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.