wikidoc - User contributions [en]

User:Saud Khan

2022-10-03T14:53:01Z

Saud Khan: /* Pages Authored */

Saud Munib Khan, MD.

Email: saudmunib@gmail.com 

==Current position==

*Associate Editor-In-Chief at Wikidoc.org
*Lecturer at Project IMG 

==Education==

*Ziauddin University, Karachi. MBBS 2019

== Pages Authored ==
[[Cellulitis]]

[[Biliary Atresia]]

[[Premature rupture of membranes|Premature Rupture of Membranes]]

[[Nodular regenerative hyperplasia|Nodular Regenerative Hyperplasia]]

[[Aggressive NK-cell leukemia|Aggressive NK-cell Leukemia]]

Receptive Aphasia

[[Lactic Acidosis]]

[[Parkes Weber syndrome|Parkes-Weber Syndrome]]

[[Postural orthostatic tachycardia syndrome|Postural Orthostatic Tachycardia Syndrome ]]

Asherman's syndrome medical therapy

2022-09-04T18:08:28Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Medical therapy usually follows surgical removal of fibrous bands in the uterus causing the condition. Estrogen provides stimulation for endometrial proliferation. Anti-adhesive gels may also be employed to prevent recurrence.
==Medical Therapy==
Hormonal therapy with synthetic or conjugated [[estrogen]] is usually prescribed following surgery to stimulate endometrial growth thereby preventing the walls of the uterus from re-adhering.

Acunzo et al found a significant effect of hyaluronic acid compared to no gel barrier for prevention of new IUA after hysteroscopic adhesiolysis. However, a large study comparing intrauterine balloon, Intrauterine contraceptive device ([[Intrauterine device|IUCD]]) and [[Hyaluronic acid|hyaluronic]] acid gel demonstrated that the balloon and IUCD were more effective than the gel. Fertility data was not accounted for in this analysis so long term results cannot be determined. Another retrospective cohort study compared balloon, IUCD, hyaluronic acid and controls. In this study no difference between balloon and IUCD was seen, yet these two modalities were significantly more effective than hyaluronic acid.<ref name="pmid25936237">{{cite journal| author=Lin XN, Zhou F, Wei ML, Yang Y, Li Y, Li TC | display-authors=etal| title=Randomized, controlled trial comparing the efficacy of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis. | journal=Fertil Steril | year= 2015 | volume= 104 | issue= 1 | pages= 235-40 | pmid=25936237 | doi=10.1016/j.fertnstert.2015.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25936237 }} </ref>

According to the literature the only specific infection that causes Ashermans Syndrome is [[Tuberculosis|genital tuberculosis]]. There is no evidence in the literature that prophylactic antibiotics can prevent secondary intrauterine infectious complications. However, antibiotics are mandatory when infection is the cause of adhesion formation.

More studies are needed to evaluate which method of treatment is most likely to have a successful outcome. Future randomized trials are needed to prove if stem cell treatment will have a clinical role in Ashermans Syndrome.
==References==
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Asherman's syndrome medical therapy

2022-09-04T18:06:09Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Medical therapy usually follows surgical removal of fibrous bands in the uterus causing the condition. Estrogen provides stimulation for endometrial proliferation. Anti-adhesive gels may also be employed to prevent recurrence.
==Medical Therapy==
Hormonal therapy with synthetic or conjugated [[estrogen]] is usually prescribed following surgery to stimulate endometrial growth thereby preventing the walls of the uterus from re-adhering.

Acunzo et al found a significant effect of hyaluronic acid compared to no gel barrier for prevention of new IUA after hysteroscopic adhesiolysis. However, a large study comparing intrauterine balloon, Intrauterine contraceptive device ([[Intrauterine device|IUCD]]) and [[Hyaluronic acid|hyaluronic]] acid gel demonstrated that the balloon and IUCD were more effective than the gel. Fertility data was not accounted for in this analysis so long term results cannot be determined. Another retrospective cohort study compared balloon, IUCD, hyaluronic acid and controls. In this study no difference between balloon and IUCD was seen, yet these two modalities were significantly more effective than hyaluronic acid.<ref name="pmid25936237">{{cite journal| author=Lin XN, Zhou F, Wei ML, Yang Y, Li Y, Li TC | display-authors=etal| title=Randomized, controlled trial comparing the efficacy of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis. | journal=Fertil Steril | year= 2015 | volume= 104 | issue= 1 | pages= 235-40 | pmid=25936237 | doi=10.1016/j.fertnstert.2015.04.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25936237 }} </ref>

According to the literature the only specific infection that causes Ashermans Syndrome is genital tuberculosis. There is no evidence in the literature that prophylactic antibiotics can prevent secondary intrauterine infectious complications. However, when obvious infection is seen, antibiotics are mandatory.

More studies are needed to evaluate which method of treatment is most likely to have a successful outcome. Future randomized trials are needed to prove if stem cell treatment will have a clinical role in Ashermans Syndrome.
==References==
{{Reflist|2}}

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Asherman's syndrome medical therapy

2022-09-04T18:05:34Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Medical therapy usually follows surgical removal of fibrous bands in the uterus causing the condition. Estrogen provides stimulation for endometrial proliferation. Anti-adhesive gels may also be employed to prevent recurrence.
==Medical Therapy==
Hormonal therapy with synthetic or conjugated [[estrogen]] is usually prescribed following surgery to stimulate endometrial growth thereby preventing the walls of the uterus from re-adhering.

Acunzo et al found a significant effect of hyaluronic acid compared to no gel barrier for prevention of new IUA after hysteroscopic adhesiolysis. However, a large study comparing intrauterine balloon, Intrauterine contraceptive device ([[Intrauterine device|IUCD]]) and [[Hyaluronic acid|hyaluronic]] acid gel demonstrated that the balloon and IUCD were more effective than the gel. Fertility data was not accounted for in this analysis so long term results cannot be determined. Another retrospective cohort study compared balloon, IUCD, hyaluronic acid and controls. In this study no difference between balloon and IUCD was seen, yet these two modalities were significantly more effective than hyaluronic acid.

According to the literature the only specific infection that causes Ashermans Syndrome is genital tuberculosis. There is no evidence in the literature that prophylactic antibiotics can prevent secondary intrauterine infectious complications. However, when obvious infection is seen, antibiotics are mandatory.

More studies are needed to evaluate which method of treatment is most likely to have a successful outcome. Future randomized trials are needed to prove if stem cell treatment will have a clinical role in Ashermans Syndrome.
==References==
{{Reflist|2}}

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Asherman's syndrome other diagnostic studies

2022-09-04T17:44:16Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''
==Overview==
Hysteroscopy remains the gold standard. There is currently no role for MRI in diagnosis of Intra Uterine Adhesions.
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Asherman's syndrome natural history, complications and prognosis

2022-09-04T17:39:33Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
Asherman's syndrome typically occurs after a triggering event such as an [[infection]] or a procedure, and is a cumulative process which may lead to [[infertility]]. Damage to the uterine cavity may also cause pain, congestion and [[endometriosis]].

==Natural History==
Usually occurring after vigorous intrauterine procedures such as [[D&C|Dilation and Curettage]], Asherman's syndrome manifests as [[amenorrhea]] and uterine congestion. Over time, due to the uterine cavity being damaged by [[adhesions]], infertility may occur.

==Complications==
Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies <ref name="Valle">{{cite journal |author=Valle RF, and Sciarra JJ |title=Intrauterine adhesions: Hystreoscopic diagnosis, classification, treatment and reproductive outcome |journal=. Am J Obstet |volume=158 |issue=6Pt1 |pages=1459–1470 |year=1988 |pmid=3381869 |doi=}}</ref>. There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to [[endometriosis]]<ref name="Buttram">{{cite journal |author=Buttram VC, Turati, G |title=Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions |journal=Int J Fertil |volume=22 |issue=2 |pages=98–103 |year=1977 |pmid=20418 |doi=}}</ref>.
==Prognosis==
The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the [[uterine cavity]] or [[fallopian tube]] openings (ostia) may require several surgical interventions or even be uncorrectable. In this case [[surrogacy]], [[IVF]] or adoption may be advised.

Patients who carry a [[pregnancy]] after correction of Asherman's syndrome may have an increased risk of having abnormal [[placentation]] including [[placenta accreta]] <ref name="Fernandez">{{cite journal |author=Fernandez H, Al Najjar F, Chauvenaud-Lambling et al. |title=Fertility after treatment of Asherman's syndrome stage 3 and 4 |journal=J Minim Invasive Gynecol |volume=13 |issue=5 |pages=398–402. |year=2006 |pmid=16962521 |doi=10.1016/j.jmig.2006.04.013}}</ref>where the placenta invades the [[uterus]] more deeply, leading to complications in placental separation after delivery. Premature delivery <ref name="Roge">{{cite journal |authro=Roge P, D'Ercole C, Cravello L et al. |title=Hysteroscopic management of uterine synechiae: a series of 102 observations |journal=Eur J Obstet Gynecol Reprod Biol |volume=65 |issue=2 |pages=189–193. |year=1996 |pmid=8730623 |doi=10.1016/0301-2115(95)02342-9 |author=Roge, P}}</ref>, second-trimester pregnancy loss<ref name="Capella">{{cite journal |author=Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. |title=Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility |journal=Hum Reprod |volume=14 |issue=5 |pages=1230–1233. |year=1999 |pmid=10325268 |doi=10.1093/humrep/14.5.1230}}</ref>, and [[uterine rupture]]<ref name="Deaton">{{cite journal |author=Deaton JL, Maier D, Andreoli J. |title=Spontaneous uterine rupture during pregnancy after treatment of Asherman's syndrome |journal=Am J Obstet Gynecol |volume=160 |issue=(5Pt1) |pages=1053–1054. |year=1989 |pmid=2729381 |doi=}}</ref> are other reported complications. They may also develop incompetent [[cervix]] where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into [[Preterm labor and birth|premature labour.]] [[Cerclage]] is a surgical stitch which helps support the cervix if needed<ref name="Capella">Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility. Hum Reprod; 14:1230-1233.</ref>.

The overall pregnancy rate after adhesiolysis (removal of [[adhesions]]) was 60% and the live birth rate was 38.9% according to one study <ref name="Siegler">{{cite journal |author=Siegler AM, Valle RF. |title=Therapeutic hysteroscopic procedures |journal=Fertil Steril |volume=50 |issue=5 |pages=685–701. |year=1988 |pmid=3053254 |doi=}}
</ref>. Success is related to the severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively <ref name="Valle">Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470.</ref>.

Age is another factor contributing to fertility outcomes after treatment of Asherman's. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35 <ref name="Fernandez">Fernandez H, Al-Najjar F, Chauveneaud-Lambling A, et al. Fertility after treatment of Asherman's syndrome stage 3 and 4. J Minim Invasive Gynecol 2006; 13:398-402.
</ref>.

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Asherman's syndrome epidemiology and demographics

2022-09-04T17:35:04Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}} [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Asherman's Syndrome may occur in up to 13% of women undergoing a termination of pregnancy during the first trimester, and 30% in women undergoing a [[Dilation and curettage (patient information)|dilation and curettage]] (D&C) after a late '''spontaneous''' abortion. Structural placental abnormalities and previous procedures done in the uterus increase the risk. 
==Epidemiology and Demographics==
The true prevalence of Asherman’s syndrome is unclear. The condition is estimated to affect 1.5% of women undergoing [[Hysterosalpingography|HSG]] <ref name="Dmowski">{{cite journal |author=Dmowski WP, Greenblatt RB. |title=Asherman’s syndrome and risk of placenta accreta |journal=Obstet Gynecol |volume=34 |issue=2 |pages=288–299. |year=1969 |pmid=5816312 |doi=}}
</ref>, between 5 and 39% of women with recurrent [[miscarriage]] <ref name="Rabau">{{cite journal |author=Rabau E, David A. |title=Intrauterine adhesions:etiology, prevention, and treatment |journal=Obstet Gynecol |volume=22 |pages=626–629. |year=1963 |pmid=14082285 |doi=}}</ref><ref name="Toaf">{{cite journal |author=Toaff R. |title=Some remarks on posttraumatic uterine adhesions.in French |journal=Rev Fr Gynecol Obstet |volume=61 |issue=7 |pages=550–552. |year=1966 |pmid=5940506 |doi=}}
</ref><ref name="Ventolini">{{cite journal |author=Ventolini G, Zhang M, Gruber J. |title=Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population |journal=Surg Endosc |volume=18 |issue=12 |pages=1782–1784. |year=2004 |pmid=15809790 |doi=10.1007/s00464-003-8258-y}}</ref> and up to 40% of patients who have undergone D&C for retained products of conception <ref name="Westendorp">{{cite journal |author=Westendorp ICD, Ankum WM, Mol BWJ, Vonk J. |title=Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion |journal=Hum Reprod |volume=13 |issue=12 |pages=3347–3350. |year=1998 |pmid=9886512 |doi=10.1093/humrep/13.12.3347}}
</ref>. It may occur in up to 13% of women undergoing a [[termination of pregnancy]] during the first [[Pregnancy|trimester]], and 30% in women undergoing a dilation and curettage (D and C) after a late [[Spontaneous abortion|'''spontaneous''' abortion]].

Women with placental abnormalities (e.g., [[Placenta accreta|placenta increta]]) may have a higher risk of developing Asherman syndrome as the placenta adheres to deeper layers within the [[uterus]] and becomes more difficult to remove. The incidence may be as high as 23.4% in patients undergoing procedures two to four weeks after the initial procedure for a vaginal delivery or missed abortion. The risk increases for patients undergoing repeated procedures for bleeding or repeated elective termination of pregnancies.

It is found in 1.5% of women evaluated with a [[Hysterosalpingography|hysterosalpingogram]] (HSG) for infertility, between 5 and 39% of women with recurrent miscarriage. Asherman’s Syndrome may occur in 31% of women after the initial hysteroscopic resection of [[leiomyoma]], and up to 46% after the second hysteroscopic resection.<ref name="pmid30454053">{{cite journal| author=Chikazawa K, Imai K, Liangcheng W, Sasaki S, Horiuchi I, Kuwata T | display-authors=etal| title=Detection of Asherman's syndrome after conservative management of placenta accreta: a case report. | journal=J Med Case Rep | year= 2018 | volume= 12 | issue= 1 | pages= 344 | pmid=30454053 | doi=10.1186/s13256-018-1869-7 | pmc=6245912 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30454053 }} </ref><ref name="pmid30335256">Tchente NC, Brichant G, Nisolle M (2018) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=30335256 [Asherman's syndrome : management after curettage following a postnatal placental retention and literature review].] ''Rev Med Liege'' 73 (10):508-512. PMID: [https://pubmed.gov/30335256 30335256]</ref>

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Asherman's syndrome causes

2022-09-04T17:32:15Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
Asherman's syndrome is most commonly linked to obstetric procedures that cause [[abrasion]] of the basal layer of the [[endometrium]]. Other causes include [[Caesarean section|caesarian]] sections, infections or pelvic [[radiation therapy]].

[[Intrauterine device]]<nowiki/>s have not been linked to Asherman's syndrome.

==Causes==
Asherman's syndrome occurs most frequently after a [[D&C|Dilation & Curettage]] (D&C) is performed on a recently pregnant uterus, following a missed or incomplete [[miscarriage]], birth, or elective termination ([[abortion]]) to remove [[retained products of conception]]/placental remains. As the same procedure is used in all three situations, Asherman's can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related [[curettage]] <ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085
|doi=}}</ref>.

