Office Hysteroscopy in Recurrent Abortion

INTRODUCTION

Three successive, unexplained pregnancy terminations before the conclusion of 20 weeks of gestation or the ejection of a baby weighing less than 500 g have long been described as recurrent pregnancy loss. There is a movement to broaden these criteria to cover women who have had just two miscarriages.¹

Uterine anomalies have been identified as one of the reasons of recurrent miscarriages, and are predicted to be found in 10% to 15% of individuals with recurrent miscarriages. Before submitting the patient to another pregnancy at risk, it's critical to rule out any intrauterine abnormality.²

Uterine anomalies have been identified as one of the reasons of recurrent miscarriages, and are predicted to be found in 10% to 15% of individuals with recurrent miscarriages. Before submitting the patient to another pregnancy at risk, it's critical to rule out any intrauterine abnormality.³

In individuals with recurrent miscarriages, the prevalence of congenital or acquired structural abnormalities is significant, ranging from 6.3 percent

to 67 percent depending on the kind of research and the study group.⁴

While a hysterosalpingogram (HSG) has traditionally been used to check for anomalies in the uterine cavity, sonohysterography might potentially be utilized to get additional information about endometrial lesions, however, the gold standard for examining the uterine cavity, hysteroscopy, may be done consistently and safely as a minimally invasive technique in the office.⁵

The purpose of hysteroscopy is to identify any intrauterine alterations that may interfere with the conceptus's implantation, growth, or both. Hysteroscopy is still an invasive operation, and its relevance in the regular therapy of recurrent miscarriages has to be assessed. Investigating parental genetic diseases, thrombophilia, and maternal hormonal disruption may be further diagnostics for recurrent pregnancy loss.⁶

Because of the smaller optical diameters, hysteroscopy may now be conducted as an outpatient procedure with no anesthetics, minimum pain, and high patient acceptability.⁷

The purpose of this research was to assess the role of office hysteroscopy (OH) in the diagnosis and treatment of patients with recurrent pregnancy loss, with the goal of recommending OH as a standard operation in such circumstances or not.

PATIENTS AND METHODS

A retrospective research was conducted on 80 patients with recurrent abortion attempt to the outpatient clinic of obstetrics and gynecology at El-Hussein University Hospital in Cairo and Dar Ismaeil Hospital in Alexandria, period from March 2021 to February 2022.

Sample size justification:

This study is based on McLaughlin et al.⁸ research. The sample size was calculated using Epi Info STATCALC using the following assumptions: With a power of 80% and a margin of error of 5%, the odds ratio estimated = 1.22 with a 95 percent two-sided confidence level. The Epi Info output yielded an 80-case sample size.

Inclusion criteria: Age group between 21-37yrs, at least two consecutive pregnancy loss, miscarriages occurred at gestation age of less than 20 weeks, and normal hormonal profile.

Exclusion criteria: Severe pelvic inflammatory disease, severe medical morbidities or metabolic diseases, and other causes of recurrent abortion except uterine anomalies

Ethical considerations: Study procedure was reviewed an approved by Al-Azhar university research ethics committee. Study objectives and expected outcomes were explained to study participants. Participation of the study was voluntary, and confidentiality of data collected was ensured.

All patients were subjected to the following:

History: Personal and marital history, menstrual history, obstetric history, history of other previous investigations, medical history and surgical history,

Clinical Examination: (1) Abdominal examination: For pelvi-abdominal masses. (2) Gynecological examination: It was done to determine any abnormalities in the genital tract or presence of infection. Bimanual examination: to detect Size and location of the uterus, Adnexial masses, any tenderness or Vaginal / cervical abnormalities. Speculum examination: For inspection of the cervix and vagina for any infection or abnormality.

 Investigations:

TVUS; A 2-D transvaginal ultrasound was performed in all cases with an empty bladder to determine the size, contour and position of the uterus, the myometrial and endometrial morphology in longitudinal and transverse planes.

Other investigations:

 Laboratory investigations of recurrent pregnancy loss:

Testing for antiphospholipid antibodies (APA): Lupus anticoagulat (LAC) and anticardiolipin antibodies (aCL) to exclude the antiphospholipid syndrome (APS)

Testing for hereditary thrombophilia: Factor V Leiden, Methylenetetrahydrofolate reductase (MTHFR), activated protein C resistance, Prothrombin G20210A and protein S deficiency.

