Subchorionic Hematoma in Early Pregnancy: Should We Care?

Subchorionic Hematoma in
Early Pregnancy:
Should We Care?
John P. Elliott, MD
Medical Director, Valley Perinatal
Services
Phoenix, Arizona
Disclosures
No relevant financial relationships or
conflicts of interest to disclose.
FDA – nothing to disclose
Subchorionic Hematoma
A hypoechoic or anechoic crescent
shaped area behind the gestational sac in
the first trimester and behind the fetal
membranes in the second trimester
Placental abruption from arterial bleeding
is probably related to pathologic processes
in the spiral arteries. Arterial bleeding is
more profuse and at higher pressure
increasing the risk of extending placental
dissection leading to severe abruption and
delivery.
Venous abruption is due to increases in
venous pressure which may obstruct
venous drainage causing rupture of the
large maternal venous channels subjacent
to the peripheral portion of the placenta.
The blood then dissects the membranes
away from the decidual tissues. If the
blood clots between the chorion and
deciduum, a hematoma forms.
Approximately 2/3 of subchorionic
hematomas diagnosed in the first and
second trimesters disappear within 1-3
months after detection
Incidence
Depending on the definition of
subchorionic hemorrhage, the incidence in
the literature ranges from 8-22%
Tuuli et al performed a systematic review
to estimate the association between
subchorionic hematoma and adverse
perinatal outcome
Inclusion Criteria
MEDLINE and EMBASE were searched from
1981 to 2010
Studies were included if they involved pregnant
women with a viable pregnancy and a
subchorionic hematoma with or without bleeding
Primary outcome: Fetal loss (spont AB or
stillbirth)
Secondary outcomes: PTD, SGA, Preeclampsia,
Abruption, PPROM
7 studies met inclusion criteria
1735 pts with subchorionic hemorrhage
70,703 control pts
Prospective cohort studies – 2
Retrospective cohort studies – 3
Case control studies - 2
Results
SAB 8.9% vs 17.6%: OR 2.18, 95% CI 1.29-3.68
Stillbirth 0.9% vs 1.9%: OR 2.09, 95% CI 1.20-3.67
Abruption 0.77% vs 3.6%: OR 5.71, 95% CI 3.91-8.33
PTD 10.1% vs 13.6%: OR 1.40, 95% CI 1.18-1.68
PPROM 2.3% vs 3.8%: OR 1.64, 95% CI 1.22 – 2.21
Results - Negative
No increase in PIH, SGA
Conclusions
“Although we found a significant
association between subchorionic
hematoma and adverse pregnancy
outcomes, a causal relationship cannot be
definitively confirmed by this review”.
Recommendations
No specific interventions for these
complications
Careful observation and vigilance
Antepartum testing in the 3rd trimester?
C.A.O.S
Chronic Abruption
Oligohydramnios Sequence
Retrospective Review
Banner Good Samaritan Medical Center,
Phoenix, AZ
All deliveries Jan 1, 1990 to June 30 1994
(4.5 years)
All pts with a diagnosis of placental
abruption were reviewed
Pts with oligohydramnios or PPROM were
selected
Definition of CAOS
Chronic abruption was defined as a delay
of ≥7 days after the initial hemorrhage
before delivery
CAOS was defined as 1) chronic
abruption, 2) with documentation of normal
AFI initially and 3) oligohydramnios
developing (AFI <5 and without evidence
of ruptured membranes)
CAOS
After a variable period of time (weeks), the
clot may lyse and release serum which
can pass vaginally as a “gush of water”
that is nitrazine positive and fern neg but
the membranes intact.
This may lead to PROM which occurs
frequently 15/24 (63%) in patients with
CAOS.
Control Group
Pts with chronic abruption who did not
develop oligohydramnios
Study Group
CAOS 24
Nulip
54%
CHTN
4%
HxofAb 0%
Smoker 21%
Control 16
36%
6%
0%
31%
A subchorionic clot was documented in
both CAOS 18/24 (75%) and control 14/16
(87%)
CAOS developed in 24/40 (60%) of
patients with chronic abruption
The mean GA at delivery was 28 weeks in
all patients with CAOS
With initial bleeding <20 weeks, delivery
occurred at <37 weeks in 18/20 (90%).
If the first bleed occurred <20 weeks,
CAOS resulted in delivery occurring 6.9
weeks earlier than controls. PPROM
eventually occurred in 63% of CAOS
patients.