It is estimated that up to 5% of D&Cs result in Asherman's. More conservative estimates put this rate at 1%. Asherman's results from 25% of D&Cs performed 1-4 weeks post-partum <ref>Parent B, Barbot J, Dubuisson JB. Uterine synechiae (in French). Encyl Med Chir Gynecol 1988; 140A (Suppl): 10-12.</ref><ref>{{cite journal |author=Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC |title=The obstetrical outcome of women with surgically treated uterine synechiae (in French) |journal=J Gynecol Obstet Biol Reprod |volume=8 |issue=8 |pages=723–726. |year=1979 |pmid=553931 |doi=}}</ref><ref name="Buttram">{{cite journal |author=Buttram UC, Turati G. |title=Uterine synechiae: variation in severity and some conditions which may be conductive to severe adhesions |journal=Int J Fertil |volume=22 |issue=2 |pages=98–103. |year=1977 |pmid=20418 |doi=}}</ref>, 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. <ref name="Adoni">{{cite journal |author=Adoni A, Palti Z, Milwidsky A, Dolberg M. |title=The incidence of intrauterine adhesions following spontaneous abortion |journal=Int J Fertil. |volume=27 |issue=2 |pages=117–118. |year=1982 |pmid=6126446
|doi=}}</ref> In the case of missed [[Miscarriage|miscarriages]], the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30.9% <ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085
|doi=}}</ref><ref>Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol 2006; 49:767-788.</ref>

Asherman's can also result from other pelvic surgeries including [[Cesarean section]]<ref>{{cite journal |author=Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC |title=The obstetrical outcome of women with surgically treated uterine synechiae (in French) |journal=J Gynecol Obstet Biol Reprod |volume=8 |issue=8 |pages=723–726. |year=1979 |pmid=553931 |doi=}}</ref>, removal of fibroid tumours ([[myomectomy]]) and from other causes such as [[IUD]]s, pelvic [[irradiation]], [[schistosomiasis]]<ref> {{cite journal |author=Krolikowski A, Janowski K, Larsen JV. |title=Asherman syndrome caused by schistosomiasis |journal=Obstet Gynecol. |volume=85 |issue=5Pt2 |pages=898–9 |year=1995 |pmid=7724154 |doi=10.1016/0029-7844(94)00371-J}}</ref> and genital [[tuberculosis]]<ref>{{cite journal |author=Netter AP, Musset R, Lambert A Salomon Y |title=Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility, and abortion |journal=Am J Obstet Gynecol. |volume=71 |issue=2 |pages=368–75 |year=1956 |pmid=13283012 |doi=}}</ref>. Chronic [[endometritis]] from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat <ref>{{cite journal |author=Bukulmez O, Yarali H, Gurgan T. |title=Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis |journal=Hum Reprod |volume=14 |issue=8 |pages=1960–1961. |year=1999 |pmid=10438408 |doi=10.1093/humrep/14.8.1960}}</ref>.

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Asherman's syndrome pathophysiology

2022-09-04T17:29:53Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Asherman syndrome most often is the result of vigorous scraping and damage to the basal layer of the endometrium during a [[Dilation and curettage (patient information)|dilation and curettage]], which may be done for a variety of reasons. It may also occur after delivery, especially if there is uncontrolled [[hemorrhage]], or after the elective [[Termination of pregnancy|termination]] of a pregnancy. Less often, it is due to [[sampling]] for [[endometrial cancer]], or removal of [[endometrial polyp]]<nowiki/>s. It may also occur after surgery to remove [[Leiomyoma|uterine fibroids]].

==Pathophysiology==
The cavity of the [[uterus]] is lined by the [[endometrium]]. This lining is composed of two layers, the functional layer which is shed during [[menstruation]] and an underlying basal layer which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a [[dilation and curettage]] (D&C) performed after a [[miscarriage]], or [[childbirth|delivery]], or for elective [[abortion]] triggers [[inflammation]] that allows adhesive bands to form from one side of the cavity to the other. The risk of developing Asherman syndrome is increased if during pregnancy, the [[placenta]] tissue burrows below the basal layer of the endometrium. The extent of the adhesions defines whether the case is mild, moderate, or severe.

The adhesions can be thin or thick, spotty in location, or confluent. The adhesive bands are usually not vascular, an important consideration when discussing treatment options. In extreme cases, the whole cavity becomes [[Scar|scarred]] and occluded. Even with relatively few scars, the endometrium may fail to respond to [[estrogen]]s and rests.

Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding ([[amenorrhea]], [[hypomenorrhea]], or [[oligomenorrhea]]) <ref name="Klein">{{cite journal |author=Klein SM, Garcia C-R |title=Asherman's syndrome: a critique and current review |journal=Fertility and Sterility |volume=24 |issue=9 |pages=722–735. |year=1973 |pmid=4725610 |doi=}}</ref> and may develop recurrent pregnancy loss or [[infertility]]. Menstrual anomalies are often but not always correlated with severity: adhesions restricted to only the [[cervix]] or lower uterus may block menstruation. Pain during menstruation and ovulation are also sometimes experienced, and can be attributed to blockages.<ref name="pmid30936754">{{cite journal| author=Dreisler E, Kjer JJ| title=Asherman's syndrome: current perspectives on diagnosis and management. | journal=Int J Womens Health | year= 2019 | volume= 11 | issue= | pages= 191-198 | pmid=30936754 | doi=10.2147/IJWH.S165474 | pmc=6430995 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30936754 }} </ref>
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Asherman's syndrome classification

2022-09-04T17:26:59Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Classification of Asherman's syndrome takes into account the amount of functional [[endometrium]] present, the [[Menstrual cycle|menstrual]] pattern, obstetric history, and more recently the location and severity of [[adhesions]] inside the [[uterus]]. There is no data showing superiority of one system over the other.

==Classification of Intra Uterine Adhesions (IUA)==
As severity of the condition correlates with prognosis, classification of IUA is useful for choosing the treatment method and providing a prognosis relating to fertility outcome following treatment.

Several classification systems have been proposed for Asherman’s syndrome, although none of them is currently endorsed universally.

The older systems were based on [[hysterosalpingography]] findings however with the advent of [[hysteroscopy]] modern classification systems are based on hysteroscopic diagnosis of adhesions. Those of the American Fertility Society <ref name="AFS">{{cite journal |author=American Fertility Society |title=The American Fertility Society classification of adnexal adhesions, distal tubal occlusions secondary to tubal ligation, tubal pregnancy, mullerian anomalies and intrauterine adhesions.|journal=Fertil Steril |volume=49 |issue=6 |pages=944-55 |year=1988 |pmid=3371491 |doi=}}</ref>, the European Society for Hysteroscopy <ref name="Wamsteker"><nowiki>{{cite journal |author=Wamsteker K, DeBlok SJ |title=Diagnostic hysteroscopy: technique and documentation. |journal=Endoscopic surgery for gynecologist New York:Lippincott Williams & Wilkins Publishers |pages=263-76 |year=1995</nowiki></ref>and Nasr's proposed system, based on March et al.'s classification <ref name=":0">{{cite journal |author=Nasr AL, AL-Inany HG, Thabet SM, Aboulghar M |title=A clinicohysteroscopic scoring system of intrauterine adhesions |journal=Gynecol Obstet Invest |volume=50 |issue=3 |pages=178-81 |year=2000 |pmid= |doi=}}</ref> are the most complex, taking into account several criteria. Nasr's point based classification system includes:
{| class="wikitable"
! colspan="1" rowspan="1" |'''''Hysteroscopic findings'''''
! colspan="1" rowspan="1" |
! colspan="1" rowspan="1" |'''''Score'''''
|-
| colspan="1" rowspan="1" |''Isthmic fibrosis''
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="2" |''Filmy adhesions''
| colspan="1" rowspan="1" |More than 50% of the cavity
| colspan="1" rowspan="1" |1
|-
| colspan="1" rowspan="1" |Less than 50% of the cavity
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="2" |''Dense adhesions''
| colspan="1" rowspan="1" |Single band
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Multiple bands
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="3" |''Tubal ostium''
| colspan="1" rowspan="1" |Both visualized
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Only one visualized
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Both not visualized
| colspan="1" rowspan="1" |4
|-
| colspan="2" rowspan="1" |''Tubular cavity'' (sound less than 6)
| colspan="1" rowspan="1" |10
|-
| colspan="1" rowspan="3" |'''''Menstrual pattern'''''
| colspan="1" rowspan="1" |Normal
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Hypomenorrhea
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="1" |Amenorrhea
| colspan="1" rowspan="1" |8
|-
| colspan="1" rowspan="6" |'''''Reproductive performance'''''
| colspan="1" rowspan="1" |Good obstetrics history
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Recurrent pregnancy loss
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Infertility
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="1" |Mild
| colspan="1" rowspan="1" |0-4
|-
| colspan="1" rowspan="1" |Moderate
| colspan="1" rowspan="1" |5-10
|-
| colspan="1" rowspan="1" |Severe
| colspan="1" rowspan="1" |11-22
|}

There is some variation between criteria used in these systems but they include

* type of adhesions,
* location,
* extent of the uterine cavity affected,
* clinical symptoms,
* menstrual characteristics or history,
* obstetric history.

* The boundaries between grade subtypes are sometimes subtle.

It is important to note that none of these classification systems have been validated by clinical studies, and research reporting treatment outcomes often lack details on exact IUA grades in patients. This adds to the difficulties in comparing study outcomes in patients treated for Asherman's syndrome.<ref name=":0" />
==References==
{{Reflist|2}}

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Asherman's syndrome historical perspective

2022-09-04T17:22:33Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
The Israeli gynecologist Joseph Asherman is credited with describing and characterizing the disease, hence it is called Asherman syndrome.

==Historical Perspective==

* [[Intrauterine adhesions]] were first described in 1894 by Heinrich Fritsch (Fritsch, 1894)<ref>>{{WhoNamedIt|synd|1521}}Fritsch H, Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung. Zentralbl Gynaekol 1894; 18:1337-1342.</ref> and further characterized and described by the gynecologist Joseph Asherman in 1948 <ref>{{cite journal |author=Asherman JG. |title=Traumatic intra-uterine adhesions |journal=J Obstet Gynaecol Br Em |volume=55 |issue=2 |pages=2–30. |year=1948. |pmid=|doi=}}</ref>.
* Asherman though that intrauterine adhesions may be linked to prior [[endometrial]] trauma.
* He later published more case series of intrauterine adhesions with documented results of [[hysterography]], with evident filling defects. It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.
* References
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Asherman's syndrome overview

2022-09-04T17:20:52Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
''' Asherman's syndrome''', also called "uterine [[synechia]]e" or intrauterine [[adhesions]], presents a condition characterized by the presence of scars within the uterine cavity.

An artificial form of Asherman's syndrome can be surgically induced by [[endometrial ablation]] in women with excessive uterine bleeding, in lieu of [[hysterectomy]].

== Historical Perspective ==
The Israeli gynecologist Joseph Asherman is credited with describing and characterizing the disease, hence it is called Asherman syndrome.

==Classification==
Classification of Asherman's syndrome takes into account the amount of functional endometrium present, the menstrual pattern, obstetric history, and more recently the location and severity of adhesions inside the uterus. There is no data showing superiority of one system over the other.

==Pathophysiology==
Asherman syndrome most often is the result of vigorous scraping and damage to the basal layer of the endometrium during a dilation and curettage, which may be done for a variety of reasons. It may also occur after delivery, especially if there is uncontrolled hemorrhage, or after the elective termination of a pregnancy. Less often, it is due to sampling for endometrial cancer, or removal of endometrial polyps. It may also occur after surgery to remove uterine fibroids.

==Causes==
Asherman's syndrome is most commonly linked to obstetric procedures that cause abrasion of the basal layer of the endometrium. Other causes include caesarian sections, infections or pelvic radiation therapy.

Intrauterine devices have not been linked to Asherman's syndrome.

==Differentiating Asherman's Syndrome from other diseases==
Asherman Syndrome must be differentiated from other conditions that may cause amenorrhea and pregnancy loss, and may cause infertility.

==Epidiology and Demographics==
Asherman's Syndrome may occur in up to 13% of women undergoing a termination of pregnancy during the first trimester, and 30% in women undergoing a dilation and curettage (D and C) after a late '''spontaneous''' abortion. Structural placental abnormalities and previous procedures done in the uterus increase the risk.

==Risk Factors==
The strongest risk factors for developing Asherman Syndrome is previous obstetric curettage procedures and infections.

==Screening==
No screening guidelines exist for Asherman's Syndrome.

==Natural History, Complications and Prognosis==
Asherman's syndrome typically occurs after a triggering event such as an infection or a procedure, and is a cumulative process which may lead to infertility. Damage to the uterine cavity may also cause pain, congestion and endometriosis.{{WikiDoc Help Menu}}

User:Saud Khan

2022-08-19T23:17:28Z

Saud Khan: /* Current position */

Premature rupture of membranes

2022-08-19T23:16:02Z

Saud Khan:

__NOTOC__
{{SI}}
{{CMG}} '''Associate Editor-In-Chief''': {{skhan}}

{{SK}}
==Overview==
'''Premature rupture of membranes''' ('''PROM''') (referred to as pre-labor rupture of membranes for simplicity in this article) is a condition which occurs in [[pregnancy]] when the [[amniotic sac]] ruptures before the onset of [[Childbirth|labor]]. A related term is '''pPROM''' which stands for preterm premature rupture of the membranes which occurs when the rupture happens before 37 weeks gestation. Risk factors include maternal vaginal infections which ascend to the amniotic membrane, vaginal bleeding during pregnancy and maternal stature, among others.

==PPROM==
Preterm prelabor rupture of membranes (PPROM) is a condition where the amniotic sac leaks fluid before 37 weeks of gestation.<ref name="pmid17674244">{{cite journal |author=Deering SH, Patel N, Spong CY, Pezzullo JC, Ghidini A |title=Fetal growth after preterm premature rupture of membranes: is it related to amniotic fluid volume? |journal=J. Matern. Fetal. Neonatal. Med. |volume=20 |issue=5 |pages=397–400 |year=2007 |pmid=17674244 |doi=10.1080/14767050701280249}}</ref> This can be caused by a bacterial infection or by a defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the leak can spontaneously heal, but in most cases of PPROM, labor begins within 48 hours of membrane rupture. When this occurs, it is necessary that the mother receive treatment to avoid possible infection in the newborn.

==Classification==
Prelabor rupture of membranes may be classified according to gestational age at which the rupture occurs. If more than 18 hours have passed after the rupture of membranes without the onset of labor it is termed as '''prolonged PROM'''. If rupture occurs before age of viability (37 weeks) it is termed as '''preterm prelabor rupture of membranes''' (pPROM). If the gestational age is between 20 0/7 weeks to 25 6/7 it is considered as "'''periviable PROM'''". Other types of rupture of membranes are artificial rupture of membranes ('''AROM'''), spontaneous rupture of membranes ('''SROM''').

==Pathophysiology==
Membrane strength is dependent on extracellular proteins including but not limited to collagen, [[fibronectin]] and [[laminin]]. Matrix metalloproteases (MMPs) degrade collagen which reduces membrane strength. These are inhibited by metalloproteinase inhibitors. The balance between these proteins maintains membrane integrity. It is thought that PROM and pPROM can be caused by a combination of events that lead to membrane weakening via direct damage or reduction of supporting elements.<ref name="pmid937390">{{cite journal| author=Artal R, Sokol RJ, Neuman M, Burstein AH, Stojkov J| title=The mechanical properties of prematurely and non--prematurely ruptured membranes. Methods and preliminary results. | journal=Am J Obstet Gynecol | year= 1976 | volume= 125 | issue= 5 | pages= 655-9 | pmid=937390 | doi=10.1016/0002-9378(76)90788-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=937390 }} </ref> <ref name="pmid2296428">{{cite journal| author=Vadillo-Ortega F, González-Avila G, Karchmer S, Cruz NM, Ayala-Ruiz A, Lama MS| title=Collagen metabolism in premature rupture of amniotic membranes. | journal=Obstet Gynecol | year= 1990 | volume= 75 | issue= 1 | pages= 84-8 | pmid=2296428 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2296428 }} </ref> Up to a third of PROM cases are linked to amniotic fluid positive for bacteria. These infections may be asymptomatic until presentation. In case of an altered flora of the vaginal canal, some invasive species of bacteria produce [[collagenase]]<nowiki/>s, proteases, which directly degrade the amniotic membranes, in addition to the inflammatory effect and subsequent damage to the membranes by the host immune system. <ref name="pmid2552366">{{cite journal| author=Schoonmaker JN, Lawellin DW, Lunt B, McGregor JA| title=Bacteria and inflammatory cells reduce chorioamniotic membrane integrity and tensile strength. | journal=Obstet Gynecol | year= 1989 | volume= 74 | issue= 4 | pages= 590-6 | pmid=2552366 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2552366 }} </ref>

Hypoxic stress to the fetus and placenta are linked to a three to seven times likelihood of PROM. This stress can be due to maternal hypertension, [[preeclampsia]]/[[eclampsia]] and problems with the umbilical cord. This stress causes release of fetal [[corticotropin releasing hormone]] (CRH), leading to inhibition of transcription in [[decidual cells]] (via the glucocorticoid and progesterone receptor ligand), leading to a state of progesterone resistance and consequent weakening of membranes.

