Spontaneous Uterine Rupture in Pregnancy After Treatment of Asherman Syndrome

Abstract

Study objective: Women with Asherman syndrome are at high risk of recurrent adhesions and pregnancy complications. Spontaneous uterine rupture is a rare but life-threatening complication, associated with severe maternal and fetal morbidity and mortality. Uterine ruptures can occur after extended induction of labor or a history of cesarean section, whereas spontaneous uterine rupture in an unscarred uterus is rare. Aim of this study is to evaluate the incidence of spontaneous uterine rupture among women with Asherman syndrome treated by hysteroscopy and without a history of cesarean section.

Design: Prospective cohort study.

Setting: Asherman Expertise Center of the Spaarne Gasthuis, The Netherlands.

Patients: Women were defined by as patients with Asherman syndrome when they had one or more clinical features and the presence of hysteroscopically confirmed intrauterine adhesions.

Interventions: Hysteroscopic adhesiolysis and a second-look hysteroscopy two months after the initial procedure.

Measurements and results: Data on the severity of adhesions and ongoing pregnancy after treatment were collected prospectively. A total of 428 women with Asherman syndrome were included, 4 women (0.9%) experienced spontaneous uterine rupture. The timing varied, none of the affected women were in active labor and the occurrence of uterine rupture was not related to the severity of adhesions. Ruptures were all found in the fundus. One woman had a history of perforation of the uterine wall located in the fundus. Neonatal outcomes were poor, two cases had intrauterine neonatal death and two cases had long-term lifelong disability. One woman had a second uterine rupture.

Conclusion: Women with Asherman syndrome are at risk of uterine rupture, a pregnancy complication with significant consequences that is challenging to predict and may also be associated with history of uterine perforation. Clinicians should be aware of this risk in women treated with hysteroscopic adhesiolysis and consider counseling these patients accordingly prior to treatment.

Keywords: Asherman syndrome; High-risk pregnancy; Hysteroscopic adhesiolysis; Unscarred uterus; Uterine rupture.