Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of Gestation in Singleton Pregnancies

Diagnostic efficacy of virtual organ computer-assisted analysis in measuring the volume ratio of subchorionic hematoma with serum progesterone

BACKGROUND

Subchorionic hematoma (SCH) is a common complication in early pregnancy characterized by the accumulation of blood between the uterine wall and the chorionic membrane. SCH can lead to adverse pregnancy outcomes such as miscarriage, preterm birth, and other complications. Early detection and accurate assessment of SCH are crucial for appropriate management and improved pregnancy outcomes.

AIM

To evaluate the diagnostic efficacy of virtual organ computer-assisted analysis (VOCAL) in measuring the volume ratio of SCH to gestational sac (GS) combined with serum progesterone on early pregnancy outcomes in patients with SCH.

METHODS

A total of 153 patients with SCH in their first-trimester pregnancies between 6 and 11 wk were enrolled. All patients were followed up until a gestational age of 20 wk. The parameters of transvaginal two-dimensional ultrasound, including the circumference of SCH (Cs), surface area of SCH (Ss), circumference of GS (Cg), and surface area of GS (Sg), and the parameters of VOCAL with transvaginal three-dimensional ultrasound, including the three-dimensional volume of SCH (3DVs) and GS (3DVg), were recorded. The size of the SCH and its ratio to the GS size (Cs/Cg, Ss/Sg, 3DVs/3DVg) were recorded and compared.

RESULTS

Compared with those in the normal pregnancy group, the adverse pregnancy group had higher Cs/Cg, Ss/Sg, and 3DVs/3DVg ratios (P < 0.05). When 3DVs/3DVg was 0.220, the highest predictive performance predicted adverse pregnancy outcomes, resulting in an AUC of 0.767, and the sensitivity, specificity were 70.2%, 75% respectively. VOCAL measuring 3DVs/3DVg combined with serum progesterone gave a diagnostic AUC of 0.824 for early pregnancy outcome in SCH patients, with a high sensitivity of 82.1% and a specificity of 72.1%, which showed a significant difference between AUC.

CONCLUSION

VOCAL-measured 3DVs/3DVg effectively quantifies the severity of SCH, while combined serum progesterone better predicts adverse pregnancy outcomes.

Prediction of antenatal bleeding and preterm deliveries using placental magnetic resonance imaging in patients with placenta previa

PURPOSE

This study aimed to clarify associations between subacute hematoma on placental magnetic resonance imaging (MRI), antenatal bleeding, and preterm deliveries in patients with placenta previa (PP) without placenta accreta spectrum (PAS).

MATERIALS AND METHODS

This retrospective study investigated 78 consecutive patients with PP (median age, 34.5 years; interquartile range [IQR], 31-37 years) who underwent placental MRI in the third trimester. Patients with PAS detected intraoperatively or pathologically were excluded. Two radiologists evaluated the presence of subacute hematomas and their locations on placental MRI. We examined associations between presence of subacute hematoma and antenatal bleeding, emergency cesarean section (CS), hysterectomy, gestational age (GA) at delivery, birth weight, and amount of blood loss at CS. We also examined the association between perinatal outcome and subacute hematoma location: marginal, retro-placental, or intra-placental. Inter-observer agreement for the detection of subacute hematoma was calculated using kappa analysis.

RESULTS

Subacute hematomas were identified on MRI in 39 of the 78 patients (50.0%). Antenatal bleeding and emergency CS were more prevalent in patients with subacute hematoma on MRI (20 patients [51.3%] and 18 patients [46.2%], respectively) than in patients without (7 patients [17.9%], Fisher's exact test, p = 0.004 and 7 patients [17.9%], p = 0.014, respectively). GA at delivery was significantly lower in patients with subacute hematoma (median 36w3d, IQR 35w4d-37w1d) than in patients without (median 37w1d, IQR 36w4d-37w2d; Mann-Whitney test: p = 0.048). Marginal hematoma was significantly associated with antenatal bleeding and emergency CS. Inter-observer agreement for the presence of subacute hematoma was moderate (κ = 0.573).

CONCLUSION

Subacute hematoma on placental MRI was associated with antenatal bleeding, emergency CS and shorter GA at delivery in patients with PP. Marginal hematoma was also associated with antenatal bleeding and emergency CS. Placental MRI appears useful for predicting antenatal bleeding and preterm delivery in patients with PP.

The impact of first-trimester subchorionic hematomas on pregnancy outcomes after euploid embryo transfer: a retrospective cohort study

BACKGROUND

The aim of the retrospective cohort study was to investigate the prognostic effect of subchorionic hematomas (SCH) in the first trimester on pregnancy outcomes after euploid embryo transfer.

