How to treat subchorionic hemorrhage?
Subchorionic Hemorrhage Explained | Causes & Treatment
Bleeding beneath the chorion membranes that surround the embryo in the uterus is known as subchorionic hemorrhage. It is believed to be caused by the chorion membranes partially separating from the uterine wall. The assessment and treatment of subchorionic hemorrhage in pregnant patients are reviewed in this activity, which also describes the function of the interprofessional team in treating patients with this problem. About 11% of occurrences of vaginal bleeding in individuals between 10 and 20 weeks gestation are caused by subchorionic hemorrhage or subchorionic hematoma.
Subchorionic hemorrhage and subchorionic hematoma, what is it?
With an incidence of 16 to 25%, vaginal bleeding during the first trimester of pregnancy is a common problem. About 11% of occurrences of vaginal bleeding in individuals between 10 and 20 weeks gestation are caused by subchorionic hemorrhage or subchorionic hematoma. Bleeding beneath the chorion membranes that surround the embryo in the uterus is known as subchorionic hemorrhage. It seems to be caused by the chorion membranes partially separating from the uterine wall.
Another word for subchorionic hemorrhage is subchorionic hematoma. While some women are asymptomatic with incidental ultrasonography findings, the majority of women come with mild vaginal bleeding.
Causes of subchorionic hemorrhage (subchorionic hematoma)
It is yet unknown what causes subchorionic hematoma.The partial detachment of the chorionic membranes from the uterine wall seems to be the cause of subchorionic hematomas. A history of repeated miscarriages, pelvic infections, or uterine malformations are all potential risk factors for a subchorionic hemorrhage.
Females of reproductive age are susceptible to subchorionic hemorrhages. When a woman experiences vaginal bleeding between weeks 9 and 20 of pregnancy, these sonographic findings are typical. There has been discussion on the clinical importance of subchorionic hemorrhages ever since they were first described in 1981. Preterm delivery, placental abruption, and hypertensive problems are among the negative pregnancy outcomes linked to subchorionic hematomas, according to certain research. Conversely, some research indicates that subchorionic hemorrhage does not have any negative consequences. Research has indicated that a history of multiparity, known uterine abnormalities, and prior recurrent pregnancy loss increases the risk of subchorionic hemorrhage.
Subchorionic hemorrhage and subchorionic hematoma: History and Physical
Patients may have vaginal bleeding or no symptoms at all. Although most people do not have abdominal pain, a small percentage may have cramps or contractions.[8] Getting a thorough obstetric and gynecologic history is crucial because of the risk factors that have been identified in earlier research. First-trimester hemorrhage complicates up to 25% of pregnancies. In the event that a patient presents with vaginal bleeding, the details of the bleeding, such as its amount, whether it is continuous or intermittent, and whether it is accompanied by any contractions or pain in the abdomen, must be recorded. It is necessary to gather the patient's medical history, including any prior pregnancies and gynecologic history (history of pelvic inflammatory disease or STDs), as well as to identify risk factors for potentially fatal disorders like ectopic pregnancy.
Examining the abdomen should also be done, beginning with light percussion in the least painful quadrant. A speculum examination is necessary when a patient exhibits vaginal bleeding in order to assess the extent of the bleeding and the cervix's appearance. This tissue should be examined and sent for pathologic analysis for additional assessment if the exam reveals any blood clots or products of pregnancy.Sonographic evidence of intrauterine bleeding can be found in up to 22% of these patients when transabdominal or transvaginal ultrasounds are performed. Fetal heartbeats should be monitored if the pregnancy is 10 to 12 weeks along; the usual range is 110 to 160 beats per minute.
Assessment
Any woman of reproductive age who exhibits menstrual irregularities, vaginal bleeding, or abdominal pain should have a urine pregnancy test performed to measure beta-hCG. To rule out any potentially fatal disorders, pregnant individuals who exhibit vaginal bleeding and/or abdominal cramps should be evaluated. Using ultrasonography to rule out ectopic pregnancy is part of this differential. When evaluating these individuals, ultrasound is the preferred imaging modality since it can identify a number of conditions that could cause bleeding in the early stages of pregnancy.
