birth) (+) resumption of menses, but was now scanty, consuming 1 minimally soaked pantyliner in 1 day lasting for 1-2 days (+) hypogastric pains, 7/10 intensity, nonradiating (+) mild fever 8 months PTA (+) persistence of symptoms (+) infertility  Sought consult with private MD in local hospital, USG done was unremarkable: referred to our institution for further evaluation and management ADMISSION

  13. Review of Systems General: no weight loss, anorexia, easy fatigability Eye: no visual dysfunction, itchiness, lacrimation or redness Ears: no dizziness, tinnitus, deafness, discharge or vertigo Nose: no congestion, no discharge, no hyperemia Mouth: no lesions or discharges Neck: no hoarseness or stiffness

  14. Review of Systems • Pulmonary: no dyspnea, no cough • Cardiac: no chest pains, no palpitations, no PND • Vascular: no phlebitis, varicosities, cyanosis • Gastrointestinal: no change in bowel movements, vomiting • Genitourinary: no dysuria, frequency, urgency, flank pains • Endocrine: no polyuria, polydipsia, polyphagia, heat/cold intolerance

  15. Review of Systems • Musculoskeletal: no joint stiffness, swelling or numbness, • Hematopoietic: no pallor or easy bruisability • Neurologic: no headache, vertigo or seizures • Psychiatric: no anxiety, depression, interpersonal relationship difficulties, illusion, delusion

  16. Physical Examination • Awake, conscious, coherent, ambulatory • Not in cardiorespiratory distress • Vital Signs: 120/80 mmHg, 74 bpm regular, 20 cpm regular, 36.9°C • Weight: 61.5 kg • Height: 150 cms • BMI: 27.33 kg/m2 (Normal)

  17. Physical Examination • Skin: warm, smooth • Head: normocephalic, normal pattern of distribution • Face: no facial asymmetry • Eyes: pink palpebral conjunctivae, anictericsclerae, pupils 2-3mm briskly reactive to light • Ears: patent ear canal; tympanic membrane non perforated, pearly white, with intact cone of light, bilateral • Nose: nasal septum midline, pink nasal mucosa, no nasal congestion. • Throat: non-hyperemictonsillopharyngeal walls

  18. Physical Examination • Neck: supple neck, no masses, no lymphadenopathies • Chest/Lungs: symmetrical chest expansion, no rib retractions, equal tactile and vocal fremitus; clear breath sounds in all lung fields • Breast/Thorax: symmetrical, no palpable masses or tenderness • Heart: adynamicprecordium, normal rate and regular rhythm, apex beat at 5th L ICS-MCL, no heaves, no thrills, no murmurs.

  19. Physical Examination • Abdomen: Flabby, normoactive bowel sounds, tympanitic, soft, nontender, no palpable masses, liver not enlarged • External pelvic examination: No lesions, redness, excoriations, hyper/hypopigmentations • IE: Cervix is short, soft, closed; uterus not enlarged, no adnexal masses or tenderness • Full and equal pulses • No bipedal edema, no cyanosis

  20. Physical Examination • Extremities: full and equal pulses, no edema, no cyanosis, no clubbing • Neurologic: essentially normal • Extremities: grossly normal extremities, no cyanosis, deformity, swelling, redness, tenderness, limitation of motion. • Pulses: full and equal

  21. Subjective SALIENT FEATURES • 35 y/o female • s/p primary CS for CPD (2008, Spain) • s/p endometrial curettage (2008, Spain) • (+) scanty menses preceded by hypogastric pains and mild fever • (+) infertility • Nonhypertensive, nondiabetic, non-asthmatic • No use of exogenous hormones • MHx: 12 yo/reg/2-3d/2-3ppd/(-) • G1P1 (1001)

  22. Objective SALIENT FEATURES • Conscious, coherent, not in CP distress • Stable vital signs • Abdomen: Flabby, soft and nontender • External pelvic examination: No lesions, redness, excoriations, hyper/hypopigmentations • IE: Cervix is short, soft, closed; uterus not enlarged, no adnexal masses or tenderness • Full and equal pulses; No bipedal edema, no cyanosis

  23. Clinical Impression • Asherman’s Syndrome

  24. Differentials • Amenorrhea without secondary sexual characteristics – rule out • Amenorrhea/Hypmenorrhea with secondary sexual characteristics

  25. Differentials Female genital tract • Anatomic abnormalities: such as imperforate hymen, transverse vaginal septum and hypoplasia or absence of uterus, cervix and vagina • Iatrogenic causes leading to anatomic abnormalities: Asherman’s syndrome • Excessive blood levels of endogenous or exogenous estrogen or progesterone will cause amenorrhea • Congenitally absent endometrium (rare)