METHODS

We retrospectively analyzed women achieving singleton pregnancy by PGT-A or PGT-SR from January 2017 to January 2022. Patients were enrolled in the study if they had a viable intrauterine pregnancy at ultrasound between 6 0/7 and 8 0/7 weeks of gestation. Pregnancy outcomes as well as the incidence of maternal complications were compared between patients with and without SCH. Logistic regression was used for adjusting for potential confounding factors.

RESULTS

A total of 1539 women were included, of which 298 with SCH and 1241 with non-SCH. The early miscarriage rate in SCH group was significantly higher than that in the non-SCH group (10.1% vs. 5.6%, adjusted odds ratio [aOR] 1.99, 95% confidence interval [CI] 1.25-3.16, P = 0.003). The live birth rate in SCH group was significantly lower than that in the non-SCH group. (85.6% vs. 91.2%, aOR 0.57, 95% CI 0.39-0.84, P = 0.005). In addition, SCH group had an increased risk of hypertensive disorder of pregnancy (HDP) (8.9% vs. 5.2%, P = 0.022), especially in hematoma with bleeding (19.3% vs. 6.0%, P = 0.002). The incidence of gestational diabetes mellitus (GDM), major congenital abnormalities rate, normal birth weight rate and low birth weight rate were similar between the two groups.

CONCLUSIONS

The presence of SCH in the first trimester was associated with worse pregnancy outcomes after euploid embryo transfer, including an increased risk of early miscarriage and hypertensive disorder of pregnancy, along with a reduced live birth rate.

Pregnancy outcomes of fetal reduction in patients with intrauterine haematoma following double embryo transfer

RESEARCH QUESTION

Is there an association between intrauterine haematoma (IUH) and pregnancy outcomes in patients who undergo fetal reduction after double embryo transfer (DET), and if so, what is the relationship between IUH-related characteristics and pregnancy outcomes?

DESIGN

Clinical information and pregnancy outcomes of women who underwent fetal reduction after DET were analysed. Patients with other systematic diseases, ectopic pregnancy or heterotopic pregnancy, monochorionic twin pregnancies and incomplete data were excluded. Stratification of IUH pregnancies was undertaken based on IUH-related characteristics. The main outcome was incidence of fetal demise (<24 weeks), with other adverse pregnancy outcomes considered as secondary outcomes.

RESULTS

Thirty-four IUH patients and 136 non-IUH patients who underwent fetal reduction after DET were included based on a 1:4 match for age, cycle type and fertilization method. IUH patients had a higher incidence of early fetal demise (20.6% versus 7.4%, P = 0.048), threatened abortion (48.1% versus 10.3%, P<0.001) and postpartum haemorrhage (PPH; 14.8% versus 4.0%, P = 0.043) compared with non-IUH patients. IUH was an independent risk factor for early fetal demise [adjusted OR (aOR) 3.34, 95% CI 1.14-9.77] and threatened abortion (aOR 8.61, 95% CI 3.28-22.61) after adjusting for potential confounders. IUH pregnancies undergoing fetal reduction that resulted in miscarriage had larger IUH volumes and earlier diagnosis (both P < 0.03). However, IUH characteristics (i.e. volume, changing pattern, presence or absence of cardiac activity) were not associated with threatened abortion or PPH.

CONCLUSIONS

Fetal reduction should be performed with caution in IUH pregnancies after DET as the risk of fetal demise is relatively high. Particular attention should be given to IUH patients with early signs of threatened abortion and inevitable fetal demise.

Association between graded subchorionic hematoma and adverse pregnancy outcomes in singleton pregnancies: a prospective observational cohort study

OBJECTIVE

To investigate whether different grades of subchorionic hematoma (SCH) are involved in the timing of birth and the development of adverse pregnancy outcomes in singleton pregnant women.

METHODS

A total of 171 women with singleton pregnancies, 72 of whom had SCH before 20 weeks and between 12 and 20 weeks of gestational age (GA), were included in this study conducted between January 2018 and December 2021. These patients were divided into three subgroups based on the size of the subchorionic hematoma on ultrasound imaging. Baseline demographic data, obstetric outcomes, and risk factors for subchorionic hematoma were compared for the two groups.

