Tuesday, November 17, 2009

Serious Post-Partum Accreta, a D&C & Now No Period...Asherman's Syndrome?


I am a healthy 28 year old who has never had any reproductive issues. I gave birth to a healthy baby in the spring of 2008. She was my third. At birth, I heard the doctor say, "Hmmm, funky placenta." The nurse looked and agreed. I later found out that it was "lobulated", but that was normal.

I went home after 1 day and all was well. Exactly 2 weeks later, when I was laying the baby down in her bassinet after a 3:00 am feeding - something "burst" and it felt like a a bucket of liquid was dumped between my legs. I had stopped the postpartum bleeding a few days earlier, and that had been light without clots the whole time.

All of a sudden it was like a faucet of bright red blood. I ran to the bathroom and was shocked by the sight of the gushing blood. I sat on a pile of towels on the floor and tried to stop the flow. The ambulance came and rushed me to the ER (30 min away). The doctor there decided that I had retained a piece of placenta and a D&C was to be done. No big deal, 30 min. procedure.
I woke up 5.5 hours later with my doctor at my bedside with a very serious look on his face. It turns out that I had accreta and they had to perform a very aggressive D&C. They could not even do a hysterectomy because I had no blood to spare. I lost 4.5 L in the OR alone. He said that he's not sure how the bleeding finally stopped, or how I lived. He had never experienced placenta accreta, nor had any of the docs in the clinic.

Anyway, after a few days in the ICU, I went home and everything has been great.

EXCEPT...it has been 6.5 months since my D&C and I have not had any period - not one drop. I was birth control pills for 3 months and nothing. So, I went off them a few months ago. Nothing. My hormone levels were checked and I had borderline hyperthydroidism, which at my most recent test seems to be correcting itself. My doc thinks this is the reason for my lack of menses.
However, I do not. I am thinking Asherman's Syndrome. He has not examined me at all since the procedure. I feel that a "borderline" hyper-thyroid (w/o symptoms) would not cause a complete stop to my period. It's hard to put in words, but I can feel a kind of crampiness or pressure in my abdomen (not a period kind). Some sexual positions are uncomfortable or painful. And the last time sex was painful, there was a spot of bright red when I wiped. And that was it. So, new blood. It seems to me that would signify something with my cervix...maybe scar tissue?

I am afraid that the hyper-thyroid will mask the true problem. I am not worried about future fertility, but more about my health in general.

What is your opinion?



You are wise beyond your years, and maybe even smarter than your doctor. It sounds clearly like Asherman's Syndrome. Let me say first, that it is amazing that you are still alive, and still have your uterus at that. What you went through is a very scary event and in many cases, fatal. Whatever your docs did, they did well, and saved your life. Be very appreciative of that.

There are two possibilities for the lack of menstruation. One is Asherman's Syndrome. This is a situation where the aggressive D&C causes scar tissue formation in the uterus. As a result, the uterine lining is unable to form and hence there is nothing to slough at the end of the month (no period). This is how endometrial ablation works to stop bleeding. The only worry I would have in this scenario, is that your cervical os (outlet) is blocked, in which case you could be having some bleeding, but it is staying within the uterus. The reason for this suspicion are the symptoms of cramping and uterine tenderness. Basically, because the uterus can stretch , it will continue to fill and fill and fill. This is called "hematometria". The easiest way to make this diagnosis is with a vaginal ultrasound. To make the diagnosis of Asherman's syndrome, you need to have a procedure called a hysteroscopy. This is where a small scope is passed into the uterine cavity to examine it. If the cervix is blocked, dilating the cervix in preparation for the hysteroscopy will open it up and the blood will be able to be discharged. If you used the birth control pill and didn't bleed, then the uterus has to be highly suspected because the birth control pill works directly on the uterine lining.

The second possibility is that excessive vaginal bleeding postpartum can lead to a pituitary dysfunction, leading to the lack of hormone production. This would result in the loss of menstruation (panhypopituitarism). That is checked for by hormone testing. If the hormones are all normal, then this diagnosis is ruled out.

I hope this answers your questions and gives you some information to take to your doctor. Please make an appointment to see him soon!

Good luck,
Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

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