Fetal ACTH release also results in a downstream increase of androgens, which are converted by the placenta into estrones. These estrones act on the myometrium to increase gap junctions and receptors for pro-contractile hormones. Coupled with the anti-progesterone effects of fetal CRH, this pathway results in an excitable and procontractile myometrium.

==Differentiating PROM from other Diseases==
Other disorders causing abnormal vaginal wetness are:

*[[Urinary incontinence]]
*Excessive discharge
*[[Urinary tract infection (UTI)|Urinary tract infection]]
*[[bacterial vaginosis]]
*cervical mucus

The diagnosis of PROM is done via careful history and physical examination, ultrasound is employed to confirm oligohydramnios. These tests can also be done to rule out the differentials listed.

==Epidemiology and Demographics==
PROM complicates 3% of preterm pregnancies and occurs in 5% to 10% of term pregnancies. 60% to 80% cases of PROM occur in term pregnancies.
Pregnant females of all age groups may develop PROM, however there is a higher chance of adolescent pregnancies progressing towards PROM and pPROM.<ref>{{Cite journal|last=|first=|date=|title=Premature and preterm premature rupture of membranes in adolescent compared to adult pregnancy|url=https://www.researchgate.net/publication/335174941_Premature_and_preterm_premature_rupture_of_membranes_in_adolescent_compared_to_adult_pregnancy|journal=Medicinski glasnik|volume=|pages=|via=}}</ref>
African american females are more likely to experience PROM.

==Risk Factors==
Common risk factors in the development of PROM include important maternal risk factors such as [[chorioamnionitis]], [[sepsis]], previous history of PROM. Additional factors are similar to those for preterm birth such as abnormal bleeding during the second trimester or late in the pregnancy, low BMI, reduced cervical length, smoking and drug abuse. Low socioeconomic status and deficiency of copper or vitamin C, along with connective tissue disorders are also linked to increased risk of PROM. Fetal factors include prematurity, [[infection]], [[cord prolapse]], or [[malpresentation]]. <ref name="pmid7088456">{{cite journal| author=Naeye RL| title=Factors that predispose to premature rupture of the fetal membranes. | journal=Obstet Gynecol | year= 1982 | volume= 60 | issue= 1 | pages= 93-8 | pmid=7088456 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7088456 }} </ref>

==Screening==
There is insufficient evidence to recommend routine screening for PROM. In women with positive vaginal-rectal [[Group B streptococcal infection|group B strep]] (GBS) cultures within the past 5 weeks, antibiotic prophylaxis is recommended intrapartum by the CDC. If the patient is not in labor, antibiotics are to be continued for 48 hours and cultures to be repeated. If repeat cultures are positive, intrapartum antibiotics are recommended. For cases of PPROM, [[Nonstress test|fetal nonstress testing]] is done to monitor status.
==Natural History, Complications, and Prognosis==
The majority of pregnancies progress to delivery within one week of membrane rupture, the common cause of induced or spontaneous labor is [[chorioamnionitis]], which complicates up to 60% of PROM cases. In usual cases of PROM, labor is induced as soon as possible if pregnancy is viable. If expectant management is practiced, the patient is at increased risk of infection, [[Placental abruption|abruptio placentae]], and [[Umbilical cord prolapse|umbilical cord]] accident as well as complications linked to [[Oligohydramnios|residual oligohydramnios]]. The risk of long term neurodevelopmental problems however, is not affected. PROM and PPROM are the most common cause of premature delivery, [[neonatal respiratory distress syndrome]] and neonatal death.
==Diagnosis==
Assessment of PROM involves taking a focused [[medical history]], a physical examination with a sterile speculum, ultrasound and other commercial tests if a diagnosis is not reached prior.
===Diagnostic Study of Choice===
The diagnosis of PROM is made according to characteristic findings on history and physical examination. Usual cases present as a woman in late trimester pregnancy complaining of leakage of fluid. The gold standard for diagnosis per speculum is pooling of fluid in the posterior vaginal vault. If there is no pooling observed, the patient is told to bear down or apply fundal pressure in order to increase the outflow of amniotic fluid and get visual confirmation of leakage. There may still be no pooling observed, in which case diagnostic testing is employed in the form of ultrasound to gauge the amniotic fluid volume. Ultrasound is also useful to assess fetal wellbeing. If [[oligohydramnios]] is detected, the diagnosis of PROM is confirmed. In cases of low-normal or normal amniotic fluid volume, other tests can be done to confirm PROM/PPROM.
===History and Symptoms===
The hallmark of PROM is pooling of fluid. A history of leakage of clear fluid from the vagina is suggestive of PROM.
===Physical Examination===
Patients with PROM usually appear well, some may be in active labor. Physical examination of patients is usually remarkable for leakage of clear or yellow fluid from the vagina, which may be a sudden gush or a slow leak that is evident by wetting of clothes. Fetal position is determined using [[Leopold's maneuvers|Leopold]]'s maneuver. For women in active labor, sterile [[Speculum (medical)|speculum]] examination is recommended to confirm pooling of amniotic fluid, as digital examination has been shown to increase the risk of infection and early labor (also called latency). Fever, foul-smelling vaginal discharge, fetal tachycardia (especially more than expected due to maternal temperature), and abdominal pain are highly indicative of infection.
===Laboratory Findings===
PROM is a clinical diagnosis, however in cases where membrane rupture is unclear or pooling is not visible in the vagina, bedside dipstick or strip based testing for specific amniotic fluid proteins has shown to be highly sensitive and specific for detecting PROM. An elevated concentration of vaginal fluid placental alpha microglobulin-1 protein is highly suggestive of PROM (Amnisure Test). IGFBP-1, or placental protein 12 (PP12) is another protein found in high concentrations in amniotic fluid and is the target of dipstick tests to detect PROM.

Less sensitive tests include the nitrazine and fern tests. A nitrazine paper test strip is used to test the pH of vaginal fluid. normal vaginal pH is from 3.8 to 4.2, the pH of urine, which is typically <6.0 but may be higher, amniotic fluid usually has a pH range of 7.0 to 7.3. False negatives can occur if the leaking sporadic or if the amniotic fluid is diluted by other vaginal fluids. False positives can be attributed to alkaline fluids in the vagina, like blood, seminal fluid, urine or soap. Urinary tract infections can also raise the urine pH.

Amniotic fluid forms a "ferning" pattern when allowed to dry on a slide. Fluid collected from the posterior fornix is dried on a glass slide for 10 minutes. Amniotic fluid produces a delicate ferning pattern, while dried cervival mucus forms a thicker, wider pattern. Well-estrogenized cervical mucus or a fingerprint <ref name="pmid2704521">{{cite journal| author=Lodeiro JG, Hsieh KA, Byers JH, Feinstein SJ| title=The fingerprint, a false-positive fern test. | journal=Obstet Gynecol | year= 1989 | volume= 73 | issue= 5 Pt 2 | pages= 873-4 | pmid=2704521 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2704521 }} </ref> on the microscope slide may cause a false positive fern test. False negatives may be because of the slide being prepared with inadequate amniotic fluid or contamination with vaginal discharge or blood.
===Electrocardiogram===
There are no ECG findings associated with PROM.
===X-ray===
There are no x-ray findings associated with PROM.
===Ultrasound===
Echocardiography/ultrasound may be helpful in the diagnosis of PROM/pPROM. Findings on an ultrasound diagnostic of PROM include:

*four quadrants amniotic fluid index (AFI): <5 cm
*two diameter pocket method: <1 x 1 cm or <15 cm2
*maximum vertical pocket depth: <2 cm

It is also used to determine fetal presentation and position.
===CT scan===
There are no CT scan findings associated with PROM.
===Other Imaging Findings===
There are no other imaging findings associated with PROM.
===Other Diagnostic Studies===
Other Studies are done if there is no clear evidence of PROM. Indigo carmine dye is injected into the amniotic sac under ultrasound guidance. Leakage of the blue dye into the vagina indicates rupture of membranes. Diamine Oxidase may also be used.<ref name="pmid6811981">{{cite journal| author=Gahl WA, Kozina TJ, Fuhrmann DD, Vale AM| title=Diamine oxidase in the diagnosis of ruptured fetal membranes. | journal=Obstet Gynecol | year= 1982 | volume= 60 | issue= 3 | pages= 297-304 | pmid=6811981 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6811981 }} </ref> 

==Treatment==
===Medical Therapy===
Initial evaluation by a physician guides the management of PROM. The risks of neonatal immaturity are weighed against the risk for infection and fetal health. In a term pregnancy where premature rupture of membranes has occurred, spontaneous labour should be permitted. Current obstetrical management includes an induction of labour at approximately 6 hours if it has not already begun, and [[Streptococcus|Group B Streptococcal]] prophylaxis at 18 hours. Some hospitals, birth centers and private midwives do not induce labor at any point after PROM, but rather watch carefully for any signs of infection and ensure that nothing is introduced into the vagina after the PROM, including sterile vaginal exams. If the pregnancy is at term or if there are signs of neonatal distress it is recommended to induce labor as soon as possible unless contraindicated, in which case delivery via caesarean section is performed. Expectant management is practiced according to the patients wishes and the assessment of the clinician. Studies have shown early induction to reduce maternal and fetal complications such as infection and cord prolapse when compared to expectant management of PROM. If management options remain unclear, fetal assessment is done for lung maturity via testing the amniotic fluid for surfactant. This helps gauge whether expectant management is viable and whether or not steroids are to be administered. <ref name="pmid9400406">{{cite journal| author=Gafni A, Goeree R, Myhr TL, Hannah ME, Blackhouse G, Willan AR | display-authors=etal| title=Induction of labour versus expectant management for prelabour rupture of the membranes at term: an economic evaluation. TERMPROM Study Group. Term Prelabour Rupture of the Membranes. | journal=CMAJ | year= 1997 | volume= 157 | issue= 11 | pages= 1519-25 | pmid=9400406 | doi= | pmc=1228562 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9400406 }} </ref> <ref name="pmid28050900">{{cite journal| author=Middleton P, Shepherd E, Flenady V, McBain RD, Crowther CA| title=Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). | journal=Cochrane Database Syst Rev | year= 2017 | volume= 1 | issue= | pages= CD005302 | pmid=28050900 | doi=10.1002/14651858.CD005302.pub3 | pmc=6464808 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28050900 }} </ref> <ref name="pmid8598837">{{cite journal| author=Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL | display-authors=etal| title=Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 16 | pages= 1005-10 | pmid=8598837 | doi=10.1056/NEJM199604183341601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8598837 }} </ref> <ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

In [[premature birth]] premature rupture of membranes, [[antibiotic]] therapy should be given to decrease the risk of sepsis. [[Ampicillin]] or [[erythromycin]] should be administered for 7 days, and [[antenatal steroid]]s if the [[gestational age]] is less than 30 weeks. [[Tocolysis]] may be used, although controversial, to reduce the risk of prematurity related complications in the fetus. The mother should be admitted to hospital and put under careful surveillance for preterm labour and [[chorioamnionitis]]. Induction of labour should happen at around 36 weeks.

One study showed that the frequency of cesarean delivery, endometritis and perinatal mortality did not differ between the groups, however, there was a higher risk of infection and fetal morbidity in the expectant managed group. <ref name="pmid14337377">{{cite journal| author=LANIER LR, SCARBROUGH RW, FILLINGIM DW, BAKER RE| title=INCIDENCE OF MATERNAL AND FETAL COMPLICATIONS ASSOCIATED WITH RUPTURE OF THE MEMBRANES BEFORE ONSET OF LABOR. | journal=Am J Obstet Gynecol | year= 1965 | volume= 93 | issue= | pages= 398-404 | pmid=14337377 | doi=10.1016/0002-9378(65)90068-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14337377 }} </ref>

'''Expectant management'''

*For women who meet the following criteria, it is considered safe to opt for expectant management.
**No signs of intrauterine infection
**Cephalic presentation of the fetus
**Encouraging fetal ECG
**Amniotic fluid pocket on ultrasound at least 2 by 2 cm
**Patient safety at home and access to hospital
**Patient is educated with regards to charting blood pressure and temperature at home every 6 hours and when to present to the hospital.
**Daily fetal kick counts
**Daily nonstress test and leukocyte count 

*The woman’s activity is limited to modified bed rest and complete pelvic rest. Vitals must be charted ≥3 times daily.

*Antibiotics (usually 48 hours of IV ampicillin and erythromycin, followed by 5 days of oral amoxicillin and erythromycin) have been shown to lengthen the latency period and reduce risk of neonatal morbidity.
*If pregnancies are periviable (>24 but <34 weeks) corticosteroids are given to facilitate lung maturity. Another course of corticosteroids may be given if the following criteria are met:
**The pregnancy is < 34 weeks.
**Women are at risk of delivering within 7 days.
**The last course was given ≥ 14 days prior. Corticosteroids should also be considered in the following circumstances:
**At gestational age 34 weeks 0 days to 36 weeks 6 days if women are at risk of delivering within 7 days and no prior corticosteroids have been given. Starting at gestational age 23 weeks 0 days if there is a risk of preterm delivery within 7 days. IV magnesium sulfate should be considered in pregnancies < 32 weeks; in utero exposure to this drug has shown to reduce the risk of severe neurologic dysfunction (eg, due to intraventricular hemorrhage), including cerebral palsy, in neonates. [[Tocolytic]] use remain controversial, and must be decided on a case basis. {{Cite web|url=https://www.msdmanuals.com/en-nz/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/prelabor-rupture-of-membranes-prom#v25896716|title=Prelabor Rupture of Membranes (PROM)|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}<ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

It is prudent to note that many studies have linked prolonged rupture of membranes to unfavorable outcomes with regards to fetal and maternal mortality. <ref name="pmid6717874">{{cite journal| author=Duff P, Huff RW, Gibbs RS| title=Management of premature rupture of membranes and unfavorable cervix in term pregnancy. | journal=Obstet Gynecol | year= 1984 | volume= 63 | issue= 5 | pages= 697-702 | pmid=6717874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6717874 }} </ref>

'''Active Management'''

In women with known vaginal Group B streptococcus (GBS) colonization, prophylactic antibiotics and early induction of labor is recommended.

Multiple studies suggest oxytocin as the drug of choice to induce labor in women with PROM.<ref name="pmid10796161">{{cite journal| author=Tan BP, Hannah ME| title=Prostaglandins versus oxytocin for prelabour rupture of membranes at term. | journal=Cochrane Database Syst Rev | year= 2000 | volume= | issue= 2 | pages= CD000159 | pmid=10796161 | doi=10.1002/14651858.CD000159 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10796161 }} </ref> <ref name="pmid16135593">{{cite journal| author=Lin MG, Nuthalapaty FS, Carver AR, Case AS, Ramsey PS| title=Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis. | journal=Obstet Gynecol | year= 2005 | volume= 106 | issue= 3 | pages= 593-601 | pmid=16135593 | doi=10.1097/01.AOG.0000172425.56840.57 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16135593 }} </ref> Oral [[misoprostol]] (100ug for up to two doses six hours apart) for induction of labor in women with term PROM was not found to be more effective. Classic management of labor induction with only oxytocin has however shown an increase in maternal as well as perinatal morbidity compared to studies with prostaglandins in patients with PROM with a unsuitable cervix ([[Bishop score]] of less than 6).

The maternal and fetal/neonatal hazards from induction of labor include failed induction leading to increased latency, uterine hyperstimulation, uterine hypotony, abruptio placentae, uterine rupture, inadvertent preterm delivery, fetal distress, electrolyte disturbances (hyponatremia), hyperbilirubinemia and postpartum hemorrhage.

