u.o. di ostetricia ginecologia 1 a.o. della provincia di lodi•introduzione iud ... pregnancy after...
TRANSCRIPT
Sinechiolisi isteroscopica
Giovanna CentinaioU.O. di Ostetricia Ginecologia 1
A.O. della Provincia di Lodi
TOTALE INFERTILITA' POLIABORTIVE
CAVITA' REGOLARE 1046 (71,3) 711 (73,1%) 335 (67,8%)
POLIPI 201 (13,7%) 145 (14,9%) 56 (11,3%)
MALFORMAZIONI 82 (5,6%) 39 (4,9%) 43 (8,7%)
SINECHIE 95 (6,5%) 47 (4,8%) 48 (9,8%)
MIOMI SOTTOMUCOSI 42 (2,9%) 30 (3,1%) 12 (2,4%)
TOTALE 1466 972 494
Isteroscopie diagnostiche
sinechie
6.5%
Aetiology
Infection (tuberculous endometritis
honeycomb synechiae)
Surgical complications (post-myomectomy,
-metroplasty, -CS, -DUB curettage)
Curettage (>90% - postpartum/postabortal)
Etiopathogenesis
Curettage
traumatic denudation of the endometrial basalis layer
exposure of the muscularis layer
adhesions by coaptation between the opposing uterine walls
Sintomi
• Infertilità
• Oligoamenorrea
• Dismenorrea
Diagnosis
Clinical hystory
Hysterography
Hysteroscopy
Transvaginal sonography
Transvaginal sonohysterography
Hysterography
radiographic filling defects
Hysteroscopy
Transvaginal sonography
Transvaginal sonohysterography
Classification
many classifications
based on hysterography, hysteroscopy,
histology and symptomatology
difficult to compare the results of treatment
and to determine the therapeutic regimen
Classificazione Sinechie Uterine AFS 1988Estensione sinechie/cavità
< 1/3
1/3 - 2/3
2/3
Punteggio
1
2
4
Tipo di sinechie
velamentose
velamentose e dense
dense
1
2
4
0
2
4
Tipo di mestruazione
normale
ipomenorrea
amenorrea
Classificazione
Stadio I – Sinechie lievi
Stadio II – Sinechie moderate
Stadio III – Sinechie severe
Punteggio
1-4
5-8
9-12
Classificazione Società Europea di Isteroscopia
Sinechie tipo I mucose
piccole formazioni aderenziali velamentose a struttura mucosa
Sinechie tipo II mucose connettivaliformazioni tenaci , singole , tese da una parete all’altra della
cavità uterina senza però coinvolgere gli osti tubarici
Sinechie tipo III muscolo connettivaliprogressivo convolgimento di aree sempre maggiori della
cavità uterina fino all’occlusione degli osti tubarici
Sinechie tipo IV occludentiformazioni aderenziali tenaci con completa obliterazione
della cavità uterina
Subseptate uterus
DIAGNOSI DIFFERENZIALE
Subseptate uterus
Diagnosi differenziale
Retained fetal bony
fragments
Retained fetal bony
fragments
Treatment
sterility / infertility
menstrual disorders (amenorrhea,
dysmenorrhea, spotting)
Indications
• rimozione per via smussa
sinechieterapia
•istmiche mucose
•fibromuscolari isolate
•fundiche
•centrocorporali
•periorifiziali
• sezione e dissezione con forbici semirigide o pinze
• elettroresezione mono o bipolare?
• laser – vaporizzazione?
Treatment
Techniques
lysis and removal
multiple procedures
division
sterility / infertility
menstrual disorders
sinechietrattamento postoperatorio
•introduzione IUD
•catetere Foley
•lamine in silastic
•palloncino gonfiabile di Neuwirth
•dispositivo di Massouras
•estroprogestinici
•controllo isteroscopico a distanza
•eventuale terapia antibiotica (sinechie a genesi infettiva accertata)
The Foley catheter is a safer and more effective
adjunctive method of treatment of IUA, after
adhesiolysis in patients presenting with infertility,
compared with the intrauterine contraceptive device.
Orhue AA, Aziken ME, Igbefoh JO.
A comparison of two adjunctive treatments for intrauterine adhesions
following lysis.
Int J Gynaecol Obstet. 2003 Jul;82(1):49-56.
Treatment
uterine perforation
fluid overload
infections
recurrence
abnormal placentation (accreta percreta)
uterine rupture (pregnancy, labour)
Complications
Hysteroscopic treatment of severe Asherman's syndrome
appeared to be effective for the reconstruction of a functional
uterine cavity with a 42.8% pregnancy rate. However, these
pregnancies were at risk for haemorrhage, with
abnormal placentation, and Caesarean hysterectomy
or hypogastric arteries ligation.
Capella-Allouc S et al. Hysteroscopic treatment of severe Asherman's
syndrome and subsequent fertility.
Hum Reprod 1999
Complications
In order to prevent intrauterine adhesions, curettage
should be restricted to cases in which retained products
of conception are suspected. It should not be performed
routinely in every case of midtrimester termination of
pregnancy after spontaneous expulsion of the placenta.
Lurie S, Appelman Z, Katz Z.
Curettage after midtrimester termination of pregnancy. Is it necessary?
J Reprod Med. 1991 Nov;36(11):786-8.
The prevalence of IUA was low after each modality of
treatment (conservative management, medical evacuation,
and surgical evacuation) for spontaneous abortion.
Conservative management and medical evacuation
are both acceptable alternatives to standard surgical
evacuation.
Tam WH, Lau WC, Cheung LP, Yuen PM, Chung TK.
Intrauterine adhesions after conservative and surgical management of
spontaneous abortion.
J Am Assoc Gynecol Laparosc. 2002 May;9(2):182-5.
Obstetric outcome
Obstetric outcome
Sinechiolisi isteroscopica: commento
L’efficacia della sinechiolisi isteroscopica è:
• elevata nelle sinechie lievi e moderate
• bassa nelle sinechie severe
pertanto
la loro prevenzione è la terapia più efficace.
Best treatment
no curettage!
Prevention!!!
Best treatment
no curettage!
Prevention!!!
but…
GRAZIE PER
L’ATTENZIONE