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Ashermans Syndrome. 2. Introduction. • Definition of what the disease is. • History of the condition. • Pathology formation. • Incidence in population and how it is.
Introduction • • • •

Definition of what the disease is History of the condition Pathology formation Incidence in population and how it is acquired • Symptoms • Patient history and what to ask

Ashermans Syndrome

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Definition • Stages of Asherman disease • Diagnostic imaging in the non-gravid uterus • Synehciae and the gravid uterus • Treatment • Conclusion

A condition where the uterine walls adhere to one another

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History • Hald* was the first to describe uterine adhesions as a consequent to curettage in 1949 • Asherman** popularized the subject in 1950 and has since been become known in the literature as the Ashenman syndrome.

*HALO, H. On uterine atresia consequent to curettage. .Acta obst. et gvnaec. scandinav., 949, 28, 169-174. **ASHERMAN, J. G. Traumatic intrauterine adhesions.:Journal. Obst. & Gvnaec. Brit. Emp., 1950, 57,892-896.3.

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• Asherman described “amenorrhoea traumatica (atretica)” secondary to stenosis in the region of the internal cervical os in 1948 [1] • in 1950 he correlated the presence of intrauterine adhesions with infertility and spontaneous abortion • Scant or absent menstrual flow is the most common disturbance of this condition [1] ASHERMAN, J. G. Amenorrhea traumatica (atrestia) .:Journal. Obst. & Gynaec. Brit. Emp., 1948, 55, 23-30.

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• Representation of normal membrane that lines the endometrial cannel • After surgical trauma fibrous bands grow

• Forms adhesions – Connects tissue normally separate

• Infertility, amenorrhea, dysmenorrhea

– Part of normal healing process

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Pathology • Failure of re-epithelialization with the development of fibromuscular adhesions principal pathologic

• The process 1-7 days to develop. • By day 7 development of adhesions is complete. • Qualitative changes continue over the next several months with adhesions becoming more dense and vascularized.

• Histologic examination – – – –

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Fibrosis distorted inactive endometrial glands fibrous stoma with round cell infiltration scant or absent vasculature.

Reed, Altemus, M.D., and David Charles, M.D., and Richard J. Stock, Jr., M.D.. "Hysterography in Diagnosis of Intrauterine Trauma ." American Journal of Roentgenology 104(1968): 865-869.

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Pathology • Adhesions or synechiae may be delicate – consisting solely of attenuated endometrial stroma

• Most often they consist of hypertrophied fibromuscular tissue stretching between the walls of the uterine cavity.

Reed, Altemus, M.D., and David Charles, M.D., and Richard J. Stock, Jr., M.D.. "Hysterography in Diagnosis of Intrauterine Trauma ." American Journal of Roentgenology 104(1968): 865-869.

How it Ashermans Syndrome acquired and what is the incidence in the population?

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Interventional Causes of Ashermans Syndrome

Causes •

• Surgical scraping. • Cleaning of the uterine wall

The primary causes of Ashermans are –

Interventional procedures



Acquired

– likely to happen after a pregnancy-related D&C

• if an infection is present in the uterus during the time of the procedure. • can also occur after other types of uterine surgery. Ashermans.org 14

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• can also result from intrauterine surgery to remove fibroids, • Uterine structural defects – septum, bicornuate uterus, large polyps

• At cesarean section sites

Uterine curettage may be followed by immediate and/or delayed complications. • immediate complications – perforation of the uterus with hemorrhage and various postabortal infections (endometritis, salpingitis, parametritis, peritonitis)

• Delayed sequelae of a D&C include the development of uterine adhesions or synechiae.

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• A D&C is the most common cause of uterine synechiae

• Incidence of intrauterine adhesions after one D&C was found to be 16%

– Ashenman encountered intrauterine adhesions in 44 out of 61 women who had undergone 2 or more curettages*

– most were mild lesions

• After two and three procedures, the incidences were 14 and 32% respectively

• May also result from

– more than 50% were severe adhesions

Friedler, S., Margalioth, E.J., Kafka, I. and Yaffe, H. (1993) Incidenceof post-abortion intra-uterine adhesions evaluated by hysteroscopy – aprospective study. Hum. Reprod., 8, 442–444.

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– cesarean section, myomectomv, metroplasty and intracavity radium insertion.

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ASHERMAN, J. G. Traumatic intrauterine adhesions.:Journal. Obst. & Gvnaec. 18 Brit. Emp., 1950, 57,892-896.3.