===Surgery===
Surgery is not the first-line treatment option for patients with PROM. Surgery is usually reserved for patients with either contraindications for vaginal delivery or labor, or cases that have been complicated with chorioamnionitis. <ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

===Primary Prevention===
There are no established measures for the primary prevention of PROM.

===Secondary Prevention===
There are no established measures for the secondary prevention of PROM.

'''Algorithm for PROM at term'''

 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01= History suggestive of [[PROM]] (leakage of [[Amniotic fluid|fluid]] from the [[vagina]])}}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= [[Physical examination]] findings confirm [[PROM]] •Pooling of [[Amniotic fluid|fluid]] •Positive [[nitrazine]] and Ferning tests}}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= [[Sterile]] [[speculum]] examination assess [[dilation]] and [[ultrasound]] if indicated}}
{{familytree | |,|-|-|^|-|-|.| | }}
{{familytree | C01 | | | | C02 | C01= [[PROM]] ruled-out| C02= [[PROM]] confirmed}}
{{familytree | | | | | | | |!| | | | }}
{{familytree | | | | | | | B01 | | | B01= Check [[gestational age]] •Arrange transportation to [[tertiary care]] if possible •Arrange prompt consult with [[obstetrician]] •[[Non-stress test|Fetal non-stress test]] and [[ECG]] to assess well being}}
{{familytree | | | | | | | |!| | | | }}
{{familytree | | | B01 |-| B02 | | | B01= Induce delivery with [[Oxytocin|oxytocin]] if at-term [[gestation]]| B02= Plan delivery if any signs of [[infection]], [[placental]] insufficiency, [[fetal distress]], or [[Labor|active labor]]}}
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | }}
{{familytree | | | B01 | | B02 | | B03 | B01= 24-31 weeks •[[Antibiotics]]+[[steroids]] •Delivery if [[lung]] maturity is satisfactory |B02= 32-33 weeks •[[Antibiotics]]+[[steroids]] •[[Delivery]] at 34 weeks or [[amniocentesis]] if [[abortion]] is suspected|B03= 34-36 weeks •[[Group B strep]] [[prophylaxis]] •[[Delivery]]}}
{{familytree/end}} 

==References==
{{reflist|2}}

{{Pathology of pregnancy, childbirth and the puerperium}}
{{SIB}}
[[Category:Obstetrics]]
[[Category:needs review]]

Premature rupture of membranes

2022-08-19T23:15:47Z

Saud Khan:

__NOTOC__
{{SI}}
{{CMG}} Associate Editor-In-Chief: {{skhan}}

{{SK}}
==Overview==
'''Premature rupture of membranes''' ('''PROM''') (referred to as pre-labor rupture of membranes for simplicity in this article) is a condition which occurs in [[pregnancy]] when the [[amniotic sac]] ruptures before the onset of [[Childbirth|labor]]. A related term is '''pPROM''' which stands for preterm premature rupture of the membranes which occurs when the rupture happens before 37 weeks gestation. Risk factors include maternal vaginal infections which ascend to the amniotic membrane, vaginal bleeding during pregnancy and maternal stature, among others.

==PPROM==
Preterm prelabor rupture of membranes (PPROM) is a condition where the amniotic sac leaks fluid before 37 weeks of gestation.<ref name="pmid17674244">{{cite journal |author=Deering SH, Patel N, Spong CY, Pezzullo JC, Ghidini A |title=Fetal growth after preterm premature rupture of membranes: is it related to amniotic fluid volume? |journal=J. Matern. Fetal. Neonatal. Med. |volume=20 |issue=5 |pages=397–400 |year=2007 |pmid=17674244 |doi=10.1080/14767050701280249}}</ref> This can be caused by a bacterial infection or by a defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the leak can spontaneously heal, but in most cases of PPROM, labor begins within 48 hours of membrane rupture. When this occurs, it is necessary that the mother receive treatment to avoid possible infection in the newborn.

==Classification==
Prelabor rupture of membranes may be classified according to gestational age at which the rupture occurs. If more than 18 hours have passed after the rupture of membranes without the onset of labor it is termed as '''prolonged PROM'''. If rupture occurs before age of viability (37 weeks) it is termed as '''preterm prelabor rupture of membranes''' (pPROM). If the gestational age is between 20 0/7 weeks to 25 6/7 it is considered as "'''periviable PROM'''". Other types of rupture of membranes are artificial rupture of membranes ('''AROM'''), spontaneous rupture of membranes ('''SROM''').

==Pathophysiology==
Membrane strength is dependent on extracellular proteins including but not limited to collagen, [[fibronectin]] and [[laminin]]. Matrix metalloproteases (MMPs) degrade collagen which reduces membrane strength. These are inhibited by metalloproteinase inhibitors. The balance between these proteins maintains membrane integrity. It is thought that PROM and pPROM can be caused by a combination of events that lead to membrane weakening via direct damage or reduction of supporting elements.<ref name="pmid937390">{{cite journal| author=Artal R, Sokol RJ, Neuman M, Burstein AH, Stojkov J| title=The mechanical properties of prematurely and non--prematurely ruptured membranes. Methods and preliminary results. | journal=Am J Obstet Gynecol | year= 1976 | volume= 125 | issue= 5 | pages= 655-9 | pmid=937390 | doi=10.1016/0002-9378(76)90788-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=937390 }} </ref> <ref name="pmid2296428">{{cite journal| author=Vadillo-Ortega F, González-Avila G, Karchmer S, Cruz NM, Ayala-Ruiz A, Lama MS| title=Collagen metabolism in premature rupture of amniotic membranes. | journal=Obstet Gynecol | year= 1990 | volume= 75 | issue= 1 | pages= 84-8 | pmid=2296428 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2296428 }} </ref> Up to a third of PROM cases are linked to amniotic fluid positive for bacteria. These infections may be asymptomatic until presentation. In case of an altered flora of the vaginal canal, some invasive species of bacteria produce [[collagenase]]<nowiki/>s, proteases, which directly degrade the amniotic membranes, in addition to the inflammatory effect and subsequent damage to the membranes by the host immune system. <ref name="pmid2552366">{{cite journal| author=Schoonmaker JN, Lawellin DW, Lunt B, McGregor JA| title=Bacteria and inflammatory cells reduce chorioamniotic membrane integrity and tensile strength. | journal=Obstet Gynecol | year= 1989 | volume= 74 | issue= 4 | pages= 590-6 | pmid=2552366 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2552366 }} </ref>

Hypoxic stress to the fetus and placenta are linked to a three to seven times likelihood of PROM. This stress can be due to maternal hypertension, [[preeclampsia]]/[[eclampsia]] and problems with the umbilical cord. This stress causes release of fetal [[corticotropin releasing hormone]] (CRH), leading to inhibition of transcription in [[decidual cells]] (via the glucocorticoid and progesterone receptor ligand), leading to a state of progesterone resistance and consequent weakening of membranes.

Fetal ACTH release also results in a downstream increase of androgens, which are converted by the placenta into estrones. These estrones act on the myometrium to increase gap junctions and receptors for pro-contractile hormones. Coupled with the anti-progesterone effects of fetal CRH, this pathway results in an excitable and procontractile myometrium.

==Differentiating PROM from other Diseases==
Other disorders causing abnormal vaginal wetness are:

*[[Urinary incontinence]]
*Excessive discharge
*[[Urinary tract infection (UTI)|Urinary tract infection]]
*[[bacterial vaginosis]]
*cervical mucus

The diagnosis of PROM is done via careful history and physical examination, ultrasound is employed to confirm oligohydramnios. These tests can also be done to rule out the differentials listed.

==Epidemiology and Demographics==
PROM complicates 3% of preterm pregnancies and occurs in 5% to 10% of term pregnancies. 60% to 80% cases of PROM occur in term pregnancies.
Pregnant females of all age groups may develop PROM, however there is a higher chance of adolescent pregnancies progressing towards PROM and pPROM.<ref>{{Cite journal|last=|first=|date=|title=Premature and preterm premature rupture of membranes in adolescent compared to adult pregnancy|url=https://www.researchgate.net/publication/335174941_Premature_and_preterm_premature_rupture_of_membranes_in_adolescent_compared_to_adult_pregnancy|journal=Medicinski glasnik|volume=|pages=|via=}}</ref>
African american females are more likely to experience PROM.

==Risk Factors==
Common risk factors in the development of PROM include important maternal risk factors such as [[chorioamnionitis]], [[sepsis]], previous history of PROM. Additional factors are similar to those for preterm birth such as abnormal bleeding during the second trimester or late in the pregnancy, low BMI, reduced cervical length, smoking and drug abuse. Low socioeconomic status and deficiency of copper or vitamin C, along with connective tissue disorders are also linked to increased risk of PROM. Fetal factors include prematurity, [[infection]], [[cord prolapse]], or [[malpresentation]]. <ref name="pmid7088456">{{cite journal| author=Naeye RL| title=Factors that predispose to premature rupture of the fetal membranes. | journal=Obstet Gynecol | year= 1982 | volume= 60 | issue= 1 | pages= 93-8 | pmid=7088456 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7088456 }} </ref>

==Screening==
There is insufficient evidence to recommend routine screening for PROM. In women with positive vaginal-rectal [[Group B streptococcal infection|group B strep]] (GBS) cultures within the past 5 weeks, antibiotic prophylaxis is recommended intrapartum by the CDC. If the patient is not in labor, antibiotics are to be continued for 48 hours and cultures to be repeated. If repeat cultures are positive, intrapartum antibiotics are recommended. For cases of PPROM, [[Nonstress test|fetal nonstress testing]] is done to monitor status.
==Natural History, Complications, and Prognosis==
The majority of pregnancies progress to delivery within one week of membrane rupture, the common cause of induced or spontaneous labor is [[chorioamnionitis]], which complicates up to 60% of PROM cases. In usual cases of PROM, labor is induced as soon as possible if pregnancy is viable. If expectant management is practiced, the patient is at increased risk of infection, [[Placental abruption|abruptio placentae]], and [[Umbilical cord prolapse|umbilical cord]] accident as well as complications linked to [[Oligohydramnios|residual oligohydramnios]]. The risk of long term neurodevelopmental problems however, is not affected. PROM and PPROM are the most common cause of premature delivery, [[neonatal respiratory distress syndrome]] and neonatal death.
==Diagnosis==
Assessment of PROM involves taking a focused [[medical history]], a physical examination with a sterile speculum, ultrasound and other commercial tests if a diagnosis is not reached prior.
===Diagnostic Study of Choice===
The diagnosis of PROM is made according to characteristic findings on history and physical examination. Usual cases present as a woman in late trimester pregnancy complaining of leakage of fluid. The gold standard for diagnosis per speculum is pooling of fluid in the posterior vaginal vault. If there is no pooling observed, the patient is told to bear down or apply fundal pressure in order to increase the outflow of amniotic fluid and get visual confirmation of leakage. There may still be no pooling observed, in which case diagnostic testing is employed in the form of ultrasound to gauge the amniotic fluid volume. Ultrasound is also useful to assess fetal wellbeing. If [[oligohydramnios]] is detected, the diagnosis of PROM is confirmed. In cases of low-normal or normal amniotic fluid volume, other tests can be done to confirm PROM/PPROM.
===History and Symptoms===
The hallmark of PROM is pooling of fluid. A history of leakage of clear fluid from the vagina is suggestive of PROM.
===Physical Examination===
Patients with PROM usually appear well, some may be in active labor. Physical examination of patients is usually remarkable for leakage of clear or yellow fluid from the vagina, which may be a sudden gush or a slow leak that is evident by wetting of clothes. Fetal position is determined using [[Leopold's maneuvers|Leopold]]'s maneuver. For women in active labor, sterile [[Speculum (medical)|speculum]] examination is recommended to confirm pooling of amniotic fluid, as digital examination has been shown to increase the risk of infection and early labor (also called latency). Fever, foul-smelling vaginal discharge, fetal tachycardia (especially more than expected due to maternal temperature), and abdominal pain are highly indicative of infection.
===Laboratory Findings===
PROM is a clinical diagnosis, however in cases where membrane rupture is unclear or pooling is not visible in the vagina, bedside dipstick or strip based testing for specific amniotic fluid proteins has shown to be highly sensitive and specific for detecting PROM. An elevated concentration of vaginal fluid placental alpha microglobulin-1 protein is highly suggestive of PROM (Amnisure Test). IGFBP-1, or placental protein 12 (PP12) is another protein found in high concentrations in amniotic fluid and is the target of dipstick tests to detect PROM.

Less sensitive tests include the nitrazine and fern tests. A nitrazine paper test strip is used to test the pH of vaginal fluid. normal vaginal pH is from 3.8 to 4.2, the pH of urine, which is typically <6.0 but may be higher, amniotic fluid usually has a pH range of 7.0 to 7.3. False negatives can occur if the leaking sporadic or if the amniotic fluid is diluted by other vaginal fluids. False positives can be attributed to alkaline fluids in the vagina, like blood, seminal fluid, urine or soap. Urinary tract infections can also raise the urine pH.

Amniotic fluid forms a "ferning" pattern when allowed to dry on a slide. Fluid collected from the posterior fornix is dried on a glass slide for 10 minutes. Amniotic fluid produces a delicate ferning pattern, while dried cervival mucus forms a thicker, wider pattern. Well-estrogenized cervical mucus or a fingerprint <ref name="pmid2704521">{{cite journal| author=Lodeiro JG, Hsieh KA, Byers JH, Feinstein SJ| title=The fingerprint, a false-positive fern test. | journal=Obstet Gynecol | year= 1989 | volume= 73 | issue= 5 Pt 2 | pages= 873-4 | pmid=2704521 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2704521 }} </ref> on the microscope slide may cause a false positive fern test. False negatives may be because of the slide being prepared with inadequate amniotic fluid or contamination with vaginal discharge or blood.
===Electrocardiogram===
There are no ECG findings associated with PROM.
===X-ray===
There are no x-ray findings associated with PROM.
===Ultrasound===
Echocardiography/ultrasound may be helpful in the diagnosis of PROM/pPROM. Findings on an ultrasound diagnostic of PROM include:

*four quadrants amniotic fluid index (AFI): <5 cm
*two diameter pocket method: <1 x 1 cm or <15 cm2
*maximum vertical pocket depth: <2 cm

It is also used to determine fetal presentation and position.
===CT scan===
There are no CT scan findings associated with PROM.
===Other Imaging Findings===
There are no other imaging findings associated with PROM.
===Other Diagnostic Studies===
Other Studies are done if there is no clear evidence of PROM. Indigo carmine dye is injected into the amniotic sac under ultrasound guidance. Leakage of the blue dye into the vagina indicates rupture of membranes. Diamine Oxidase may also be used.<ref name="pmid6811981">{{cite journal| author=Gahl WA, Kozina TJ, Fuhrmann DD, Vale AM| title=Diamine oxidase in the diagnosis of ruptured fetal membranes. | journal=Obstet Gynecol | year= 1982 | volume= 60 | issue= 3 | pages= 297-304 | pmid=6811981 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6811981 }} </ref> 

==Treatment==
===Medical Therapy===
Initial evaluation by a physician guides the management of PROM. The risks of neonatal immaturity are weighed against the risk for infection and fetal health. In a term pregnancy where premature rupture of membranes has occurred, spontaneous labour should be permitted. Current obstetrical management includes an induction of labour at approximately 6 hours if it has not already begun, and [[Streptococcus|Group B Streptococcal]] prophylaxis at 18 hours. Some hospitals, birth centers and private midwives do not induce labor at any point after PROM, but rather watch carefully for any signs of infection and ensure that nothing is introduced into the vagina after the PROM, including sterile vaginal exams. If the pregnancy is at term or if there are signs of neonatal distress it is recommended to induce labor as soon as possible unless contraindicated, in which case delivery via caesarean section is performed. Expectant management is practiced according to the patients wishes and the assessment of the clinician. Studies have shown early induction to reduce maternal and fetal complications such as infection and cord prolapse when compared to expectant management of PROM. If management options remain unclear, fetal assessment is done for lung maturity via testing the amniotic fluid for surfactant. This helps gauge whether expectant management is viable and whether or not steroids are to be administered. <ref name="pmid9400406">{{cite journal| author=Gafni A, Goeree R, Myhr TL, Hannah ME, Blackhouse G, Willan AR | display-authors=etal| title=Induction of labour versus expectant management for prelabour rupture of the membranes at term: an economic evaluation. TERMPROM Study Group. Term Prelabour Rupture of the Membranes. | journal=CMAJ | year= 1997 | volume= 157 | issue= 11 | pages= 1519-25 | pmid=9400406 | doi= | pmc=1228562 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9400406 }} </ref> <ref name="pmid28050900">{{cite journal| author=Middleton P, Shepherd E, Flenady V, McBain RD, Crowther CA| title=Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). | journal=Cochrane Database Syst Rev | year= 2017 | volume= 1 | issue= | pages= CD005302 | pmid=28050900 | doi=10.1002/14651858.CD005302.pub3 | pmc=6464808 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28050900 }} </ref> <ref name="pmid8598837">{{cite journal| author=Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL | display-authors=etal| title=Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. | journal=N Engl J Med | year= 1996 | volume= 334 | issue= 16 | pages= 1005-10 | pmid=8598837 | doi=10.1056/NEJM199604183341601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8598837 }} </ref> <ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

In [[premature birth]] premature rupture of membranes, [[antibiotic]] therapy should be given to decrease the risk of sepsis. [[Ampicillin]] or [[erythromycin]] should be administered for 7 days, and [[antenatal steroid]]s if the [[gestational age]] is less than 30 weeks. [[Tocolysis]] may be used, although controversial, to reduce the risk of prematurity related complications in the fetus. The mother should be admitted to hospital and put under careful surveillance for preterm labour and [[chorioamnionitis]]. Induction of labour should happen at around 36 weeks.

