Any factor that causes endometrial destruction can cause uterine adhesions, which are associated with pregnancy in about 9l% of cases.
Causes
1. History of uterine operations
(1) Pregnancy factor: pregnancy-related uterine operations such as early pregnancy negative pressure aspiration, mid-pregnancy forceps scraping, mid-pregnancy induction scraping, postpartum bleeding scraping and spontaneous abortion scraping. This may be due to the fact that the basal layer of the endometrium of the pregnant uterus is more easily damaged and the uterine walls stick to each other, resulting in permanent adhesions.
(2) Non-pregnancy factors: enucleation of uterine fibroids (into the uterine cavity), transuterine removal of submucosal fibroids, longitudinal hysterectomy, and double hysterectomy destroy the basal layer of the endometrium, exposing the myometrium to the uterine cavity and leading to anterior and posterior adhesions of the uterine wall.
2.Surgical inflammatory factors
Intrauterine infection of uterine tuberculosis, postmenopausal senile endometritis, secondary infection after uterine operation, puerperal infection, secondary infection caused by intrauterine device placement, etc.
3.Man-made factors
Artificially destroy the endometrial basal layer to make the uterine cavity adhesions. For example: after endometrial electrodesection, intrauterine microwave, freezing, chemical drug treatment and local radiation therapy.
4, endometrial damage during scraping for various reasons
Such as repeated scraping, which is very easy to damage the basal layer, caused by this cause of cavity adhesions is called injury adhesions, the most common, so the obstetrician and gynecologist in the scraping depth should be moderate, women of childbearing age to implement good contraceptive measures, avoid abortion, especially the first abortion may cause cavity adhesions later secondary infertility.
Diagnostic basis
(a) Clinical manifestations vary according to the location and degree of adhesions.
The symptoms are not identical according to the site of adhesion, but the main symptoms are amenorrhea with cyclic abdominal pain, menorrhagia, and secondary infertility after repeated abortions or curettage.
(1) Amenorrhea (or hypomenorrhea) can occur in cases of complete adhesions of the uterine cavity, which can be very long and do not cause withdrawal bleeding with estrogen or progestin treatment. In cases of partial adhesions and/or partial destruction of the endometrium, menorrhagia may be observed, but the menstrual cycle is normal.
(2) Periodic abdominal pain usually occurs about one month after abortion or curettage, with sudden onset of cramping pain in the lower abdomen, more than half of which are accompanied by anal swelling; some patients have severe abdominal pain, restlessness, difficulty in movement, even exhaustion and defecation are painful, and sometimes there is a feeling of urgency and heaviness. The pain usually lasts for 3-7 days and then gradually decreases and disappears, and after an interval of about one month, periodic abdominal pain occurs again and gradually increases.
(3) Infertility and recurrent miscarriage and preterm delivery are likely to occur after the adhesion of uterine cavity, and even if pregnant, recurrent miscarriage and preterm delivery are likely to occur. Due to the adhesions in the uterine cavity, the endometrium is damaged and the volume of the uterus is reduced, which affects the normal implantation of the embryo. It also affects the survival of the fetus in the uterine cavity until full term.
2.Signs of pressure pain in the lower abdomen, rebound pain in severe cases, and even refusal to press. Gynecological examination reveals that the uterine body is normal or slightly larger and softer, with obvious pressure pain, sometimes with cervical pain; bilateral adnexal examination, normal in mild cases, but in severe cases there may be pressure pain or thickening, or a mass may be found: there may be tenderness in the posterior fornix, and even a posterior fornix puncture may extract non-coagulated dark red blood, so it is called ectopic pregnancy-like syndrome.
(B) Auxiliary diagnosis
1, the uterine probe examination general uterine probe inserted into the cervix about l-3 cm that there is a sense of resistance, to about 2 cm is the most common. Resistance can vary according to the different adhesions tissue, only endometrial adhesions probe is easy to insert; muscle adhesions must be slightly force according to the direction of the uterus to insert the probe; such as the sense of tissue tough and hard, the probe is not easy to insert, do not blindly force. To avoid causing perforation of the uterus. After entering the uterine cavity, the probe can fan across the official cavity to try the size of the uterine cavity and the extent of adhesions. Severe adhesions can feel the uterine cavity like a narrow tube, the probe activity range is very small, or simply can not probe into.