If the first bleed occurred ≥20 wks, the
outcome in CAOS patients was the same
as control with the mean G.A. at delivery
of 31 weeks.
As in ‘Get Smart’, it is better to be control
than CAOS
Symptomatic Patients with
Subchorionic Hematoma
Vag bleeding or uterine contractions persisting
22 pts 22/4763 (0.46%)
– 8 vag bleeding only (36.4%)
– 4 contractions only (18.2%)
– 10 both (45.5%)
Outcome:
–
–
–
–
Abortion 3 (13.6%)
PTL & PTD 17 (77.3%) 7 were <32 weeks
Term Delivery 2 (9.1%)
PROM 9 (40.9%)
Seki H et al Int J Gynecol & Obstet 1998
Volume of the Hematoma
Approximated by multiplying the 3
orthogonal diameters
LxWxH
– If volume <60 ml 12/14 (86%) term delivery
– If volume >60 ml 13/16 (81%) PTD
Borlum et al. 1989
18 months
1034 pts admitted with symptoms of
threatened abortion in 1st or 2nd trimester
380 pts study group
SCH 86 (22.1%)
Control 294
Observed in the hospital until bleeding
stopped
Outcome
SCH (86) Control (294) P
Abortion in hosp 6 (7%)
8 (2.7%)
Abortion after d/c 13 (16.3%) 16 (5.6%)
NS
<0.5
PTD 2nd trimester bleed
6/41 (14.6%) 16 (5.6%)
Borlum et al. 1989
<0.5
SCH Detected at the Anatomy
Scan 17-22 weeks
Retrospective cohort study 14 yrs 19942008
1081/63,966 (1.7%) SCH identified
SCH associated with higher G and P,
lower BMI, non AA race
Abruption 3.6% vs 0.6%: OR 2.6, 95% CI
1.8-3.7
– Bleeding hx: OR 1.6, 95% CI 1.0-2.7
– No bleeding: OR 5.0, 95% CI 3.0-8.3
SCH Detected – cont’d
PTD <37 wks 15.5% vs 10.5%: OR 1.3,
95% CI 1.1-1.5
PTD <34 wks 5.3% vs 2.8%: OR 1.5, 95%
CI 1.1-2.0
IUFD, PROM, PIH – NS
Norman SM, et al. Obstet Gynecol 2010
SCH
In patients with a threatened AB, SCH and
a live fetus: SAB occurred in 14%
regardless of trimester and PTD occurred
in 12%
Sauerbrei E et al. Radiology 1986
There is no information in the medical
literature about the incidence of SCH as
detected by US in a population of normal
pregnant patients
Management of SCH
No management strategy has been tested
Bed rest?
– May provide psychological benefit
US surveillance
– No evidence of IUGR
– CAOS
Assessment in office for PTL
– FFN?
Tocolysis?
References
Tuuli MG, et al. Perinatal Outcomes in Women
With Subchorionic Hematoma. Obstet &
Gynecol. Vol. 117, No. 5, pp 1205-12, May
2011.
Elliott JP, et al. Chronic AbruptionOligohydramnios Sequence. J of Reproductive
Med. Vol. 43, No. 5, pp 418-22, May 1998.
Ball RH, et al. The clinical significance of
ultrasonographically detected subchorionic
hemorrhages. Am J Obstet Gynecol. Vol 174,
No. 3, pp 996-1002, March 1996.
References
Seki H, et al. Persistent subchorionic
hematoma with clinical symptoms until
delivery. Int J Gynecol & Obstet. Vol. 63 (1998)
pp 123-28.
Pearlstone M and Baxi L. Subchorionic
Hematoma: A Review. Obstet & Gynecol
Survey. Vol. 48, No. 2, pp 65-68, 1993.
Borlum K, et al. Long-Term Prognosis of
Pregnancies in women with Intrauterine
Hematomas. Obstet & Gynecol. Vol. 74, No. 2,
pp 231-33, August 1989.
References
Norman S, et al. Ultrasound-Detected
Subchorionic Hemorrhage and the Obstetric
Implications. Obstet & Gynecol. Vol. 116, No. 2,
Part 1, pp 311-315, August, 2010.
Sauerbrei E and Pham D. Placental Abruption
and Subchorionic Hemorrhage in the First Half
of Pregnancy: US Appearance and Clinical
Outcome. Radiology. Vol. 160, No. 1, pp 109112, July, 1986.