RESULTS

A higher number of pregnancies from the SCH group resulted in miscarriage (30.56% versus 2.02%, p < 0.0001), early preterm birth (8.33% versus 1.01%, p = 0.0035), premature rupture of membranes (15.28% versus 4.04%, p = 0.0103), fetal growth restriction (9.72% versus 0%, p = 0.0015), and delivery 13.18 days earlier (274.34 ± 11.25 versus 261.16 ± 29.80, p = 0.0013) than those from the control group. Compared with SCH detected before 12 weeks of GA, the rate of miscarriage increased, and the live birth rate decreased significantly in patients with SCH caught between 12 and 20 weeks of GA. With the increase in hematoma size, the likelihood of miscarriage increased significantly. Further analysis found that delivery occurred earlier in the medium/large SCH group (271.49 ± 23.61 versus 253.28 ± 40.68/261.77 ± 22.11, p = 0.0004/0.0073) but not in the small SCH group (274.34 ± 11.25 versus 267.85 ± 21.01, p = 0.2681) compared to the control group. Our results also showed that the anterior placenta (52.04% versus 33.33%, p = 0.0005, OR = 0.3137, 95% CI [0.1585, 0.601]) is a protective factor for subchorionic hematoma.

CONCLUSION

Our study shows that women with SCH are at a higher risk of adverse pregnancy outcomes and are independently associated with miscarriage, early preterm birth, premature rupture of membranes, and fetal growth restriction. A subchorionic hematoma, especially detected between 12 and 20 weeks of GA, is very likely to cause miscarriage or preterm birth in women with a medium or large subchorionic hematoma.

Associations between the size and duration of asymptomatic subchorionic hematoma and pregnancy outcomes in women with singleton pregnancies

BACKGROUND

The purpose of this study was to investigate the relationship between the size and duration of asymptomatic subchorionic hematoma and pregnancy outcomes in women with singleton pregnancies.

METHODS

This was a retrospective study that enrolled 701 singleton pregnant women who were diagnosed with asymptomatic subchorionic hematoma by ultrasound at 5-10 gestational weeks. The control group recruited 640 normal pregnant women without subchorionic hematoma who were matched with subchorionic hematoma group on baseline characteristics. The pregnancy outcomes were compared between the two groups, and the associations of the size and duration of subchorionic hematoma with pregnancy outcomes were analyzed by logistic regression model.

RESULTS

Compared with the normal pregnancy group, the incidence of, gestational diabetes mellitus, gestational thrombocytopenia, placenta adhesion, fetal growth restriction, macrosomia in subchorionic hematoma group were higher (all P < 0.05). After adjusting for confounding factors, the hematoma size was positively associated with the occurrence of gestational hypothyroidism (adjusted OR[95%CI]: 1.029[1.004-1.054]), intrahepatic cholestasis of pregnancy (adjusted OR[95%CI]: 1.095[1.047-1.146]), term premature rupture of membranes (adjusted OR[95%CI]: 1.044[1.005-1.085]), hypertensive disorders of pregnancy (adjusted OR[95%CI]: 1.030[1.0004-1.060]), gestational thrombocytopenia (adjusted OR[95%CI]: 1.078 [1.045-1.113]), placenta adhesion (adjusted OR[95%CI]: 1.054 [1.027-1.082]), and the duration of hematoma was positively associated with the incidence of term premature rupture of membranes (adjusted OR[95%CI]: 1.070[1.027-1.115]), gestational diabetes mellitus (adjusted OR[95%CI]: 1.938 [1.886-1.993]) and fetal growth restriction (adjusted OR[95%CI]: 1.194 [1.124-1.268]).

CONCLUSIONS

The presence, size and duration of a first-trimester asymptomatic subchorionic hematoma may be associated with adverse pregnancy outcomes at later gestations such as term premature rupture of membranes and fetal growth restriction.

Subchorionic Hematoma Association with Pregnancy Complications and Outcomes in the Third Trimester

Introduction: Our objective was to explore the clinical features, pregnancy complications, and outcomes of subchorionic hematomas (SCHs) in the third trimester. Material and methods: This was a retrospective analysis and evaluation of 1112 cases diagnosed with SCHs from January 2014 to December 2020. Comparisons were performed according to the clinical features (e.g., number of pregnancies, parity, gestational weeks, and age), pregnancy complications, and outcomes associated with SCHs. Results: In total, 71.85% (799/1112) of the patients were diagnosed with different pregnancy complications. The overall rates of gestational diabetes mellitus (GDM), hypertensive disorder complicating pregnancy (HDCP), premature rupture of membranes (PROM), and IVF were 12.14%, 7.55%, 17.27%, and 10.34%, respectively. The positive rates for newborn outcomes such as premature birth and low birth weight (LBW) were 9.35% and 6.47%, respectively. There was a significant relationship between repeated pregnancies and the incidence of GDM (p < 0.05), but not HDCP, PROM, or IVF. The proportion of SCH patients who conceived through IVF was significantly higher among primiparas than among multiparas (p < 0.05), but was not significantly different in terms of GDM, HDCP, or PROM. Premature birth was not a high-risk factor for most SCH patients with HDCP, IVF, or PROM (p < 0.05), most of whom delivered at term. The rate of cesarean sections for SCH patients with GDM, HDCP, or IVF was significantly higher than that for vaginal deliveries (p < 0.05), but this was not affected by age. Conclusions: The coexistence of SCHs with HDCP, IVF, or PROM lacked an effective predictive value for premature birth, but increased the rate of a cesarean section.