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Acquired Causes of Ashermans Syndrome

Related Condition

• A severe pelvic infection unrelated to surgery Surgical scraping. • sporadic inflammation of mucous membrane lining the uterus. • Endometritis caused by tuberculosis or certain other infectious disease. • Spontaneous synechiae may develop after healing of an endometritis. • Infections related to IUD use (or the placement of any foreign object within the uterine cavity).

• Gynatresia • Occlusion of some part of the female genital tract, especially of the vagina. (Dorland, 28th ed)

Ashermans.org Ashermans.org

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patient history •

Patient Symptoms The adhesions vary in extent, causing partial on complete obliteration of the uterine cavity. • mild cases

What questions should we ask when obtain a patient history? – – – –

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– no clinical symptoms normal menstruation is maintained.

Past interventional procedures When was the last surgery Describe their menstrual cycle leading since the surgery History of past miscarriages

• there may be oligomenorrhea, hypomenorrhea, dysmenorrhea, amenorrhea, infertility and abortion • In more severe cases there may be atresia of the uterine cavity

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Symptoms of Ashermans Syndrome

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Symptoms of Ashermans Syndrome

Asherman support group

Asherman support group

• Symptoms may be related to several conditions and are more likely to indicate Asherman's syndrome if

• No menstrual flow (amenorrhea) or decreased menstrual flow • Infertility • Recurrent miscarriages • patients have hypomenorrhea or amenorrhea

– they occur suddenly after a D&C – or other uterine surgery.

– some have normal periods

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Symptoms of Ashermans Syndrome

stages of Ashermans Syndrome

Asherman support group



Some patients have feel pain at the time each month that their period would normally arrive.



– may indicate that menstruation is occuring but the blood cannot exit the uterus because the cervix is blocked by adhesions.

Ashermans.org

I - Thin or filmy adhesions easily ruptured by hysteroscope sheath alone, cornual areas normal

The American Fertility Society

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stages of Ashermans Syndrome

stages of Ashermans Syndrome





II - Singular firm adhesions connecting separate parts of the uterine cavity – visualization of both tubal ostia possible – cannot be ruptured by hysteroscope sheath alone;



III - Multiple firm adhesions connecting separate parts of the uterine cavity – unilateral obliteration of ostial areas of the tubes

IIa - Occluding adhesions only in the region of the internal cervical OS. – Upper uterine cavity normal; The American Fertility Society

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The American Fertility Society

stages of Ashermans Syndrome

stages of Ashermans Syndrome







IIIa - Extensive scarring of the uterine cavity wall with amenorrhea or hypomenorrhea IIIb - Combination of III and IIIa;

IV - Extensive firm adhesions with agglutination of the uterine walls. Both tubal ostial areas occluded

The American Fertility Society The American Fertility Society

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Stage 1 - Diagnosis • Normally done by the OBGYN when problems have occurred such as

Stages of Asherman's Syndrome according an online community for patient information

– absence of menstruation – abdominal pain. – very light period however – no success in conception.

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Stage 1 - Diagnosis

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Stage 2 – treatment

• Diagnosis is usually made by

• Hysteroscopic to remove adhesions.

– HSG – SHG – Diagnostic hysteroscopy.

• Laparascopic surgery to remove adhesions.

Ashermans.org

Stage 2 – treatment

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Stage 2 - treatment

• After surgery a balloon catheter may be inserted into uterus • Used to keep uterine walls from adhering together during the healing process. (5-14 days)

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• Antibiotics given – prevent infection.

• When balloon is removed a regimen of estrogen and progesterone may be prescribed

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Stage 3 – living with it

Stage 2 - treatment

• Once healed from your surgery free of scar tissue patients may to try and conceive. • It is very important that the uterus is at least 90% free of scar tissue before getting pregnant.

• 2-3 months after post-op – HSG, SIS, hysteroscopy – Evaluate uterus fallopian tubes for remaining scar tissue.

• Subsequent surgery may be necessary.

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risks patients face with carrying a child are • • • •

Placenta Previa Placenta Accreta Premature rupture of membranes possibly incompetent cervix.

Ashermans.org

Diagnostic imaging in the nongravid uterus

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Diagnostic procedures in the non-gravid uterus •

Diagnostic procedures performed to confirm the condition

• Uterine synechiae can be mimicked by subseptate uterus,

– sonography – Hysterosalpingogram – Hysterosonogram

– membrane originates from the uterine fundus and aligns itself in the sagittal plane.

– Hysterooscopy

RD Harris and RA Barth Sonography of the gravid uterus and placenta: current concepts Am. J. Roentgenol., Mar 1993; 160: 455 - 465.

