Monday, July 19, 2010

Misoprostol for miscarriage management: the facts and the fiction

This is my latest Youtube video presentation. It explains the truth behind often repeated misinformation about misoprostol.

video

Misoprostol for miscarriage management is underused despite evidence of its efficacy and safety. It is an ideal alternative to D&C. It can also prevent Asherman's syndrome which mainly occurs from D&C, a blind surgery. This clip clarifies concerns about misoprostol which may be hindering its use by clinicians and patients alike.

Monday, July 12, 2010

Recent and upcoming articles on Asherman's syndrome (July 2010)

There are two articles in press about Asherman's syndrome in peer-reviewed medical journals.

One is titled: Human amnion as a temporary biologic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study, by Amer et al. in Egypt will appear in The journal of minimally invasive gynecology. To read the abstract, please click here. It is a continuation of and follow-up on the reproductive outcome of patients from a previous study published four years earlier by the same group (Amnion graft following hysteroscopic lysis of intrauterine adhesions, Amer I and Abd-El-Maeboud J Obstet Gynecol Res Vol 32, No. 6:559-566, 2006). Although the method could be promising, there are restrictions for using amnion in Western countries due to fears of cross-contamination between donors and recipients (ie. women treated for Asherman's syndrome with the tissue). Amnion is obtained from fresh amniotic membranes shortly after birth from 'donor' patients undergoing elective cesarean section. These donor patients are screened for hepatitis B, hepatitis C, syphilis and HIV. The tissue is placed around an intrauterine balloon and inserted in the uterus following hysteroscopic lysis of intrauterine adhesions and left in place for 2 weeks. Amnion was previously used in developed countries for different gynecologic reconstructive surgeries but was abandoned after the outbreak of Creuzfeldt Jakob disease (CJD), the human variant of 'mad cow' disease. It is an incurable and fatal transmissible degenerative neurological disorder for which there is no test to screen infected tissue. I will wait until the article is published before making further comments. There is one contradiction of note in the abstract; although the patients in the study were reported to have severe intrauterine adhesions, they were described as having infertility with or without menstrual disorders such as amenorrhea or hypomenorrhea. It seems inconsistent to have severe adhesions without any changes in menstrual bleeding, and suggests that perhaps the diagnosis of severity was exaggerated. Severe adhesions are more difficult to treat and tend to recur more frequently than mild ones. Severe adhesions are also associated with poorer fertility outcomes.

The second article in press is: Separated from birth: An initial examination suggested Asherman's syndrome (Oakes and Fisseha, Am J Obstet Gynecol, 2010). This is a case study where a patient appeared to have intrauterine adhesions following a C-section (a rare cause of Asherman's syndrome), but on closer inspection turned out to have a uterine dehiscence from a hysterotomy scar. Uterine dehiscence is the incomplete separation of the myometrium at a uterine scar site.

The article Impact of previous uterine artery embolization on fertility. (Berkane N, Moutafoff-Borie C. Curr Opin Obstet Gynecol. 2010 Jun;22(3):242-7) suggests that Asherman's syndrome is a possible risk after uterine artery embolization (UAE). In another recent study (Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L.BJOG. 2010 Jan;117(1):84-93) researchers claim that pelvic arterial embolisation for postpartum hemorrhage does not affect future fertility even though around 12% of study participants were diagnosed with Asherman's syndrome after the procedure and a further 11% exhibited symptoms of it although they declined diagnostic hysterocopy. However it is unclear from the article whether the intrauterine adhesions were pre-existing, or if they resulted from additional procedures carried out in addition to PAE to stem blood flow, such as manual removal of placenta or uterine packing. UAE and PAE are uterine-sparing alternatives to hysterectomy which employs a vascular radiological technique to treat pospartum hemorrhage and fibroids.

A new cause of Asherman's syndrome, B-lynch suture, was recently reported in Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. (Goojha CA, Case A, Pierson R. Fertil Steril. 2010 Mar 25.) B-lynch suture is a 'conservative' surgical compression technique for managing postpartum hemorrhage.

I have also been told that there will be a case report on the association between pregnancy after Asherman's syndrome and an obstetric complication not previously reported, pre-eclampsia. This is consistent with the fact that pre-eclampsia is caused by ischemia and  the presence of insufficient blood flow to the placenta in Asherman's syndrome that sometimes persist even after treatment. This will be added to the list of complications in post AS pregnancies I have already written about.

There will also be a study published on reproductive outcomes following treatment where pregnancy rates were about 60%, live birth rates 40% and miscarriage rates were supposedly equivalent to those of the general population.

Friday, July 2, 2010