Subchorionic Hemorrhage Imaging

No Results

No Results

processing….

Subchorionic hemorrhage (subchorionic hematoma) is the most common sonographic abnormality in the presence of a live embryo. Vaginal bleeding affects 25% of all women during the first half of pregnancy and is a common reason for first-trimester ultrasonography. Sonographic visualization of a subchorionic hematoma is important in a symptomatic woman because pregnant women with a demonstrable hematoma have a prognosis worse than women without a hematoma (see example images below). However, small, asymptomatic subchorionic hematomas do not worsen the patient’s prognosis. ^{[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]}

In women whose sonogram shows a subchorionic hematoma, the outcome of the fetus depends on the size of the hematoma, the mother’s age, and the fetus’s gestational age. Rates of miscarriage increase with advancing maternal age and increasing size of hematoma. Late first- or second-trimester bleeding also worsens the prognosis. The presence of sonographically detected subchorionic hemorrhage (subchorionic hematoma) increases the risk of miscarriage, stillbirth, abruptio placentae, and preterm labor.

The subchorionic hemorrhage (subchorionic hematoma) collects between the uterine wall and the chorionic membrane and may leak through the cervical canal. Later in the first trimester and early second trimester, the subchorionic hematoma may partially strip the developing placenta away from its attachment site. Therefore, the prognosis of patients with this type of hematoma is worse than the prognosis of patients with hematoma early in first trimester. ^{[12, 13]}

The subchorionic hematoma often regresses, especially if it is small or moderate in size. Large hematomas, which strip at least 30-40% of placenta away from endometrium, may enlarge further, compressing the gestational sac and leading to premature rupture of membranes with consequent spontaneous abortion.

Small hematomas on the surface of the placenta (subamniotic hemorrhage) are common at 18 to 20 weeks on ultrasound, but hemorrhages identified beneath the placenta, at the edge of the placenta, or behind an isolated area of the fetal membranes is of greater significance. Large intrauterine hematomas in the second trimester may compromise maternal health. ^[14]

In a meta-analysis of 7 studies that included 1735 women with subchorionic hematoma, hematomas were associated with an increased risk of early and late pregnancy loss, abruption, and preterm premature rupture of membranes. Sequela of subchorionic hemorrhage included one extra spontaneous abortion per 11 women and one extra stillbirth per 103 women. ^[15]

Massive subchorionic thrombohematoma (Breus’ mole) has been diagnosed in the second trimester by ultrasound assessment of the placenta. Normal fetal growth and umbilical artery Doppler waveforms have been described as being associated with perinatal survival. ^[16]

The frequency of subchorionic hematoma has been shown to be high with infertility treatment by in vitro fertilization (IVF) (22.4%) versus non-IVF (11%). Frozen-thawed embryo transfer, parity of 1 or greater, and blastocyst transfer may be contributing factors in IVF patients. ^[17]

Ultrasonography is the imaging modality of choice for subchorionic hemorrhage (subchorionic hematoma) because it can be performed rapidly at the patient’s bedside and because it has no known risk, as with radiation. ^{[18, 19, 20]}

The sensitivity of sonography is low and varies between 2% and 20%, as blood may pass vaginally and not collect in the subchorionic space. Hematomas may also appear isoechoic relative to the placenta.

CT scanning is relatively contraindicated during pregnancy because of the risk of radiation to the fetus. Pregnant patients may undergo CT for reasons such as an evaluation of trauma or acute abdomen. Scans may show an incidental or injury-related hyperattenuating subchorionic hemorrhage (subchorionic hematoma).

The sensitivity of CT may be high compared with that of sonography. However, because of the risk of radiation with CT, no large comparisons of the 2 modalities have been reported.

Normal chorioamniotic separation should not be confused with placental abruption.

MRI is not routinely performed to detect subchorionic hemorrhage (subchorionic hematoma); a more common indication is the detection of fetal anomalies. ^{[21, 22]} MRI may incidentally show a subchorionic hematoma and help in characterizing and determining the acuity of the hematomas by showing changes in signal intensity produced by various blood products. T1-weighted spin-echo and gradient-echo images are particularly useful in evaluating the hemorrhage.

In one study, fetal MRI techniques were evaluated to determine whether they were sufficient for the assessment of placental pathologies, and based on the study findings, MRI was considered by the authors to be a promising tool for the assessment of placental insufficiency. Pathologically, 26 placentas showed infarctions (96.2% on MR scans); 2 retroplacental hematomas were detected by MRI and confirmed by pathology; 9 of 14 subchorionic hematomas were confirmed; 6 of 8 intervillous hemorrhages were seen on MRI; and 3 of 6 cases of severe chorioamnionitis were diagnosed prenatally. ^[23]

Fetal motion sometimes limits MRI. However, the observer can confidently determine the age of the blood products.

Acute subchorionic hemorrhages (subchorionic hematomas) vary in echogenicity and are seen between the chorion and the uterine wall on sonograms (see images below). Isoechoic hematomas may be missed on initial sonograms, or they may be recognized as heterogeneous and thickened placentas.

