Endometriosis
7 min read

Intrauterine Adhesions and the Case of the Hidden Pregnancy

Intrauterine Adhesions and the Case of the Hidden Pregnancy

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Video Description

This video will discuss the clinical presentation of androgen insensitivity syndrome highlighting the different options of gonadal management in these cases which include gonadectomy followed by hormone replacement therapy, surveillance and gonadal transposition which facilitate monitoring. It will also demonstrate the principles of laparoscopic bilateral orchidectomy in these cases with a video demonstrating the steps.

Presented By

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Dr. Chelsie Warshafsky
Dr. Julie Thorne
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Dr. Mostafa Atri
Dr. Heather Millar
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Affiliations

Mount Sinai & Woman’s College Hospital; Department of Obstetrics and Gynecology

University of Toronto, Department of Diagnostic Imaging

University of Toronto

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Click here to watch this video on YouTube.

What is Intrauterine adhesions and the case of the hidden pregnancy?

Intrauterine adhesions (IUA), also known as Asherman syndrome, occur when scar tissue forms within the uterine cavity, often due to uterine trauma, surgery (e.g., dilation and curettage, or C-section), or infection. These adhesions can cause parts of the uterine walls to stick together, leading to complications such as infertility, menstrual abnormalities, and pain.

  • Causes and Symptoms: IUAs commonly arise after uterine surgery or infections and can lead to symptoms like reduced or absent menstrual flow, pain, infertility, or recurrent pregnancy loss.

  • “Hidden Pregnancy”: A hidden pregnancy occurs when an embryo implants in an area obscured by scar tissue. This can prevent early detection on standard ultrasounds, delaying necessary care and increasing risks for both mother and baby.

  • Diagnosis and Treatment: IUAs are diagnosed through imaging techniques like hysteroscopy or ultrasound. Treatment typically involves hysteroscopic surgery to remove adhesions and restore the uterine cavity.

In cases involving hidden pregnancies within adhesions, close monitoring and early intervention are crucial for optimizing outcomes, as the condition complicates both pregnancy detection and maternal care.

What are the Risks of Intrauterine adhesions and the case of the hidden pregnancy? 

The risks of intrauterine adhesions (IUA) and the challenges associated with a “hidden pregnancy” (pregnancy undetected within an area of scar tissue or adhesions) include:

  • Infertility: IUA can cause blockage or narrowing of the uterine cavity, making it difficult for an embryo to implant, leading to primary or secondary infertility.

  • Ectopic or “Hidden” Pregnancy: Adhesions can create abnormal uterine spaces, increasing the risk of implantation in areas difficult to detect, such as behind scar tissue, which can delay diagnosis and proper prenatal care.

  • Miscarriage: The presence of adhesions disrupts the normal uterine environment, which can result in poor implantation, inadequate blood supply, or growth restrictions for the fetus, leading to early pregnancy loss.

  • Placental Abnormalities: IUAs are associated with conditions like placenta accreta (where the placenta attaches too deeply), which can cause significant complications during childbirth, including heavy bleeding.

  • Chronic Pelvic Pain and Menstrual Irregularities: IUAs can lead to irregular or painful periods and chronic pelvic pain due to the restricted movement of the endometrial lining and scar tissue buildup.

  • Complications During Pregnancy: Adhesions can cause uterine deformations, increasing the risk of preterm labor, growth restriction of the fetus, and complications with delivery.

In cases involving hidden pregnancies within adhesions, timely diagnosis is essential to managing these risks, as delayed detection can complicate maternal and fetal outcomes.

Video Transcript: Intrauterine adhesions and the case of the hidden pregnancy

Intrauterine adhesions and the case of the hidden pregnancy. The objective of this video is to review the literature on intrauterine adhesions and to discuss a case of pregnancy termination complicated by intrauterine adhesions.

Intrauterine adhesions are bands of fibrous tissue that form within the endometrial cavity. Although commonly used interchangeably, the term Asherman’s syndrome is when there are signs and symptoms present along with intrauterine adhesions. Clinical manifestations include menstrual irregularities and, in severe cases, secondary amenorrhoea, in addition to cyclic pelvic pain, infertility, and recurrent pregnancy loss.

