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

Guideline No. 460: Diagnosis and Management of Intrauterine Early Pregnancy Loss

OBJECTIVE

To provide an evidence-based approach to guide the diagnosis and management of intrauterine early pregnancy loss.

TARGET POPULATION

This population includes patients experiencing pregnancy loss/miscarriage and incomplete pregnancy loss in the context of a normally sited intrauterine pregnancy. It does not include patients with a pregnancy of unknown location, ectopic pregnancy or recurrent pregnancy loss (2 or more pregnancy losses).

BENEFITS, HARMS, AND COSTS

Incorrect diagnosis of a pregnancy loss increases the risk of harming a live, normally sited pregnancy. Prolonged waiting for confirmation of a diagnosis can increase anxiety and delay treatment. Patient-centred care discussions can help patients understand their pregnancy loss risk and make decisions about their management and follow-up, including time off for bereavement and mental health support.

EVIDENCE

The following search terms were entered into PubMed from January 2021 to December 2024: early pregnancy loss, incomplete, spontaneous abortion, diagnosis, and management. The International Society of Ultrasound in Obstetrics and Gynecology (2021 and 2022), and Association of Early Pregnancy Units presentations and references were also used.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations).

INTENDED AUDIENCE

Health care providers who provide care to pregnant patients experiencing intrauterine early pregnancy loss.

TWEETABLE ABSTRACT

Early pregnancy loss is a common experience that can be traumatic. Patient-centred care in an Early Pregnancy Assessment Clinic can help patients make informed decisions.

SUMMARY STATEMENTS

RECOMMENDATIONS.

A nomogram for predicting the risk of fetal growth restriction in singleton pregnancies with subchorionic hematomas detected in first trimester

OBJECTIVE

To investigate the relationship between first trimester subchorionic hematoma (SCH) and fetal growth restriction (FGR), and to develop a nomogram for predicting the risk of FGR in patients with SCH.

METHODS

We conducted a retrospective cohort study from January 2021 to December 2021, involving singleton pregnancies that received routine prenatal care since the first trimester at our hospital. We excluded pregnancies loss before 20 weeks and ultimately included 1,055 individuals in the study, dividing them into two groups based on whether they were diagnosed with SCH. We compared the pregnancy outcomes in women with and without a SCH. After confirming an independent association between FGR and SCH detected in the first trimester, we conducted a subgroup analysis to identify high-risk factors for FGR among patients with SCH. Logistic regression was employed to identify risk factors for FGR in patients with SCH, and the nomogram was constructed based on the regression coefficients of relevant variables. The calibration of the prediction model was confirmed through the Hosmer-Lemeshow goodness-of-fit test (P > 0.05), and discrimination was assessed using the area under the receiver operating characteristic curve (ROC).

RESULTS

A total of 1,055 individuals were enrolled in the study, with 504 identified with SCH during the first trimester ultrasound examination. Women with SCH had a higher likelihood of experiencing vaginal bleeding (36.5% vs. 21.8%, P < 0.001). The presence of a first trimester SCH was independently associated with FGR [adjusted odds ratio (OR) 4.30, 95% confidence interval (CI) 1.58-11.66]. Subgroup analysis of women with SCH showed that gestational age at diagnosis of SCH ≥ 7 weeks (OR 3.04, 95% CI 1.03-9.00), SCH persisting in the second trimester (OR 4.93, 95% CI 1.71-14.25), leiomyoma ≥ 4 cm (OR 17.23, 95% CI 3.78-78.56), and GDM (OR 3.42, 95% CI 1.18-9.87) were risk factors for FGR. The prediction model was developed based on these factors and presented as a nomogram. The AUC of the nomogram was 0.769 (95% CI: 0.655-0.883, P < 0.001), suggesting a good prediction capability.

CONCLUSIONS

First trimester SCH is independently associated with an increased risk of FGR, and the nomogram developed effectively predicts FGR in pregnancies with SCH.