The ultrasound will show a crescent-shaped, hypoechoic or anechoic region behind the fetal membranes, which may also raise the placenta's border. Because of the thin membranes and the consistency of the hematoma, it can occasionally be difficult to recognize and diagnose a subchorionic hematoma. It could be mistaken for amniotic fluid if the consistency seems anechoic. It can be mistaken for the myometrium if it is more isoechoic, and placental tissue if it is hyperechoic. Hemoglobin/hematocrit, coagulation investigations, and the type and crossmatch should be ordered when a patient exhibits excessive vaginal bleeding. Patients who are hemodynamically unstable or at risk of becoming so must receive treatment as soon as possible.
Management and Treatment
Specific patient complaints, gestational age, and whether the patient is hemodynamically stable or unstable should be the main focus of treatment and management. Treatment should be started as soon as possible, depending on how serious the patient's complaint is (usually vaginal bleeding in the context of a subchorionic hemorrhage). Anti-D immune globulin should be administered to RhD-negative patients who exhibit vaginal bleeding in order to prevent alloimmunization in future pregnancies.The patient, the kind and intensity of their symptoms, and the size and location of the subchorionic hematoma should all be taken into consideration when designing a treatment plan.
For patients experiencing vaginal bleeding during the first trimester, some sites offer vaginal progesterone supplementation; however, this has not been demonstrated to improve live birth rates, and regular use is not advised. Though these studies have not been substantial enough to alter current recommendations and guidelines, researchers have found that patients receiving bed rest have a greater rate of term pregnancy and fewer spontaneous abortions. Conservative treatment combined with a follow-up ultrasound examination is sufficient when the mother and fetus are stable and there is no indication of significant blood loss.
Differential Diagnosis
A female patient of reproductive age who presents with vaginal bleeding or abdominal pain has a wide range of differential diagnoses. The first objective is to determine whether a patient's symptoms indicate a serious or life-threatening illness or condition. To rule out a potentially fatal ectopic pregnancy, intrauterine pregnancy should be confirmed by ultrasound if the patient is known or proven to be pregnant. A tubo-ovarian abscess, uterine rupture, ovarian torsion, placental abruption, placenta previa, vasa previa, gestational trophoblastic illness, early pregnancy loss (miscarriage or spontaneous abortion), threatened abortion, and implantation hemorrhage are further common differential diagnoses.
Prognosis
The size of the hematoma, the mother's age, and the gestational age all affect the fetal outcome for women who have a sonographically detected subchorionic hematoma. If a subchorionic hematoma makes up 25% or more of the gestational sac's volume, there is a higher chance that the pregnancy may end. Additionally, if the hematoma is retroplacental rather than marginal, there is a higher chance of a negative result. The likelihood of later pregnancy failure increases with the early detection of a subchorionic hematoma.
While the rate and mechanism of premature delivery remain unaffected if pregnant women are able to carry their pregnancy to term, subchorionic hematoma raises the risk of spontaneous abortion. At more than 20 weeks gestation, there is no correlation between a first-trimester subchorionic hematoma and unfavorable pregnancy outcomes. When nonspecific pelvic discomfort is present, the ratio of surrounding hematoma to gestational sac increases, as does the length of hospital stay and the ratio of pregnancy loss.
Complications
Early pregnancy loss is more likely to occur in pregnant women who have subchorionic hematomas (SCH). The risk of placental abruption is five times higher for women who have subchorionic hematoma. Subchorionic hematoma patients are also susceptible to early and late pregnancy loss, premature membrane rupture, and preterm labor.
One risk factor for third-trimester pregnancy-induced hypertension is a subchorionic hematoma identified early in pregnancy. Early-stage SCH diagnosis has no bearing on the delivery procedure and does not raise the chance of unfavorable pregnancy outcomes.
Despite not being seen as typical during pregnancy, subchorionic hematomas are not uncommon. Patients should be informed that this does not imply that their pregnancy will end. Most of these cases result in the delivery of healthy babies under careful observation. Although subchorionic bleeding does not indicate that the pregnancy is in immediate danger, it is nevertheless advisable to consult the doctor. Patients must be aware of the appropriate safety measures and when to seek medical attention or go back to the hospital. These precautions include, but are not restricted to, abdominal pain and vaginal bleeding or spotting.
