Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure

Vanessa K. Dalton, M.D., Natalie A. Saunders, M.D., Lisa H. Harris, M.D., Jennifer A. Williams, M.D., and Dan I. Lebovic, M.D., M.A.
University of Michigan Medical School, Department of Obstetrics and Gynecology, Ann Arbor, Michigan

Objective: To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure. Design: Case series. Setting: Tertiary care center. Patient(s): Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure. Intervention(s): Chart review. Main Outcome Measure(s): Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration. Result(s): Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration. Conclusion(s): Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss. (Fertil Steril 2006;85:1823.e13. 2006 by American Society for Reproductive Medicine.) Key Words: Early pregnancy failure, manual vacuum aspiration, intrauterine adhesions

Early pregnancy failure (EPF) occurs in up to 20% of clinically recognized pregnancies and is commonly managed surgically with suction dilation and curettage (D&C) (1). Although EPF is traditionally treated with electric suction in an operative suite, ofce-based management with a handheld suction device is an effective alternative. The efcacy of manual vacuum aspiration (MVA) is comparable to traditional electric suction and is an ideal tool for an ofce-based procedure because of its portability and low cost (1). Since January 2002, almost half of women presenting to the University of Michigan Hospitals with EPF were treated with MVA in an ofce setting. A known postoperative complication of suction D&C is intrauterine adhesions (IUAs) or Ashermans syndrome (2). No previous report of IUAs after MVA was identied in the literature. This article describes three women with Ashermans syndrome after undergoing MVA for EPF. An exemption for full review was obtained from the institutional review board for this project. The same provider utilizing the same techniques and equipment performed all the procedures. Briey, each procedure was performed in an ofce setting under a paracervical block using MVAa
Received May 25, 2005; revised and accepted November 1, 2005. Dr. Dalton was supported by the Building Interdisciplinary Research Careers in Womens Health (BIRCWH) program, US HHS PHS National Institutes of Health (1 K12 HDO1438-01). Dr. Harris is a consultant for Ipas, a manufacturer of the manual vacuum aspirator, and has received honorarium from Ipas in the past. These funds are in no way related to this manuscript. Reprint requests: Vanessa K. Dalton, M.D., Department of Obstetrics and Gynecology, University of Michigan Medical School, L4000 Womens Hospital, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109 (FAX: 734-647-9727; E-mail: daltonvk@med.umich.edu).

handheld suction device consisting of a 60-cc syringe (Ipas, Chapel Hill, NC). The sharp curette was not utilized in any of the cases. The implications of these cases and a brief review of intrauterine adhesions after surgical management of pregnancy loss are discussed in the concluding section. CASE REPORTS Case 1 A 38-year-old gravida 5 para 1 presented at 10 weeks from her last menstrual period with an ultrasound documenting an EPF corresponding to 6 weeks gestation. Before this pregnancy, she reported regular menses, lasting from 4 5 days. Her previous obstetrical history was signicant for an EPF requiring suction D&C, an uncomplicated term vaginal delivery, a midtrimester induction for severe fetal anomalies, and an electric suction D&C for a partial molar pregnancy. Subsequent to these pregnancies and immediately before the index pregnancy, she underwent a hysterosalpingogram during an infertility workup, which was negative for intrauterine adhesions. The patient underwent an ofce-based MVA that was completed without complication. Subsequently, she presented with a decreased menstrual ow and an inability to conceive 5 months after her procedure. A sonohysterogram revealed a large intracavitary defect that was consistent with intrauterine adhesions. The patient was taken to the operating room for a hysteroscopy and resection of brotic bands. Hysteroscopy conrmed the presence of American Fertility Society (AFS) stage 1 intrauterine adhesions (3). These bands were resected sharply without complication. Two

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Fertility and Sterility Vol. 85, No. 6, June 2006 1823.e1 Copyright 2006 American Society for Reproductive Medicine, Published by Elsevier Inc.