Color Doppler sonography may help in distinguishing the avascular hematoma from the highly vascular placenta. Follow-up sonography may also help in resolving hematomas.

A subchorionic hematoma can be considered large if it is greater than 50% of the size of the gestation sac, medium if it is 20-50%, and small if it is less than 20%. Large hematomas by size (>30-50%) and volume (>50 mL) worsen the patient’s prognosis.

Hematomas may resolve over 1-2 weeks. During this time, they may be seen as complex fluid collections with mixed echogenicity. In addition, sonographic findings also confirm fetal viability ^[24] and can help in differentiating and diagnosing other conditions associated with miscarriage in the first trimester, such as ectopic pregnancy, blighted ovum, and twin gestation.

Follow-up ultrasonography should be performed as clinically indicated.

Ultrasonography lacks high sensitivity for small bleeds. However, it is the most useful modality in a pregnant patient with vaginal bleeding. The finding of a subchorionic or retroplacental hematoma as demonstrated on sonography performed immediately after an episode of vaginal bleeding indicates a prognosis worse than that expected if no hematoma were seen. ^{[18, 19, 25, 26, 27]}

Uterine fibroids or focal myometrial contractions (see image below) can cause the placenta to appear thickened, or they may look like subchorionic or retroplacental hematomas. Hematomas are avascular on color Doppler scanning. Fibroids have a characteristic hypoechoic appearance with or without calcifications and typical peripheral blood flow in color Doppler images. Color flow is seen in contracted myometrium, and transient myometrial contractions usually resolve within 30 minutes of scanning.

Chorioamniotic separation has an anechoic appearance and usually resolves by 16 weeks. It can be distinguished from an anechoic hematoma by finding elevation of the membrane in chorioamniotic separation that extends over the fetal surface of the placenta and that terminates at the origin of the umbilical cord. The amniotic membrane is also thinner than the chorionic membrane (see image below).

Primary intra-amniotic hemorrhage can occur with a large subchorionic hematoma, with trauma, or with an invasive procedure such as chorionic villous sampling ^[28] or amniocentesis. Floating echoes (see Image below) or echogenic clots may be seen in the amniotic cavity.

Hematomas of the umbilical cord are rare and may result from amniocentesis and sampling of blood from the umbilical cord. These hematomas are seen as echogenic masses limited to the cord itself.

Prominent retroplacental and myometrial vessels should be distinguished from heterogeneous bleeding. The vessels appear as serpentine, anechoic structures and demonstrate flow on color Doppler sonography (see images below); these features differentiate them from avascular hematomas.

Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. 2009 Jun 1. 79(11):985-92. [Medline].

Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound. Obstet Gynecol. 2003 Sep. 102(3):483-7. [Medline].

Kadir R, Chi C, Bolton-Maggs P. Pregnancy and rare bleeding disorders. Haemophilia. 2009 Feb 27. [Medline].

Koifman A, Levy A, Zaulan Y, Harlev A, Mazor M, Wiznitzer A, et al. The clinical significance of bleeding during the second trimester of pregnancy. Arch Gynecol Obstet. 2008 Jul. 278(1):47-51. [Medline].

Kurjak A, Schulman H, Zudenigo D, et al. Subchorionic hematomas in early pregnancy: clinical outcome and blood flow patterns. J Matern Fetal Med. 1996 Jan-Feb. 5(1):41-4. [Medline].

Pearlstone M, Baxi L. Subchorionic hematoma: a review. Obstet Gynecol Surv. 1993 Feb. 48(2):65-8. [Medline].

Pedersen JF, Mantoni M. Prevalence and significance of subchorionic hemorrhage in threatened abortion: a sonographic study. AJR Am J Roentgenol. 1990 Mar. 154(3):535-7. [Medline].

Bennett GL, Bromley B, Lieberman E, Benacerraf BR. Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology. 1996 Sep. 200(3):803-6. [Medline].

Mazzariol FS, Roberts J, Oh SK, Ricci Z, Koenigsberg M, Stein MW. Pearls and pitfalls in first-trimester obstetric sonography. Clin Imaging. 2015 Mar-Apr. 39 (2):176-85. [Medline].

Podrasky AE, Javitt MC, Glanc P, Dubinsky T, Harisinghani MG, Harris RD, et al. ACR appropriateness Criteria® second and third trimester bleeding. Ultrasound Q. 2013 Dec. 29 (4):293-301. [Medline].

Xiang L, Wei Z, Cao Y. Symptoms of an intrauterine hematoma associated with pregnancy complications: a systematic review. PLoS One. 2014. 9 (11):e111676. [Medline].

Leite J, Ross P, Rossi AC, Jeanty P. Prognosis of very large first-trimester hematomas. J Ultrasound Med. 2006 Nov. 25(11):1441-5. [Medline].

