How to manage uterine scar tissue in a patient with no previous surgical procedures and a history of one miscarriage?

Management of Uterine Scar Tissue Without Prior Surgery

In a patient with uterine scar tissue but no previous surgical procedures and only one miscarriage, the most likely diagnosis is Asherman syndrome (intrauterine adhesions) secondary to post-miscarriage curettage or spontaneous formation, and management should focus on hysteroscopic evaluation and adhesiolysis if symptomatic or fertility is desired. 1

Diagnostic Approach

Initial Evaluation

• Obtain detailed menstrual history focusing on changes in flow pattern, duration, and presence of amenorrhea or hypomenorrhea, as these are hallmark features of intrauterine adhesions 1
• Assess fertility concerns and reproductive plans, as this directly impacts treatment decisions 1
• Document symptoms including pelvic pain (particularly cyclic pain suggesting trapped menstrual blood) and any irregular bleeding patterns 2

Imaging Studies

• Saline infusion sonohysterography (SIS) or hysterosalpingogram (HSG) are the preferred initial confirmatory tests for intrauterine adhesions 1
• Transvaginal ultrasound can detect uterine wall abnormalities and should evaluate the anterior uterine wall for scar dehiscence or thinning 2
• MRI may be considered for complex cases or when ultrasound findings are equivocal 1
• Hysteroscopy remains the gold standard for both definitive diagnosis and treatment 1

Treatment Algorithm

For Symptomatic Patients or Those Desiring Fertility

Hysteroscopic adhesiolysis is the primary treatment method 1:

• Dense adhesions or difficult cervical entry may require laparoscopic or ultrasound guidance for safe entry 1
• Post-operative management should include:
  • Intrauterine stent placement 1
  • Sequential estrogen and progesterone therapy to promote endometrial regeneration 1
  • Early follow-up with repeat SIS, HSG, or flexible hysteroscopy to assess for adhesion reformation 1

For Asymptomatic Patients Not Desiring Fertility

• Observation is reasonable if the patient has normal menses and no fertility concerns 1
• Serial ultrasound monitoring may be considered if future pregnancy is planned 2

Critical Considerations for Future Pregnancy

Risk Assessment

• Intrauterine adhesions significantly increase placenta accreta spectrum risk in subsequent pregnancies, with associated risks of hemorrhage, transfusion requirement, and potential hysterectomy 1
• Pregnancy rates after treatment range from 22-45% for intrauterine pregnancies, with live birth rates of 28-32% 1

Pregnancy Monitoring

• Early ultrasound evaluation is essential to assess placental location and attachment 1
• Screen for placenta accreta spectrum if placenta previa develops, as the risk increases dramatically with uterine scarring 3
• Deliver at a tertiary care center with blood banking facilities and multidisciplinary expertise if placenta accreta spectrum is suspected 4

Important Caveats

Etiology Without Surgery

• Most intrauterine adhesions occur within 4 months of pregnancy and are typically associated with curettage procedures 1
• The single miscarriage likely involved curettage (D&C), which is the most common cause even without other surgical history 1
• Rare spontaneous cases can occur, though trauma to the endometrium from surgical procedures remains the predominant mechanism 1

Treatment Outcomes

• No universally agreed-upon classification system exists, making outcome comparisons difficult across studies 1
• Prospective controlled studies are lacking for optimal diagnostic and treatment protocols 1
• Dense scar tissue carries worse prognosis than filmy adhesions 1

Avoid Common Pitfalls

• Do not delay hysteroscopic evaluation in symptomatic patients or those with fertility concerns, as early intervention improves outcomes 1
• Do not underestimate future pregnancy risks, particularly placenta accreta spectrum, which requires specialized delivery planning 1, 3
• Ensure adequate follow-up after adhesiolysis, as recurrence is common without proper post-operative management 1