Fondaparinux sodium combined with conventional therapy improves subchorionic hematoma with protein S deficiency

BACKGROUND

Fondaparinux sodium can prevent and treat acute illnesses and venous thromboembolism in patients undergoing surgery. At present, no studies have reported on treating subchorionic hematoma combined with protein S deficiency using fondaparinux sodium.

OBJECTIVE

To investigate the clinical efficacy of fondaparinux sodium in the treatment of patients with subchorionic hematoma combined with protein S deficiency.

METHODS

This single-center, open-ended, and prospective study enrolled 78 patients with subchorionic hematoma and protein S deficiency. They were randomly assigned to the treatment and control groups. The control group received conventional treatment, and the observation group received subepithelial injections of fondaparinux sodium (2.5 mg/day) based on conventional treatment. After 30 days of continuous treatment, the hematoma was evaluated by ultrasonography.

RESULTS

After treatment with fondaparinux sodium, a significant improvement in subchorionic hematoma was observed in the observation group compared with that in the control group (p< 0.05). A substantial improvement in prothrombin time and activated partial thromboplastin time was observed in the observation group after fondaparinux sodium treatment (p< 0.05). Furthermore, after fondaparinux sodium treatment, the duration of hematoma maintenance and incidence of adverse pregnancy outcomes were significantly reduced in the observation group compared with that in the control group (p< 0.05).

CONCLUSION

With a favorable safety profile, fondaparinux sodium is effective in treating subchorionic hematoma combined with protein S deficiency. The results provide new ideas and methods for treating this disease, which is worthy of further promotion and application in clinical practice.

Association between subchorionic hematoma in the first trimester and outcomes of singleton pregnancies achieved through assisted reproductive technology: a systematic review and meta-analysis

PURPOSE

To evaluate the association between first trimester (≤ 12 weeks gestation) subchorionic hemorrhage (SCH), and maternal and neonatal outcomes in women who conceived with the help of assisted reproductive technique (ART).

METHODS

PubMed, Embase, Web of Science, and Scopus databases were searched for observational studies that specifically focused on women who achieved pregnancy via ART and investigated the relationship between early pregnancy (within 12 weeks of gestation) SCH and maternal and neonatal outcomes. Only studies with singleton pregnancies and reporting data on the comparator group (women without SCH) were included. Primary outcomes of interest included incidences of early (within 20 weeks of gestation) pregnancy loss, preterm delivery, caesarean section, and live birth rates. Pooled effect sizes were reported as odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Nine studies were included. All studies had a cohort design. In all studies, the primary assisted reproduction technique used was in-vitro fertilization (IVF). Compared to pregnancies without SCH, women with diagnosed early pregnancy SCH have a similar risk of preterm birth (< 37 weeks) (OR 1.01, 95% CI 0.83, 1.22), low birth weight (< 2500 g) (OR 1.01, 95% CI 0.59, 1.73) and fetal growth restriction (OR 1.57, 95% CI 0.62, 4.02). The gestational age (in weeks) (weighted mean difference (WMD) - 0.06, 95% CI - 0.18, 0.06) and the birth weight (in grams) (WMD - 16.5, 95% CI - 62.9, 29.8) were also similar in the two groups. The odds of early pregnancy loss (OR 1.39, 95% CI 0.97, 2.01), live birth (OR 0.77, 95% CI 0.55, 1.08) and caesarean delivery (OR 0.97, 95% CI 0.81, 1.16) were statistically similar in both groups. The risk of maternal adverse outcomes such as gestational diabetes (OR 0.98, 95% CI 0.74, 1.29), hypertensive disorder (OR 0.95, 95% CI 0.63, 1.43), premature rupture of membranes (PROM) (OR 1.36, 95% CI 0.90, 2.05) and placental abruption (OR 2.44, 95% CI 0.57, 10.5) was also similar in both the groups. There was no evidence of publication bias.

CONCLUSION

The findings suggest that SCH may not significantly increase the risk of adverse maternal and perinatal outcomes in pregnancies conceived through ART, particularly IVF.

TRIAL REGISTRATION

PROSPERO registration number CRD42024533996.

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.

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.