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Sonongraphy

non gravid synechiae

• In the diagonosis of endometrial abnormalities Ghare et.al found that SIS has a higher sensitivity (83-88%) than transvaginal sonogaphy (60- 69%) • They also reported that 3D imaging was an adjunct to diagnosis

Sujata V. Ghate, Michele M. Crockett, Brita K. Boyd, and Erik K. Paulson Sonohysterography: Do 3D Reconstructed Images Provide Additional Value? Am. J. Roentgenol., Apr 2008; 190: W227 - W233.

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photos by Lisa Pearson

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Case 1

Pelvis Ashermans syndrome my seminal case

Preop diagnosis Hematometra Postop diagonosis hematometra

6-05-02 2 mo post mechanical Abortion no period

Pathology: Portions of hylainized and partially necrotic appearing endometrial tissue 45

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Note shape of EC during contractions

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Area of occlusion in LUS

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Note shape of EC during contractions Ultrasound images Case 2 3 months post abortion and no period

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Ultrasound images Case 3 • • •

Elevated WBC No period No pelvic discharge

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Ultrasound images Case 4 • •

D & C two months prior No period

Area of occlusion

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Ultrasound images Case 5 • •

Transabdominal imaging

Patient had a conization 3 months ago G3 P2 AB1

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EV imaging

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EV with focus on Cervix

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Showing vagina Hysterosonogram

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Without SIS

Catheter is in place

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Infusion of saline • Endometrial cavity obliterated by adhesions

• After a saline infused sonogram 69

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RadioGraphics

• Sonohysterogram of a patient with a Hx of multiple misciarrages • Note an irregular thick echogenic band traversing the poorly distended cavity

RadioGraphics 71

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• Sonohysterogram of a 46 year old who presented with excessive vaginal bleeding • Note the echogenic strands traversing the canal

•American Journal of Roentgenology

HYSTEROSONOGRAM POST BICORNUATE REPAIR

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Movie

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The use of 3D • 2D Ultrasound may not the best methodology • 3D Ultrasound alone or • 3D with Hysterosonogram may be the better methodolies

• Mendelson described the EC appearance on ultrasound as – Serpiginous echogenic endometrial irregularities

• He found that the HSG correlated with the sonographic appearance in one of two patient • In both cases, the images obtained transvaginally were of better quality information.

•3DGyn.com

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Mendelson, Ellen B., and Marcela Bohm-Valez, Neal Joseph, Harvey L. Neiman. "Endometrial Abnormalities: Evaluation with Transvaginal Sonography." American Journal of Radiology 150(1988): 139142.

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Hysteroscopy solved the diagnostic dilemma in the diagnosis of Asherman’s syndrome. • Adhesions can result in: – Menstrual disturbances – Infertility – Recurrent abortions

Hysterosalpingogram

• During pregnancy adhesions can result in – Premature labor – Placenta previa – Placenta accreta[*] [*] Schenker, J.G. and Margalioth, E.J. Intrauterine adhesions: an update appraisal. Fertil. Steril., 1982 37 593-610

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• In a study by Iris et al. reevaluated 50 women who had: – a D&C, digital evacuation post delivery or a missed or medical abortion

5 had grade I six had grade II six had grade III three had grade IV

Iris, C.D.Westendorp, Wilhm M. Ankum, Ben W.J. Mol and Han Vonk. "Prevalence of Asherman’s syndrome after secondary removal of placental remnants or repeat curettage for incomplete abortion." Human Reproduction 13(1998): 3347-3350.

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• 25 year old with intrauterine synechiae • HSG shows sharp demarcated adhesions • Areas lacking contrast

American Journal of Roentgenology

• HSG showing contrast filling defects caused by intrauterine adhesions. – arrows show the areas of front to back adhesion partially occluding the cavity and disrupting the normal endometrium

• 3 months after the procedure. Adhesions were encountered in 20 /50 40 % – – – –

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BMJ 2003;327:610-613 (13 September), doi:10.1136/bmj.327.7415.610

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• HSG shows irregular filling defects representing adhesions

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RadioGraphics

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Hysteroscopy image

Hysteroscopy

Normal cervix normal endometrial canal

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Hysteroscopy

http://www.gynaecology.spotmysite.com/page/295/miscarriage.htm

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Hysteroscopy • 2 bands of scar tissue going from the floor ot ceiling of the uterine cavity

Tubal subfertility Khalaf BMJ.2003; 327: 610-613 BMJ 2003;327:610-613 (13 September), doi:10.1136/bmj.327.7415.610

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Advanced Fertility Center of Chicago

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Hysteroscopy Fibroids • Asherman’s syndrome has been reported to be present in almost 20% of the patients with previous D&C or intrauterine infection* • The majority of cases were type I

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* Iris, C.D.Westendorp, Wilhm M. Ankum, Ben W.J. Mol and Han Vonk. "Prevalence of Asherman’s syndrome after secondary removal of placental remnants or repeat curettage for incomplete abortion." Human Reproduction 13(1998): 3347-3350.

