Pregnancy after endometrial ablation: English literature review and case report

Pregnancy after endometrial ablation: English literature review and case report

Journal of Minimally Invasive Gynecology (2006) 13, 88 –91 Review article Pregnancy after endometrial ablation: English literature review and case r...

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Journal of Minimally Invasive Gynecology (2006) 13, 88 –91

Review article

Pregnancy after endometrial ablation: English literature review and case report Jenny S.Y. Lo, MRCOG, and Andrew Pickersgill, MD, MRCOG From the Department of Obstetrics and Gynaecology, South Manchester University Hospitals NHS Trust, Manchester, UK (Ms. Lo), and Department of Obstetrics and Gynaecology, Stepping Hill Hospital, Stockport, UK (Mr. Pickersgill). KEYWORDS: Endometrial ablation; Endometrial resection; Pregnancy complications; Dysfunctional uterine bleeding

Endometrial ablation is an effective treatment for dysfunctional uterine bleeding. The incidence of pregnancy after endometrial destruction is low and is reported to be 0.7%. We report what is to the best of our knowledge the first case of pregnancy after microwave endometrial ablation and review the outcomes of 74 pregnancies after various methods of endometrial destruction. © 2006 AAGL. All rights reserved.

Since the introduction of endometrial laser ablation to treat dysfunctional uterine bleeding in 1981,1 both extrauterine and intrauterine pregnancies following different techniques of ablation or resection have been reported throughout the world. To date, we have identified 74 pregnancies in the English literature reported after any form of endometrial destruction (including this one). These cases were identified by a MEDLINE search from January 1966 through November 2005, reviewing published English- language reports. References from the publications were cross-referenced to identify additional case reports. Cases that were reported more than once were counted only once. This is the first reported pregnancy after microwave endometrial ablation (MEA). It is also the only pregnancy ever to have been documented as occurring concurrently at the time of the procedure.

Corresponding author: Jenny S.Y. Lo, MRCOG, The Department of Obstetrics and Gynaecology, South Manchester University Hospitals NHS Trust, Southmoor Road, Wythenshawe, Manchester, UK M23 9LT. E-mail: [email protected] Submitted August 29, 2005; accepted for publication December 28, 2005.

1553-4650/$ -see front matter © 2006 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.12.006

Case report A 39-year-old woman, gravida 7 para 3-0-3-1, who had completed her family reported a 6-year history of menorrhagia. She had a regular menstrual cycle, bleeding for 7 days every 28. The bleeding was heavy, resulting in a chronic microcytic hypochromic anemia requiring longterm iron supplementation. At one time, her hemoglobin was as low as 8.2 g/dL, with a mean cell volume of 67.7 fL and a ferritin level of 2 ␮g/L. She found alternate methods of treatment for her menorrhagia and contraceptive needs unsuitable and was using a Mirena intrauterine device (Schering Health, West Sussex, UK) at the time of referral. Her pelvic examination was normal. She decided to undergo MEA. Due to ill-tolerated side effects of the intrauterine device, she had it removed and started taking the progesteroneonly pill. As per guidelines, she received goserelin 3.6 mg intramuscularly (Zoladex, AstraZeneca, Luton, UK) from her general practitioner (GP) 4 weeks before the procedure. At the time of her surgery, she was still taking the progesterone-only pill and was advised to use barrier methods for contraception. A pregnancy test was not performed before the procedure. A pretreatment hysteroscopy was carried out using CO2 distension; the results were normal. The MEA probe was

Lo and Pickersgill

Pregnancy after endometrial ablation

inserted, and treatment was completed within 6 minutes, with a normal treatment profile. The patient had an uneventful recovery and was discharged home later the same day with appropriate advice as to what to expect postoperatively. Follow-up arrangements were made for a review after 4 months to assess the outcome of the ablation, as is standard practice. However, the patient was referred by her GP for nausea and concerns that she had suffered no postoperative bleeding, and she was seen again after only 12 days. A urinary pregnancy test was positive. An ultrasound scan confirmed a viable intrauterine pregnancy of 5 to 6 weeks’ gestation. She was undecided as to whether to continue with the pregnancy and later opted for termination at 12 weeks’ gestation. She was given mifepristone orally and returned for misoprostol vaginally 48 hours later. After a further 10 hours, she delivered a macroscopically normal male fetus and placental tissue of appropriate size. No excessive bleeding occurred. She declined a postmortem examination.

