The Adverse Impact of Endometrial Trauma on Pregnancy Outcomes; A Real-World Evidence Study

Abstract

Study Objective

Evaluate pregnancy outcomes in women following uterine surgery, including hysteroscopic adhesiolysis.

Design

Retrospective study.

Setting

Database.

Patients or Participants

A 6.5-year United States 150-payor database comprising 120 million patients with commercial, Medicaid, or Medicare coverage.

Interventions

Pregnancy outcomes in women with hysteroscopic adhesiolysis, uterine surgery without adhesiolysis, or no documented uterine surgery.

Measurements and Main Results

The database was searched for individuals with continuous enrollment, identifying three cohorts with trailing data back to April 2017: A history of intrauterine adhesiolysis (HA), a uterine procedure, but no adhesiolysis (UP), and those without any history of uterine surgery (NoUP). All cohorts were followed until May 2023 (41 months) to identify those with a completed pregnancy. Propensity score matching was employed to make the baseline cohort composition similar. Preterm delivery, placenta accreta spectrum, placenta previa, and postpartum hemorrhage were all identified more frequently in those undergoing previous surgery as follows: Preterm Delivery: HA - 14.5%, UP - 10.1%, NoUP - 8.4%, p <0.05. Placenta Accreta Spectrum: HA - 4.6%, UP – 0.9%, NoUP – 0%, p <0.05. Placenta Previa: HA - 13.5%, UP - 10.1%, NoUP – 3.9%, p < 0.05. Postpartum Hemorrhage HA – 17.7%, UP – 25%, NoUP – 7.8% p < 0.05.

Conclusion

In this study, women identified with a history of hysteroscopic adhesiolysis experienced increased risks of preterm delivery, placenta accreta spectrum, placenta previa, and postpartum hemorrhage compared to those without a history of uterine surgery in the study interval. While the magnitude of the difference was less, those with uterine surgery absent adhesiolysis were also at increased risk. These data align with findings from other cohort studies and suggest that endometrial trauma is a risk factor for adverse pregnancy outcomes for both the women and the fetus, likely incurring the expenditure of considerable healthcare resources. Research and development of means by which such trauma could be minimized is needed.