Subchorionic Hemorrhage 

  • Author: Avneesh Chhabra, MD; Chief Editor: Eugene C Lin, MD   more...
 
Updated: May 25, 2011
 

Overview

Subchorionic hemorrhage (subchorionic hematoma) is the most common sonographic abnormality in the presence of a live embryo. Vaginal bleeding affects 25% of all women during the first half of pregnancy and is a common reason for first-trimester ultrasonography. Sonographic visualization of a subchorionic hematoma is important in a symptomatic woman because pregnant women with a demonstrable hematoma have a prognosis worse than women without a hematoma (see example images below). However, small, asymptomatic subchorionic hematomas do not worsen the patient's prognosis.[1, 2, 3, 4, 5, 6, 7, 8]

Transverse endovaginal scan of the uterus in a 45-Transverse endovaginal scan of the uterus in a 45-year-old woman in 8th week of gestation. Small subchorionic hematoma is anterior to a gestational sac. Sagittal endovaginal scan of the uterus demonstratSagittal endovaginal scan of the uterus demonstrates a small subchorionic hematoma (red arrow) in a 26-year-old woman in the 7th week of gestation. Also note the prominent retroplacental veins (blue arrow), which are normally in pregnancy. Color Doppler scan in a 21-year-old woman in 33rd Color Doppler scan in a 21-year-old woman in 33rd week of pregnancy demonstrates prominent retroplacental vessels mimicking a retroplacental hematoma.

In women whose sonogram shows a subchorionic hematoma, the outcome of the fetus depends on the size of the hematoma, the mother's age, and the fetus's gestational age. Rates of miscarriage increase with advancing maternal age and increasing size of hematoma. Late first- or second-trimester bleeding also worsens the prognosis. The presence of sonographically detected subchorionic hemorrhage (subchorionic hematoma) increases the risk of miscarriage, stillbirth, abruptio placentae, and preterm labor.

The subchorionic hemorrhage (subchorionic hematoma) collects between the uterine wall and the chorionic membrane and may leak through the cervical canal. Later in the first trimester and early second trimester, the subchorionic hematoma may partially strip the developing placenta away from its attachment site. Therefore, the prognosis of patients with this type of hematoma is worse than the prognosis of patients with hematoma early in first trimester.[9]

The subchorionic hematoma often regresses, especially if it is small or moderate in size. Large hematomas, which strip at least 30-40% of placenta away from endometrium, may enlarge further, compressing the gestational sac and leading to premature rupture of membranes with consequent spontaneous abortion.

Preferred examination

Ultrasonography is the imaging modality of choice for subchorionic hemorrhage (subchorionic hematoma) because it can be performed rapidly at the patient's bedside and because it has no known risk, as with radiation.[10, 11, 12]

Limitations of techniques

The sensitivity of sonography is low and varies between 2% and 20%, as blood may pass vaginally and not collect in the subchorionic space. Hematomas may also appear isoechoic relative to the placenta.

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Computed Tomography

CT scanning is relatively contraindicated during pregnancy because of the risk of radiation to the fetus. Pregnant patients may undergo CT for reasons such as an evaluation of trauma or acute abdomen. Scans may show an incidental or injury-related hyperattenuating subchorionic hemorrhage (subchorionic hematoma).

Degree of confidence

The sensitivity of CT may be high compared with that of sonography. However, because of the risk of radiation with CT, no large comparisons of the 2 modalities have been reported.

False positives/negatives

Normal chorioamniotic separation should not be confused with placental abruption.

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Magnetic Resonance Imaging

MRI is not routinely performed to detect subchorionic hemorrhage (subchorionic hematoma); a more common indication is the detection of fetal anomalies.[13] MRI may incidentally show a subchorionic hematoma and help in characterizing and determining the acuity of the hematomas by showing changes in signal intensity produced by various blood products. T1-weighted spin-echo and gradient-echo images are particularly useful in evaluating the hemorrhage.

In one study, fetal MRI techniques were evaluated to determine whether they were sufficient for the assessment of placental pathologies, and based on the study findings, MRI was considered by the authors to be a promising tool for the assessment of placental insufficiency. Pathologically, 26 placentas showed infarctions (96.2% on MR scans); 2 retroplacental hematomas were detected by MRI and confirmed by pathology; 9 of 14 subchorionic hematomas were confirmed; 6 of 8 intervillous hemorrhages were seen on MRI; and 3 of 6 cases of severe chorioamnionitis were diagnosed prenatally.[14]

Degree of confidence

Fetal motion sometimes limits MRI. However, the observer can confidently determine the age of the blood products.