One study showed that the frequency of cesarean delivery, endometritis and perinatal mortality did not differ between the groups, however, there was a higher risk of infection and fetal morbidity in the expectant managed group. <ref name="pmid14337377">{{cite journal| author=LANIER LR, SCARBROUGH RW, FILLINGIM DW, BAKER RE| title=INCIDENCE OF MATERNAL AND FETAL COMPLICATIONS ASSOCIATED WITH RUPTURE OF THE MEMBRANES BEFORE ONSET OF LABOR. | journal=Am J Obstet Gynecol | year= 1965 | volume= 93 | issue= | pages= 398-404 | pmid=14337377 | doi=10.1016/0002-9378(65)90068-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14337377 }} </ref>

'''Expectant management'''

*For women who meet the following criteria, it is considered safe to opt for expectant management.
**No signs of intrauterine infection
**Cephalic presentation of the fetus
**Encouraging fetal ECG
**Amniotic fluid pocket on ultrasound at least 2 by 2 cm
**Patient safety at home and access to hospital
**Patient is educated with regards to charting blood pressure and temperature at home every 6 hours and when to present to the hospital.
**Daily fetal kick counts
**Daily nonstress test and leukocyte count 

*The woman’s activity is limited to modified bed rest and complete pelvic rest. Vitals must be charted ≥3 times daily.

*Antibiotics (usually 48 hours of IV ampicillin and erythromycin, followed by 5 days of oral amoxicillin and erythromycin) have been shown to lengthen the latency period and reduce risk of neonatal morbidity.
*If pregnancies are periviable (>24 but <34 weeks) corticosteroids are given to facilitate lung maturity. Another course of corticosteroids may be given if the following criteria are met:
**The pregnancy is < 34 weeks.
**Women are at risk of delivering within 7 days.
**The last course was given ≥ 14 days prior. Corticosteroids should also be considered in the following circumstances:
**At gestational age 34 weeks 0 days to 36 weeks 6 days if women are at risk of delivering within 7 days and no prior corticosteroids have been given. Starting at gestational age 23 weeks 0 days if there is a risk of preterm delivery within 7 days. IV magnesium sulfate should be considered in pregnancies < 32 weeks; in utero exposure to this drug has shown to reduce the risk of severe neurologic dysfunction (eg, due to intraventricular hemorrhage), including cerebral palsy, in neonates. [[Tocolytic]] use remain controversial, and must be decided on a case basis. {{Cite web|url=https://www.msdmanuals.com/en-nz/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/prelabor-rupture-of-membranes-prom#v25896716|title=Prelabor Rupture of Membranes (PROM)|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}<ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

It is prudent to note that many studies have linked prolonged rupture of membranes to unfavorable outcomes with regards to fetal and maternal mortality. <ref name="pmid6717874">{{cite journal| author=Duff P, Huff RW, Gibbs RS| title=Management of premature rupture of membranes and unfavorable cervix in term pregnancy. | journal=Obstet Gynecol | year= 1984 | volume= 63 | issue= 5 | pages= 697-702 | pmid=6717874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6717874 }} </ref>

'''Active Management'''

In women with known vaginal Group B streptococcus (GBS) colonization, prophylactic antibiotics and early induction of labor is recommended.

Multiple studies suggest oxytocin as the drug of choice to induce labor in women with PROM.<ref name="pmid10796161">{{cite journal| author=Tan BP, Hannah ME| title=Prostaglandins versus oxytocin for prelabour rupture of membranes at term. | journal=Cochrane Database Syst Rev | year= 2000 | volume= | issue= 2 | pages= CD000159 | pmid=10796161 | doi=10.1002/14651858.CD000159 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10796161 }} </ref> <ref name="pmid16135593">{{cite journal| author=Lin MG, Nuthalapaty FS, Carver AR, Case AS, Ramsey PS| title=Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis. | journal=Obstet Gynecol | year= 2005 | volume= 106 | issue= 3 | pages= 593-601 | pmid=16135593 | doi=10.1097/01.AOG.0000172425.56840.57 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16135593 }} </ref> Oral [[misoprostol]] (100ug for up to two doses six hours apart) for induction of labor in women with term PROM was not found to be more effective. Classic management of labor induction with only oxytocin has however shown an increase in maternal as well as perinatal morbidity compared to studies with prostaglandins in patients with PROM with a unsuitable cervix ([[Bishop score]] of less than 6).

The maternal and fetal/neonatal hazards from induction of labor include failed induction leading to increased latency, uterine hyperstimulation, uterine hypotony, abruptio placentae, uterine rupture, inadvertent preterm delivery, fetal distress, electrolyte disturbances (hyponatremia), hyperbilirubinemia and postpartum hemorrhage.

===Surgery===
Surgery is not the first-line treatment option for patients with PROM. Surgery is usually reserved for patients with either contraindications for vaginal delivery or labor, or cases that have been complicated with chorioamnionitis. <ref name="pmid19623003">{{cite journal| author=ACOG Committee on Practice Bulletins -- Obstetrics| title=ACOG Practice Bulletin No. 107: Induction of labor. | journal=Obstet Gynecol | year= 2009 | volume= 114 | issue= 2 Pt 1 | pages= 386-97 | pmid=19623003 | doi=10.1097/AOG.0b013e3181b48ef5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19623003 }} </ref>

===Primary Prevention===
There are no established measures for the primary prevention of PROM.

===Secondary Prevention===
There are no established measures for the secondary prevention of PROM.

'''Algorithm for PROM at term'''

 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01= History suggestive of [[PROM]] (leakage of [[Amniotic fluid|fluid]] from the [[vagina]])}}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= [[Physical examination]] findings confirm [[PROM]] •Pooling of [[Amniotic fluid|fluid]] •Positive [[nitrazine]] and Ferning tests}}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= [[Sterile]] [[speculum]] examination assess [[dilation]] and [[ultrasound]] if indicated}}
{{familytree | |,|-|-|^|-|-|.| | }}
{{familytree | C01 | | | | C02 | C01= [[PROM]] ruled-out| C02= [[PROM]] confirmed}}
{{familytree | | | | | | | |!| | | | }}
{{familytree | | | | | | | B01 | | | B01= Check [[gestational age]] •Arrange transportation to [[tertiary care]] if possible •Arrange prompt consult with [[obstetrician]] •[[Non-stress test|Fetal non-stress test]] and [[ECG]] to assess well being}}
{{familytree | | | | | | | |!| | | | }}
{{familytree | | | B01 |-| B02 | | | B01= Induce delivery with [[Oxytocin|oxytocin]] if at-term [[gestation]]| B02= Plan delivery if any signs of [[infection]], [[placental]] insufficiency, [[fetal distress]], or [[Labor|active labor]]}}
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | }}
{{familytree | | | B01 | | B02 | | B03 | B01= 24-31 weeks •[[Antibiotics]]+[[steroids]] •Delivery if [[lung]] maturity is satisfactory |B02= 32-33 weeks •[[Antibiotics]]+[[steroids]] •[[Delivery]] at 34 weeks or [[amniocentesis]] if [[abortion]] is suspected|B03= 34-36 weeks •[[Group B strep]] [[prophylaxis]] •[[Delivery]]}}
{{familytree/end}} 

==References==
{{reflist|2}}

{{Pathology of pregnancy, childbirth and the puerperium}}
{{SIB}}
[[Category:Obstetrics]]
[[Category:needs review]]

Biliary atresia

2022-08-19T23:14:56Z

Saud Khan:

__NOTOC__
{{Biliary atresia}}
'''For patient information, click [[Biliary atresia (patient information)|here]]'''

{{CMG}} '''Assosciate Editor(s)-In-Chief:''' {{skhan}}

{{SK}} Extrahepatic ductopenia; progressive obliterative cholangiopathy; atresia of bile ducts

==[[Biliary atresia overview|Overview]]==

==[[Biliary atresia classification|Classification]]==

==[[Biliary atresia pathophysiology|Pathophysiology]]==

==[[Biliary atresia causes|Causes]]==

==[[Biliary atresia differential diagnosis|Differentiating Biliary Atresia from other Diseases]]==

==[[Biliary atresia epidemiology and demographics|Epidemiology and Demographics]]==

==[[Biliary atresia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

==Diagnosis==

[[Biliary atresia history and symptoms|History and Symptoms]] | [[Biliary atresia physical examination|Physical Examination]] | [[Biliary atresia laboratory findings|Laboratory Findings]] | [[Biliary atresia CT|CT]] | [[Biliary atresia MRI|MRI]] | [[Biliary atresia echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Biliary atresia other imaging findings|Other Imaging Findings]] | [[Biliary atresia other diagnostic studies|Other Diagnostic Studies]]

==Treatment==

[[Biliary atresia medical therapy|Medical Therapy]] | [[Biliary atresia surgery|Surgery]] | [[Biliary atresia prevention|Prevention]] | [[Biliary atresia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Biliary atresia future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
[[Biliary atresia case study one|Case #1]]

[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Pediatrics]]
[[Category:Congenital disorders]]
[[Category:Rare diseases]]
[[Category:Neonatology]]
[[Category:Disease]]

[[fr:Atrésie biliaire]]
[[pl:Atrezja dróg żółciowych]]

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{{WS}}

Asherman's syndrome secondary prevention

2022-08-01T17:33:51Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Reevaluation one to two weeks postoperatively after hysteroscopy to remove adhesions may allow earlier identification of recurrent scar tissue while immature and small in size, allowing resection before these adhesions worsen.
==References==
{{Reflist|2}}

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Asherman's syndrome primary prevention

2022-08-01T17:31:57Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
No primary prevention exists for Asherman's syndrome.
==Primary Prevention==
Asherman's is not usually caused by an 'over-aggressive' D&C: a properly performed D&C can lead to Asherman’s. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including [[misoprostol]] methotrexate and mifepristone. Studies show this less invasive and cheaper method to be to be efficacious, safe and an acceptable alternative to surgical management for most women.<ref>{{cite journal |author=Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM |title= National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial.A comparison of medical management with misoprostol and surgical management for early pregnancy failure |journal=N Engl J Med. |volume=353 |issue=8 |pages=761–9. |year=2005 |pmid=16120856 |doi=}}</ref> <ref name="Weeks">{{cite journal |author=Weeks A, Alia G, Blum J, Winikoff B, Ekwaru P, Durocher J, Mirembe F. |title=A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion |journal=Obstet Gynecol. |volume=106 |issue=3 |pages=540–7.|year=2005 |pmid=16135584 |doi=}}</ref>. It was suggested as early as in 1993 <ref name="Friedler">{{cite journal |author=Friedler S, Margalioth EJ, Karfka I, Yaffe H. |title=Incidence of post-abortionintrauterine adhesions evaluated by hysteroscopy-a prospective study |journal=Hum Reprod |volume=8 |issue=3 |pages=442–444 |year=1993 |pmid=8473464 |doi=}}</ref> that the incidence of IUA might be lower following medical evacuation (eg. Misoprostol) of the uterus, thus avoiding any intra-uterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did <ref>{{cite journal |author=Tam WH, Lau WC, Cheung LP, Yuen PM, Chung TK. |title=Intrauterine adhesions after conservative and surgical management of spontaneous abortion |journal=J Am Assoc Gynecol Laparosc. |volume=9 |issue=2 |pages=182–185 |year=2002 |pmid=11960045 |doi=10.1016/S1074-3804(05)60129-6}}</ref>. The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging.

Alternatively, D&C could be performed under ultrasound guidance rather than blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.

Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurence of Asherman’s as adhesions are more likely to occur after a D&C the longer the period after fetal death <ref name="Schenker">Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of postabortion intra-uterine adhesions evaluated by husteroscopy: a prospective study. Hum Reprod 1993;8:442-444.</ref>. Therefore immediate evacuation following fetal death may prevent IUA.

The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative, although it could be ineffective if a lot of tissue is present. Also, hysteroscopy is not a widely or routinely-used technique and requires expertise.

There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration.<ref>{{cite journal |author=Dalton VK, Saunders NA, Harris LH, Williams JA, Lebovic DI|title=Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure|journal=Fertil. Steril. |volume=85 |issue=6 |pages=1823.e1–3. |year= 2006 |pmid=16674955 |doi=10.1016/j.fertnstert.2005.11.065}}</ref>
==References==
{{Reflist|2}}

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Asherman's syndrome surgery

2022-08-01T17:30:47Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Hysteroscopy is diagnostic and therapeutic for Asherman's syndrome. In severe cases, laparoscopy is used to protect against perforation of the uterus.
== Surgery==
Fertility can be restored by removal of adhesions. Fluoroscopically guided operative [[hysteroscopy]] is used for visual inspection of the uterine cavity and dissection of scar tissue (adhesiolysis). In more severe cases, laparoscopy is used in addition to hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended <ref name="Kodaman">{{cite journal |author=Kodaman PH, Arici AA. |title=Intra-uterine adhesions and fertility outcome: how to optimize success? |journal=Curr Opin Obstet Gynecol |volume=19 |issue=3 |pages=207–214. |year=2007 |pmid=17495635 |doi=}}</ref>. Devices to prevent the apposition of the uterine walls may be placed intraoperatively to reduce scar formation. Sometimes a balloon stent ([[Foley catheter]] or Cook stent) filled with saline is inserted in the uterus for up to 3 weeks to keep the walls of the uterus apart as they heal to prevent the reformation of adhesions. These may however, cause the unintended side effect of wall atrophy due to pressure.

Experimental protocols to rebuild the endometrium by infusing stem cells derived from the patient's blood cells, fresh or freeze-dried amniotic tissue may be used in the future. However, these remain untested. Although adhesive gels containing synthetic hyaluronidase have been studied and show promise.

Reevaluation one to two weeks postoperatively may allow earlier identification of recurrent adhesions while small and allow resection before these adhesions worsen. Follow-up testing is necessary to ensure that scars have not reformed. Further surgery may be necessary to restore a normal uterine cavity.

According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27.9% and in severe cases this was 41.9%. <ref name="yu">{{cite journal |author=Yu D, Li T, Xia E, Huang X, Peng X. |title=Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman's syndrome |journal=Fertility and Sterility |volume=89 |issue=3 |pages=715–722 |year=2008 |pmid=17681324 |doi=10.1016/j.fertnstert.2007.03.070}}</ref> Another study found that postoperative adhesions reoccur in close to 50% of severe Asherman's and in 21.6% of moederate cases <ref name="Valle">Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470. </ref>. Mild IUA unlike moderate to severe synechiae do not appear to reform.

