Perinatal outcomes in women with subchorionic hematoma: a systematic review and meta-analysis

Vaginal bleeding in pregnancy and adverse clinical outcomes: a systematic review and meta-analysis

Background: Vaginal bleeding during pregnancy has been recognised as a significant risk factor for adverse pregnancy outcomes. This study aimed to investigate the association between vaginal bleeding during the first trimester of pregnancy and clinical adverse effects using a systematic review and meta-analysis.Methods: Databases of Scopus, Web of Science, PubMed (including Medline), Cochrane Library and Science Direct were searched until June of 2023. Data analysis using statistical test fixed- and random-effects models in the meta-analysis, Cochran and meta-regression. The quality of the eligible studies was assessed by using the Newcastle-Ottawa Scale checklist (NOS).Results: A total of 46 relevant studies, with a sample size of 1,554,141 were entered into the meta-analysis. Vaginal bleeding during the first trimester of pregnancy increases the risk of preterm birth (OR: 1.8, CI 95%: 1.6-2.0), low birth weight (LBW; OR: 2.0, CI 95%: 1.5-2.6), premature rupture of membranes (PROMs; OR: 2.3, CI 95%: 1.8-3.0), abortion (OR: 4.3, CI 95%: 2.0-9.0), stillbirth (OR: 2.5, CI 95%: 1.2-5.0), placental abruption (OR: 2.2, CI 95%: 1.4-3.3) and placenta previa (OR: 1.9, CI 95%: 1.5-2.4).Conclusions: Vaginal bleeding in the first trimester of pregnancy is associated with preterm birth, LBW, PROMs, miscarriage, stillbirth, placental abruption and placenta previa. Therefore, physicians or midwives need to be aware of the possibility of these consequences and manage them when they occur.

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.

Is intrauterine hematoma associated with adverse pregnancy and obstetric outcomes of ART singletons? A systematic review and meta-analysis

The objective of our meta-analysis was to estimate the effect of intrauterine hematoma (IUH) on obstetric and pregnancy outcomes of assisted reproductive technology (ART) pregnancies. Four electronic databases were searched up to December 2021 to find studies reporting relevant outcomes of ART pregnancies with IUH. Dichotomous data were expressed as odds ratios (OR) with 95% confidence intervals (CI). Continuous data were expressed as weighted mean difference (WMD) with 95% CI. A total of six observational studies were included in this meta-analysis. Our data suggested that IUH in pregnancies achieved by ART are not associated with increased risks of miscarriage, low birth weight, placenta previa, or premature rupture of membranes. Similar birthweight was noted between the two groups. However, IUH was associated with significantly shorter gestational age at delivery (GA) as well as higher risks of preterm birth. Subgroup analyses have found that the presence of retroplacental haematoma was associated with an increased risk of miscarriage. IUH may be associated with decreased GA and an increased risk of preterm birth. Therefore, Women diagnosed with IUH should be offered increased surveillance during the course of their pregnancy.

The effects of first-trimester subchorionic hematoma on pregnancy outcomes: a retrospective cohort study

BACKGROUND

Although first-trimester subchorionic hematoma (SCH) always concerns expectant parents, its clinical significance remains controversial. This study aimed to examine the relationship between SCH and its association with subsequent miscarriage and other perinatal outcomes in singleton pregnancies.

METHODS

We conducted a retrospective cohort study including 43,660 women who underwent routine prenatal care since the first trimester and then were followed up for maternal and neonatal outcomes. SCH was detected in the first-trimester ultrasound examinations. Robust Poisson regression was used to estimate adjusted risk associations of SCH with maternal and neonatal outcomes.

RESULTS

A total of 815 (1.87%) SCH cases were detected in the first-trimester ultrasound examinations. The rate of miscarriage was statistically significantly higher in women with SCH than without [35.21% vs. 23.92%, P < 0.01; adjusted relative risk (RR):1.44, 95% confidence interval (CI): 1.31-1.58]. Subgroup analysis of women with SCH showed a clear trend that the earlier SCH occurred, the higher the risk of miscarriage was [adjusted RR (95% CI) for onset at the gestational weeks of 8-9, 6-7, and < 6 vs. ≥ 10: 1.30 (0.69-2.46), 2.33 (1.28-4.23), and 4.18 (2.30-7.58), respectively; Ptrend < 0.01]. In addition, women with SCH volume ≥ 1 ml showed higher risk than did those with SCH volume < 1 ml [adjusted RR (95% CI) for 1-4.9 ml, and ≥ 5 ml vs. < 1 ml: 1.36 (1.10-1.68) and 1.56 (1.18-2.07), respectively]. There was no statistically significant difference in the rates of other pregnancy outcomes between women with and without SCH.

CONCLUSIONS

First-trimester SCH, particularly when characterized by early presence and large size, might significantly increase the risk of miscarriage. Data from this study suggest no associations between SCH and other maternal and neonatal outcomes.

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.

A simple scoring system for the prediction of early pregnancy loss developed by following 13,977 infertile patients after in vitro fertilization

A retrospective study was conducted to investigate a convenient simple scoring system for the prediction of early pregnancy loss (EPL) based on simple demographics. A total of 13,977 women undergoing transvaginal ultrasound scans on Days 27-29 after in vitro fertilization-embryo transfer (IVF-ET) from June 2016 and December 2017 were included. The first trimester pregnancy outcome was recorded at 12 weeks of gestation. The areas under the curve of this scoring system were 0.884 (95% confidence interval (CI) 0.870-0.899) and 0.890 (95% CI 0.878-0.903) in the training set and test set, respectively. The score totals ranged from -8 to 14 points. A score of 5 points, which offered the highest predictive accuracy (94.01%) and corresponded to a 30% miscarriage risk, was chosen as the cutoff value, with a sensitivity of 62.84%, specificity of 98.79%, positive predictive value (PPV) of 88.87% and negative predictive value (NPV) of 94.54% for the prediction of EPL in the training set. In the test set, a score of 5 points had a sensitivity of 64.69%, specificity of 98.78%, PPV of 89.87% and NPV of 93.62%, and 93.91% of the cases were correctly predicted. Therefore, the simple scoring system using conventionally collected data can be conveniently used to predict EPL after ET. However, considering the limitations, its predictive value needs to be further verified in future clinical practice.

