This document provides information about Prof. Narendra Malhotra, including his professional qualifications and positions held. It lists that he is a practicing obstetrician gynecologist in Agra with special interests in high risk obstetrics, ultrasound, laparoscopy, infertility and genetics. It also provides information about Malhotra Nursing & Maternity Home Pvt. Ltd. and Global Rainbow Health Care in Agra.

1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.A.M.S.,F.I.A.P
• Prof. Dubrovnick International University
• VICE PRESIDENT W.A.P.M.
• PRESIDENT ISAR 2016-17
• PRESIDENT ISPAT 2017-19
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Senior V. P. of FOGSI (2003)
• Vice Dean Indian College of Medical Ultrasound (2006)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy and
Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• FOGSI Imaging Science Chairman (1996-2000)
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award, Corion
award, Man of the year award, Best Citizens of India award
• Over 30 published and 100 presented papers
• Over 50 guest lectures given in India & Abroad
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 8 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology (2007)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194
www.malhotrahospitals.com,www.rainbow

2. PREVENTION OF ADHESIONS
REFORMATION AFTER
HYSTEROSCOPIC SURGERY
narendra malhotra
rahul manchanda
jaideep malhotra
shally gupta
manpreet sharma
shemi bansal
keshav malhotra
www.rainbowhopitals.org

3. Work Place

4. DISCLOSURES
I have no financial relationship with the manufacturers
of any products or the
providers of any services that are mentioned in this presentation.
I do not intend to discuss any unapproved use of any device
mentioned in the presentation

5. adhesions in uterus what are they
ASHERMAN SYNDROME
• Abnormal fibrous connections
• Joining tissue surfaces in abnormal locations
• Intrauterine adhesions cause significant fertility problems
Infertility
Recurrent preg loss
Abnormal uterine bleeding
Amenorrhea
Dysmenorrhea
Abnormal placentation
Hematometra
Chronic pelvic pain
Asheman 1948 obstet gyneacol

6. adhesions can be primary or
secondary
• Denovo
• After surgery
• Secondary to adhesiolysis
(recurrent adhesions)
Curettage
Myomectomy
Metroplasty
Ablation procedures
Shenker 1996 eur j obstet gynecol
Also following infections
TUBERCULOSIS
ENDOMETRITIS
SEPTIC ABORTIONS
FORMATION DEPENDS ON AGE;NUTRITIONAL STATUS;IMMUNE STATUS;
PREDISPOSITION DUE TO CO EXISTING DISEASE

7. intrauterine adhesions
ashermans syndrome

8. synechiae
In thick synechiea 3D US can
be used for exact assessment
of restriction of endometrial
cavity.

9. hysteroscopy
• Gold standard for diagnosis and for treatment
of intrauterine adhesions
March CM 1978 Obstet Gynecol Clin North Am
March Cm 1978 Am J Obstet Gynecol

10. prevention
• no gen concensus on a single modality proven
to be unequivocally effective in preventing
adhesion formation

11. The American Fertility Society Classification Of Intrauterine Adhesions.1988.
• Extent of < 1/3 1/3 - 2/3 >2/3
Cavity Involved 1 2 4
• Type of Filmy Filmy & Dense Dense
Adhesions 1 2 4
• Menstrual Normal Hypomenorrhea Amenorrhea
Pattern 0 2 4
• Stage I (Mild) 1 - 4
• Stage II (Moderate) 5 - 8
• Stage III (Severe) 9 - 12
DENSE OR FLIMSY
PARTIAL OR COMPLETE
SUPERFICIAL OR DEEP

12. Intrauterine Synechiae: Operative Treatment
Restoration of menses: 70- 90%
Pregnancy rate : 60% - 90%.
Term pregnancy : 40- 80%
Poor Prognosis :
Severe disease,
Multiple procedures have been necessary
Perforation : 2%.
Infection : 2%.
Adhesion reformation :20-40%.
Placental complications :2-40%..

13. prevention strategy
• 1.SURGICAL MANAGEMENT
• 2.EARLY SECOND LOOK
• 3.BARRIER AGENTS
• 4.PHARMACOLOGICAL
THERAPY
• 5.IMPROVE GEN HEALTH AND
NUTRITION OF PT.