==References==
{{Reflist|2}}

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Asherman's syndrome classification

2022-08-01T17:23:29Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Classification of Asherman's syndrome takes into account the amount of functional endometrium present, the menstrual pattern, obstetric history, and more recently the location and severity of adhesions inside the uterus. There is no data showing superiority of one system over the other.

==Classification of IUA==
As severity of the condition correlates with prognosis, classification of IUA is useful for choosing the treatment method and providing a prognosis relating to fertility outcome following treatment. Several classification systems have been proposed for Asherman’s syndrome, although none of them is currently endorsed universally.
The older systems were based on [[hysterosalpingography]] findings however with the advent of [[hysteroscopy]] modern classification systems are based on hysteroscopic diagnosis of adhesions. Those of the American Fertility Society <ref name="AFS">{{cite journal |author=American Fertility Society |title=The American Fertility Society classification of adnexal adhesions, distal tubal occlusions secondary to tubal ligation, tubal pregnancy, mullerian anomalies and intrauterine adhesions.|journal=Fertil Steril |volume=49 |issue=6 |pages=944-55 |year=1988 |pmid=3371491 |doi=}}</ref>, the European Society for Hysteroscopy <ref name="Wamsteker"><nowiki>{{cite journal |author=Wamsteker K, DeBlok SJ |title=Diagnostic hysteroscopy: technique and documentation. |journal=Endoscopic surgery for gynecologist New York:Lippincott Williams & Wilkins Publishers |pages=263-76 |year=1995</nowiki></ref>and Nasr's proposed system, based on March et al.'s classification <ref name=":0">{{cite journal |author=Nasr AL, AL-Inany HG, Thabet SM, Aboulghar M |title=A clinicohysteroscopic scoring system of intrauterine adhesions |journal=Gynecol Obstet Invest |volume=50 |issue=3 |pages=178-81 |year=2000 |pmid= |doi=}}</ref> are the most complex, taking into account several criteria. Nasr's point based classification system includes:
{| class="wikitable"
! colspan="1" rowspan="1" |'''''Hysteroscopic findings'''''
! colspan="1" rowspan="1" |
! colspan="1" rowspan="1" |'''''Score'''''
|-
| colspan="1" rowspan="1" |''Isthmic fibrosis''
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="2" |''Filmy adhesions''
| colspan="1" rowspan="1" |More than 50% of the cavity
| colspan="1" rowspan="1" |1
|-
| colspan="1" rowspan="1" |Less than 50% of the cavity
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="2" |''Dense adhesions''
| colspan="1" rowspan="1" |Single band
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Multiple bands
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="3" |''Tubal ostium''
| colspan="1" rowspan="1" |Both visualized
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Only one visualized
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Both not visualized
| colspan="1" rowspan="1" |4
|-
| colspan="2" rowspan="1" |''Tubular cavity'' (sound less than 6)
| colspan="1" rowspan="1" |10
|-
| colspan="1" rowspan="3" |'''''Menstrual pattern'''''
| colspan="1" rowspan="1" |Normal
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Hypomenorrhea
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="1" |Amenorrhea
| colspan="1" rowspan="1" |8
|-
| colspan="1" rowspan="6" |'''''Reproductive performance'''''
| colspan="1" rowspan="1" |Good obstetrics history
| colspan="1" rowspan="1" |0
|-
| colspan="1" rowspan="1" |Recurrent pregnancy loss
| colspan="1" rowspan="1" |2
|-
| colspan="1" rowspan="1" |Infertility
| colspan="1" rowspan="1" |4
|-
| colspan="1" rowspan="1" |Mild
| colspan="1" rowspan="1" |0-4
|-
| colspan="1" rowspan="1" |Moderate
| colspan="1" rowspan="1" |5-10
|-
| colspan="1" rowspan="1" |Severe
| colspan="1" rowspan="1" |11-22
|}

There is some variation between criteria used in these systems but they include type of adhesions, location, extent of the uterine cavity affected, clinical symptoms, menstrual characteristics or history, and/or obstetric history. The boundaries between grade subtypes are sometimes subtle.

It is important to note that none of these classification systems have been validated by clinical studies, and research reporting treatment outcomes often lack details on exact IUA grades in patients. This adds to the difficulties in comparing study outcomes in patients treated for Asherman's syndrome.<ref name=":0" />
==References==
{{Reflist|2}}

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Asherman's syndrome other diagnostic studies

2022-08-01T17:22:15Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''
==Overview==
Hysteroscopy remains the gold standard. MRI may be needed when there is total obliteration of the uterine cavity.
==References==
{{Reflist|2}}

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Asherman's syndrome other imaging findings

2022-08-01T17:20:43Z

Saud Khan:

__NOTOC__
[[Image:HSG Ashermans syndrome.jpg|thumb|HSG view.]]
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''
==Overview==
Saline sonography or hysterosalpingography may be used initially in the evaluation of Asherman's syndrome. Though hysteroscopy remains the gold standard.

== Diagnosis ==
Hysteroscopy is the gold standard for diagnosis <ref name="Valle">Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470.</ref>. Imaging by [[sonohysterography]] or [[hysterosalpingography]] will reveal the extent of the scar formation. Hormone studies show normal levels consistent with reproductive function. Advantages of saline sonography compared with hysterosalpingography are that it does not involve radiation or a special suite, it may be done in-office. Hysterosalpingography must be performed in a radiology suite. The advantage of Hysterosalpingography is the feature that allows evaluation of tubal patency, although newer techniques for saline sonography that involve infusion of a water/air combination may improve assessment of tubal patency.<ref name="pmid21187197">{{cite journal| author=Luciano DE, Exacoustos C, Johns DA, Luciano AA| title=Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients? | journal=Am J Obstet Gynecol | year= 2011 | volume= 204 | issue= 1 | pages= 79.e1-5 | pmid=21187197 | doi=10.1016/j.ajog.2010.08.065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21187197 }} </ref>

===Hysterosalpingography===

(Images courtesy of RadsWiki)

<gallery>
Image:Asherman's syndrome 001.jpg|[[Hysterosalpingography]]: Asherman's syndrome
Image:Asherman's syndrome 002.jpg|[[Hysterosalpingography]]: Asherman's syndrome
Image:Asherman's syndrome 003.jpg|[[Hysterosalpingography]]: Asherman's syndrome
Image:Asherman's syndrome 004.jpg|[[Hysterosalpingography]]: Asherman's syndrome
</gallery>
==References==
{{Reflist|2}}

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Asherman's syndrome other imaging findings

2022-08-01T17:15:41Z

Saud Khan:

Asherman's syndrome ultrasound

2022-08-01T17:13:28Z

Saud Khan:

__NOTOC__
[[Image:Ultrasound_of_Asherman's_syndrome.jpg‎|thumb|Ultrasound view.]]
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''
==Overview==
Ultrasound on its own is not a diagnostic modality, it however is an important tool to rule out other causes of amenorrhea before confirming the diagnosis of Asherman's syndrome.

==Ultrasonography==
Ultrasonography is not a reliable method of diagnosing Asherman's Syndrome. A very thin endometrium following amenorrhea, or endometrial irregularity with hyperechoic regions may be suggestive of adhesions. It is more often evaluated initially with saline sonography or hysterosalpingography to demonstrate adhesions. Hysteroscopy remains the gold standard for diagnosing, classifying and treating the disease.<ref name="pmid28473177">{{cite journal| author=AAGL Elevating Gynecologic Surgery| title=AAGL Practice Report: Practice Guidelines on Intrauterine Adhesions Developed in Collaboration With the European Society of Gynaecological Endoscopy (ESGE). | journal=J Minim Invasive Gynecol | year= 2017 | volume= 24 | issue= 5 | pages= 695-705 | pmid=28473177 | doi=10.1016/j.jmig.2016.11.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28473177 }} </ref>

==References==
{{Reflist|2}}

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Asherman's syndrome laboratory findings

2022-08-01T17:01:18Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''
==Overview==
Patients with Asherman's syndrome induced amenorrhea usually have normal lab values.

==Lab values==
Amenorrhea or infertility caused by Asherman's syndrome does not show specific changes in biomarkers. Normal, age-appropriate levels or estrogen, progesterone and testosterone are expected.
==References==
{{Reflist|2}}
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Asherman's syndrome physical examination

2022-08-01T16:58:11Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''

==Overview==

Asherman's syndrome is typically occult, as such, a proper history consisting of menstrual change, infertility, dysmenorrhea, history of prior pregnancies, and history of prior uterine procedures is required. Cervical probing and dilation is usually deferred for the second clinical encounter. Ultrasound and hysteroscopy are used in conjunction to form a diagnosis.

== Physical Examination ==
In most cases, bimanual pelvic examination does not help in diagnosis. Probing of the cervix or dilation at the initial visit is also not recommended. If cervical dilation is indicated for another procedure (eg, endometrial biopsy), physicians may experience resistance from obstructive adhesions blocking entry of the instrument.

Estrogen/progestin withdrawal test was historically used, however this has fallen out of practice for diagnosing Asherman's syndrome as this test requires additional time and only delays the diagnosis. An estrogen-progestin withdrawal test is a two-month process during which the patient receives progestin alone followed by estrogen and progestin.

Ultrasound is commonly used in the initial workup. A very thin endometrium lining in a patient with amenorrhea, or other irregularities with hyperechoic regions may be suggestive of an adhesive process. Further workup using a hysteroscopy is required to confirm the diagnosis. Hysteroscopy, with lysis of adhesions as indicated, can be performed in an office or operating room setting. This is diagnostic and therapeutic, as well as decreasing the likelihood of trauma to the surrounding tissue.

Additional testing is done to rule out infective processes, especially for women from Tubercolosis endemic areas. <ref name="pmid28473177">{{cite journal| author=AAGL Elevating Gynecologic Surgery| title=AAGL Practice Report: Practice Guidelines on Intrauterine Adhesions Developed in Collaboration With the European Society of Gynaecological Endoscopy (ESGE). | journal=J Minim Invasive Gynecol | year= 2017 | volume= 24 | issue= 5 | pages= 695-705 | pmid=28473177 | doi=10.1016/j.jmig.2016.11.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28473177 }} </ref>

==References==
{{Reflist|2}}

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Asherman's syndrome physical examination

2022-08-01T16:57:29Z

Saud Khan: /* Overview */

__NOTOC__
{{Asherman's syndrome}}
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''

==Overview==

Asherman's syndrome is typically occult, as such, a proper history consisting of menstrual change, infertility, dysmenorrhea, history of prior pregnancies, and history of prior uterine procedures is required. Cervical probing and dilation is usually deferred for the second clinical encounter. Ultrasound and hysteroscopy are used in conjunction to form a diagnosis.

== Physical Examination ==
In most cases, bimanual pelvic examination does not help in diagnosis. Probing of the cervix or dilation at the initial visit is also not recommended. If cervical dilation is indicated for another procedure (eg, endometrial biopsy), physicians may experience resistance from obstructive adhesions blocking entry of the instrument.

Estrogen/progestin withdrawal test was historically used, however this has fallen out of practice for diagnosing Asherman's syndrome as this test requires additional time and only delays the diagnosis. An estrogen-progestin withdrawal test is a two-month process during which the patient receives progestin alone followed by estrogen and progestin.

Ultrasound is commonly used in the initial workup. A very thin endometrium lining in a patient with amenorrhea, or other irregularities with hyperechoic regions may be suggestive of an adhesive process. Further workup using a hysteroscopy is required to confirm the diagnosis. Hysteroscopy, with lysis of adhesions as indicated, can be performed in an office or operating room setting. This is diagnostic and therapeutic, as well as decreasing the likelihood of trauma to the surrounding tissue.

Additional testing is done to rule out infective processes, especially for women from Tubercolosis endemic areas.

==References==
{{Reflist|2}}

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Asherman's syndrome physical examination

2022-08-01T16:40:06Z

Saud Khan: /* References */

__NOTOC__
{{Asherman's syndrome}}
Please help WikiDoc by adding content here. It's easy! Click [[Help:How_to_Edit_a_Page|here]] to learn about editing.
{{CMG}} '''Associate Editor-In-Chief: {{Skhan}}'''

==Overview==

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Asherman's syndrome history and symptoms

2022-08-01T16:38:17Z

Saud Khan: /* History and Symptoms */

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
There are no overt symptoms of Asherman's syndrome. Signs of Asherman's syndrome include amenorrhea and repeated miscarriages.

==History and Symptoms==

*The adhesions in the uterine cavity may cause:
**[[Secondary amenorrhea (patient information)|amenorrhea]] (lack of menstrual periods)
**[[Dysmenorrhea (patient information)|Dysmenorrhea]] (painful menstrual periods)
**[[Miscarriage (patient information)|repeated miscarriages]]
**[[Infertility (patient information)|infertility]].

However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a [[D&C]] or other uterine surgery.

==References==
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Asherman's syndrome differential diagnosis

2022-08-01T16:36:51Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==

Asherman Syndrome must be differentiated from other conditions that may cause [[amenorrhea]] and pregnancy loss, and may cause infertility.
==Differential Diagnosis==
Ashermans Syndrome must be differentiated from:

*Thyroid disease
**[[Hypothyroidism]]
**[[Hyperthyroidism]]
*[[Hypothalamic dysfunction]]
*[[Pituitary gland|Pituitary]] gland dysfunction
*[[Androgen]]-secreting [[ovarian]]/[[Adrenal gland|adrenal]] tumors
*[[Polycystic ovarian disease]]
*[[Pelvic inflammatory disease]]
*[[Cervical|Cervical stenosis]] (Narrowing of the cervix and blockage of the outlet)
*Premature [[menopause]]<ref>Smikle C, Yarrarapu SNS, Khetarpal S. Asherman Syndrome. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK448088/</nowiki></ref>

==References==
{{Reflist|2}}

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Asherman's syndrome natural history, complications and prognosis

2022-08-01T16:30:05Z

Saud Khan: /* Overview */

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
Asherman's syndrome typically occurs after a triggering event such as an infection or a procedure, and is a cumulative process which may lead to infertility. Damage to the uterine cavity may also cause pain, congestion and endometriosis.

== Natural History ==
Usually occurring after vigorous intrauterine procedures such as [[D&C|Dilation and Curettage]], Asherman's syndrome manifests as [[amenorrhea]] and uterine congestion. Over time, due to the uterine cavity being damaged by adhesions, infertility may occur.

==Complications==
Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies <ref name="Valle">{{cite journal |author=Valle RF, and Sciarra JJ |title=Intrauterine adhesions: Hystreoscopic diagnosis, classification, treatment and reproductive outcome |journal=. Am J Obstet |volume=158 |issue=6Pt1 |pages=1459–1470 |year=1988 |pmid=3381869 |doi=}}</ref>. There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to [[endometriosis]]<ref name="Buttram">{{cite journal |author=Buttram VC, Turati, G |title=Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions |journal=Int J Fertil |volume=22 |issue=2 |pages=98–103 |year=1977 |pmid=20418 |doi=}}</ref>.
==Prognosis==
The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) may require several surgical interventions or even be uncorrectable. In this case [[surrogacy]], [[IVF]] or adoption may be advised.