months postoperatively, she conceived and delivered at term after an uncomplicated pregnancy. Case 2 A 36-year-old gravida 1 para 0 presented with an EPF corresponding to a gestational age of 6 weeks. Her obstetrical history before this pregnancy was notable for primary infertility, without history of uterine infection or intracavitary instrumentation. She spontaneously conceived during her infertility workup. Four days after diagnosis of pregnancy failure, she underwent an uncomplicated ofce MVA. She subsequently presented with secondary amenorrhea at 3 months postop. An ofce hysteroscopy noted dense adhesions obstructing the internal os, and a hematometra was noted upon dilation of the cervix. Additional adhesions were noted in the lower uterine segment (AFS stage 2), which were lysed by the ofce exible hysteroscope. Subsequently, menses resumed, and the patient spontaneously conceived 5 months later. She delivered at term after an uncomplicated pregnancy. Case 3 A 35-year-old gravida 1 para 0 who had no prior medical or gynecological problems presented with an EPF measuring approximately 10 weeks gestation. At the time of this pregnancy, she had been actively attempting to conceive for approximately 6 months. Before that time, she had regular menses on oral contraceptives for many years. She had no history of uterine infection or surgery. After reviewing treatment options, she had an uncomplicated ofce MVA 3 days after diagnosis. Three months later, she presented with secondary amenorrhea. At that time, she failed to have withdrawal bleeding with medroxyprogesterone and was noted to have a 2-mm endometrial stripe on transvaginal ultrasound. Ofce hysteroscopy was attempted but not completed because of dense adhesions at the internal os that prevented cervical dilation. She was taken to the operating room where the cervical adhesions were lysed. Hysteroscopy revealed AFS stage 2 fundal and cornual adhesions, causing signicant distortion of the uterine cavity. The adhesions were taken down sharply until the cavity was normalized. Postoperatively, an intrauterine foley catheter (Bard, Covington, GA) was placed for 5 days. Additionally, she was started on 2.5 mg of conjugated estrogens on postoperative days 130 and 10 mg of medroxyprogesterone acetate on days 10 30. Three weeks postoperatively, the follow-up ofce hysteroscopy revealed a largely normalized cavity. Eight months later, she conceived; however, this pregnancy also ended in a rst trimester loss. DISCUSSION Intrauterine adhesions are a known but infrequently addressed complication of D&C (2). The formation of IUAs is
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thought to occur during processes that destroy the endometrial stratum basalis, with the gravid uterus being particularly vulnerable. Surgical procedures, infection, and retained products of conception are implicated as etiologies (2). Previous studies estimate that adhesion formation occurs in 7%30% of patients undergoing hysteroscopic examination after D&C for EPF (2, 4 7). Although hysteroscopy was not performed before their treatment for pregnancy failure, several studies have found both increased incidence of IUAs as well as more signicant diseases in patients with a history of multiple D&Cs, as compared with those undergoing a single procedure (5, 8). A case series cannot attribute the IUAs noted among these patients to their previous MVAs with certainty. Although Case 1 had a hysterosalpingogram (HSG) documenting a normal uterus immediately before her MVA, she had numerous other risk factors and procedures. It is possible that these factors placed her at particular risk for the development of IUAs or that her rst HSG failed to visualize preexisting adhesions. Even given these limitations, however, the cases described suggest that IUAs may occur after an MVA even in the absence of sharp curettage, and this risk should be considered when assessing treatment options and consenting patients in the face of a pregnancy loss. No studies have been undertaken to examine the risk of IUA after MVA as compared with electric vacuum aspiration (EVA). After 262 ofce MVAs for rst trimester pregnancy losses, we have identied 5 cases of IUAs corresponding to a rate consistent with published rates for EVA (7%30%) (2, 4 7) In this article, we present the three cases without obvious alternate etiologies for their IUAs. The other two cases had multiple uterine procedures or infections without documentation of a normal cavity before the index pregnancy. Based on our experience to date, we have not noted a higher rate of IUAs among those patients undergoing MVA as compared with traditional electric suction D&C and continue to offer either technique to patients with EPF. Although we have not established causation, the possibility of IUAs after MVA does warrant attention. Many patients present to us with a perception that ofce-based MVA is less invasive than traditional electric suction and, presumably, would result in fewer complications such as uterine scarring. There is insufcient information to suggest that either procedure offers an advantage when it comes to the prevention of IUAs. Advantages of ofce MVA make it a favorable option for some women who desire surgical completion of EPF, such as avoidance of general anesthesia, less noise, improved privacy, the presence of their partners, and less time spent overall on the part of the patient and her family. Intrauterine adhesions are a possible complication of ofce MVA, even in the absence of sharp curettage, and should be considered when discussing treatment options
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for EPF with patients. Further studies are needed to determine the incidence of IUAs associated with MVA. REFERENCES
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