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