The risk factors and impact of subchorionic hematoma in the first trimester in IVF twin pregnancies: a prospective cohort study

Objective

This study aimed to identify the risk factors for subchorionic hematoma (SCH) in the first trimester of in vitro fertilization (IVF) twin pregnancies and investigate the impact of SCH on pregnancy outcomes.

Study design

A prospective cohort study was conducted at Chengdu Women and Children's Central Hospital. The study recruited patients who were identified with twin pregnancies in the first trimester, undergoing IVF treatment from January 2020 to May 2021. The demographic characteristics and pregnancy outcomes were compared between the SCH and the non-SCH groups. A logistic regression analysis was used to determine the risk factors for SCH and adverse pregnancy outcomes.

Results

In the first trimester, 38% of patients developed SCH. The independent risk factors for SCH included male factor, hydrosalpinx, polycystic ovary syndrome (PCOS), previous miscarriage, and adenomyosis. With respect to the pregnancy outcomes, only the rate of twin pregnancy loss before 20 gestational weeks was significantly higher in the SCH group than in the non-SCH group. After adjusting for the confounding factors, the presence of SCH diminished the ovarian reserve, and previous miscarriage was independently related to twin pregnancy loss before 20 gestational weeks.

Conclusion

This may be the first study to evaluate the risk factors of SCH in twin pregnancies who underwent IVF-ET/FET treatment, which may provide some theoretical basis for clinical practice in the future. Furthermore, it was found that the occurrence of SCH was associated with the loss of both pregnancies before 20 gestational weeks. Therefore, these patients should be offered increased surveillance and timely treatment.

The Utility of Transvaginal Ultrasound After Intrauterine Pregnancy Identification on Transabdominal Ultrasound in Emergency Department Patients

Introduction

Ultrasonography has an important role in the evaluation of Emergency Department (ED) patients presenting with early pregnancy complaints. Both transabdominal (TAUS) and transvaginal ultrasound (TVUS) can be utilized. While TVUS generally allows for greater detail, it is unclear how much added benefit exists in performing TVUS once an intrauterine pregnancy (IUP) has been identified on TAUS.

Methods

This was a retrospective study utilizing Radiology Department ultrasound examinations obtained in first trimester pregnancy ED patients during a consecutive four month period in 2019. Studies wherein both TAUS and TVUS were both performed were included. Two ED physicians with specialized training in point of care ultrasound reviewed only the TAUS images from these studies. Their findings were compared to the Radiologist interpretation, which was inclusive of both TAUS and TVUS components of the study.

Results

108 studies met inclusion criteria. Amongst these, 82 had IUP's identified on the radiologist report. 69 studies had an IUP identified by ED physician review of the TAUS images, with 1 false positive. Each case of intrauterine fetal demise (IUFD) was identified on ED physician review of TAUS. Two ectopic pregnancies were present, neither of which was mistaken for IUP on ED physician TAUS review. There were 15 studies with subchorionic hemorrhage and 3 studies with an ovarian cyst noted on the radiologist report.

Conclusion

Following the identification of an IUP on TAUS, the added diagnostic value of TVUS amongst this cohort of ED patients was low. Given the added time and cost of TVUS, selective instead of routine usage should be encouraged.

Do First-Trimester Subchorionic Hematomas Affect Pregnancy Outcomes?

OBJECTIVE

The aim of this study is to investigate the relationship between first trimester subchorionic hematomas and pregnancy outcomes in women with singleton pregnancies.

MATERIAL AND METHODS

Between January 2018 and January 2019, patients who had a single pregnancy between the 6th and 14th weeks of their pregnancy and were hospitalized with the diagnosis of abortus imminens in the early pregnancy service were included in the study. According to the ultrasonographic examination, those with subchorionic hematoma and those with no hematoma were compared in terms of demographic data, pregnancy outcomes and pregnancy complications.

RESULTS

400 abortus immines cases with subchorionic hematoma and 400 abortus imminens cases without subchorionic hematoma were compared. Preterm delivery percentages were similar in both groups, however abortus percentage was significantly higher in the hematoma group (34.2 vs. 24.7%; p=0.007). In addition, it was revealed that the presence of subchorionic hematoma before the 20th gestational week increased the risk of miscarriage 1.58 times. However, no data could be found in the study that could correlate the size of the hematoma with pregnancy loss.

CONCLUSION

The presence of subchorionic hematoma increases abortion rates in abortus imminens cases. And the presence of subchorionic hematoma in cases with ongoing pregnancy does not increase the complications of delivery.

Ultrasound in Pregnancy

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

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.

Subchorionic Hemorrhage in the Second and Third Trimesters of Pregnancy: A Review

Importance

Subchorionic hemorrhage (SCH) in the second and third trimesters of pregnancy can be associated with maternal morbidity and fetal morbidity/mortality. Management of SCH in the second or third trimesters can be complicated, especially in the setting of a large SCH that requires hospitalization and blood transfusion.

Objective

The aim of this review is to describe SCH in second and third trimesters, risk factors, diagnosis, maternal and fetal outcomes, and management of this uncommon pregnancy complication.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched.

Results

There were 123 abstracts and/or articles reviewed, with 48 articles being the basis of review. The only known risk factors for SCH are maternal factor deficiency and anticoagulation therapy. The diagnosis is usually made by ultrasound imaging. Subchorionic hemorrhage in second and third trimesters has been associated with several adverse fetal outcomes including preterm birth, preterm prelabor rupture of membranes, fetal growth restriction, fetal demise, and neonatal pulmonary morbidity. There is no proven treatment for SCH, although there are several investigational therapies reported.

Conclusions

Subchorionic hemorrhage can be complex and difficult to manage in the second and third trimesters. There are no recommendations or guidelines for management; however, serial growth ultrasounds, umbilical artery Doppler studies, and antenatal fetal testing should be considered particularly if the SCH is large or treatment requires a maternal blood transfusion.

Relevance

Subchorionic hemorrhage in the second and third trimester is associated with poor fetal outcomes and maternal morbidity, especially if the SCH is significant.