Discussion The incidence of pregnancy after endometrial destruction is low and is reported to be 0.7%.2 The first to report3 is of pregnancy after transcervical resection of the endometrium (TCRE). The pregnancy was terminated surgically, and the patient had a concomitant laparoscopic sterilization. A literature review reveals that the length of time between surgery and subsequent unplanned pregnancy is very variable. The shortest interval from resection to conception was 5 weeks4; the longest duration was 12 years after a laser ablation with concomitant tubal ligation.5 The total number of reported pregnancies after endometrial destruction is 74, including this one (Tables 1 and 2). Seventy-two of the pregnancies were intrauterine; there were two (2.7%) extrauterine pregnancies. The reported outcomes reveal that 28 (37.8%) women opted for termination of pregnancy. Fourteen (18.9%) women miscarried. Of the 40.6% of ongoing pregnancies beyond 24 weeks’ gestation, 15 women delivered prematurely (20.3%), and 15 women progressed to term (20.3%). There was one set of monochorionic twins reported. Overall in pregnancies after endometrial destruction, there is a significant risk of major obstetric complications, and only a minority will have a completely uncomplicated pregnancy.6 However, a blanket recommendation of termination for pregnancies after endometrial destruction may be unwarranted.2 In those cases where terminations have not taken place, there is an increased risk of miscarriage and ectopic pregnancy. Later complications include antepartum hemorrhage, intrauterine growth restriction, premature rupture of membranes, and preterm delivery.2,4,5,7 There is also increased abnormal placental adherence necessitating cesarean hysterectomy.2,7 Considering these factors, if a woman chooses to continue with the pregnancy, she will require hospital antenatal care with serial growth scans to monitor fetal growth, liquor volume, and

89 Table 1

Reference 2 4 5 6 7 8

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 †

Pregnancy longer than 24 weeks Mode of delivery

Gestation (weeks)

Method of ablation

CS CS CS CS VD CS CS CS CS* CS CS* CS CS CS VD VD CS VD VD CS VD CS CS CS VD CS CS CS CS VD

39 30 38 38 38 39 Term 31 34 29 26 35 37 34 36 40 Term 38 35 38 Term 34 28 38 35 28 31 38 39 Term

Rollerball TCRE Laser Laser Rollerball Laser Laser Laser Laser Laser Rollerball TCRE Rollerball TCRE Rollerball TCRE Laser Rollerball Thermal balloon TCRE TCRE Rollerball TCRE Rollerball Rollerball Partial TCRE TCRE Rollerball/TCRE TCRE Laser

CS ⫽ cesarean section; VD ⫽ vaginal delivery; TCRE ⫽ transcervical resection of the endometrium. *Hysterectomy required for abnormal placentation as advised by one of the reviewers. †Emens JM. Personal communication; 2002.

placental site; and at delivery, a senior obstetrician should be present. There have been two case reports of a congenital anomaly in this group of 74 women: single suture craniosynotosis8 after laser ablation and a fetal anomaly associated with uterine synechiae9 7 years after a rollerball procedure. It is impossible to say whether or not the procedure of neodymium:yttriumaluminum-garnet laser ablation was in any way associated with fetal anomaly, because of the rarity of pregnancy in this group.8 Similarly, no studies have been performed in humans or animals looking at thermal damage or microwave effects on the development of an embryo or fetus. Furthermore, there is no reliable test to predict the definite effect and extent of damage, and no other reported cases to base assumptions upon. Thus, it was impossible to advise our patient whether or not her fetus would in any way be damaged directly as a result of the procedure. Early ultrasound scans suggested that the pregnancy was developing appropriately; and once the pregnancy had been terminated, the fetus looked morphologically normal, but formal examination of it was not permitted.

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Journal of Minimally Invasive Gynecology, Vol 13, No 2, March/April 2006

Table 2

Pregnancy less than 24 weeks

Reference 3 6 7 8

12 15 20 21 26 27 28 29 30 31 32 33 34 35 36 37 38 Present case

Mode of delivery

Gestation (weeks)

Method of ablation

TOP Misc TOP Misc Misc TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP TOP Misc TOP TOP TOP Misc Misc Misc Misc TOP TOP TOP Ectopic TOP Misc Misc* Ectopic TOP Misc Misc Misc Misc TOP

12 8 — 6 12 — 12 — — — — — — — — — — — — — — — 17 12 ⬍13 ⬍13 17 7 5 9 — — 8 Operated — 10 20 Operated — — 22 7 6 12

TCRE Laser Laser Rollerball — — Partial TCRE — — — — — — — — — — — — — — — TCRE Laser TCRE TCRE TCRE Rollerball Rollerball Hydrothermal TCRE TCRE/Rollerball Thermal balloon Thermal balloon TCRE Thermal balloon — TCRE — TCRE TCRE Rollerball Rollerball MEA

— ⫽ no information provided. MEA ⫽ microwave endometrial ablation; Misc ⫽ miscarriage; TCRE ⫽ transcervical resection of the endometrium; TOP ⫽ termination of pregnancy.