Testing for endocrinolgical causes: Thyroid function tests, anti-thyroid antibodies, and insulin resistance test, serum androgen, serum prolactin and serum vitamin D.

Laboratory investigations for preparation of operation: Complete blood count, ABO blood grouping & RH, coagulation profile (BT - CT - PT - PTT - INR), Liver function test, Renal fucntion test, Random blood sugar, virology ( HBV, HCV & HIV)

Study instruments: Office hysteroscope (BETTOCCHI hysteroscope with semirigid instruments), BETOCCHI Recommended set, Size 5 mm (based on a 2.9 mm telescope).

Statistical analysis:

SPSS (Statistical Package for Social Sciences) version 22 for Windows® was used to code, process, and analyze the obtained data (IBM SPSS Inc, Chicago, IL, USA). The Shapiro Walk test was used to determine whether the data had a normally distributed. Frequencies and relative percentages were used to depict qualitative data. To compute the difference between two or more sets of qualitative variables, use the Chi square test (χ2). The mean ± standard deviation (SD) was used to convey quantitative data (Standard deviation). To compare two independent groups of normally distributed variables, the independent samples t-test was utilized (parametric data). P values of

RESULTS

Table 1: Distribution of the analyzed patients regarding the age and duration of marriage.

Table (1) shows distribution of the analyzed patients according the age and duration of marriage. Age ranged from 21-35 with mean value 27.75±4.601. Duration of marriage ranged from 2-8 with mean value 5±2.04.

Table 2: Distribution of the analyzed patients according the number of pregnancy loss.

Table (2) shows distribution of the studied patients according the number of pregnancy loss. Number of pregnancy loss 4 was higher with 28(35%), it ranged from 2-5 with mean value 3.5125±1.06728.

Table 3: Distribution of the analyzed patients according the menstrual regularity, amount of menstrual flow and duration of menstrual flow (days).

Regular menstrual regularity was higher with 69(86.3%), while irregular menstrual regularity was 11(13.8%). Normal amount of menstrual flow was higher with 56(70%) followed by low with 14(17.5%) and higher with 10(12.5%). Duration of menstrual flow 4 days was higher with 26(32.5%) followed by 3 days with 20(25%), 5 days with 18(22.5%), 7 days with 13(16.25%) and 6 days was 3(3.75%). Duration of menstrual flow ranged from 3-7 with mean value 4.237±1.808 (Table 3).

Table 4:  Distribution of the analyzed patients according number of previous preterm deliveries and mode of delivery.

Patients who did not have previous preterm deliveries were 40 (50.0%), patients who had one previous preterm delivery were 31 (38.8%) and patients who had two previous preterm deliveries were 9 (11.3%). Number delivery was 50% of the patients, while CS delivery was 30 cases (37.5%) and NV delivery was 10 (12.5%) (Table 4).

Table 5: Distribution of the analyzed patients according the office Hysteroscopy results.

table (5) shows distribution of the analyzed patients according the office Hysteroscopy results.  Normal was 42 (52.5%). Congenital was 14 (17.5%): Arcuate ut. 7(8.8%), septate ut. 2(2.5%), Bicornuate ut. 3(3.8%) & unicornuate ut. 2(2.5%). Acquired were 24 (30.0%): Endometrial Adhesions 2(2.5%), Fibroid 6(7.5%) & endometrial polyps 16(20%).

Table 6: Distribution of the analyzed group according to operative hysteroscopy, incidence of hysteroscope complication and incidence of anesthesia complication.

The removal of small polyp was 16(20%), removal of small submucus myoma was 18(22.5%), removal of adhesions was 2(2.5%) and septum dissection was 2(2.5%). The injury of Cervix was 3(3.75%), perforation of uterus was 1(1.25%), bleeding was 4(5%), volume overload was 2 (2.5%), venous air embolism was 0(0.0%) and abdominal pain was 5(6.25%). The nausea was 12(15%), vomiting was 15(18.75%), itching was 6(7.5%) and headache was 7(8.75%) (Table 6).