 Intrauterine procedures are the most common risk factor for adhesions. However, studies indicate that pregnancy status at the time of procedure is an independent risk factor. Uterine compression sutures at the time of postpartum haemorrhage are another identified risk. Last, chronic endometritis unrelated to uterine procedures has been known to cause intrauterine adhesions.

The damage is thought to be caused by trauma to the basalis layer of the endometrium. Patients are most susceptible in the first four postpartum or postabortal weeks, potentially due to a low oestrogenic state or physiologic changes to the layer at this time.

The prevalence of intrauterine adhesions varies based on the presenting symptoms and prior surgeries. In any patients presenting with secondary amenorrhoea, the overall rate of intrauterine adhesions is only 1.7%. However, in a patient with an elective abortion D&C, the rate is 13% and it increases with subsequent procedures. The highest rate identified is in patients with multiple hysteroscopic myomectomies, likely due to tissue healing on opposing surfaces that fuses to produce tissue bridges.

Multiple classification systems for intrauterine adhesions exist and one has not proven to be better than the other. The authors commonly use the March classification system of mild, moderate, and severe.

Hysteroscopy is the gold standard in diagnosing and treating intrauterine adhesions. However, hysterosalpingography and saline infusion sonohysterography are reasonable alternatives if access to hysteroscopy is limited for the purpose of diagnosis. Transvaginal ultrasound findings may show a thin endometrial lining and 3D ultrasound is being further investigated.

We now present the case of a 29-year-old, G7P0A6, who presented to a family planning clinic with an unplanned pregnancy after missing a shot of Depo-Provera. Her history is significant for six prior therapeutic abortions, of which at least two were surgical. Risk factors also include a previous sexually transmitted infection.

Ultrasound confirmed an intrauterine pregnancy and the patient underwent a suction D&C. However, it was noted at the time of the OR that there was no tissue identified. Misoprostol was given postoperatively to induce spontaneous passage of the pregnancy tissue and a formal ultrasound was ordered postoperatively that confirmed that the pregnancy still remained intrauterine.

The patient was therefore taken for a diagnostic hysteroscopy, suction D&C, with ultrasound guidance. A bedside ultrasound again confirmed an intrauterine pregnancy, measuring eight weeks and zero days with no foetal heart rate. However, on hysteroscopy, the cavity appeared empty and short with no tubal ostia identified. Dense tissue was seen to bulge out from the fundus and an attempt was made to bluntly lyse these adhesions with the hysteroscope, but this was unsuccessful.

At this point, a radiologist with expertise in gynaecologic imaging was consulted and reviewed the formal ultrasound images. He confirmed that there was an intrauterine pregnancy, likely above a dense intrauterine adhesion, with a stripe of endometrium below.

With this information, the MIS team was consulted and a joint OR was planned. The patient was brought to the operating room to undergo a hysteroscopic resection of intrauterine adhesions and suction D&C under ultrasound guidance with possible laparoscopy.

A Bettocchi hysteroscope was used with bedside ultrasound guidance throughout. A small amount of blood clot was seen in the cavity and, on what appeared to be the posterior uterine wall, a small opening was identified. This opening extended with fluid distension and, upon further exploration, it led to a cavity in which the gestational tissue was identified.

Pulling back, it became clear that there was a dense transverse adhesion that had been obscuring the pregnancy. The micro-scissors were used to open the dense transverse adhesion to allow adequate access to the pregnancy tissue. Once the cavity was sufficiently opened, a number seven suction curette was introduced and the pregnancy tissue was evacuated under ultrasound guidance.

The hysteroscope was then reinserted and the dense adhesion was completely resected. Although it is more common to simply open adhesions as opposed to resecting them, given the density of this adhesion and the desire to prevent future complications, it was warranted in this case. At the end of the procedure, the cavity was opened up and the tubal ostia had been identified just posterior to the adhesion bilaterally. As the goal was pregnancy termination and not fertility, the decision was made to stop at this time.

Postoperatively, a paediatric Foley catheter was inserted in the uterus for one week, although the authors do acknowledge there is mixed evidence on the utility of this approach. The patient elected to have an Nexplanon placed for ongoing contraception.

In conclusion, intrauterine adhesions are more common than expected and can lead to multiple complications. The risk of intrauterine adhesions increases with repeat uterine procedures and in relation with pregnancy timing. Lastly, hysteroscopy and concurrent ultrasound guidance should be considered for any uterine procedures in patients with known risk factors. Thank you for your attention.