"The threat of Asherman syndrome": a propensity score-matched study of fetal-maternal outcomes

Abstract

Objective: To study fetal-maternal outcomes in pregnancies after hysteroscopic treatment of Asherman syndrome (AS) compared with pregnancies without a history of AS. A secondary objective was to examine whether outcomes varied on the basis of AS characteristics.

Design: A propensity score-matched cohort study conducted at a tertiary referral center between January 2011 and December 2022.

Subjects: The study included 428 women treated for AS who subsequently achieved a viable pregnancy (>22 weeks of gestation) and 2,145 matched comparison group without a history of AS.

Exposure: Women underwent hysteroscopic adhesiolysis for AS, followed by standardized postoperative care, including intrauterine device placement and hormonal treatment. Propensity score matching was applied to control for age, calendar year, parity, and gravidity.

Main outcome measures: The primary outcomes included perinatal death, preterm delivery, breech presentation, birth weight, manual removal of the placenta, and mode of delivery and postpartum hemorrhage.

Results: Women with a history of AS experienced statistically significantly higher risks of adverse fetal-maternal outcomes than the comparison group. Twelve perinatal deaths (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.8-8.2) occurred in the AS cohort, primarily associated with extreme prematurity. Furthermore, outcomes included increased risks of preterm birth (OR, 3.14; 95% CI, 2.31-4.26), breech presentation (OR, 3.57; 95% CI, 2.44-5.23), and postpartum hemorrhage (OR, 2.52; 95% CI, 1.95-3.25). The likelihood of manual removal of the placenta was eightfold higher (OR, 8.5; 95% CI, 6.2-11.7). Although the birth weight was lower in the AS group, this was largely due to prematurity, with no observed increase in the rate of small for gestational age infants. Subgroup analyses revealed the highest risk in women with a postpartum procedure preceding AS and those with severe adhesions.

Conclusion: Pregnancies after hysteroscopic treatment for AS are associated with statistically significantly increased risks of fetal-maternal complications. These findings highlight the need for specialized prenatal care and risk management for women with AS. This study underscores the importance of developing clinical guidelines to optimize pregnancy outcomes in this high-risk population.

Keywords: Gynatresia; fetal-maternal outcome; hysteroscopy; postpartum hemorrhage; premature birth.