14. barrier foley’s balloon after surgery

15. surgical therapies
• Avoid trauma to healthy endometrium and
myometrium
• Reduce use of electrosurgery
• Avoid forceful cervical manipulations
Mazzon 2014 cold loop hyst myomectomy fertil steril
Touboul et al 2009 fertil steril adhesion after bipolar resection
Golan et al 2011

16. 1.hysteroscopic techniques to reduce
adhesions
• Cold loop on resectoscope
Mazzon 2014 cold loop hyst myomectomy fertil steril
• Bipolar plasma cutting cautery
Touboul et al 2009 fertil steril adhesion after
bipolar resection
• Partial roller ball in case of
ablations for AUB
• Hysteroscopic guidance to
separate RPOC rather than a blind
curettage and suction
Rein etal 2011
Barel 2015
Golan et al 2011

17. 2.Early second look hysteroscopy
• As early as one week
• Rather than done 1-3 months
after E & P therapy
Robinson et al 2008 fertil steril
• IUCD and early one week second
look led to lesser adhesions as
compared to controls at 2 months
Pabuccu et al 2008 and Yang et al 2008 (fertil
steril)

18. 3. barrier methods
• commonly used
IUCD with copper removed
LIPPES LOOP
PAEDIATRIC CATHETER with tip cut
INTRAUTERINE BALLONS
Intrauterine ballon or foley’s catherters are more effective in adhesion prevention
(no randomised control trial)
(plus there is a bias as estrogen and progesterone and antibiotics are used)
Orhue et al 2003 int j gynecol obstet
Roy et al 2010 arch gynecol obstet
Tongue et al 2010 int j gynecol obstet
Lin et al 2013 eur j obstet gynecol reprod biol

19. amniotic membrane
• Amniotic memberane graft(fresh or dried) put
over the foley’s bulb left inside for 2 weeks
(dried is equally good …more studies needed)
The AM has been shown to have anti-
inflammatory, anti-fibrotic, anti-angiogenic as
well as anti-microbial properties. Also because
of its transparent structure, lack of
immunogenicity and the ability to provide an
excellent substrate for growth, migration and
adhesion of epithelial corneal and conjunctival
cells, it is being used increasingly for ocular
surface reconstruction in a variety of ocular
pathologies including corneal disorders

20. anti adhesive gels
• ACP gel auto crosslinked hyaluronic acid
• CH carboxymethylcellulosemembrane
• POC polyethylene oxide sodium
carboxymethycellullose gel
Very few studies comparing choice of one
barrier (Guida,Acunzo,De Iaco) Gudia 2004
Acunza 2003
De Iaco 2003
We have no personal experience with these antiadhesives

21. ACP GEL
• ACP gel make it a more suitable to
inject at the end of the hysteroscopy
surgery through the outflow channel
as the surgeon reduces the inflow
…….under hysterocopic view
• The high viscosity and adhesiveness of
this gel into the uterine cavity makes it
easy to introduce
• Ultrasound scan shows the gel
remains in uterus for 72 hrs atleast
( good enough time for early
adhesion prevention)

22. CH GEL
CARBOXYMETHYLCELLULOSE GEL
• Used alone
• With hyaluronic acid gel or alginate
• Combination mor effective for adhesion
prevention

23. POC GEL
• POC or INTERCOAT is
used traditionally in
laparoscopic surgeries
• Di Spiezio has
demonstrated significant
reduction of denovo
intrauterine adhesions in
a study
Di Spiezio Sardo et al 2011 j minim invas gynecol

24. 4.antibiotics
• Not recommended routinely(ACOG and AAGL)
• However in developing countries we are
using routine one shot of broad spectrum
antibiotics before and after surgery
• Probably reduces infection and inflammation
and hence prevents adhesion formation

25. 5.pre operative hormonal suppression
• Preop use of GnRh analogues and Danazol
• Widely used before some procedures like
• TCRE/MYOMECTOMY and METROPLASTY
• Provides technically optimal conditions for
surgery(suppressing endometrium,decreasing
vascularity and oedema)
• Minimises perioperative
copmplications(pefortaion,fluid overload and
bleeding)
• Role for prevention of adhesions is questionable