2, hysteroscopy can understand the presence of uterine adhesions, and determine the site, scope, degree of adhesions and adhesions of the tissue. The characteristics of each group of adhesions are: endometrial adhesions are very similar to the surrounding endometrium; myofibrous adhesions are the most common and are characterized by a thin layer of endometrium overlying the surface with many glandular openings; and connective tissue adhesions have no endometrial formation on the surface.
3. Iodine oil hysterosalpingography is characterized by the following.
(1) There may be one or more well-defined, sharp-edged, abnormally shaped, irregular filling defect shadows in the uterine cavity, which are not altered by the pressure or amount of contrast agent injected.
(2) The uterine cavity is locally unevenly bordered.
(3) A fine reticulated vascular image is often seen, which is due to the high pressure of iodine oil injected during the imaging, and therefore the iodine oil enters the uterine vessels from the peeling surface.
(4) In some cases, the uterus is highly anteflexed or retroflexed, so the cervical image and the cervical image often overlap and the uterus is olive-shaped. In this case, cervical forceps can be used to pull the cervix to stretch the uterus, and the uterine image can be changed from an olive shape to a triangle. A water-soluble contrast agent can also be used to prevent chronic inflammation caused by oil plugs and oil agents. Mild adhesions can be separated by contrast.
4. Basal body temperature is biphasic.
5.Vaginal exfoliative cell examination has cyclic changes.
6.Serum progesterone and urinary progesterone glycolysis have cyclic changes and ovulation.
7.Cervical mucus crystals may appear as lambdoid crystals and ellipsoid.
8.Hormone therapy test estrogen, progesterone or artificial cycle therapy, repeatedly three cycles are no withdrawal bleeding.
9, hysteroscopy in recent years useful hysteroscopy as a method of diagnosis and treatment of uterine cavity adhesions.
Differential diagnosis
(a) Ectopic pregnancy: uterine adhesions presenting with amenorrhea and lower abdominal pain should be differentiated from ectopic pregnancy. The former has a history of abortion or curettage, abdominal pain is mainly cyclic, although there is pressure pain or rebound pain in the lower abdomen, but there is no internal bleeding and shock and other symptoms, uterine probe or hysteroscopy can mostly confirm the diagnosis, when the detection of menstrual blood drainage smooth, abdominal pain symptoms will be reduced or disappear. In ectopic pregnancy, abdominal pain is often followed by internal bleeding symptoms and signs, and posterior fornix aspiration can confirm the diagnosis.
(ii) pelvic infection after abortion or curettage can also cause lower abdominal pain if it causes pelvic infection, but the abdominal pain caused by infection is persistent dull pain, without a history of periodic episodes, and there are fever, leukocytosis and other manifestations of infection. In contrast, abdominal pain caused by official adhesions is cyclic, spasmodic contraction pain, and there is no fever, leukocytosis and other phenomena.
(c) Endometriosis is also a periodic abdominal pain and progressive aggravation, but the abdominal pain is not relieved after the menstrual blood is discharged freely, while the abdominal pain caused by the adhesion of the uterine cavity is obstructive dysmenorrhea, and the symptoms can be relieved immediately or even disappear after the menstrual blood is discharged by dilating the cervix. Endometriosis is often infertility, while uterine adhesions mostly occur after abortion.
(d) Early pregnancy, amenorrhea after aspiration and curettage should also be ruled out, early pregnancy is usually no history of abdominal pain, there is often a history of pregnancy reaction, uterine enlargement and pregnancy month often match, a positive urine pregnancy test often helps to diagnose.
(E) Amenorrhea after uterine adhesions only simple amenorrhea without abdominal pain or abdominal pain is not obvious, need to be distinguished from pituitary or hypothalamic amenorrhea, premature ovarian failure, etc. In cases of amenorrhea due to uterine adhesions, menstruation cannot be restored after treatment with progesterone, estrogen or artificial cycles, while basal body temperature measurement, cervical mucus crystallization and vaginal exfoliative cell smear examination all show normal ovarian function.