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Ultrasonography

Acute subchorionic hemorrhages (subchorionic hematomas) vary in echogenicity and are seen between the chorion and the uterine wall on sonograms (see images below). Isoechoic hematomas may be missed on initial sonograms, or they may be recognized as heterogeneous and thickened placentas.

Transverse endovaginal scan of the uterus in a 45-Transverse endovaginal scan of the uterus in a 45-year-old woman in 8th week of gestation. Small subchorionic hematoma is anterior to a gestational sac. Sagittal endovaginal scan of the uterus in a 19-yeSagittal endovaginal scan of the uterus in a 19-year-old woman in 20th week of gestation demonstrates a small anterior subchorionic hematoma adjacent to the lower edge of the placenta. Transverse scan demonstrates a hematoma in a 19-yeTransverse scan demonstrates a hematoma in a 19-year-old woman in 20th week of gestation. Sagittal endovaginal scan of the uterus demonstratSagittal endovaginal scan of the uterus demonstrates a small subchorionic hematoma (red arrow) in a 26-year-old woman in the 7th week of gestation. Also note the prominent retroplacental veins (blue arrow), which are normally in pregnancy. Transverse endovaginal scan of the uterus in 45-yeTransverse endovaginal scan of the uterus in 45-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy demonstrates an anterior subchorionic hematoma (cursors). Also note the normal chorioamniotic separation in the posterior sac. Sagittal endovaginal scan of the uterus in 37-yearSagittal endovaginal scan of the uterus in 37-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy demonstrates an anterior subchorionic hematoma. Sagittal endovaginal scan in 37-year-old woman in Sagittal endovaginal scan in 37-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy shows extension of the hematoma in the intertwin membrane cleft, where the 2 placentas fuse.

Color Doppler sonography may help in distinguishing the avascular hematoma from the highly vascular placenta. Follow-up sonography may also help in resolving hematomas.

A subchorionic hematoma can be considered large if it is greater than 50% of the size of the gestation sac, medium if it is 20-50%, and small if it is less than 20%. Large hematomas by size (>30-50%) and volume (>50 mL) worsen the patient's prognosis.

Hematomas may resolve over 1-2 weeks. During this time, they may be seen as complex fluid collections with mixed echogenicity. In addition, sonographic findings also confirm fetal viability[15] and can help in differentiating and diagnosing other conditions associated with miscarriage in the first trimester, such as ectopic pregnancy, blighted ovum, and twin gestation.

Follow-up ultrasonography should be performed as clinically indicated.

Degree of confidence

Ultrasonography lacks high sensitivity for small bleeds. However, it is the most useful modality in a pregnant patient with vaginal bleeding. The finding of a subchorionic or retroplacental hematoma as demonstrated on sonography performed immediately after an episode of vaginal bleeding indicates a prognosis worse than that expected if no hematoma were seen.[10, 11, 16, 17, 18]

False positives/negatives

Uterine fibroids or focal myometrial contractions (see image below) can cause the placenta to appear thickened, or they may look like subchorionic or retroplacental hematomas. Hematomas are avascular on color Doppler scanning. Fibroids have a characteristic hypoechoic appearance with or without calcifications and typical peripheral blood flow in color Doppler images. Color flow is seen in contracted myometrium, and transient myometrial contractions usually resolve within 30 minutes of scanning.

Sagittal endovaginal scan of a dichorionic-diamnioSagittal endovaginal scan of a dichorionic-diamniotic twin pregnancy in the 13th week of gestation in a 45-year-old woman. An empty gestation sac mimics a subchorionic collection (red arrow). Also note the transient uterine contraction (yellow arrow).

Chorioamniotic separation has an anechoic appearance and usually resolves by 16 weeks. It can be distinguished from an anechoic hematoma by finding elevation of the membrane in chorioamniotic separation that extends over the fetal surface of the placenta and that terminates at the origin of the umbilical cord. The amniotic membrane is also thinner than the chorionic membrane (see image below).