Subchorionic Hematoma Volume Measured by Virtual Organ Computer-Aided Analysis in the Prediction of First-Trimester Pregnancy Outcome

ABSTRACT

This study aimed to assess the association of subchorionic hematoma (SCH) size measured by virtual organ computer-aided analysis (VOCAL) with the first-trimester pregnancy outcome. A total of 139 first-trimester pregnancies from 6 to 12 weeks of gestational age with SCH were included. The circumference, area, and volume of the SCH (Cs, As, and 3DVs) and gestational sac (Cg, Ag, and 3DVg) were automatically calculated by VOCAL. Interobserver agreement was assessed with the intraclass correlation coefficient and Bland-Altman plot. Odds ratios for the clinical and ultrasound characteristics of adverse pregnancy outcomes were estimated by univariate or multivariable logistic regression. There was high interobserver agreement in VOCAL measurements of the SCH and gestational sac (intraclass correlation coefficients, >0.900). By univariate regression analysis, women with adverse pregnancy outcomes were more likely to have vaginal bleeding, a larger As and 3DVs, and higher Cs/Cg, As/Ag, and 3DVs/3DVg ratios (all P < 0.05). In the multivariable regression analysis, a higher 3DVs/3DVg ratio of SCH (odds ratio, 1.034; 95% confidence interval [CI], 1.015-1.053; P = 0.000) and vaginal heavy bleeding had a significant positive relationship with the risk of adverse pregnancy outcomes (odds ratio, 7.846; 95% CI, 1.104-55.737; P = 0.039) remained associated with an increased risk of adverse pregnancy outcomes. With 11.87% as the cutoff, the receiver operating characteristic curve yielded a good predictive performance (area under the curve, 0.713) and high sensitivity (91.18%). The measurements of SCH by VOCAL provide high reliability for estimating the total hematoma burden in first-trimester pregnant patients. A greater volume proportion (3DVs/3DVg) of SCH worsens the pregnancy outcome, and a greater risk of adverse pregnancy outcome also associated with the severity of vaginal bleeding.

Fourfold Improved Odds of a Good First Trimester Outcome Once a Yolk Sac Is Seen in Early Pregnancy

OBJECTIVES

To compare first trimester prognosis when an early pregnancy sonogram demonstrates a gestational sac with yolk sac versus gestational sac without yolk sac.

METHODS

Our study comprised 823 transvaginal sonograms without identifiable embryo performed at least 35 days from last menstrual period (LMP), in which mean sac diameter was <16 mm and first trimester outcome (live or early pregnancy loss) was known. We recorded the presence or absence of yolk sac, first trimester outcome, and several clinical features: maternal age, time since LMP, and presence or absence of vaginal bleeding. We compared the likelihood of a successful first trimester outcome in cases with a visible yolk sac to those without a yolk sac.

RESULTS

At the end of the first trimester, 113 of 270 (41.9%) cases without a yolk sac and 414 of 553 (74.9%) with a yolk sac were live (P < .000001, chi-square). This corresponds to an odds ratio of 4.14 for the presence of yolk sac, a result confirmed by logistic regression. Advanced maternal age, ≥42 days since LMP, and vaginal bleeding all carried an increased risk of loss (P < .000001, chi-square). Outcome was better with a visualized yolk sac than without a yolk sac, regardless of number of risk factors (P < .001, chi-square).

CONCLUSIONS

The odds of successful first trimester outcome are 4-fold higher when a yolk sac is seen on an early pregnancy sonogram than when no yolk sac is seen. For any level of risk, based on maternal age, vaginal bleeding, and time since LMP, outcome is significantly better when a yolk sac is seen.

Doppler evaluation of normal and abnormal placenta

Doppler techniques are needed for the evaluation of the intraplacental circulation and can be of great value in the diagnosis of placental anomalies. Highly sensitive Doppler techniques can differentiate between the maternal (spiral arteries) and fetal (intraplacental branches of the umbilical artery) components of the placental circulation and assist in the evaluation of the placental functional units. A reduced number of placental functional units can be associated with obstetric complications, such as fetal growth restriction. Doppler techniques can also provide information on decidual vessels and blood movement. Abnormal decidual circulation increases the risk of placenta accreta. Doppler evaluation of the placenta greatly contributes to the diagnosis and clinical management of placenta accreta, vasa previa, placental infarcts, placental infarction hematoma, maternal floor infarction, massive perivillous fibrin deposition and placental tumors. However, it has a limited role in the diagnosis and clinical management of placental abruption, placental hematomas, placental mesenchymal dysplasia and mapping of placental anastomoses in monochorionic twin pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Intrauterine Hematoma in the First Trimester and Pregnancy Complications: A Systematic Review and Meta-Analysis

Background

Studies evaluating the relationship between intrauterine hematoma in the first trimester and prenatal complications are conflicting.

Objectives

To evaluate whether intrauterine hematoma identified in the first trimester in women with singleton pregnancies is associated with adverse perinatal outcomes.

Search Strategy

A comprehensive literature search of three databases (Embase, PubMed, and Web of Science) was performed up to September 2021.

Selection Criteria

Cohort and case-control studies that have evaluated the relationship between intrauterine hematoma identified before 14 gestational weeks and the risk of prenatal complications, in women with a singleton pregnancy.

Data Collection and Analysis

Two members of our team independently assessed the studies for inclusion, collected the data of interest, and assessed the risk of bias, and calculated pooled odds ratios (ORs) using random-effects models.

Main Results

Nine studies, including 1,132 women with intrauterine hematoma and 11,179 controls met the inclusion criteria. Intrauterine hematoma increased the risk of spontaneous abortion [OR 2.15, 95% confidence interval (CI) 1.23–3.75], preterm birth (OR 1.83, 95% CI 1.37–2.43), fetal growth restriction (OR 2.33, 95% CI 1.13–4.83) and placental abruption (OR 3.16, 95% CI 1.23–8.13). No statistically significant association was found between intrauterine hematoma and preeclampsia (OR 1.30, 95% CI 0.87–1.94).

Conclusion

Intrauterine hematoma in the first trimester of pregnancy increases the risk of spontaneous abortion, preterm birth, placental abruption, and fetal growth restriction.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/.

The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 2: Trauma in Pregnancy, Vascular, and Genitourinary Injuries

Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. Our second installment will focus on the use of MR in pregnant patients and in the characterization of vascular and genitourinary trauma. Body MR can be useful in pregnant patients in characterizing injuries both specific for and not specific for pregnancy. Placental injuries and hematomas in particular may be better seen on MR relative to CT, owing to its superior contrast resolution. MR angiography can be performed either without or with contrast and can be useful to monitor low-grade traumatic aortic injuries. Renal and ureteral injuries can be followed with MR to help identify urine leaks, either in a delayed presentation or in patients who have an iodinated contrast allergy. Lastly, penile injuries are often imaged with ultrasound, but may benefit from additional imaging with MR when the tunica albuginea cannot be completely seen due to overlying hematoma.