Subchorionic hematoma and risk of preterm delivery: a systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the association between early pregnancy with subchorionic hematoma and preterm delivery and other adverse pregnancy outcomes in singleton pregnancies.

DATA SOURCES

English studies published from 2000 to July 15, 2022 were retrieved from PubMed, Web of Science, and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

The inclusion criteria were: singleton pregnancy, subchorionic hematoma, and perinatal outcomes. Studies including multiple pregnancy, basic molecular studies, case reports (series), and conference reviews were excluded.

METHODS

Data analysis was mainly conducted with Review Manager (RevMan) and Stata, and the results were represented with odds ratios and 95% confidence intervals. The methodological quality of the included studies was evaluated by the Cochrane risk assessment scale.

RESULTS

In total, 370 studies were retrieved from the above databases. Our review included 16 studies and divided them into 2 subgroups: natural pregnancy (12 studies) and assisted reproductive pregnancy (4 studies). The relevant characteristics of each study were analyzed in detail. The primary outcome was preterm delivery. The secondary outcomes were miscarriage, fetal growth restriction, cesarean delivery, and preeclampsia. We found that subchorionic hematoma in the first trimester was not significantly associated with preterm delivery (odds ratio, 1.11; 95% confidence interval, 0.82-1.51) or other adverse outcomes in singleton pregnancy. Regression analysis found that the large heterogeneity of the included studies might be related to whether the included study population (early pregnancy with subchorionic hematoma) was complicated with threatened abortion (P<.05). However, no studies caused large heterogeneity according to sensitivity analysis. Finally, 15 studies related to preterm delivery did not have publication bias (Egger test: P=.26). However, subchorionic hematoma in the first trimester was associated with miscarriage in single pregnancies (natural pregnancy: odds ratio, 3.07; 95% confidence interval, 1.98-4.75; assisted reproductive pregnancy: odds ratio, 1.45; 95% confidence interval, 1.1-1.90).

CONCLUSION

In singleton pregnancy, we found no association between subchorionic hematoma in the first trimester and preterm delivery. Although there was a correlation with miscarriage, the possible gestational age of miscarriage was not stated. More studies are needed to further address the herein posed research questions.

Outcomes of subchorionic hematoma-affected pregnancies in the infertile population

OBJECTIVE

To determine the implications of an incidentally noted subchorionic hematoma on pregnancy outcomes in the infertile population.

METHODS

Retrospective cohort study at a tertiary care, university-based facility. All patients with intrauterine pregnancy on initial obstetric ultrasound presenting to an infertility clinic between January 2015 and March 2018 (n = 1210), regardless of treatment cycle, were included. Nonviable pregnancies were excluded. The main outcome measured was association between subchorionic hematoma and first trimester miscarriage.

RESULTS

The prevalence of subchorionic hematoma was 12.5% (n = 151) and did not differ by type of fertility treatment. There was no association between subchorionic hematoma and first trimester miscarriage; however, among patients with subchorionic hematoma, those who reported both bleeding and cramping had an increased probability of miscarriage compared to those without symptoms (0.62 vs. 0.12, P <0.001). The live birth rate in this sample was 81.3% and there were no statistically significant differences in pregnancy outcomes between those with and without subchorionic hematoma.

CONCLUSION

Among an infertile population, there was no increased risk of miscarriage when subchorionic hematoma was seen on early ultrasound; however, when patients noted both vaginal bleeding and cramping, their probability of miscarriage was significantly increased.

Outcomes of in vitro fertilization pregnancies complicated by subchorionic hematoma detected on first-trimester ultrasound

Objective

To estimate the association between subchorionic hematoma (SCH) on ultrasound and pregnancy outcomes in in vitro fertilization (IVF) pregnancies.

Design

Institutional Review Board–approved, retrospective cohort study.

Setting

Tertiary care university-based facility.

Patient(s)

In this study, 1,004 patients who underwent IVF with a viable singleton pregnancy from January 1, 2009 through December 31, 2017.