Transverse endovaginal scan of the uterus in 45-yeTransverse endovaginal scan of the uterus in 45-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy demonstrates an anterior subchorionic hematoma (cursors). Also note the normal chorioamniotic separation in the posterior sac.

Primary intra-amniotic hemorrhage can occur with a large subchorionic hematoma, with trauma, or with an invasive procedure such as chorionic villous sampling[19] or amniocentesis. Floating echoes (see Image below) or echogenic clots may be seen in the amniotic cavity.

Transverse endovaginal scan in a 29-year-old womanTransverse endovaginal scan in a 29-year-old woman in 21st week of gestation demonstrates intra-amniotic hemorrhage as fine echoes dispersed in the amniotic fluid.

Hematomas of the umbilical cord are rare and may result from amniocentesis and sampling of blood from the umbilical cord. These hematomas are seen as echogenic masses limited to the cord itself.

Prominent retroplacental and myometrial vessels should be distinguished from heterogeneous bleeding. The vessels appear as serpentine, anechoic structures and demonstrate flow on color Doppler sonography (see images below); these features differentiate them from avascular hematomas.

Sagittal endovaginal scan of the uterus demonstratSagittal endovaginal scan of the uterus demonstrates a small subchorionic hematoma (red arrow) in a 26-year-old woman in the 7th week of gestation. Also note the prominent retroplacental veins (blue arrow), which are normally in pregnancy. Sagittal gray-scale endovaginal scan (top) of the Sagittal gray-scale endovaginal scan (top) of the uterus in a 16-year-old mother in 25th week of gestation demonstrates a hypoechoic area adjacent to the lower edge of the placenta; this finding suggests a small subchorionic hematoma. However, color Doppler scan (bottom) at the same level confirms that this finding represents prominent vessels mimicking a subchorionic hematoma. Sagittal endovaginal gray-scale scan in a 21-year-Sagittal endovaginal gray-scale scan in a 21-year-old woman in 33rd week of pregnancy demonstrates prominent retroplacental vessels mimicking a retroplacental hematoma. Color Doppler scan in a 21-year-old woman in 33rd Color Doppler scan in a 21-year-old woman in 33rd week of pregnancy demonstrates prominent retroplacental vessels mimicking a retroplacental hematoma.
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Contributor Information and Disclosures
Author

Avneesh Chhabra, MD  Staff Radiologist, Department of Radiology, Drexel University College of Medicine

Avneesh Chhabra, MD is a member of the following medical societies: American Medical Association, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Kiran Batra, MD, DNB  Neuroradiology Fellow, Radiology Resident, Drexel University College of Medicine

Kiran Batra, MD, DNB is a member of the following medical societies: American Roentgen Ray Society, Pennsylvania Radiological Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Nancy A Mohsen, MD  Assistant Professor, Department of Radiology, Drexel University College of Medicine, Hahnemann Hospital

Nancy A Mohsen, MD is a member of the following medical societies: American College of Radiology

Disclosure: Nothing to disclose.

Michael J Hallowell, MD, RVT  Chairman and Associate Professor, Department of Radiologic Sciences, Drexel University College of Medicine; Clinical Service Chief, Department of Radiology, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Kathleen A Kuhlman, MD  Associate Professor, Director of Reproductive Ultrasound, Department of Obstetrics and Gynecology, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Victoria Tway, RDMS  Clinical Supervisor of Reproductive Ultrasound, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Drexel Center for Genetics, Fetal and Maternal Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Christopher L Sistrom, MD  Associate Chair for Research, Assistant Professor, Department of Radiology, University of Florida School of Medicine

Christopher L Sistrom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of University Radiologists, Phi Beta Kappa, and Radiological Society of North America

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD  Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Karen L Reuter, MD, FACR  Professor, Department of Radiology, Lahey Clinic Medical Center

Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Robert M Krasny, MD  Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America

Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD  Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine

Disclosure: Nothing to disclose.

References

  1. Deutchman M, Tubay AT, Turok D. First trimester bleeding. Am Fam Physician. Jun 1 2009;79(11):985-92. [Medline].

  2. Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound. Obstet Gynecol. Sep 2003;102(3):483-7. [Medline].

  3. Kadir R, Chi C, Bolton-Maggs P. Pregnancy and rare bleeding disorders. Haemophilia. Feb 27 2009;[Medline].

  4. Koifman A, Levy A, Zaulan Y, Harlev A, Mazor M, Wiznitzer A, et al. The clinical significance of bleeding during the second trimester of pregnancy. Arch Gynecol Obstet. Jul 2008;278(1):47-51. [Medline].