Vanishing twin syndrome is associated with first-trimester intrauterine hematoma in twin pregnancies after in vitro fertilization

RESEARCH QUESTION

Is there an association between intrauterine hematoma (IUH), vanishing twin syndrome (VTS), and subsequent complications in twin pregnancies after in vitro fertilization (IVF)? What are the risk factors for these complications?

DESIGN

Women who presented with two live gestational sacs following double embryo transfer were included. Patients with systematic diseases, artificial fetal reduction, and incomplete data were excluded. Further stratification of IUH pregnancies was performed according to IUH-related characteristics (i.e., volume, changing pattern, and relationship with fetal cardiac activities). The primary outcome was the incidence of VTS, while adverse outcomes in the surviving singleton and the gestational age of VTS were secondary outcomes.

RESULTS

The incidence of IUH was 13.8%. A total of 1,078 twin pregnancies including 539 IUH pregnancies and 539 non-IUH pregnancies were included. IUH pregnancy was associated with higher risks of VTS (26.9% vs. 18.7%, p = 0.001) as well as a higher incidence of preterm birth (p = 0.001, crude OR = 1.98, 95% CI 1.28-3.09, adjusted OR = 1.19, 95% CI 1.09-1.24), threatened abortion (p < 0.001, crude OR = 9.12, 95% CI 2.90-28.69, adjusted OR = 6.63, 95% CI 1.69-14.67), and postpartum hemorrhage (p = 0.024, crude OR = 3.13, 95% CI 1.09-8.99, adjusted OR = 1.16, 95% CI 1.08-1.32) in the surviving singleton. There was no significant difference in risks of other complications. The absence of fetal cardiac activities at the diagnosis of IUH predicted VTS (p < 0.001, crude OR 4.67, 95% CI 3.67-5.78, adjusted OR 3.33, 95% CI 1.56-5.14) and fetal loss at smaller gestational age (7.81 ± 2.10 vs. 11.39 ± 5.60 weeks, p < 0.001), while an IUH with an increasing volume did not increase the risk of VTS but might induce threatened abortion in the surviving fetus (p < 0.001, crude OR 1.84, 95% CI 1.32-2.55, adjusted OR 1.72, 95% CI 1.13-2.13).

CONCLUSIONS

IUH was a risk factor for VTS in twin pregnancies following double embryo transfer and elevated the risks of threatened abortion, preterm birth, and postpartum hemorrhage in the surviving singleton. The absence of fetal cardiac activities at the diagnosis of IUH elevated the risks of VTS, while an IUH with an increasing volume was associated with threatened abortion without elevating the risks of VTS. An IUH diagnosed before the presence of fetal cardiac activities also resulted in an earlier miscarriage. The study suggests that attention be paid to twin pregnancies with first-trimester IUH to prevent VTS and subsequent adverse perinatal outcomes.

HIGHLIGHTS

First-trimester intrauterine hematoma (IUH) following double embryo transfer is associated with a higher incidence of vanishing twin syndrome (VTS) and elevated subsequent risk of threatened abortion, preterm birth, and postpartum hemorrhage in the surviving singleton. Other perinatal outcomes were not associated with the diagnosis of first-trimester IUH. The absence of fetal cardiac activities at the diagnosis of IUH was of predictive value toward VTS, while an IUH with an increasing size was associated with threatened abortion without elevating the risk of VTS. Incomplete fetal cardiac activities and earlier detection of an IUH might also predict miscarriage at smaller gestational age.

Autoantibodies in association with subchorionic haematoma in early pregnancy

OBJECTIVE

To explore the possible aetiology of subchorionic haematoma (SCH), especially its association with autoantibodies.

MATERIAL AND METHODS

Early pregnant women who were detected SCH through ultrasonography were identified as the study group and those without SCH at comparable ages who visited the clinic at the same period of time were compared as the control group. Indexes of laboratory immune tests were compared between the two groups, as well as their pregnancy outcomes.

RESULTS

A total of 97 SCH patients and 130 control cases were recruited in this study. A higher proportion of women was detected autoantibodies in the SCH group compared with control group (45.36% vs 21.54%, p = .000). Positive rates of ANA (24.74% vs 10.77%, p = .005) and laboratory antiphospholipid antibodies (ACL, anti-β2 GP1 or LA) (25.77% vs 11.54%, p = .005) showed significant differences between the two groups. The incidence of vaginal bleeding was significantly higher in the SCH group (43.30% vs 20.00%, p = .000). While the miscarriage rates were not significantly different (17.53% vs 15.38%, p = .666). And there were no significant differences in terms of preterm delivery rate, caesarean section rate, birth weight and pregnancy complications. Most SCHs (96.25%) were absorbed before 20th gestational week. In the SCH group, the average birth weight was significantly lower in women with autoantibodies. Clinical features and other pregnancy outcomes showed no significant differences between SCH patients with and without autoantibodies.

CONCLUSIONS

The occurrence of SCH may be associated with autoantibodies. The pregnancy outcomes were comparable between women with and without SCH.KEY MESSAGESSubchorionic haematoma (SCH) is increasingly commonly observed in early pregnancy period, but the aetiology is uncertain and the clinical significance of SCH is controversial.The occurrence of SCH may be associated with autoantibodies.The pregnancy outcomes were not significantly different between women with and without SCH.

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.

Molecular Changes on Maternal-Fetal Interface in Placental Abruption-A Systematic Review

Placental abruption is the separation of the placenta from the lining of the uterus before childbirth. It is an infrequent perinatal complication with serious after-effects and a marked risk of maternal and fetal mortality. Despite the fact that numerous placental abruption risk factors are known, the pathophysiology of this issue is multifactorial and not entirely clear. The aim of this review was to examine the current state of knowledge concerning the molecular changes on the maternal–fetal interface occurring in placental abruption. Only original research articles describing studies published in English until the 15 March 2021 were considered eligible. Reviews, book chapters, case studies, conference papers and opinions were excluded. The systematic literature search of PubMed/MEDLINE and Scopus databases identified 708 articles, 22 of which were analyzed. The available evidence indicates that the disruption of the immunological processes on the maternal–fetal interface plays a crucial role in the pathophysiology of placental abruption. The features of chronic non-infectious inflammation and augmented immunological cytotoxic response were found to be present in placental abruption samples in the reviewed studies. Various molecules participate in this process, with only a few being examined. More advanced research is needed to fully explain this complicated process.