Patients who carry a [[pregnancy]] after correction of Asherman's syndrome may have an increased risk of having abnormal placentation including [[placenta accreta]] <ref name="Fernandez">{{cite journal |author=Fernandez H, Al Najjar F, Chauvenaud-Lambling et al. |title=Fertility after treatment of Asherman's syndrome stage 3 and 4 |journal=J Minim Invasive Gynecol |volume=13 |issue=5 |pages=398–402. |year=2006 |pmid=16962521 |doi=10.1016/j.jmig.2006.04.013}}</ref>where the placenta invades the [[uterus]] more deeply, leading to complications in placental separation after delivery. Premature delivery <ref name="Roge">{{cite journal |authro=Roge P, D'Ercole C, Cravello L et al. |title=Hysteroscopic management of uterine synechiae: a series of 102 observations |journal=Eur J Obstet Gynecol Reprod Biol |volume=65 |issue=2 |pages=189–193. |year=1996 |pmid=8730623 |doi=10.1016/0301-2115(95)02342-9 |author=Roge, P}}</ref>, second-trimester pregnancy loss<ref name="Capella">{{cite journal |author=Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. |title=Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility |journal=Hum Reprod |volume=14 |issue=5 |pages=1230–1233. |year=1999 |pmid=10325268 |doi=10.1093/humrep/14.5.1230}}</ref>, and uterine rupture<ref name="Deaton">{{cite journal |author=Deaton JL, Maier D, Andreoli J. |title=Spontaneous uterine rupture during pregnancy after treatment of Asherman's syndrome |journal=Am J Obstet Gynecol |volume=160 |issue=(5Pt1) |pages=1053–1054. |year=1989 |pmid=2729381 |doi=}}</ref> are other reported complcations. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed<ref name="Capella">Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility. Hum Reprod; 14:1230-1233.</ref>.

The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study <ref name="Siegler">{{cite journal |author=Siegler AM, Valle RF. |title=Therapeutic hysteroscopic procedures |journal=Fertil Steril |volume=50 |issue=5 |pages=685–701. |year=1988 |pmid=3053254 |doi=}}
</ref>. Success is related to the severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively <ref name="Valle">Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470.</ref>.

Age is another factor contributing to fertility outcomes after treatment of Asherman's. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35 <ref name="Fernandez">Fernandez H, Al-Najjar F, Chauveneaud-Lambling A, et al. Fertility after treatment of Asherman's syndrome stage 3 and 4. J Minim Invasive Gynecol 2006; 13:398-402.
</ref>.

==References==
{{Reflist|2}}

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Asherman's syndrome overview

2022-08-01T16:15:49Z

Saud Khan: /* References */

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
''' Asherman's syndrome''', also called "uterine [[synechia]]e" or intrauterine [[adhesions]], presents a condition characterized by the presence of scars within the uterine cavity.

An artificial form of Asherman's syndrome can be surgically induced by [[endometrial ablation]] in women with excessive uterine bleeding, in lieu of [[hysterectomy]].

==References==
{{Reflist|2}}

{{WikiDoc Help Menu}}

Asherman's syndrome (patient information)

2022-08-01T16:14:26Z

Saud Khan:

'''For the WikiDoc page for this topic, click [[Asherman’s syndrome|here]]'''

{{Asherman’s syndrome (patient information)}}

{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{skhan}}

'''''Synonyms and Keywords:''''' Uterine synechiae

==Overview==
Asherman's syndrome is the formation of intrauterine adhesions (scar tissue), which typically develop after uterine surgery.

==What are the symptoms of Asherman’s syndrome?==

*The adhesions may cause [[Secondary amenorrhea (patient information)|amenorrhea]] (lack of menstrual periods), [[Miscarriage (patient information)|repeated miscarriages]], and [[Infertility (patient information)|infertility]].

*However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a [[D&C]] or other uterine surgery.

==What causes Asherman’s syndrome?==

*Asherman syndrome is a rare condition.

*In most cases, it occurs in women who have had several [[D&C|dilatation and curettage]] procedures.

*A severe pelvic infection unrelated to surgery may also lead to Asherman syndrome.

*[[Intrauterine adhesions]] can also form after infection with [[Tuberculosis (patient information)|tuberculosis]] or [[schistosomiasis]]. These infections are rare in the United States, and uterine complications such as Asherman syndrome related to these infections are even less common.

==When to seek urgent medical care?==

*Call your health care provider if your menstrual periods do not resume after a gynecologic or obstetrical procedure.

*An evaluation for [[Infertility (patient information)|infertility]] is also warranted if you are unable to achieve a pregnancy after 6 to 12 months of trying.

==Diagnosis==

*A pelvic exam is usually normal.

*Tests may include:

:*[[Hysteroscopy]]
:*Hysterosonogram
:*[[Infertility (patient information)|Infertility evaluation]]
:*[[Transvaginal ultrasound|Transvaginal ultrasound examination]]
:*Blood tests to detect [[Tuberculosis (patient information)|tuberculosis]] or [[schistosomiasis]]

==Treatment options==

*Treatment involves surgery to cut and remove the adhesions or scar tissue. This can usually be done with [[hysteroscopy]], which uses small instruments and a camera placed into the uterus through the cervix.

*After scar tissue is removed, the uterine cavity must be kept open while it heals to prevent adhesions from returning. Your health care provider may place a small balloon inside the uterus for several days and prescribe estrogen therapy while the uterine lining heals.

*Antibiotic treatment may be necessary if there is an infection.

==Where to find medical care for Asherman’s syndrome?==

[http://maps.google.com/maps?q={{urlencode:{{#if:{{{1|}}}|{{{1}}}|map+top+hospital+Asherman’s syndrome}}}}&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&sa=N&hl=en&tab=wl Directions to Hospitals Treating Asherman’s syndrome]

==What to expect (Outlook/Prognosis)?==

*Asherman syndrome can be cured in most women with surgery, although sometimes more than one procedure will be necessary.

*Women who are [[Infertility (patient information)|infertile]] because of Asherman syndrome may have a successful pregnancy after treatment.

*Successful pregnancy depends on the severity of Asherman syndrome and the difficulty of the treatment, as well as other factors that affect fertility and pregnancy.

==Possible complications==

*Complications of hysteroscopic surgery are uncommon and include bleeding, perforation of the uterus, and pelvic infection.

*In some cases, treatment of Asherman syndrome will not cure infertility.

==Prevention==
Most cases of Asherman syndrome cannot be predicted or prevented.

==Support groups==
[http://www.ashermans.org Asherman syndrome support group]

==Source==
http://www.nlm.nih.gov/medlineplus/ency/article/001483.htm

{{WH}}
{{WS}}

[[Category:For review]]
[[Category:Overview complete]]
[[Category:Template complete]]
[[Category:Disease]]
[[Category:Patient information]]
[[Category:Gynecology]]
[[Category:Gynecology patient information]]
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[[Category:Obstetrics patient information]]

Asherman's syndrome (patient information)

2022-08-01T16:12:44Z

Saud Khan:

'''For the WikiDoc page for this topic, click [[Asherman’s syndrome|here]]'''

{{Asherman’s syndrome (patient information)}}

{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{skhan}}
'''''Synonyms and Keywords:''''' Uterine synechiae

==Overview==
Asherman syndrome is the formation of intrauterine adhesions (scar tissue), which typically develop after uterine surgery.

==What are the symptoms of Asherman’s syndrome?==
*The adhesions may cause [[Secondary amenorrhea (patient information)|amenorrhea]] (lack of menstrual periods), [[Miscarriage (patient information)|repeated miscarriages]], and [[Infertility (patient information)|infertility]].

*However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a [[D&C]] or other uterine surgery.

==What causes Asherman’s syndrome?==
*Asherman syndrome is a rare condition.

*In most cases, it occurs in women who have had several [[D&C|dilatation and curettage]] procedures.

*A severe pelvic infection unrelated to surgery may also lead to Asherman syndrome.

*[[Intrauterine adhesions]] can also form after infection with [[Tuberculosis (patient information)|tuberculosis]] or [[schistosomiasis]]. These infections are rare in the United States, and uterine complications such as Asherman syndrome related to these infections are even less common.

==When to seek urgent medical care?==
*Call your health care provider if your menstrual periods do not resume after a gynecologic or obstetrical procedure.

*An evaluation for [[Infertility (patient information)|infertility]] is also warranted if you are unable to achieve a pregnancy after 6 to 12 months of trying.

==Diagnosis==
*A pelvic exam is usually normal.

*Tests may include:
:*Blood tests to detect [[Tuberculosis (patient information)|tuberculosis]] or [[schistosomiasis]]
:*[[Hysteroscopy]]
:*Hysterosonogram
:*[[Infertility (patient information)|Infertility evaluation]]
:*[[Transvaginal ultrasound|Transvaginal ultrasound examination]]

==Treatment options==
*Treatment involves surgery to cut and remove the adhesions or scar tissue. This can usually be done with [[hysteroscopy]], which uses small instruments and a camera placed into the uterus through the cervix.

*After scar tissue is removed, the uterine cavity must be kept open while it heals to prevent adhesions from returning. Your health care provider may place a small balloon inside the uterus for several days and prescribe estrogen therapy while the uterine lining heals.

*Antibiotic treatment may be necessary if there is an infection.

==Where to find medical care for Asherman’s syndrome?==

[http://maps.google.com/maps?q={{urlencode:{{#if:{{{1|}}}|{{{1}}}|map+top+hospital+Asherman’s syndrome}}}}&oe=utf-8&rls=org.mozilla:en-US:official&client=firefox-a&um=1&ie=UTF-8&sa=N&hl=en&tab=wl Directions to Hospitals Treating Asherman’s syndrome]

==What to expect (Outlook/Prognosis)?==
*Asherman syndrome can be cured in most women with surgery, although sometimes more than one procedure will be necessary.

*Women who are [[Infertility (patient information)|infertile]] because of Asherman syndrome may have a successful pregnancy after treatment.

*Successful pregnancy depends on the severity of Asherman syndrome and the difficulty of the treatment, as well as other factors that affect fertility and pregnancy.

==Possible complications==
*Complications of hysteroscopic surgery are uncommon and include bleeding, perforation of the uterus, and pelvic infection.

*In some cases, treatment of Asherman syndrome will not cure infertility.

==Prevention==
Most cases of Asherman syndrome cannot be predicted or prevented.

==Support groups==
[http://www.ashermans.org Asherman syndrome support group]

==Source==
http://www.nlm.nih.gov/medlineplus/ency/article/001483.htm

{{WH}}
{{WS}}

[[Category:For review]]
[[Category:Overview complete]]
[[Category:Template complete]]
[[Category:Disease]]
[[Category:Patient information]]
[[Category:Gynecology]]
[[Category:Gynecology patient information]]
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[[Category:Obstetrics patient information]]

Biliary atresia echocardiography or ultrasound

2022-08-01T16:10:32Z

Saud Khan:

{{CMG}} '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
Ultrasonography shows a hypoplastic or absent gallbladder. Prandial state is not relevant to testing. Non filling of the gallbladder can be seen. The triangular cord sign described by Park et al. can be visualised.
 

==Key Ultrasound Findings in biliary atresia==
On abdominal ultrasound, biliary atresia shows:

*echogenic fibrous tissue anterior to the portal vein: triangular cord sign showing a solid proximal biliary remnant anterior to the bifurcation of the portal vein. <ref name="pmid14595143">{{cite journal| author=Lee HJ, Lee SM, Park WH, Choi SO| title=Objective criteria of triangular cord sign in biliary atresia on US scans. | journal=Radiology | year= 2003 | volume= 229 | issue= 2 | pages= 395-400 | pmid=14595143 | doi=10.1148/radiol.292020472 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14595143 }} </ref>
**It represents the remnant of the extrahepatic bile duct
*Changes of the hepatic artery
**larger hepatic artery caliber <ref name="pmid19561262">{{cite journal| author=Lee MS, Kim MJ, Lee MJ, Yoon CS, Han SJ, Oh JT | display-authors=etal| title=Biliary atresia: color doppler US findings in neonates and infants. | journal=Radiology | year= 2009 | volume= 252 | issue= 1 | pages= 282-9 | pmid=19561262 | doi=10.1148/radiol.2522080923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561262 }} </ref>
**Doppler showing subcapsular hepatic arterial flow
**right proximal hepatic artery diameter >1.5 mm
**hepatic artery to portal vein diameter ratio >0.45
*gallbladder ghost triad <ref name="pmid12695863">{{cite journal| author=Tan Kendrick AP, Phua KB, Ooi BC, Tan CE| title=Biliary atresia: making the diagnosis by the gallbladder ghost triad. | journal=Pediatr Radiol | year= 2003 | volume= 33 | issue= 5 | pages= 311-5 | pmid=12695863 | doi=10.1007/s00247-003-0867-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12695863 }} </ref>
{{Biliary atresia}}

==References==

{{Reflist|2}}
[[Category:Needs content]]
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Pediatrics]]
[[Category:Congenital disorders]]
[[Category:Rare diseases]]
[[Category:Neonatology]]
[[Category:Disease]]

Biliary atresia echocardiography or ultrasound

2022-08-01T16:10:10Z

Saud Khan:

{{CMG}} Associate Editor-In-Chief {{skhan}}

==Overview==
Ultrasonography shows a hypoplastic or absent gallbladder. Prandial state is not relevant to testing. Non filling of the gallbladder can be seen. The triangular cord sign described by Park et al. can be visualised.
 

==Key Ultrasound Findings in biliary atresia==
On abdominal ultrasound, biliary atresia shows:

*echogenic fibrous tissue anterior to the portal vein: triangular cord sign showing a solid proximal biliary remnant anterior to the bifurcation of the portal vein. <ref name="pmid14595143">{{cite journal| author=Lee HJ, Lee SM, Park WH, Choi SO| title=Objective criteria of triangular cord sign in biliary atresia on US scans. | journal=Radiology | year= 2003 | volume= 229 | issue= 2 | pages= 395-400 | pmid=14595143 | doi=10.1148/radiol.292020472 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14595143 }} </ref>
**It represents the remnant of the extrahepatic bile duct
*Changes of the hepatic artery
**larger hepatic artery caliber <ref name="pmid19561262">{{cite journal| author=Lee MS, Kim MJ, Lee MJ, Yoon CS, Han SJ, Oh JT | display-authors=etal| title=Biliary atresia: color doppler US findings in neonates and infants. | journal=Radiology | year= 2009 | volume= 252 | issue= 1 | pages= 282-9 | pmid=19561262 | doi=10.1148/radiol.2522080923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19561262 }} </ref>
**Doppler showing subcapsular hepatic arterial flow
**right proximal hepatic artery diameter >1.5 mm
**hepatic artery to portal vein diameter ratio >0.45
*gallbladder ghost triad <ref name="pmid12695863">{{cite journal| author=Tan Kendrick AP, Phua KB, Ooi BC, Tan CE| title=Biliary atresia: making the diagnosis by the gallbladder ghost triad. | journal=Pediatr Radiol | year= 2003 | volume= 33 | issue= 5 | pages= 311-5 | pmid=12695863 | doi=10.1007/s00247-003-0867-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12695863 }} </ref>
{{Biliary atresia}}

==References==

{{Reflist|2}}
[[Category:Needs content]]
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Pediatrics]]
[[Category:Congenital disorders]]
[[Category:Rare diseases]]
[[Category:Neonatology]]
[[Category:Disease]]

Asherman's syndrome medical therapy

2022-07-06T20:10:57Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==
Medical therapy usually follows surgical removal of fibrous bands in the uterus causing the condition. Estrogen provides stimulation for endometrial proliferation.
==Medical Therapy==
Hormonal therapy with synthetic or conjugated [[estrogen]] is usually prescribed following surgery to stimulate endometrial growth thereby preventing the walls of the uterus from re-adhering.

More studies are needed to evaluate which method of treatment is most likely to have a successful outcome.
==References==
{{Reflist|2}}

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Asherman's syndrome history and symptoms

2022-07-06T20:08:03Z

Saud Khan: /* Overview */

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
There are no overt symptoms of Asherman's syndrome. Signs of Asherman's syndrome include amenorrhea and repeated miscarriages.

== History and Symptoms ==

*The adhesions in the uterine cavity may cause:
**[[Secondary amenorrhea (patient information)|amenorrhea]] (lack of menstrual periods)
**[[Miscarriage (patient information)|repeated miscarriages]]
**[[Infertility (patient information)|infertility]].

However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a [[D&C]] or other uterine surgery.

==References==
{{Reflist|2}}

{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Asherman's syndrome history and symptoms

2022-07-06T20:04:25Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
*The adhesions may cause [[Secondary amenorrhea (patient information)|amenorrhea]] (lack of menstrual periods), [[Miscarriage (patient information)|repeated miscarriages]], and [[Infertility (patient information)|infertility]].

