intrauterine adhesions
Introduction
Introduction to intrauterine adhesions Intrauterine adhesions are related to pregnancy, accounting for about 9l%, often after artificial abortion or spontaneous abortion curettage, any factors that cause endometrial destruction can cause uterine cavity adhesions. And postpartum hemorrhage curettage. Because the uterine wall of the pregnancy is soft, it is not easy to control the depth when the curettage is performed, or the uterine cavity is excessively rubbed. When the suction is weak, the negative pressure is too large. The time is too long. The endometrial basal layer is scraped off to produce postoperative intrauterine adhesions; Repeated in and out of the cervix, irregular expansion of the cervix can aggravate the injury, increase the chance of postoperative intrauterine adhesions, non-pregnancy caused by intrauterine adhesions accounted for about 9%, such as endometrial tuberculosis, uterine fibroids excavation , diagnostic curettage, etc. basic knowledge Probability ratio: Susceptible people: good for postpartum women Mode of infection: non-infectious Complications: amenorrhea infertility
Cause
Causes of intrauterine adhesions
Pregnancy factors (25%):
Pregnancy-related uterine surgery such as early pregnancy negative pressure suction surgery, mid-pregnancy clamp surgery, mid-pregnancy induction of curettage, postpartum hemorrhage curettage and spontaneous abortion curettage. This may be due to the fact that the lining of the intima of the uterus is more likely to be damaged, causing the walls of the uterus to stick to each other and form a permanent adhesion.
Non-pregnant factors (30%):
Uterine fibroids removal surgery (into the uterine cavity), uterine submucosal fibroids by uterine cavity removal, uterine mediastinal resection, double uterine orthopedics, etc., destroy the basal layer of the intima, expose the myometrium to the uterine cavity , leading to the front and back adhesion of the palace wall.
Surgical inflammatory factors (30%):
Intrauterine infection of uterine tuberculosis, postmenopausal senile endometritis, secondary infection after intrauterine operation, infection during puerperium, secondary infection after placement of intrauterine device.
Human factors (10%):
Artificially destroy the basal layer of the endometrium, causing intrauterine adhesions. Such as: endometrial electrical resection, intrauterine microwave, cryotherapy, chemical drug treatment and local radiotherapy.
Other factors (5%):
Such as repeated curettage, which is very easy to damage the basal layer, the intrauterine adhesion caused by this cause is called damage adhesion, the most common, so the obstetrician should be moderate in the curettage, women of childbearing age Implement contraceptive measures to avoid abortion, especially the first fetus may cause infertility after intrauterine adhesions.
Prevention
Intrauterine adhesion prevention
1, before surgery should actively treat patients with chronic cervicitis, endometritis to prevent postoperative infection.
2, if you find that the expansion of the cervix can not be violent, use the dilator can not jump, so as not to damage the cervical canal.
3. The negative pressure should be appropriate when attracting, and the negative pressure should be closed when entering and leaving the cervix.
4, the method of de-adhesive can be extended by probe or small, can effectively use the placement of intrauterine device, some people use adrenal cortex to prevent fibrosis, or estrogen, progesterone for artificial cycle to effectively treat.
5. Family planning, reducing the number of induced abortions and induction of labor. Pay attention to aseptic operation during artificial abortion and uterine surgery to prevent excessive suction and cervical canal trauma.
Complication
Complications of intrauterine adhesions Complications, amenorrhea, infertility
1, less menstruation, amenorrhea: uterine adhesions can lead to amenorrhea, accounting for about 60% -90%, long duration.
2, periodic abdominal pain: one month after the operation will have sudden lower abdominal pain, anal swelling, restlessness, difficulty in action, pain duration of 3-7 days, a periodic episode.
3, female infertility: secondary infertility or repeated abortion, premature delivery. Due to the destruction of the endometrium of the intrauterine adhesion, the volume of the uterus is reduced, affecting the normal implantation of the embryo and causing infertility. Even if the pregnancy is affected, the embryo after implantation will be affected, and the fetus will grow and develop, resulting in miscarriage and premature birth.