A case of successful pregnancy in a septate uterus after discharge of decidual tissue in the second trimester

In pregnant patients with a divided uterine cavity, the decidual tissue on the nonpregnant side may be discharged prior to the delivery of the fetus. The pregnancy can continue if the uterine contractions and vaginal bleeding are controlled and the fetus is not in distress.

Fetal-Maternal Hemorrhage in First-Trimester Intrauterine Hematoma

OBJECTIVE

The objective of this study was to compare the frequency and percentage of fetal hemoglobin (HbF%) by flow cytometry of (1) first-trimester asymptomatic patients with intrauterine hematoma (IUH), (2) first-trimester pregnant patients with vaginal bleeding (VB), and (3) first-trimester asymptomatic pregnant women without hematoma.

METHODS

Prospective study involving pregnant women in the first trimester of pregnancy. Patients with ultrasound findings of asymptomatic hematoma and with VB were paired with asymptomatic pregnant women of same gestational age without hematoma (control group [CG]). Maternal blood HbF% was evaluated by flow cytometry. The groups were compared in terms of circulating fetal hemoglobin and HbF%.

RESULTS

Sixty-six patients were selected, 22 with hematoma, 17 with bleeding, and 27 in the CG. Fetal hemoglobin was detected in 15 patients with hematoma (68.2%) and 13 with bleeding (76.5%) and in 20 of the control (74.1%) (p = 0.830). The mean HbF% of each group was 0.054, 0.012, and 0.042 for hematoma, bleeding, and control, respectively, and differences were not significant (p = 0.141). There was a moderate negative correlation between the volume of hematoma and HbF% (rSpearman = -0.527; p = 0.012).

CONCLUSIONS

The fetal-maternal hemorrhage expressed by Hbf% in first-trimester pregnancies did not seem to differ between patients with and without ultrasound findings of IUH.

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.

Application of a Nomogram for Predicting the Risk of Subchorionic Hematoma in Early Pregnancy With In Vitro Fertilization-Embryo Transfer/Frozen Embryo Transfer

BACKGROUND

Subchorionic hematoma (SCH) is common in early pregnancy achieved by in vitro fertilization-embryo transfer/frozen embryo transfer (IVF-ET/FET), and is associated with adverse obstetric outcomes. However, there are no methods known to accurately predict the occurrence of SCH.

OBJECTIVE

To establish a nomogram prediction model for predicting the risk of SCH in early pregnancy with IVF-ET/FET and to analyze pregnancy outcomes of patients with SCH.

METHODS

Patients who underwent IVF-ET/FET treatment and were diagnosed with clinical pregnancy were enrolled in our study. A total of 256 patients with SCH were enrolled in the SCH group, and 526 patients without SCH in the control group. Logistic regression was used to screen risk factors for SCH, and the nomogram was developed according to the regression coefficient of relevant variables. Discrimination, effect, calibration, and the predictive model's clinical usefulness were assessed using the C-index, the area under the receiver operating characteristic standard curve, calibration plot, and decision curve analysis. Internal validation was assessed using bootstrapping validation. The effects of SCH on pregnancy outcomes were analyzed.

RESULTS

A multivariate logistic regression analysis showed that fresh embryo transfer, polycystic ovary syndrome, hydrosalpinx, and thin endometrium were risk factors affecting the occurrence of SCH. Based on the above factors, a predictive model for the risk of SCH was created. The model displayed good discrimination, with a C-index of 0.783 (95% confidence interval: 0.750-0.816), area under the receiver operating characteristic standard curve of 0.783, and good calibration. A high C-index value of 0.765 could still be reached in the interval validation. Decision curve analysis showed that the nomogram was clinically useful when the intervention was decided at the SCH possibility threshold of 4%-87%. For patients with successful deliveries, the occurrence of SCH did not influence the gestational weeks of delivery, mode of delivery, preterm birth, height, and weight of the newborn.

CONCLUSION

We screened the risk factors for SCH in patients who underwent IVF-ET/FET treatment. Successful establishment of a nomogram can effectively predict the occurrence of SCH. Furthermore, the incidence of miscarriage is higher in patients with SCH.

Clinical and Ultrasound Evaluation of Early Threatened Miscarriage to Predict Pregnancy Continuation up to 28 Weeks: A Prospective Cohort Study

OBJECTIVES

(1) To study the predictors of pregnancy continuation up to 28 weeks in first-trimester threatened miscarriage after a single clinical and ultrasound (US) evaluation. (2) To assess the role of both clinical and US predictors in counseling and decreasing repeated emergency follow-up scans.

METHODS

A prospective observational study that included a cohort of 241 patients with threatened miscarriage (≥6-12 weeks) was conducted. They had a single clinical and US evaluation, and then they were contacted by weekly phone calls until completing 28 weeks' gestation or reporting miscarriage. Independently, all patients were followed by the recommended routine US scanning with or without emergency visits.

RESULTS

Two hundred thirty-three patients completed the study, of whom 193 patients continued up to 28 weeks' gestation, and 40 miscarried (17.1%). Only spotting/mild bleeding episodes and progesterone treatment were the clinical predictors of fetal viability. The embryonic/fetal heart rate (E/FHR) was the best single US predictor, with a specificity and positive predictive value of 95.3% and 97.2%, respectively. Combining 3 US parameters, at their best cutoff points (E/FHR >113 beats per minute, crown-rump length >19.9 mm, and gestational sac diameter >27.3 mm), had a specificity and positive predictive value of 98% and 99% (first-trimester US triad of fetal viability).

CONCLUSIONS

[1] In first-trimester threatened miscarriage, clinical parameters that could predict fetal viability included spotting/ mild bleeding and progesterone treatment. [2] After a single US scan, the presence of at least an E/FHR of greater than 113 bpm or the suggested first-trimester US triad appeared as a simple, measurable, and effective predictor of pregnancy continuation up to 28 weeks. [3] These US predictors are not to replace the recommended scheduled scanning during pregnancy. [4] This can improve patients' counseling and decrease the need for repeated emergency follow-up scans. Otherwise, there is an indication for repeating US scans at a 1-week to 10-day interval.

Association Between First-Trimester Bleeding and Retained Placenta Requiring Dilatation and Curettage

OBJECTIVE

Early subchorionic hemorrhage may lead to a disruption in the placental-uterine matrix, which may result in an adherence of the placenta to the endometrium. We evaluated the effect of a first-trimester bleed on the need for a post-vaginal delivery dilatation and curettage (D&C) for removal of retained placenta.

