CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.
“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).
Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.
Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.
In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.
The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.
In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.
In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.
Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.
“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”
Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.
“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”