Yamada T, Atsuki Y, Wakasaya A, Kobayashi M, Hirano Y, Ohwada M. Characteristics of patients with subchorionic hematomas in the second trimester. J Obstet Gynaecol Res. 2012 Jan. 38(1):180-4. [Medline].

Windrim C, Athaide G, Gerster T, Kingdom JC. Sonographic findings and clinical outcomes in women with massive subchorionic hematoma detected in the second trimester. J Obstet Gynaecol Can. 2011 May. 33 (5):475-9. [Medline].

Tuuli MG, Norman SM, Odibo AO, Macones GA, Cahill AG. Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis. Obstet Gynecol. 2011 May. 117(5):1205-12. [Medline].

Alanjari A, Wright E, Keating S, Ryan G, Kingdom J. Prenatal diagnosis, clinical outcomes, and associated pathology in pregnancies complicated by massive subchorionic thrombohematoma (Breus’ mole). Prenat Diagn. 2013 Oct. 33 (10):973-8. [Medline].

Asato K, Mekaru K, Heshiki C, Sugiyama H, Kinjyo T, Masamoto H, et al. Subchorionic hematoma occurs more frequently in in vitro fertilization pregnancy. Eur J Obstet Gynecol Reprod Biol. 2014 Oct. 181:41-4. [Medline].

Abu-Yousef MM, Bleicher JJ, Williamson RA, Weiner CP. Subchorionic hemorrhage: sonographic diagnosis and clinical significance. AJR Am J Roentgenol. 1987 Oct. 149(4):737-40. [Medline].

Ball RH, Ade CM, Schoenborn JA, Crane JP. The clinical significance of ultransonographically detected subchorionic hemorrhages. Am J Obstet Gynecol. 1996 Mar. 174(3):996-1002. [Medline].

Trop I, Levine D. Hemorrhage during pregnancy: sonography and MR imaging. AJR Am J Roentgenol. 2001 Mar. 176(3):607-15. [Medline].

Gupta R, Sharma R, Jain T, Vashisht S. Antenatal MRI diagnosis of massive subchorionic hematoma: a case report. Fetal Diagn Ther. 2007. 22(6):405-8. [Medline].

Linduska N, Knoezinger A, Dekan S, Weber M, Hayde M, Prayer D, et al. Placental pathologies on fetal MRI are associated with high impairment rates: a prospective long-term outcome study. J Matern Fetal Neonatal Med. 2015 Jul. 28 (10):1219-23. [Medline].

Linduska N, Dekan S, Messerschmidt A, Kasprian G, Brugger PC, Chalubinski K, et al. Placental pathologies in fetal MRI with pathohistological correlation. Placenta. 2009 Jun. 30(6):555-9. [Medline].

Poulose T, Richardson R, Ewings P, Fox R. Probability of early pregnancy loss in women with vaginal bleeding and a singleton live fetus at ultrasound scan. J Obstet Gynaecol. 2006 Nov. 26(8):782-4. [Medline].

Nyberg DA, Cyr DR, Mack LA, et al. Sonographic spectrum of placental abruption. AJR Am J Roentgenol. 1987 Jan. 148(1):161-4. [Medline].

Richards DS, Bennett BB. Prenatal ultrasound diagnosis of massive subchorionic thrombohematoma. Ultrasound Obstet Gynecol. 1998 May. 11(5):364-6. [Medline].

Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound. 2008 Jul-Aug. 36(6):352-66. [Medline].

Akhlaghpoor S, Tomasian A. Safety of chorionic villus sampling in the presence of asymptomatic subchorionic hematoma. Fetal Diagn Ther. 2007. 22(5):394-400. [Medline].

Avneesh Chhabra, MD Staff Radiologist, Department of Radiology, Drexel University College of Medicine

Avneesh Chhabra, MD is a member of the following medical societies: American Medical Association, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Carl D Butcher, MD Fellow, Body Cross Sectional Imaging, Johns Hopkins University

Carl D Butcher, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Kiran Batra, MD, DNB Neuroradiology Fellow, Radiology Resident, Drexel University College of Medicine

Kiran Batra, MD, DNB is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, Pennsylvania Radiological Society

Disclosure: Nothing to disclose.

Nancy A Mohsen, MD Assistant Professor, Department of Radiology, Drexel University College of Medicine, Hahnemann Hospital

Nancy A Mohsen, MD is a member of the following medical societies: American College of Radiology

Disclosure: Nothing to disclose.

Michael J Hallowell, MD, RVT Chairman and Associate Professor, Department of Radiologic Sciences, Drexel University College of Medicine; Clinical Service Chief, Department of Radiology, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Kathleen A Kuhlman, MD Associate Professor, Director of Reproductive Ultrasound, Department of Obstetrics and Gynecology, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Karen L Reuter, MD, FACR Professor, Department of Radiology, Lahey Clinic Medical Center

Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Victoria Tway, RDMS Clinical Supervisor of Reproductive Ultrasound, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Drexel Center for Genetics, Fetal and Maternal Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Subchorionic Hemorrhage Imaging

Research & References of Subchorionic Hemorrhage Imaging|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us