26. 6.post operative hormonal therapy
• Estrogen and progesterone frequently used but
role is uncertain(belived to initiate endometrial
growth so the lesion will be covered )
• Scarred surface are re-epithialised
• cyclical E and P regimns(1.25-5 mg estrogen)
• In India we usually follow a regimn of 2 mg tds of
estrogen valerate for 21 days followed by 7 days
of norethistrone 10 mg cyclically for 2-3 months
Or a continouous estrogen for 2 months

27. 7. Stem cells
• Epithelial proginator cells and
MSC(mesenchymal stem/stromal cells) are
rich in basal layer of endometrium
• Severe damage to endometrium destroys
these cells and causes asherman syndrome
and amenorrhea
• Damage to basal layer of endometrium causes
loss of ability to regenerate the endometrium

28. stem cells
• Adult bone marrow derived MSC are known for their
property to repair and regenerate
• CD 9+ ,CD 90+ and CD 133+ have shown promising
results to generate a receptive endometrium
• Intrauterine transplant of these cells can promote
endometrial regeneration by
Production of trophic factors
Promoting angiogenesis
Tissue growth transdifferentiate into resident
endometrila stem cells(stimulation of dormant
endometrial stem/proginator cells into active cell cycle)
Singh et al 2014 j human reproduction

29. Bone marrow aspiration and
processing MSC cells

30. novel treatment
intrauterine transplantation of adult bone marrow
stem cells
This technique represents a new therapeutic
approach for the treatment of endometrial
regeneration problems such Asherman
Syndrome and the endometrial atrophy since
currently no specific treatment for these
endometrial pathologies exist.

31. Endometrial regeneration using autologous
adult stem cells followed by conception by in
vitro fertilization in a patient of severe
Asherman's syndrome
Chaitanya B Nagori, Sonal Y
Panchal, and Himanshu Patel1
Author information ► Article
notes ► Copyright and License information ►

33. PRP
platelet rich plasma
• Autologus PRP and mononuclear cells
promote endometrial groth and improves
preg outcomes in IVF
• PRP is prepared by centrifuging blood
• 0.5-1 ml is induced in the ut cavity on day 10
of an HRT cycle of IVF
• Endom thickness if does not improve in 72 hrs
second instillation is done

34. Autologous Platelet-rich plasma
promotes pregnancy

37. AT RAINBOW IVF CENTRE
14 cases done with PRP
10 FOR POOR ENDOMETRIUM AND IVF FAILURE who had a normal hsteroscopy
4 had PRP injected just after surgery(moderate and severe adhesiolysis)
Till now one pregnancy in the poor endom with normal hysteroscopy group
No pregnancy in the PRP injected in group who underwent injection at surgery
Second look in these 4 cases shows no reformation of adhesions in any of the cases

38. PRP POST OP
• After hysteroscopic adhesiolysis
• Injection of 1 ml of PRP thru the
foleys ballon kept in the cavity
• For 72 hrs
• Repeat injection protocols are
being worked out
• We have tried reinjection at 1
week and 2 week intervals in all
our 4 cases of moderate/severe
adhesiolysis cases

39. Autologous platelet-rich plasma promotes endometrial growth and ...
https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
by Y Chang - 2015 - Cited by 12 - Related articles
Jan 15, 2015 - If endometrial thickness failed to increase 72 h later, PRP infusion was done
1-2 ... This study was to evaluate the effectiveness of PRP in the therapy of ... red
blood cells at the bottom,cellular plasma in the supernatant and a ...
Effects of autologous platelet-rich plasma on
implantation and ... - NCBI
https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC5124324/
by L Nazari - 2016 - Related articles
PRP has been investigated as
a therapeutic approach for several medical ....
blastocysts to increase blastocyst attachment
to endometrial epithelial cells in vitro.