In the 37.8% of women who opted for a termination, it is not clear as to which was the preferred method. Therefore, we cannot deduce which method of termination is superior. We recommended a medical termination for two reasons. First, because we felt that the uterine cavity would have been distorted by the MEA. This could have made surgical termination more complex with perhaps a higher chance of it failing, unless performed under ultrasound control. Second, we were also keen to examine the fetus, to see if there were any obvious abnormalities that existed. It is also interesting to note that the

medical termination was successful in a short period of time (10 hours after administration of misoprostol). This may suggest that the placental tissue was not morbidly adherent as can sometimes occur. The Royal College of Obstetricians and Gynaecologists (RCOG) in the UK has recommended the use of mifepristone for medical terminations in pregnancy of up to 20 weeks’ gestation to sensitize the myometrium to prostaglandin-induced contractions and soften and dilate the cervix.39 In our patient, it would appear that she was pregnant at the time of the procedure, despite taking the progesterone-only pill and having had a gonadotropin-releasing hormone (GnRH) agonist administered before the procedure. Neither of these drugs should have had any teratogenic effects on the fetus. Pregnancies have been documented following GnRH agonist administration, but they are rare.40 A pregnancy test was not performed on the day of surgery, and it is unlikely that it would have been positive had one been done. In the UK, the RCOG has recommended that a pregnancy test must be performed before a sterilization procedure to exclude a preexisting pregnancy. However, a negative test does not exclude the possibility of a luteal phase pregnancy.41 However, a pregnancy test is not routinely performed for other gynecologic procedures including endometrial destruction. It is interesting to postulate as to whether this would have been an ectopic pregnancy had the patient been sterilized on the day of the ablation. She had previously declined sterilization on several occasions. The guidelines for endometrial ablation released by the British Society of Gynaecological Endoscopy42 recommend that laparoscopic sterilization should be offered at the same time. In cases of TCRE, laser, and rollerball ablation, this reduces the absorption of irrigant, and may reduce the risk of pelvic inflammatory disease. With the second-generation technique Thermachoice Uterine Balloon System (Gynecare, Ethicon Ltd., Edinburgh, UK), Essure (Conceptus, San Carlos, CA) hysteroscopic sterilization can be performed at the same time. However, sterilization at the time of endometrial destruction still does not guarantee sterility; though the risk of failure is low, it has been reported.5,26 The chance of a pregnancy occurring after both sterilization and endometrial ablation is thought to be approximately 0.002% (or 1 in 50 000).26 Women who decline concomitant sterilization should be advised to use a barrier method or hormonal contraception. On the other hand, if a woman is contemplating pregnancy after endometrial destruction, then a hysteroscopic assessment is recommended. The uterine cavity becomes shrunken and shortened and shows various degrees of distortion, and it frequently resembles that seen in a postmenopausal woman within 2 months of an endometrial ablation.43 One study27 of hysteroscopies in 68 patients 3 and 12 months after endometrial resection reported variable fundal fibrosis with shortening of the uterine cavity. None of the conservative surgical procedures leads to a complete and definitive destruction of the endometrium; and as long as there is viable endometrium present within the endometrial cavity, the risk of pregnancy exists.

Lo and Pickersgill

Pregnancy after endometrial ablation

Conclusion Clinicians must maintain an index of suspicion for pregnancy after endometrial destruction, even in patients who are amenorrheic. Pregnancy is a rare event after any method of endometrial destruction, and no method of endometrial destruction guarantees sterility. Equally, it should be noted that pregnancies have also been reported following hysterectomy. Appropriate contraceptive advice remains essential. With the development of Essure and other mechanical devices, perhaps hysteroscopic sterilizations may become more commonplace at the time of the procedure, even in the outpatient setting. One researcher44 has suggested that it is important to consider establishing a register of women who become pregnant after endometrial destruction and that training standards for ablation should include knowledge of a need for a mechanism of reporting. While the true effect of endometrial destruction on pregnancy outcome remains unknown, it is essential that these cases continue to be reported, so that evidence can accrue allowing patients to be counseled more effectively in future.

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