subchorionic haemorrhages in pregnancy

1. Subchorionic Haemorrhages
Dr. Meenakshi Sharma
Specialist
Dept Obstetrics & Gynaecology
Dr. Hedgewar Arogya Sansthan
Govt NCT Delhi
2011

2. Subchorionic haemorrhages
Definition
• Echo-free area located between the membranes
and the uterine wall
Kurjak A,J Matern Fetal Med, 1996
• 25% have first trimester bleeding
• SCH accounts for 9-18% of all cases of first
trimester bleeding
Pelinescu-Onciul D, Gynecol Endocrinol, 2007
Avi Ben Haroush,IMAJ, 2003

3. Perinatal outcome in subchorionic
haemorrhages
• Retrospective study of 516 patients with bleeding,
SCH and live fetus
• Rate of SA 9.3%, 18.8% for large hematoma, 7.7%
for small hematoma, 9.2% for moderate ones
• Rate of miscarriage increases with advancing
maternal age , gestational age and size of
haematoma
• Increased risk of miscarriage, stillbirth, abruptio,
preterm labour
• Large hematoma in late first or second trimester
stripping > 30-40% of placenta worse prognosis
than hematoma in first trimester
Bennett GL et al, Radiology, 1996

4. Subchorionic haemorrhages in
threatened abortion
• Prospective study, 342 women with
subchorionic haemorrhages and live fetus
presenting with threatened abortion
• Subchorionic haematoma in 62(18%)
• Rate of SA same 7/62(11%) and 28/280(10%) in
with and without haematoma
• Rate of preterm delivery same 7/62(11%) vs
32/280(11%)
• Rates similar to other studies published till date
Pedersen JF, Mantoni M, AJR, 1990

5. Subchorionic haemorrhages
• Retrospective study, 230/2556 (9%) women
with vaginal bleeding in first trimester had SCH
with live fetus
• 20(8.7%) had SA, 11(4.8%) had preterm birth
• No association of pregnancy outcome with
duration of bleeding, gestational age at diagnosis
or size of SCH
Avi Ben Haroush,IMAJ, 2003

6. Subchorionic haemorrhages
• Prospective study in general population
• 187 women with intrauterine haematoma and 6488
controls, incidence 3.1% in general population
• Abruptio -RR5.6, CI2.8-11.1
• PIH – RR2.1, CI1.5-2.9
• Preeclampsia – RR 4, CI 2.4-6.7
• Preterm delivery- RR2.3, CI1.6-3.2
• IUGR – RR2.4, CI 1.4-4.1
• Increased perinatal mortality and IUD but not
statistically significant
Nagy S, Obstet Gynecol, 2003

7. Perinatal outcome in Subchorionic
Haematoma
Metanalysis of 7 studies, 1735women with SH 70703
controls
• One SA estimated to occur with every 11 women
with subchorionic hematoma (OR-2.18)
• One stillbirth is estimated to occur with 103 women
with subchorionic haematoma (OR-2.09)
• Increased risk for
▫ Abruptio – OR 5.71, 95% CI 3.93-8.33 (NNH-24)
▫ Preterm labour – OR1.4 95% CI 1.18-1.68 (NNH-28)
▫ PPROM – OR1.64, 95% CI 1.22-2.21 (NNH- 69)
• No increased risk for SGA and preeclampsia
Tuuli, Methodious G, Obstet Gynaecol, 2011

8. Treatment Subchorionic haemorrhages

9. Treatment options
• Expectant management
• Bed rest
• Dydrogesterone
• Micronised progesterone
• 17- hydroxy caproate
• Tranexamic acid
• Daflon

10. SCH effect of bed rest
• Retrospective study- 230 women with
threatened abortion with subchorionic
haemorrhages advised bed rest
• 200 adhered compared with rest
• Women adhered to bed rest had fewer abortions
( 9.9% vs 23.3%, p-0.006) and higher rate of
term pregnancy (89% vs 70%, p-0.004)than who
did not
Avi Ben-Haroush, IMAJ, 2003

11. Pathophysiology subchorionic
haemorrhages
• T helper 1 cytokine control
• Endothelial cells activated by IL-1, TNF α, IFN γ
release prothrombinase, which converts
prothrombin to activated thrombin
• Activated thrombin stimulates endothelial cells to
secrete IL-8 recruits PMN cells
• PMN cells destroy decidual endothelial cells
activated by IL-1, TNF α, IFN γ leads to coagulation
in decidual vessels
• Coagulation prevented by IL4 and IL10which inhibit
activity of endothelial prothombinases under Th2
control

12. Rationale of dydrogesterone
• Dydrogesterone influence immune decidual
process under Th2 control
• Immunomodulatory effect of changing balance
Th1/Th2 increasing number of progesterone
receptors on CD56+ cells and PIBF tipping the
scale towards Th2 control is essential for
prevention and treatment of subchorionic
haemorrhages
Pelinescu-Onciul D, Gynecol Endocrinol, 2007

13. Dydrogesterone
• Open label prospective study
• 100 women 7-11 wks pregnancy with subchorionic
haemorrhages, 40 mg/day till 16 wks
• Abortion rate was 7% and when compared with
abortion rate of 18.7% in previous study of SCH
treated with micronised progesterone
• Abortion rate reduced by 37%
• Marked immunomodulatory effect of
dydrogesterone on T helper 2 cytokine balance
seems good in prevention of miscarrige in SCH
Pelinescu-Onciul D, Gynecol Endocrinol, 2007

14. • 15 trials (2118) women
• No diff in risk of miscarriage in Progesterone vs
placebo or no treatment ( OR 0.98, 95% CI 0.78,
1.24) in all women irrespective of gravidity and age
• In subgroup analysis, statistically significant
decrease in miscarriage rate in women with RM (OR
0.38, 95% CI, 0.20, 0.70)
• No significant difference in adverse effect to mother
or baby
• No difference in route of Progesterone
oral/IM/vaginal vs placebo or no treatment
Hass DM, Cochrane Database Syst Rev, 2008
Progesterone in prevention of
miscarraige

15. • Cochrane review, 2011, by Whabi et al,
• Two studies (n 84) included in meta-analysis
• No evidence of effectiveness with use of vaginal
Progesterone compared to placebo in reducing
risk of miscarriage (RR 0.47%, 95% CI 0.17,
1.30)
• Scarce data, no evidence for routine use of
progesterone in treatment of threatened
abortion
• Large RCT are needed
Progesterone for treatment of
threatened miscarriage