The impact of first-trimester intrauterine hematoma on adverse perinatal outcomes

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.

The significance of ultrasound features of sub-chorionic haemorrhage as a predictor of adverse perinatal outcome: A retrospective review

INTRODUCTION

This retrospective single centre study considers the predictive value of specific ultrasound features of sub-chorionic haemorrhage (SCH) as potential indicators of adverse pregnancy outcome.

METHODS

Ultrasound reports and images were reviewed for 160 participants presenting to an early pregnancy assessment unit from January 2018 to January 2019. Participants were selected based upon the presence of SCH within the first trimester. The outcome of each pregnancy and the features of SCH, including the size, location and echogenicity were recorded and multinominal logistic regression was used to establish predictive value.

RESULTS

The majority of participants were asymptomatic and delivered healthy babies. 24% miscarried prior to delivery or had stillborn babies; the features of bleed within this group revealed an increased prevalence of adverse outcome in the presence of moderate sized haemorrhage (p = 0.02). 61% of miscarried pregnancies presented with "wrapping" SCH, in which haemorrhage encased the gestation sac, suggesting wrapping posed a probable risk (p = 0.01). 71% of miscarriages occurred within 5 + 0-10 + 0 weeks gestation. Persistent SCH was of greater incidence within those participants with adverse outcome (57%). There was no association between fetal abnormality and miscarriage. Jaundice babies and premature delivery occurred more frequently (p = 0.001) and may be a secondary finding following SCH.

CONCLUSION

There was a strong correlation between presence of SCH in early pregnancy and rate of miscarriage. Specific ultrasound features of SCH, most notably a wrapping location with moderate size, may be indicative of increased risk of miscarriage or post-natal complications. Jaundice and premature births may have an association with placental compromise.

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/.

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.

Study on the correlation between vaginal bleeding in first trimester and preterm birth: A birth cohort study in Lanzhou, China

OBJECTS

To investigate the correlation between first trimester vaginal bleeding and preterm birth (PB), and to offer suggestions on the perinatal health care and preterm birth prevention.

METHODS

A birth cohort study was conducted on 10 179 pregnant women. Unconditional logistic regression model was used to evaluate the associations between vaginal bleeding and preterm birth in sub-preterm groups.

RESULTS

Of the 10 179 pregnant women included, a total of 1001 women suffered from vaginal bleeding during the first trimester, of which 119 suffered from PB. Any vaginal bleeding increased the risk of PB. Severe bleeding was a high-risk factor of PB, associated with 4.8-fold risk of very PB, 2.7-fold risk of spontaneous PB without PROM (premature rupture of membrane) and 4.6-fold risk of medical induced PB. Bleeding prolonged more than 1 week increased 66% risk of PB and 36% risk of PB on initial episode happened in 5-12 weeks of gestation age, especially in moderate PB, in medical-induced PB and in spontaneous PB with PPROM (preterm premature rupture of membrane which is one cause of PB). Mild bleeding or bleeding within 1 week or initial episode happened within 4 weeks of gestation age possibly had no influence on PB.

CONCLUSION

Vaginal bleeding in the first-trimester was an independent risk factor for PB. The severity, duration and initial time of vaginal bleeding had different effects on different subtypes of PB.

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.

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.