40. GCSF
Currently we are evaluating
GSF injection post operation
Followed by repeat injection
We have a series of GCSF
Injected for poor endometrium
During the ART cycle
Improves the thickness in
Almost 75 % cases and
Pregnancy rates reported higher
In this group
Needs more study

41. Our study 2011-2014
Indications No. Of patients
(N =135)
Percentage
Infertility
Primary 63 46.67%
Secondary 54 40%
Menstrual disorder Secondary
amenorrhoea
16 11.8%
Hypomenorrhoea 11 8.1%
Oligomenorrhoea 9 6.6%
Irregular spotting 2 1.48%
Chronic pelvic pain 2 1.48%
Post Hysteroscopic
procedural adhesions
2 1.48%
Post Caesarean
section adhesions
3* 2.22%
Patients with Intra uterine adhesions
2 had B-Lynch sutures in the previous caesarian section

42. Diagnosis of intrauterine adhesions (Gold standard: hysteroscopy)
Approach Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Ultrasound 0.5 95.2 0.0 95.2
Soares et al.
2000 [24]
Sonohysterography 75 93.4 42.9 98.3
Soares et al.
2000 [24]
Hysterosalpingograp
hy
75 95.1 50 98.3
Soares et al.
2000 [24]

43. Our study
• Adhesions were removed with sharp scissors.
Ultrasound or laparoscopic guidance was used where
ever required.
• Dissection was carried on until the pink myometrial
tissue of fundus was seen and both tubal ostia were
sighted in the same plane.
• Fluid balance was kept in check during the procedure.
• Mean operation time varied according to the cases, but
in general it was around 15-35 minutes.
• All the patients with moderate to severe adhesions
were given oral hormonal therapy (1.25 mg estradiol
valerate twice daily for 21 days in mild cases, and 6-8
mg, for 21 days in cases with moderate to severe
degrees of adhesions. All patients were administered
10 mg MPA twice daily on last 7-10 days of the month.
• Additionally, those patients with severe degrees of
adhesions( according to MEC classification Table 2)
were considered for IUCD insertion.

44. Second look hysteroscopy
recurrence
Stage
initially
2nd look
hysteroscopy
done
Mild Moderate Severe
Mild <1/3rd 14/48 2
Moderate
<2/3rd
23/53 3 2
Severe
>2/3rd
12/34 1 1 2
Saline infusion sonograhy with 3D was done in all and only positive finding
cases were taken up for 2nd look hysteroscopy.

45. Pregnancy outcome in our study
Outcome Number =135
Pregnancies 48 (35.5%)
Spontaneous abortion 5 (10.4%)
Therapeutic abortion 2 ( 4.1%)
Ectopic 1 (1.47%)
Live Birth 30
Preterm delivery 9
Term delivery 21
Cervical incompetence 1*
IUGR 5
Placenta accreta 4
Caesarian hystrectomy 4
Pregnancy outcome in women treated for IUAs
* Cervical cerclage was given.

46. Conclusions of our study
• Intra uterine adhesions have a high impact on the
pregnancy outcome.
• Iatrogenic reasons are the biggest contributors to their
cause, hence prevention should be top most on our mind.
• There is a lack of classification which will be accepted by all.
• Hysteroscopy remains the gold standard in diagnosis and
management.
• Post operative management needs further research.
• Stem cells is an area for research.
• Pregnancy outcome and complications needs to be
counselled.

47. guidelines for Treatment of IUAs
1. It is reasonable to offer expectant management as an alternative to
intervention in selected women with IUAs. Level C.
2. There is no evidence to support the use of blind cervical probing. Level C.
3. There is no evidence to support the use of blind dilation and curettage.
Level C.
4. Hysteroscopic guidance is the treatment of choice for symptomatic
IUAs. Level C.
5. Direct visualization of the uterine cavity at hysteroscopy in conjunction
with a tool for adhesiolysis is the treatment of choice for IUAs. Level B.
6. In the presence of extensive or dense adhesions, treatment should be
performed by an expert hysteroscopist familiar with at least one of the
methods described. Level C.
AAGL Practice Report: Practice Guidelines for Management
of Intrauterine Synechiae 2009

48. conclusions
• Intrauterine adhesions are fairly common findings
specially in women with oligomenorrhea and
amenorrhea
• Specially seen in Asians and developing countries
with a high previlance of PID
• Proper technique
• Early relook
• Use of barriers
• Use of stem cells and PRP in grd 4 ashemans
which are recurring may be the last resort

49. Acronym ‘PRACTICE’
Principles critical to a successful approach to AS
are encompassed
• Prevention,
• Anticipation,
• Comprehensive therapy,
• Timely surveillance of subsequent pregnancies,
• Investigation,
• Continuing Education.

50. THANK YOU