METHODS

We conducted a case-control study at a tertiary care centre between 2012 and 2016. Patients identified through medical records as having required a post-vaginal delivery D&C for retained placenta were considered cases and were matched 1:5 with patients delivering vaginally within 1 week who did not require a D&C. History of first-trimester bleeding and subchorionic hemorrhage were identified through chart review. Conditional logistic regression analyses estimated the effect of a first-trimester bleed on the requirement for D&C for retained placenta. Models were adjusted for maternal age and previous uterine surgery.

RESULTS

There were 68 cases of retained placenta requiring D&C, for an estimated 3 in 1000 deliveries. Patients requiring D&C were slightly older than controls but were otherwise comparable with respect to baseline demographic characteristics. In adjusted analyses, patients who required a postpartum D&C were more likely than controls to have had a first-trimester bleed at 11.8% and 0.6%, respectively (OR 25.3; 95% CI 4.7-135.4, P < 0.001). Postpartum D&C for retained placenta was associated with postpartum hemorrhage, need for blood transfusion, and manual removal of placenta.

CONCLUSION

First-trimester bleeding should be considered a high-risk determinant for post-vaginal delivery D&C for retained placenta and for severe postpartum hemorrhage.

Impact of subchorionic hematoma in early pregnancy on obstetric complications: A retrospective cohort study in women who had live births after frozen-thawed embryo transfer

Purpose

We investigated the contribution of subchorionic hematoma (SCH) involvement in early pregnancy to the risk of pregnancy complications in women who underwent frozen‐thawed embryo transfer (FET).

Methods

A hypoechogenic area surrounding the gestational sac at early pregnancy on ultrasound was defined as SCH. Simultaneously, the presence of vaginal bleeding was evaluated. We included 1416 women with live births after FET between March 2015 and September 2018 in this study. The frequency of pregnancy complications was compared between the SCH (n = 340) and non‐SCH (n = 1076) groups.

Results

The adjusted odds ratio of abnormal placental adhesion and placenta previa for the SCH group relative to the non‐SCH group was 7.01 [2.96‐18.00] and 3.77 [1.24‐11.91], respectively. In contrast, hypertensive disorders of pregnancy, non‐reassuring fetal status, fetal growth restriction, chorioamnionitis, and premature rupture of the membrane showed no differences between both groups. Furthermore, the frequency of abnormal placental adhesion was higher in the SCH group with vaginal bleeding than in the SCH group without vaginal bleeding.

Conclusions

Subchorionic hematoma in early pregnancy may cause abnormal placental adhesion and placenta previa in pregnant women with FET. SCH presence should be carefully noted, particularly in cases with vaginal bleeding during early pregnancy after FET.

Subchorionic hematoma in early pregnancy may cause abnormal placental adhesion and placenta previa in pregnant women with frozen embryo transfer. SCH presence should be carefully noted, particularly in cases with vaginal bleeding during early pregnancy after frozen embryo transfer.

Heme Oxygenase Protects against Placental Vascular Inflammation and Abortion by the Alarmin Heme in Mice

Both infectious as non-infectious inflammation can cause placental dysfunction and pregnancy complications. During the first trimester of human gestation, when palatogenesis takes place, intrauterine hematoma and hemorrhage are common phenomena, causing the release of large amounts of heme, a well-known alarmin. We postulated that exposure of pregnant mice to heme during palatogenesis would initiate oxidative and inflammatory stress, leading to pathological pregnancy, increasing the incidence of palatal clefting and abortion. Both heme oxygenase isoforms (HO-1 and HO-2) break down heme, thereby generating anti-oxidative and -inflammatory products. HO may thus counteract these heme-induced injurious stresses. To test this hypothesis, we administered heme to pregnant CD1 outbred mice at Day E12 by intraperitoneal injection in increasing doses: 30, 75 or 150 μmol/kg body weight (30H, 75H or 150H) in the presence or absence of HO-activity inhibitor SnMP from Day E11. Exposure to heme resulted in a dose-dependent increase in abortion. At 75H half of the fetuses where resorbed, while at 150H all fetuses were aborted. HO-activity protected against heme-induced abortion since inhibition of HO-activity aggravated heme-induced detrimental effects. The fetuses surviving heme administration demonstrated normal palatal fusion. Immunostainings at Day E16 demonstrated higher numbers of ICAM-1 positive blood vessels, macrophages and HO-1 positive cells in placenta after administration of 75H or SnMP + 30H. Summarizing, heme acts as an endogenous “alarmin” during pregnancy in a dose-dependent fashion, while HO-activity protects against heme-induced placental vascular inflammation and abortion.

Comparison of subchorionic hematoma in medicated or natural single euploid frozen embryo transfer cycles

OBJECTIVE

To study the effect of frozen embryo transfer (FET) preparation protocol on incidence of subchorionic hematoma (SCH) and serum hormone levels.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated fertility center.

PATIENT(S)

Patients who underwent FET at the New York University Langone Fertility Center.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was incidence of SCH by protocol in FET cycles.

RESULT(S)

There were 1,273 FET cycles that met criteria for inclusion. The frequency of SCH was lower in natural compared with programmed cycles (P<.05; relative risk = 0.4 [0.27-0.78]; odds ratio = 0.4 [0.23-0.75]). Serum estrogen level was higher in programmed compared with natural cycles on day of progesterone initiation (P<.001) and cycle day 28 (P<.001). However, serum estrogen levels at the same time points were not associated with formation of SCH in programmed or natural cycles.

CONCLUSION(S)

This is the first study to evaluate the formation of SCHs by FET protocol type. Our results highlight that high serum estradiol levels do not independently lead to an increase in rate of SCH. Further research must be done to understand other clinical, or perhaps molecular, differences between natural and programmed FET cycle preparations that can be better associated with SCH formation.

A large subchorionic hematoma in pregnancy: A case report

INTRODUCTION

Subchorionic hematoma (SCH) is a rare type of intrauterine hematoma, usually with limited impact on fetuses and pregnant women. But massive hematoma causes significant space occupying effect, affects blood supply of the fetus and finally may lead to fetus demise.

PATIENT CONCERNS

In this case report, we reported a 22-year-old pregnant woman presented to our hospital with complaint of irregular lower abdominal pain.

