Intrauterine Adhesions Following Miscarriage: Look and Learn.

OBJECTIVE: To examine the incidence of intrauterine adhesions (IUA) following the management of miscarriage in women with previously documented normal uterine cavities. METHODS: We conducted a retrospective cohort study from two fertility clinics with standard practice protocols for evaluating the uterine cavity prior to infertility treatment and following clinical pregnancy loss. A database query and manual chart review identified 144 women with normal uterine cavities who experienced a miscarriage between January 2010 and November 2012 and returned to the clinic for follow-up hysteroscopy. Following documentation of a non-viable clinical pregnancy using transvaginal ultrasound, patients chose expectant, medical, or surgical management according to standardized clinical protocols. The primary outcome was the detection of IUA. Secondary outcomes included the presence of retained products of conception and various risk factors associated with the development of IUA. RESULTS: The incidence of IUA following early pregnancy loss was 6.3%. There were no significant differences in patient characteristics between those with and without IUA. There was a significant association between IUA and increasing uterine size, particularly in the presence of multiple gestation (P = 0.039). Mechanical suction dilatation and curettage (D&C) was a risk factor for IUA, but manual vacuum aspiration was not a risk factor (P = 0.003). Retained products of conception were found in 13.9% of study participants, and the incidence did not differ among management options. CONCLUSIONS: This appears to be the first documentation of IUA that were entirely attributable to the index miscarriage or its management. There appears to be an increased risk of IUA following D&C with larger uteri and multiple pregnancies and following mechanical suction D&C.

Curettage and Asherman's syndrome-lessons to (re-) learn?

OBJECTIVE: To investigate the noted cluster of cases of Asherman's syndrome in an 18-month period at an Early Pregnancy Assessment Centre at a tertiary care institution. METHODS: A practice audit was performed involving (a) a detailed chart review of the six index cases; and (b) compilation of treatment choices for all new patient referrals in the same 18-month time frame from July 2011 to December 2012. Diagnosis of Asherman's syndrome was made with a combination of clinical menstrual symptoms and hysteroscopic diagnosis of intrauterine adhesions. RESULTS: Of 1580 new patient referrals, 884 chose one of four forms of active management for early pregnancy failure. Six women (6/844, 0.7%) were subsequently found to have Asherman's syndrome. All six women (100%) underwent sharp curettage, and three (50%) had repeat curettage performed. No cases of Asherman's were reported following manual vacuum aspiration (0/191) or medical management with misoprostol (0/210). CONCLUSION: Asherman's syndrome remains a risk for those undergoing dilatation and curettage for management of spontaneous abortion and should be an important component of the informed consent for this procedure. Both sharp and repeated curettage remain important risk factors and should be employed judiciously. The evaluation of the common risk factors associated with these cases could target changes in practice.

Objectif : Se pencher sur le groupe de cas de syndrome d'Asherman qui ont été constatés sur une période de 18 mois au sein du centre d'évaluation de la grossesse précoce d'un établissement de soins tertiaires. Méthodes : Nous avons mené un audit de pratique mettant en jeu (a) une analyse détaillée des dossiers des six cas probants et (b) une compilation des choix de traitement pour toutes les nouvelles patientes de ce centre au cours de la même période de 18 mois (de juillet 2011 à décembre 2012). Un diagnostic de syndrome d'Asherman a été porté en fonction d'une combinaison de symptômes menstruels cliniques et d'un diagnostic hystéroscopique d'adhérences intra-utérines. Résultats : Chez les 1 580 nouvelles patientes de ce centre, 884 ont choisi l'une des quatre formes de prise en charge active de l'échec précoce de la grossesse. On a par la suite constaté la présence du syndrome d'Asherman chez six femmes (6/844, 0,7 %). Ces six femmes (100 %) ont subi une dilatation-curetage; trois d'entre elles (50 %) ont dû subir un deuxième curetage. Aucun cas de syndrome d'Asherman n'a été signalé à la suite d'une aspiration manuelle (0/191) ou d'une prise en charge médicale au moyen de misoprostol (0/210). Conclusion : Le syndrome d'Asherman demeure un risque pour les femmes qui subissent une dilatation-curetage aux fins de la prise en charge d'un avortement spontané et devrait constituer une composante importante du processus de consentement éclairé en ce qui concerne cette intervention. La tenue d'une dilatation-curetage et d'un deuxième curetage demeurent d'importants facteurs de risque; ces interventions devraient donc être utilisées de façon judicieuse. L'évaluation des facteurs de risque courants associés à ces cas pourrait permettre de cibler des changements en matière de pratique.

A Canadian urban early pregnancy assessment clinic: a review of the first year of operation.

OBJECTIVE: To review the services provided by an early pregnancy assessment clinic (EPAC) in Vancouver, British Columbia, and to assess the characteristics of the women accessing their services and their satisfaction with the care provided. METHODS: The EPAC at BC Women's Hospital and Health Centre was opened in September 2007 to offer assessment of early pregnancy complications and management of early pregnancy loss. We conducted a review of the records of all patients who accessed the clinic in its first year of operation to review the origin of referrals, patient assessments, diagnoses, treatment, complications, and follow-up. Additionally, we distributed satisfaction surveys to patients. RESULTS: A total of 411 patients were referred to the EPAC in its first year of operation. Most referrals were from family physicians (38%), and the primary reason for referral was most commonly cramping and/or spotting (57%). The mean wait time for patients to be seen was 2.02 working days, and the majority of women (91%) were given a diagnosis at their first clinic visit. After assessment, 48% of women had manual vacuum aspiration or dilatation and curettage arranged, 21% had expectant management, and 17% required no treatment, because of complete miscarriage. While 94% of patients with non-viable pregnancies were treated at EPAC, 6% were referred to other health care agencies. In the satisfaction surveys completed, comments about the EPAC were largely positive and primarily focused on the emotional support and level of care received. CONCLUSION: In its first year of operation, the EPAC was well used and provided efficient and compassionate care. Patients reported high satisfaction with the quality of care received from staff, and showed particular appreciation for the emotional care received.

The association of placental abnormalities with maternal and neonatal clinical findings: a retrospective cohort study.

OBJECTIVES: (1) To determine the nature and extent of placental pathologic findings; (2) to associate placental pathologic findings with clinical indicators of infection; (3) to evaluate placental pathology in the context of the guidelines outlined by the College of American Pathologists (CAP). METHODS: A retrospective cohort study, through review of maternal and neonatal charts and placental pathology, of 100 sequential pregnancies in which placentas were submitted to pathology. Data were examined using descriptive statistics, and proportional differences were compared using the chi-square test and Fisher's exact test. RESULTS: Overall, 75% of placentas submitted for pathology review had pathologic abnormalities. Fifty percent had findings consistent with inflammation, 38% had findings consistent with vascular abnormalities, and 18% had findings consistent with meconium. Fetal clinical indicators of infection were associated with placental findings of chorioamnionitis (p < or = 0.01), while maternal clinical indicators were not. Similarly, fetal clinical indicators were associated with placental findings of fetal inflammation (p < or = 0.025), whereas maternal indicators were not associated with placental findings of maternal inflammation. A diagnosis of chorioamnionitis in labour by the attending physician was associated with pathologic findings (p < or = 0.05). A CAP indication was found in 75% of the placentas. There was no difference in incidence of placental pathology between those placentas submitted with and without a CAP indication. CONCLUSION: Placental findings of inflammation or infection were associated with fetal clinical indicators of infection, but not with maternal indicators. Placental pathology is very useful in identifying undiagnosed maternal infection or inflammation.