  26. Differentials • Pituitary • Malformations • Inflammation: sarcoidosis, tuberculosis • Neoplasm which can cause hypopituitarism: adenomas • Trauma (from postpartum hemorrhage): Sheehan syndrome Ovary • Malformations • Intoxication • Neoplasm • Trauma • systemic diseases Hyperthyroidism Adrenal hyperplasia or Addison’s

  27. ASHERMAN’S SYNDROME

  28. Asherman’s Syndrome (AS) • J.G. Asherman described the syndrome that now bears his name in a 1948 publication in what was then known as the Journal of Obstetrics and Gynecology of the British Empire • Also known as intrauterine adhesions (IUA) or uterine synechiae • Characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars

  29. Asherman’s Syndrome: Causes • Intraoperative or post-operative complications of uterine evacuations for menorrhagia, pregnancy termination or postpartum hemorrhage • Occurs most frequently after a Dilatation &Curettage (D&C) is performed on a recently pregnant uterus, following a missed or incomplete abortion, birth or elective termination to remove retained products of conception

  30. Asherman’s Syndrome: Causes • Pelvic surgeries including caesarian section and myomectomy • Pelvic irradiation and IUDs • Severe pelvic inflammatory disease • Infection with tuberculosis or schistosomiasis

  31. Asherman’s Syndrome: Incidence and Prevalence • Risk of developing Asherman’s from a D&C is 25% 2-4 weeks after delivery and 30.9% of D&Cs for missed miscarriages and 6.4% of D&Cs for incomplete miscarriages • Risk of AS also increases with the number of procedures •  A 5% estimate of D&Cs result in AS, although true prevalence is unclear • About 13% of 78 infertile women scheduled for IVF treatment were found to have intrauterine adhesions after evaluation with diagnostic hysteroscopy

  32. Uterus

  33. Asherman’s Syndrome: Pathophysiology Presence of intrauterine scars resulting to adhesions Trauma to the endometrial lining (e.g. D&C performed for abortion or delivery) Menstrual irregularities, infertility or recurrent abortions Obliteration of uterine cavity leading to failure to respond to estrogen

  34. Asherman’s Syndrome: Illustration

  35. Asherman’s Syndrome: Features • Menstrual irregularities (hypomenorrhea, amenorrhea) following uterine evacuation procedures • Hypogastric pains preceding menstruation • Infertility or recurrent spontaneous abortion, with or without amenorrhea

  36. Asherman’s Syndrome: Features • Amenorrhea, menstrual irregularities, recurrent pregnancy loss and spontaneous abortion are already associated with severe AS

  37. Asherman’s Syndrome: Risks and Complications • Endometriosis • Placentation abnormalities • Miscarriage • Cervical incompetence • IUGR • Premature birth • Uterine rupture

  38. Asherman’s Syndrome: Classification Classification systems take into account the following factors: • amount of functioning residual endometrium • menstrual pattern • obstetric history • other factors which are thought to play a role in determining the prognoses • location and severity of adhesions inside the uterus

  39. Asherman’s Syndrome: Classification* Stage I – mild Stage II – moderate Stage III and IV – severe *American Fertility Society/American Society for Reproductive Medicine classification of intrauterine adhesions

  40. DIAGNOSIS History and Physical Examination Procedures • Hysteroscopy – for direct visualization of the uterus • Sonohysterography • Hysterosalpingogram (HSG)

  41. MANAGEMENT • Hysteroscopic resection/operative hysteroscopy – method of choice for management of intrauterine synechiae • Estrogen therapy – conjugated estrogen 2.5-5mg per day for 1-2 months • Estrogen therapy in combination with intrauterine device (balloons, stents, catheter)

  42. MANAGEMENT • Hysteroscopy can also be combined with laparoscopy

  43. MANAGEMENT: Hysteroscopy • Thin and fragile synechiae may be divided with the tip of a rigid diagnostic hysteroscope • Thicker lesions may then require division by semirigid or rigid scissors or energy based instruments such as resectoscope or an operative hysteroscope with Nd:YAG laser

  44. PREVENTION • Minimal pregnancy D&C-related procedures • Use of Misoprostol for evacuation following miscarriage or birth for retained placenta and hemorrhage • Ultrasound-guided D&C • Prophylactic antibiotics in patients who opt to defer uterine evacuation following fetal loss

  45. PROGNOSIS • Reproductive outcome depends on the extent of the preoperative endometrial damage • For mild to moderate adhesions, you might expect a 60-80% chance of successful pregnancy after repair •  In moderate to severe Asherman’s syndrome, recurrence rates range between 20-40% and 40-50%

  46. THANK YOU! 

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