DIAGNOSIS

Ultrasonography and magnetic resonance imaging confirmed an intrauterine mass with a compressed growth-restricted fetus.

INTERVENTIONS

The patient underwent diseases induced labor after confirmation of fetus demise by ultrasonography.

OUTCOMES

Histopathological examination of the mass revealed a SCH.

CONCLUSION

Though small SCH can be found in quite a few pregnant women and is usually harmless, enormous hematoma can result in adverse pregnancy outcomes. It may be difficult, in some cases, to differentiate it from uterine tumors or placental tumors by means of ultrasonography and magnetic resonance imaging, especially when the mass is hyperechoic under ultrasonography. This case report stresses the importance of regular examinations of pregnant women.

Mechanisms of thrombin-Induced myometrial contractions: Potential targets of progesterone

Intrauterine bleeding during pregnancy is a major risk factor for preterm birth. Thrombin, the most abundant coagulation factor in blood, is associated with uterine myometrial contraction. Here, we investigated the molecular mechanism and signaling of thrombin-induced myometrial contraction. First, histologic studies of placental abruption, as a representative intrauterine bleeding, revealed that thrombin was expressed within the infiltrating hemorrhage and that thrombin receptor (protease-activated receptor 1, PAR1) was highly expressed in myometrial cells surrounding the hemorrhage. Treatment of human myometrial cells with thrombin resulted in augmented contraction via PAR1. Thrombin-induced signaling to myosin was then mediated by activation of myosin light chain kinase- and Rho-induced phosphorylation of myosin light chain-2. In addition, thrombin increased prostaglandin-endoperoxidase synthase-2 (PTGS2 or COX2) mRNA and prostaglandin E2 and F2α synthesis in human myometrial cells. Thrombin significantly increased the mRNA level of interleukine-1β, whereas it decreased the expressions of prostaglandin EP3 and F2α receptors. Progesterone partially blocked thrombin-induced myometrial contractions, which was accompanied by suppression of the thrombin-induced increase of PTGS2 and IL1B mRNA expressions as well as suppression of PAR1 expression. Collectively, thrombin induces myometrial contractions by two mechanisms, including direct activation of myosin and indirect increases in prostaglandin synthesis. The results suggest a therapeutic potential of progesterone for preterm labor complicated by intrauterine bleeding.

First-trimester intrauterine hematoma and pregnancy complications

OBJECTIVE

To assess whether sonographic diagnosis of intrauterine hematoma (IUH) in the first trimester of pregnancy is associated with first-trimester miscarriage and antenatal, delivery and neonatal complications.

METHODS

This was a prospective observational cohort study of women with an intrauterine singleton pregnancy between 5 and 14 weeks' gestation recruited at Queen Charlotte's and Chelsea Hospital, London, UK, between March 2014 and March 2016. Participants underwent serial ultrasound examinations in the first trimester, and the presence, location, size and persistence of any IUH was evaluated. First-trimester miscarriage was defined as pregnancy loss before 14 weeks' gestation. Clinical symptoms, including pelvic pain and vaginal bleeding, were recorded at each visit using validated symptom scores. Antenatal, delivery and neonatal outcomes were obtained from hospital records. Logistic regression analysis and the chi-square test were used to assess the association between the presence and features of IUH and the incidence of adverse pregnancy outcome. Odds ratios (OR) were first adjusted for maternal age (aOR) and then further adjusted for the presence of vaginal bleeding or pelvic pain in the first trimester.

RESULTS

Of 1003 women recruited to the study, 946 were included in the final analysis and of these, 268 (28.3%) were diagnosed with an IUH in the first trimester. The presence of IUH was associated with the incidence of preterm birth (aOR, 1.94 (95% CI, 1.07-3.52)), but no other individual or overall antenatal, delivery or neonatal complications. No association was found between the presence of IUH in the first trimester and first-trimester miscarriage (aOR, 0.81 (95% CI, 0.44-1.50)). These findings were independent of the absolute size of the hematoma and the presence of vaginal bleeding or pelvic pain in the first trimester. When IUH was present in the first trimester, there was no association between its size, content or position in relation to the gestational sac and overall antenatal, delivery and neonatal complications. Diagnosis of a retroplacental IUH was associated with an increased risk of overall antenatal complications (P = 0.04).

CONCLUSIONS

Our findings demonstrate that there is no association between the presence of IUH in the first trimester and first-trimester miscarriage. However, an association with preterm birth, independently of the presence of symptoms of pelvic pain and/or vaginal bleeding, is evident. Women diagnosed with IUH in the first trimester should be counseled about their increased risk of preterm birth and possibly be offered increased surveillance during the course of their pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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

OBJECTIVE

To assess the association of first-trimester subchorionic hematomas with pregnancy outcomes after 20 weeks of gestation in women with singleton pregnancies.

METHODS

We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients underwent routine first-trimester ultrasound examinations. We compared rates of adverse pregnancy outcomes at more than 20 weeks of gestation in women with and without a subchorionic hematoma on the initial ultrasound examination, excluding women with pregnancy loss before 20 weeks of gestation.

RESULTS

From January 2015 to December 2017, a total of 2,172 women met the inclusion criteria for the study, 389 (17.9%) of whom had a subchorionic hematoma (mean largest diameter 2.1±1.4 cm). Women with subchorionic hematomas had their first ultrasound examination at earlier gestational ages (8 5/7 vs 9 6/7 weeks, P<.001) and were more likely to have vaginal bleeding at the time of the ultrasound examination (31.9% vs 7.9%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was not associated with any pregnancy outcomes at more than 20 weeks of gestation, including gestational age at delivery, preterm birth, birth weight, birth weight less than the 10th percentile for gestational age, gestational hypertension, preeclampsia, placental abruption, intrauterine fetal death at more than 20 weeks of gestation, cesarean delivery, blood transfusion, and antepartum admissions. On regression analysis including subchorionic hematoma, vaginal bleeding, and gestational age at ultrasound examination, vaginal bleeding was independently associated with preterm birth at less than 37 weeks of gestation and birth weight less than the 10th percentile. Subchorionic hematoma was not independently associated with pregnancy outcomes. This study had 80% power to detect a 5% absolute difference in the frequency of preterm birth; that is, from 10% to 15%.

CONCLUSION

In singleton pregnancies, a first-trimester subchorionic hematoma is not associated with adverse pregnancy outcomes at more than 20 weeks of gestation.