Symptom
Symptoms of intrauterine adhesions Common symptoms Menstrual cycle changes abortion amenorrhea
1. Pain in the lower abdomen: If the patient's condition deteriorates continuously, abdominal pain will occur, and some may even sleep in the night, which will have a great impact on women's life and work. Generally, a month after artificial abortion or curettage, sudden lower abdominal pain occurs. Some patients have severe abdominal pain, restlessness, difficulty in movement, and even exhaustion and defecation are painful.
2, abnormal pregnancy: patients are prone to pregnancy failure, including early and mid-pregnancy abortion, premature delivery, ectopic pregnancy, expired abortion, fetal death and so on. Infertility is the most common symptom of the disease. This disease often leads to blockage of the fallopian tube in women, which leads to the inability of the fertilized egg to form properly, eventually leading to infertility. Even if it is pregnant, repeated abortion and premature birth will occur.
3, menstrual abnormalities: complete cervix adhesion, can occur amenorrhea, partial adhesion of the cervix or partial destruction of the endometrium, it is characterized by less menstruation, but the menstrual cycle is normal. If it is caused by cervicitis or other inflammation, it will lead to amenorrhea in patients, some patients have irregular menstruation, prolonged menstruation, menstrual blood black and so on.
4, press the lower abdomen pain: female friends if you have intrauterine adhesions, there will be symptoms of abdominal pain, in the examination will also find that the size of the uterus is generally normal, the texture is soft, there is obvious tenderness symptom.
Examine
Examination of intrauterine adhesions
Auxiliary inspection
1. Uterine probe examination Generally, the uterus probe is inserted into the cervix about 1-3 cm, which means there is a sense of resistance, and the most common is about 2 cm. The resistance can vary according to the adhesion tissue. Only the endometrial adhesion probe is easy to insert. When the muscle layer is stuck, the probe should be inserted with a little force in the direction of the uterus. If the tissue is tough and the probe is not easy to insert, it should not be blind. Use force. So as not to cause uterine perforation. After the probe enters the uterine cavity, the fan can be swept left and right to sweep the official cavity to test the size of the uterine cavity and the extent of adhesion. A severely adherent person may feel a narrow tube in the uterine cavity, and the probe has a small range of motion or cannot be penetrated at all.
2. Hysteroscopy can be used to determine the presence or absence of intrauterine adhesions, and to determine the location, extent, extent and adhesion of the adhesion. The characteristics of adhesion in each group are: endometrial adhesion is very similar to the surrounding endometrium; muscle fiber adhesion is the most common, characterized by a thin layer of endometrium covering the surface with many gland openings; and connective tissue adhesion is the surface No endometrial formation.
3. Uterine lipiodol angiography is characterized by:
(1) There may be one or more contours in the uterine cavity, sharp edges, abnormal shape, irregular filling defect shadows, and not subject to the pressure or amount of contrast agent injected.
(2) A fine mesh-like blood vessel image often appears. This is because the pressure of injecting iodized oil during the contrast is too large, so that the lipiodol enters the uterine blood vessel from the peeling surface.
(3) The local edge of the uterine cavity is not neat.
(4) Some uterus that adheres to the uterus, with high flexion or flexion, often overlaps the image of the uterus and the cervix. The uterus is olive-shaped. In this case, the cervical canal can be used to pull the cervix to stretch the uterus, and the uterus image can be changed from olive to triangle. In order to prevent chronic inflammation caused by oil plugs and oils, water-soluble contrast agents can also be used. Mild adhesion can be separated by contrast.