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Uterine synechiae in pregnancy • Complications of trauma to the basal layer of the endometrium Asherman • During pregnancy, intrauterine adhesions may appear as an intraamniotic membrane* • Must be distinguished from the more ominous amniotic band syndrome.

Synehciae and the gravid uterus

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* RD Harris and RA Barth Sonography of the gravid uterus and placenta: current concepts Am. J. Roentgenol., Mar 1993; 160: 455 - 465.

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Uterine synechiae in pregnancy • The membrane associated is created by the amnion and chorion draping over the intrauterine scar. • consists of two layers of amnion and two layers of chorion enveloping the scar at the free edge of the membrane

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RD Harris and RA Barth Sonography of the gravid uterus and placenta: current concepts Am. J. Roentgenol., Mar 1993; 160: 455 - 465.

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Pregnancy synechiae

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photos by Lisa Pearson

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Obstetric complications in pregnancies

What happened: the synechiae seemed to disappear • Ball et al. Speculated that as the intrauterine cavity dimensions increase, the fixed adhesions snap and the membranes reapproximate to the uterine wall. Ball, Robert H MD, Sherrie E. Buchneier, Buchneier, RT, RDMS, and Michelle Longnecker, Longnecker, RT, RDMS. "Clinical Significance of Sonographically Setected uterine Synechiae in Pregnant Patients ." Journal of ultrasound in medicine 16(1997): 465465-469.

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Severe obstetric complications in subsequent pregnancies

• Fineberg and lazebnik et al. suggested an increase risk for – malpresentation and related need for cesarean delivery in patients with uterine synechiae... , particularly when the orientation was perpendicular to the placenta. Fineberg HJ: “Uterine synechiae in pregnancy: Expanded criteria for recognition recognition and clinical significance in 28 cases.” cases.” Journal of ultrasound in medicine 10 (1991): 547 Lazebnik N, Hill LM, Many A, et al: “The effect of amniotic sheet orientation on subsequent maternal and fetal complications.” complications.” Ultrasound Obstet. Gynechol 8 (1996): 267

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Endovaginal image of C-section scar

• Deaton et al. reported a spontaneous uterine rupture during pregnancy – after Hysteroscopic treatment of Asherman’s syndrome and complicated by a fundal perforation

• Friedman et al. described three severe complications – uterine sacculation, a uterine dehiscence and a placenta accreta. Deaton, J.L., Maier, D. and Andreoli, Andreoli, J. (1989) Spontaneous uterine rupture during pregnancy after treatment treatment of Asherman’ Asherman’s syndrome. Am. J. Obstet. Gynecol., 160, 1053– 1053–1054.

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Severe obstetric complications in subsequent pregnancies

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Treatment of Ashermans Syndrome • Asherman's syndrome should be treated if it is causing infertility or amenorrhea. • Surgical treatment includes cutting and removing adhesions or scar tissue within the uterine cavity

• Jewelewicz et al. found a rate of placenta accreta of 9% in a series of 137 term pregnancies • In a study by Sylvie et al. two out of nine pregnancies with live births (22.2%) were complicated with placenta accreta – one had a past history of abnormal placentation. Jewelewicz, Jewelewicz, R., Khalaf, Khalaf, S., Neuwirth, Neuwirth, R.S. and Vande Wiele, Wiele, R.L. (1976) Obstetric complications after treatment of intrauterine intrauterine adhesions (Asherman (Asherman’’s syndrome). Obstet. Gynecol., 67, 864– 864–867. Sylvie, CapellaCapella-Allouc, Allouc, and Catherine RongieeresRongieeres-Bertrand, Sabine Taylor and Herve Fernandez. "Hysteroscopic treatment of severe Asherman’ 1230-1233. Asherman’s syndrome." Human Reproduction 14(1999): 1230-

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Treatment of Ashermans Syndrome

Treatment of Ashermans Syndrome

• After surgery may place a small balloon inside the uterus for several days – To prevent the walls from reattaching estrogen replacement therapy may be prescribed while the uterine lining heals. • Antibiotic treatment may be necessary if infection is identified.

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Keys to treatment include • Early recognition • Early treatment – by a Physician experienced with the condition.

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Conclusion • women with menstrual disorders after an intervention had a strong increased risk in developing intrauterine adhesions • These adhesions can result in

• Watch for complications in all patients with a history of intrauterine adhesion removal

– Menstrual disturbances – Infertility – Recurrent abortions

• Knowing the right question to ask you patients can help steer the clinician in making the right diagnosis

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