*However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a [[D&C]] or other uterine surgery.
==References==
{{Reflist|2}}

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Asherman's syndrome natural history, complications and prognosis

2022-07-06T19:35:25Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
==Complications==
Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies <ref name="Valle">{{cite journal |author=Valle RF, and Sciarra JJ |title=Intrauterine adhesions: Hystreoscopic diagnosis, classification, treatment and reproductive outcome |journal=. Am J Obstet |volume=158 |issue=6Pt1 |pages=1459–1470 |year=1988 |pmid=3381869 |doi=}}</ref>(see Prognoses below). There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to [[endometriosis]]<ref name="Buttram">{{cite journal |author=Buttram VC, Turati, G |title=Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions |journal=Int J Fertil |volume=22 |issue=2 |pages=98–103 |year=1977 |pmid=20418 |doi=}}</ref>.
== Prognosis ==
The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) may require several surgical interventions or even be uncorrectable. In this case [[surrogacy]], [[IVF]] or adoption may be advised.

Patients who carry a [[pregnancy]] after correction of Asherman's syndrome may have an increased risk of having abnormal placentation including [[placenta accreta]] <ref name="Fernandez">{{cite journal |author=Fernandez H, Al Najjar F, Chauvenaud-Lambling et al. |title=Fertility after treatment of Asherman's syndrome stage 3 and 4 |journal=J Minim Invasive Gynecol |volume=13 |issue=5 |pages=398–402. |year=2006 |pmid=16962521 |doi=10.1016/j.jmig.2006.04.013}}</ref>where the placenta invades the [[uterus]] more deeply, leading to complications in placental separation after delivery. Premature delivery <ref name="Roge">{{cite journal |authro=Roge P, D'Ercole C, Cravello L et al. |title=Hysteroscopic management of uterine synechiae: a series of 102 observations |journal=Eur J Obstet Gynecol Reprod Biol |volume=65 |issue=2 |pages=189–193. |year=1996 |pmid=8730623 |doi=10.1016/0301-2115(95)02342-9 |author=Roge, P}}</ref>, second-trimester pregnancy loss<ref name="Capella">{{cite journal |author=Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. |title=Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility |journal=Hum Reprod |volume=14 |issue=5 |pages=1230–1233. |year=1999 |pmid=10325268 |doi=10.1093/humrep/14.5.1230}}</ref>, and uterine rupture<ref name="Deaton">{{cite journal |author=Deaton JL, Maier D, Andreoli J. |title=Spontaneous uterine rupture during pregnancy after treatment of Asherman's syndrome |journal=Am J Obstet Gynecol |volume=160 |issue=(5Pt1) |pages=1053–1054. |year=1989 |pmid=2729381 |doi=}}</ref> are other reported complcations. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed<ref name="Capella">Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility. Hum Reprod; 14:1230-1233.</ref>.

The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study <ref name="Siegler">{{cite journal |author=Siegler AM, Valle RF. |title=Therapeutic hysteroscopic procedures |journal=Fertil Steril |volume=50 |issue=5 |pages=685–701. |year=1988 |pmid=3053254 |doi=}}
</ref>. Success is related to the severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively <ref name="Valle">Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470.</ref>.

Age is another factor contributing to fertility outcomes after treatment of Asherman's. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35 <ref name="Fernandez">Fernandez H, Al-Najjar F, Chauveneaud-Lambling A, et al. Fertility after treatment of Asherman's syndrome stage 3 and 4. J Minim Invasive Gynecol 2006; 13:398-402.
</ref>.

==References==
{{Reflist|2}}

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Asherman's syndrome screening

2022-07-06T19:35:06Z

Saud Khan:

__NOTOC__

Editor-in-Chief: {{CMG}} '''Associate Editor-in-Chief:''' {{skhan}}
{{Asherman's syndrome}}

==Screening for Asherman's Syndrome==
No screening guidelines exist for Asherman's Syndrome.

==References==
{{Reflist|2}}

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Asherman's syndrome differential diagnosis

2022-07-06T19:33:52Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}
==Overview==

Asherman Syndrome must be differentiated from other conditions that may cause [[amenorrhea]] and pregnancy loss, and may cause infertility.
==Differential Diagnosis==
Ashermans Syndrome must be differentiated from:

* Thyroid disease
** [[Hypothyroidism]]
** [[Hyperthyroidism]]
* [[Hypothalamic dysfunction]]
* [[Pituitary gland|Pituitary]] gland dysfunction
* [[Androgen]]-secreting [[ovarian]]/[[Adrenal gland|adrenal]] tumors
* [[Polycystic ovarian disease]]
* [[Pelvic inflammatory disease]]
* [[Cervical|Cervical stenosis]] (Narrowing of the cervix and blockage of the outlet)
* Premature [[menopause]]

==References==
{{Reflist|2}}

[[Category:Needs content]]

Asherman's syndrome causes

2022-07-06T19:33:08Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
Asherman's syndrome is most commonly linked to obstetric procedures that cause abrasion of the basal layer of the endometrium. Other causes include caesarian sections, infections or pelvic radiation therapy.

Intrauterine devices have not been linked to Asherman's syndrome.

==Causes==
Asherman's syndrome occurs most frequently after a [[D&C|Dilation & Curettage]] is performed on a recently pregnant uterus, following a missed or incomplete [[miscarriage]], birth, or elective termination ([[abortion]]) to remove [[retained products of conception]]/placental remains. As the same procedure is used in all three situations, Asherman's can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related curettage <ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085
|doi=}}</ref>.

It is estimated that up to 5% of D&Cs result in Asherman's. More conservative estimates put this rate at 1%. Asherman's results from 25% of D&Cs performed 1-4 weeks post-partum <ref>Parent B, Barbot J, Dubuisson JB. Uterine synechiae (in French). Encyl Med Chir Gynecol 1988; 140A (Suppl): 10-12.</ref><ref>{{cite journal |author=Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC |title=The obstetrical outcome of women with surgically treated uterine synechiae (in French) |journal=J Gynecol Obstet Biol Reprod |volume=8 |issue=8 |pages=723–726. |year=1979 |pmid=553931 |doi=}}</ref><ref name="Buttram">{{cite journal |author=Buttram UC, Turati G. |title=Uterine synechiae: variation in severity and some conditions which may be conductive to severe adhesions |journal=Int J Fertil |volume=22 |issue=2 |pages=98–103. |year=1977 |pmid=20418 |doi=}}</ref>, 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. <ref name="Adoni">{{cite journal |author=Adoni A, Palti Z, Milwidsky A, Dolberg M. |title=The incidence of intrauterine adhesions following spontaneous abortion |journal=Int J Fertil. |volume=27 |issue=2 |pages=117–118. |year=1982 |pmid=6126446
|doi=}}</ref> In the case of missed miscarriages, the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30.9% <ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085
|doi=}}</ref><ref>Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol 2006; 49:767-788.</ref>

Asherman's can also result from other pelvic surgeries including [[Cesarean section]]<ref>{{cite journal |author=Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC |title=The obstetrical outcome of women with surgically treated uterine synechiae (in French) |journal=J Gynecol Obstet Biol Reprod |volume=8 |issue=8 |pages=723–726. |year=1979 |pmid=553931 |doi=}}</ref>, removal of fibroid tumours ([[myomectomy]]) and from other causes such as [[IUD]]s, pelvic [[irradiation]], [[schistosomiasis]]<ref> {{cite journal |author=Krolikowski A, Janowski K, Larsen JV. |title=Asherman syndrome caused by schistosomiasis |journal=Obstet Gynecol. |volume=85 |issue=5Pt2 |pages=898–9 |year=1995 |pmid=7724154 |doi=10.1016/0029-7844(94)00371-J}}</ref> and genital [[tuberculosis]]<ref>{{cite journal |author=Netter AP, Musset R, Lambert A Salomon Y |title=Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility, and abortion |journal=Am J Obstet Gynecol. |volume=71 |issue=2 |pages=368–75 |year=1956 |pmid=13283012 |doi=}}</ref>. Chronic [[endometritis]] from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat <ref>{{cite journal |author=Bukulmez O, Yarali H, Gurgan T. |title=Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis |journal=Hum Reprod |volume=14 |issue=8 |pages=1960–1961. |year=1999 |pmid=10438408 |doi=10.1093/humrep/14.8.1960}}</ref>.

==References==
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Asherman's syndrome historical perspective

2022-07-06T19:32:26Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
The Israeli gynecologist Joseph Asherman is credited with describing and characterizing the disease, hence it is called Asherman syndrome.

==Historical Perspective==
Intrauterine adhesions were first described in 1894 by Heinrich Fritsch (Fritsch, 1894)<ref>>{{WhoNamedIt|synd|1521}}Fritsch H, Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung. Zentralbl Gynaekol 1894; 18:1337-1342.</ref> and further characterized and described by the gynecologist Joseph Asherman in 1948 <ref>{{cite journal |author=Asherman JG. |title=Traumatic intra-uterine adhesions |journal=J Obstet Gynaecol Br Em |volume=55 |issue=2 |pages=2–30. |year=1948. |pmid=|doi=}}</ref>. Asherman though that intrauterine adhesions may be linked to prior endometrial trauma. He later published more case series of intrauterine adhesions with documented results of hysterography, with evident filling defects. It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.
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Asherman's syndrome overview

2022-07-06T19:31:48Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}}; [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
''' Asherman's syndrome''', also called "uterine [[synechia]]e" or intrauterine [[adhesions]], presents a condition characterized by the presence of scars within the uterine cavity.

An artificial form of Asherman's syndrome can be surgically induced by [[endometrial ablation]] in women with excessive uterine bleeding, in lieu of [[hysterectomy]].

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Asherman's syndrome

2022-07-06T19:30:47Z

Saud Khan:

'''For patient information, click [[Asherman’s syndrome (patient information)|here]]'''

{{Infobox_Disease
| Name = {{PAGENAME}}
| Image = Hysteroscopy of Asherman's Syndrome.jpg
| Caption = Hysteroscopic view.
| DiseasesDB = 946
| ICD10 = {{ICD10|N|85|6|n|80}}
| ICD9 = {{ICD9|621.5}}
| ICDO =
| OMIM =
| MedlinePlus = 001483
| eMedicineSubj =
| eMedicineTopic =
| MeshID = D006175
}}
{{Asherman's syndrome}}

'''Editor(s)-in-Chief:''' {{CMG}} [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==[[Asherman's syndrome overview|Overview]]==

==[[Asherman's syndrome historical perspective|Historical Perspective]]==

==[[Asherman's syndrome classification|Classification]]==

==[[Asherman's syndrome pathophysiology|Pathophysiology]]==

==[[Asherman's syndrome causes|Causes]]==

==[[Asherman's syndrome differential diagnosis|Differentiating Asherman's syndrome from other Diseases]]==

==[[Asherman's syndrome epidemiology and demographics|Epidemiology and Demographics]]==

==[[Asherman's syndrome risk factors|Risk Factors]]==

==[[Asherman's syndrome screening|Screening]]==

==[[Asherman's syndrome natural history, complications and prognosis|Natural History, Complications and Prognosis]]==

== Diagnosis ==

[[Asherman's syndrome history and symptoms| History and Symptoms]] | [[Asherman's syndrome physical examination | Physical Examination]] | [[Asherman's syndrome laboratory findings | Laboratory Findings]] | [[Asherman's syndrome ultrasound|Ultrasound]] | [[Asherman's syndrome other imaging findings|Other imaging findings]] | [[Asherman's syndrome other diagnostic studies|Other diagnostic studies]]

==Treatment==
[[Asherman's syndrome medical therapy|Medical therapy]] | [[Asherman's syndrome surgery|Surgery]] | [[Asherman's syndrome primary prevention|Primary prevention]] | [[Asherman's syndrome secondary prevention|Secondary prevention]] | [[Asherman's syndrome cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Asherman's syndrome future or investigational therapies|Future or Investigational Therapies]]

==Case Studies==
[[Asherman's syndrome case study one|Case #1]]

{{WH}}
{{WS}}

[[Category:Overview complete]]
[[Category:Disease]]
[[Category:Obstetrics]]
[[Category:Gynecology]]
[[Category:Surgery]]
[[Category:Fertility]]
[[Category:Abortion]]

Asherman's syndrome screening

2022-06-27T20:06:07Z

Saud Khan:

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Editor-in-Chief: {{CMG}} Associate Editor-in-Chief: {{skhan}}
{{Asherman's syndrome}}

== Screening for Asherman's Syndrome ==
No screening guidelines exist for Asherman's Syndrome.

==References==
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Asherman's syndrome screening

2022-06-27T20:05:23Z

Saud Khan:

__NOTOC__

Editor-in-Chief: {{CMG}} Associate Editor-in-Chief: {{skhan}}
{{Asherman's syndrome}}

Screening for Asherman's Syndrome

No screengin guidelines exist for Asherman's Syndrome.

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Asherman's syndrome risk factors

2022-06-27T20:03:08Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}} [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
The strongest risk factors for developing Asherman Syndrome is previous obstetric curettage procedures and infections.
==Risk Factors==
The risk of Asherman's increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs <ref name="Friedler">{{cite journal |author=Friedler S, Margalioth EJ, Kafka I, Yaffe H. |title=Incidence of postabortion intra-uterine adhesions evaluated by hysteroscopy: a prospective study |journal=Hum Reprod |volume=8 |issue=3 |pages=442–444. |year=1993 |pmid=8473464 |unused_data=|doi}}</ref>. Other risk factors may include

*embolization of the uterus
*B-Lynch sutures
*abdominal [[myomectomy]]
*hysteroscopic myomectomy
*[[Tuberculosis|genital tuberculosis]]
*surgical treatment of [[Mullerian duct anomalies classification system|Mullerian anomalies]]

Women may be predisposed to intrauterine adhesions if they are of increased age, poor nutritional status during pregnancy, and have experienced intrauterine or genital infectious processes. However, such factors are not supported in the literature, where the dominant factor seems to be surgical trauma (frequent hysteroscopic surgery, repeat curettages and infection).<ref name="pmid27337414">{{cite journal| author=Di Spiezio Sardo A, Calagna G, Scognamiglio M, O'Donovan P, Campo R, De Wilde RL| title=Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2016 | volume= 203 | issue= | pages= 182-92 | pmid=27337414 | doi=10.1016/j.ejogrb.2016.05.050 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27337414 }} </ref>

 
==References==
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Asherman's syndrome risk factors

2022-06-27T20:01:23Z

Saud Khan:

__NOTOC__
{{Asherman's syndrome}}
'''Editor(s)-in-Chief:''' {{CMG}} [[User:Csinfor|Canan S Fornusek, Ph.D.]]; '''Associate Editor-In-Chief:''' {{skhan}}

==Overview==
 
==Risk Factors==
The risk of Asherman's increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs <ref name="Friedler">{{cite journal |author=Friedler S, Margalioth EJ, Kafka I, Yaffe H. |title=Incidence of postabortion intra-uterine adhesions evaluated by hysteroscopy: a prospective study |journal=Hum Reprod |volume=8 |issue=3 |pages=442–444. |year=1993 |pmid=8473464 |unused_data=|doi}}</ref>. Other risk factors may include

* embolization of the uterus
* B-Lynch sutures
* abdominal [[myomectomy]]
* hysteroscopic myomectomy
* [[Tuberculosis|genital tuberculosis]]
* surgical treatment of [[Mullerian duct anomalies classification system|Mullerian anomalies]]

Women may be predisposed to intrauterine adhesions if they are of increased age, poor nutritional status during pregnancy, and have experienced intrauterine or genital infectious processes. However, such factors are not supported in the literature, where the dominant factor seems to be surgical trauma (frequent hysteroscopic surgery, repeat curettages and infection).<ref name="pmid27337414">{{cite journal| author=Di Spiezio Sardo A, Calagna G, Scognamiglio M, O'Donovan P, Campo R, De Wilde RL| title=Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review. | journal=Eur J Obstet Gynecol Reprod Biol | year= 2016 | volume= 203 | issue= | pages= 182-92 | pmid=27337414 | doi=10.1016/j.ejogrb.2016.05.050 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27337414 }} </ref>

 
==References==
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