Association Between First-Trimester Subchorionic Hematomas and Pregnancy Loss in Singleton Pregnancies

OBJECTIVE

To assess the association of a first-trimester subchorionic hematoma with pregnancy loss in women with singleton pregnancies.

METHODS

We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients had routine first-trimester ultrasound scans. We reviewed ultrasound data from the first ultrasound scan performed between 6 0/7 and 13 6/7 weeks of gestation and compared rates of pregnancy loss before 20 weeks in women with and without a subchorionic hematoma. Logistic regression analysis was used to control for potential confounding variables.

RESULTS

From January 2015 to December 2017, a total of 2,446 women met inclusion criteria, 451 (18.4%) of whom had subchorionic hematomas. Women with subchorionic hematomas had their first ultrasound scans at an earlier gestational age (8 5/7 vs 9 6/7 weeks of gestation, P<.001) and were more likely to have vaginal bleeding (33.3% vs 8.1%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, prior number of losses, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was associated with an increased risk of pregnancy loss before 20 weeks of gestation (7.5% vs 4.9%, P=.026); however, after adjusting for gestational age and vaginal bleeding, this association was no longer significant (adjusted odds ratio 1.13, 95% CI 0.74-1.74). In the 451 women with subchorionic hematomas, no characteristics of the subchorionic hematoma, including size by volume, largest diameter, presence of vaginal bleeding, and presence of an additional subchorionic hematoma, were associated with pregnancy loss. Post hoc power analysis showed we had 80% power to detect an increase in pregnancy loss before 20 weeks of gestation from 4.9% in women with no subchorionic hematoma to 8.3% in women with subchorionic hematoma.

CONCLUSION

In this cohort of women with singleton pregnancies, subchorionic hematoma before 14 weeks of gestation was not independently associated with pregnancy loss before 20 weeks of gestation.

Role of ultrasound in the evaluation of first-trimester pregnancies in the acute setting

In patients presenting for an evaluation of pregnancy in the first trimester, transvaginal ultrasound is the modality of choice for establishing the presence of an intrauterine pregnancy; evaluating pregnancy viability, gestational age, and multiplicity; detecting pregnancy-related complications; and diagnosing ectopic pregnancy. In this pictorial review article, the sonographic appearance of a normal intrauterine gestation and the most common complications of pregnancy in the first trimester in the acute setting are discussed.

Gynecologic and reproductive health in patients with pathogenic germline variants in DICER1

OBJECTIVE

Germline pathogenic variation in DICER1 underlies a tumor-predisposition disorder with increased risk for cervical embryonal rhabdomyosarcoma and ovarian sex-cord stromal tumors, particularly Sertoli-Leydig cell tumors. The gynecologic and reproductive health of these females has not yet been described.

METHODS

All female subjects recruited from November 2011 to July 2018 participating in an epidemiologic study of families with pathogenic DICER1 germline variation were included in this cross-sectional analysis. Participant evaluation included obstetric-gynecologic history, physical examination, hormone testing, pelvic ultrasound and record review.

RESULTS

Of 64 females aged 2-72 years, fifteen underwent treatment for pleuropulmonary blastoma as children and three were treated for cervical embryonal rhabdomyosarcoma. Of nine patients reporting a history of ovarian tumors, all presented with virilization or amenorrhea; eight occurred in adolescence. Post-pubertal females with no history of ovarian tumors experienced normal pubertal development, reported regular menstrual cycles, were fertile and underwent natural menopause at median age of 52 years. Thirty-two of 33 women who tried to conceive successfully delivered liveborn children. Of these 32, 10 experienced pregnancy-related thyroid enlargement resulting in thyroidectomy within one year of pregnancy; nine others had undergone pre-pregnancy thyroidectomy.

CONCLUSION

In these DICER1-carrier females, DICER1-related gynecological tumors occurred during childhood or adolescence in some after which women generally experienced healthy reproductive lives. Individual education and screening for these tumors is warranted. The high rate of DICER1-related multinodular goiter resulting in pre- and post-pregnancy thyroidectomy underscores the importance of thyroid monitoring during pregnancy to ensure maternal and fetal wellbeing.

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.

Complications in Early Pregnancy

Early in pregnancy women frequently experience nausea, vomiting, and vaginal bleeding. Nausea and vomiting can be mild, managed by dietary modifications and medications, or severe, requiring intravenous fluids and medications. Care should be used when selecting medications for nausea to avoid additional side effects or potential harm to the developing fetus. When evaluating vaginal bleeding in early pregnancy, ectopic pregnancy must be ruled out. If an intrauterine pregnancy is seen, threatened miscarriage should be considered and the patient appropriately counseled. If neither intrauterine pregnancy nor ectopic pregnancy can be established, a management algorithm for pregnancy of unknown location is presented.

IMMUNOLOGICAL AND GENETIC CHANGES AS PREDICTORS IN THE LOSS OF PREGNANCY IN THE FORMATION OF RETROCHORIAL HEMATOMA IN THE FIRST TRIMESTER

Background. Pregnancy with a retrochorial hematoma in a third of cases ends prematurely. Detection of early markers of pregnancy loss is extremely necessary for the prevention and therapy of miscarriage.

Aims. The aim of the study is development and pathogenetically substantiation a new diagnostic algorithm in the formation of retrochorial hematoma in the first trimester of pregnancy.

Materials and methods. A prospective study of women of reproductive age with retrochorial hematoma applied at the gestational age of 6–12 weeks was performed. A study was made of polymorphic variants of genes of hemostasis system; the folate cycle by polymerase chain reaction. The level of embryotropic antibodies was determined by the ELI-P-Complex-12 system test. The course of pregnancy and delivery was monitored.

Results. The study involved 113 women. There was no correlation between the isolated carrier of polymorphisms and an increased risk of pregnancy loss (p ˃ 0.05). Polymorphic variants of genes of hemostasis system; the folate cycle in combination with an increase in the level of rheumatoid factor or autoantibodies to thyroglobulin have a relationship with the risk of miscarriage (р ˂ 0.05).

Conclusion. Polymorphic variants of genes of hemostasis system; the folate cycle in combination with an increase in the level of rheumatoid factor or autoantibodies to thyroglobulin are predictors of an unfavorable outcome of pregnancy. Therefore; the definition of these markers can be used for individualization of the survey; treatment at the precognitive stage and during pregnancy.

Placental abruption and hemorrhage-review of imaging appearance

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.