4. The basal body temperature is biphasic.
5. Vaginal exfoliated cells have periodic changes.
6. Serum progesterone and urinary gestational diol have periodic changes and ovulation.
7. Cervical mucus crystals can appear as fern-like crystals and ellipsoids.
8. Hormone treatment test estrogen, progesterone or artificial cycle treatment, no withdrawal bleeding in three cycles.
9. Hysteroscopy In recent years, hysteroscopy has been used as a method for diagnosing and treating uterine adhesions.
Pathological examination
1. Gross pathology can be divided into three types: 1 uterine cavity and cervical canal adhesion; 2 partial adhesion in the uterine cavity, adhesion site can be in the center of the uterine cavity, the fallopian tube corner, or the left and right side walls, make the uterine cavity smaller; The marginal adhesions of the uterus are more common on the right side.
2. The structure of the adhesion part is: 1 endometrial adhesion to the endometrium, this adhesion is often easy to separate; 2 endometrium and myometrial adhesions; 3 myometrial adhesion to myometrial tissue, such Adhesions are difficult to separate; 4 connective tissue of the uterine wall adheres to connective tissue, forms a scar tissue band or heals together. This adhesion is very strong and difficult to separate by blunt separation.
3. Histological examination of the tissue scraped during intrauterine adhesions, histological examination. There are secretory endometrium, proliferative endometrium, atrophic endometrium and hyperplastic endometrium, and even intrauterine Membrane base layer, muscle tissue and fibrous tissue. Bergman reported that only 14/4 of the normal endometrium was scraped, and the rest showed irregular structure of the intima and few ducts. Interstitial cell fibrosis, there are many plasma cells and lymphocytes.
Diagnosis
Diagnosis of intrauterine adhesions
diagnosis
Diagnosis is based on clinical performance and examination.
Differential diagnosis
(a) ectopic pregnancy
When uterine adhesions occur in amenorrhea and lower abdominal pain, it should be differentiated from ectopic pregnancy. The former has a history of induced abortion or curettage, abdominal pain is mainly periodic, although the lower abdomen has tenderness or rebound pain, but no symptoms such as internal bleeding and shock, uterine probe or hysteroscopy can be diagnosed, when the blood is detected After the circulation is smooth, the symptoms of abdominal pain are alleviated or disappeared. Patients with ectopic pregnancy often have symptoms and signs of internal bleeding after abdominal pain, and more can be diagnosed after puncture.
(two) pelvic infection
If abortion occurs after artificial abortion or curettage, it can also cause lower abdominal pain, but the abdominal pain caused by infection is persistent dull pain, no history of periodic attacks, and fever, leukocytosis and other infections. The abdominal pain caused by the adhesion of the uterus is periodic, spastic uterine contraction pain, and there is no fever, white l cells and so on.
(three) endometriosis
Although the disease is caused by dysmenorrhea, it is also periodic abdominal pain. And progressive exacerbation, but the blood discharge is smooth, the symptoms of abdominal pain are not alleviated after menstrual blood flow; and the abdominal pain caused by uterine cavity adhesion is obstructive dysmenorrhea, and the symptoms of the menstrual blood can be relieved or even disappeared after dilating the cervix. Can also be identified from the history of the disease, endometriosis is often infertility, and official adhesions occur after artificial abortion.
(four) early pregnancy
Inhalation of the palace, curettage after surgery should also rule out early pregnancy, early pregnancy generally no history of abdominal pain, often a history of pregnancy reaction. Uterine enlargement and pregnancy months are often consistent, urine pregnancy test is often helpful for diagnosis.
(5) Amenorrhea
After the intrauterine adhesions, only simple amenorrhea without abdominal pain or abdominal pain is not obvious, it needs to be differentiated from pituitary or hypothalamic amenorrhea, premature ovarian failure. Amenorrhea caused by adhesion of the uterine cavity, menstruation can not be recovered after treatment with progesterone, estrogen or artificial cycle, and basal body temperature measurement, cervical mucus crystallization and vaginal exfoliation smear examination showed normal ovarian function.