Intervention(s)

Subchorionic hematoma versus no hematoma diagnosed on first-trimester ultrasound.

Main Outcome Measure(s)

Live birth, preterm birth, and spontaneous abortion.

Result(s)

We found that 1,004 women met the criteria and 187 (18.6%) had an SCH. In bivariate and multivariate regression models, there were no associations between SCH and the outcomes of live birth, preterm birth, or birth weight.

Conclusion(s)

Subchorionic hematoma detected on first-trimester ultrasound after IVF is not associated with probability of live birth, probability of preterm birth, or infant birth weight in this patient population.

Subchorionic Hematomas and Adverse Pregnancy Outcomes among Twin Pregnancies

OBJECTIVE

This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies.

STUDY DESIGN

Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 6^0/7 to 13^6/7 weeks. Regression analysis was used to control for any differences in baseline characteristics.

RESULTS

A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63-6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes.

CONCLUSION

In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

Associations between first-trimester intrauterine hematoma and twin pregnancy outcomes: a retrospective cohort study

Background

In recent years, first-trimester intrauterine hematoma (IUH) has become increasingly common in twin pregnancy. The majority of studies on IUH have excluded twin pregnancies, and others did not differentiate between singleton and twin pregnancies. The impact of IUH on twin pregnancy is unclear. Therefore, the primary objective of our study was to examine associations between first-trimester IUH and pregnancy outcomes in twin pregnancies.

Methods

The data of 1020 twin pregnancies in women who received a routine examination from January 2014 to December 2018 were reviewed. We compared baseline data and pregnancy outcomes between those with and without IUH. Multivariable logistic regression analysis was used to adjust for possible confounding factors.

Results

A total of 209 patients (21.3%) developed IUH in the first trimester. First-trimester IUH was significantly associated with increased odds of miscarriage (adjusted odds ratio 14.27, 95% CI 8.25–24.70) and vanishing twin syndrome (adjusted odds ratio 3.26, 95% CI 1.11–4.61). However, there were no differences in the rates of stillbirth, preeclampsia, preterm labor (< 34 weeks), low birth weight, postpartum hemorrhage or fetal distress between the two groups. Maternal age, previous preterm birth, chorionicity in twins and the gestational week at first ultrasound did not differ between the two groups. The women with IUH had high rates of previous miscarriage (46.73% vs 38.37%, p = 0.01), assisted conception (48.56% vs 32.60%, p < 0.001) and accompanied vaginal bleeding (67.46% vs 13.43%, p < 0.001). According to the logistic regression analyses, these characteristics were not associated with pregnancy loss or vanishing twin syndrome. No IUH characteristics, including volume, largest diameter, or the presence of vaginal bleeding, were associated with pregnancy loss or vanishing twin syndrome before 20 weeks of gestation (P > 0.05).

Conclusion

In women with twin pregnancy, the presence of IUH in the first trimester was associated with the loss of one or both fetuses before 20 weeks of gestation. However, previous miscarriage, the conception method, the IUH size and the presence of vaginal bleeding were not independently associated with miscarriage or vanishing twin syndrome.

Factors associated with subchorionic hematoma formation in pregnancies achieved via assisted reproductive technologies

Purpose

To determine if certain clinical and/or embryologic factors are independently associated with the increased prevalence of subchorionic hematoma (SCH) among pregnancies achieved via in vitro fertilization (IVF) with fresh embryo transfer (ET).

Design

Retrospective chart review.

Methods

In this retrospective study, data were abstracted from 210 autologous oocyte IVF clinical pregnancies that resulted from fresh ET at a single fertility center from January 2012 through December 2016. Clinical and embryology laboratory variables were analyzed as possible factors associated with the presence or absence of SCH in IVF pregnancies via bivariate associations and multivariable logistic regression analyses. Independent variables included prior uterine surgery versus no uterine surgery, peak estradiol, and progesterone levels, day 3 (n = 92) versus day 5 (n = 118) ET, and assisted hatching versus no assisted hatching. Among the day 5 ET subgroup of 118 patients, 117 had data for the variables inner cell mass (ICM) grading and trophectoderm (TE) because one day 5 ET was at the morula stage.

Results

We found a significant bivariate association between TE grading and SCH, where cases with TE grade “A” were significantly less likely to have SCH compared with cases with grades “B” or “C.” This significant difference remained when adjusting for the other factors considered in a multivariable logistic regression model for the probability of SCH.

Conclusions

The data analyzed here suggest that a less-advanced trophectoderm grade may be a potential factor that is associated with the presence of SCH in pregnancies achieved via IVF.