  5. Kurjak A, Schulman H, Zudenigo D, et al. Subchorionic hematomas in early pregnancy: clinical outcome and blood flow patterns. J Matern Fetal Med. Jan-Feb 1996;5(1):41-4. [Medline].

  6. Pearlstone M, Baxi L. Subchorionic hematoma: a review. Obstet Gynecol Surv. Feb 1993;48(2):65-8. [Medline].

  7. Pedersen JF, Mantoni M. Prevalence and significance of subchorionic hemorrhage in threatened abortion: a sonographic study. AJR Am J Roentgenol. Mar 1990;154(3):535-7. [Medline].

  8. Bennett GL, Bromley B, Lieberman E, Benacerraf BR. Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology. Sep 1996;200(3):803-6. [Medline].

  9. Leite J, Ross P, Rossi AC, Jeanty P. Prognosis of very large first-trimester hematomas. J Ultrasound Med. Nov 2006;25(11):1441-5. [Medline].

  10. Abu-Yousef MM, Bleicher JJ, Williamson RA, Weiner CP. Subchorionic hemorrhage: sonographic diagnosis and clinical significance. AJR Am J Roentgenol. Oct 1987;149(4):737-40. [Medline].

  11. Ball RH, Ade CM, Schoenborn JA, Crane JP. The clinical significance of ultransonographically detected subchorionic hemorrhages. Am J Obstet Gynecol. Mar 1996;174(3):996-1002. [Medline].

  12. Trop I, Levine D. Hemorrhage during pregnancy: sonography and MR imaging. AJR Am J Roentgenol. Mar 2001;176(3):607-15. [Medline].

  13. Gupta R, Sharma R, Jain T, Vashisht S. Antenatal MRI diagnosis of massive subchorionic hematoma: a case report. Fetal Diagn Ther. 2007;22(6):405-8. [Medline].

  14. Linduska N, Dekan S, Messerschmidt A, Kasprian G, Brugger PC, Chalubinski K, et al. Placental pathologies in fetal MRI with pathohistological correlation. Placenta. Jun 2009;30(6):555-9. [Medline].

  15. Poulose T, Richardson R, Ewings P, Fox R. Probability of early pregnancy loss in women with vaginal bleeding and a singleton live fetus at ultrasound scan. J Obstet Gynaecol. Nov 2006;26(8):782-4. [Medline].

  16. Nyberg DA, Cyr DR, Mack LA, et al. Sonographic spectrum of placental abruption. AJR Am J Roentgenol. Jan 1987;148(1):161-4. [Medline].

  17. Richards DS, Bennett BB. Prenatal ultrasound diagnosis of massive subchorionic thrombohematoma. Ultrasound Obstet Gynecol. May 1998;11(5):364-6. [Medline].

  18. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound. Jul-Aug 2008;36(6):352-66. [Medline].

  19. Akhlaghpoor S, Tomasian A. Safety of chorionic villus sampling in the presence of asymptomatic subchorionic hematoma. Fetal Diagn Ther. 2007;22(5):394-400. [Medline].

 
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Transverse endovaginal scan of the uterus in a 45-year-old woman in 8th week of gestation. Small subchorionic hematoma is anterior to a gestational sac.
Sagittal endovaginal scan of the uterus in a 19-year-old woman in 20th week of gestation demonstrates a small anterior subchorionic hematoma adjacent to the lower edge of the placenta.
Transverse scan demonstrates a hematoma in a 19-year-old woman in 20th week of gestation.
Sagittal endovaginal scan of the uterus demonstrates a small subchorionic hematoma (red arrow) in a 26-year-old woman in the 7th week of gestation. Also note the prominent retroplacental veins (blue arrow), which are normally in pregnancy.
Transverse endovaginal scan of the uterus in 45-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy demonstrates an anterior subchorionic hematoma (cursors). Also note the normal chorioamniotic separation in the posterior sac.
Sagittal endovaginal scan of the uterus in 37-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy demonstrates an anterior subchorionic hematoma.
Sagittal endovaginal scan in 37-year-old woman in the 13th week of a dichorionic-diamniotic twin pregnancy shows extension of the hematoma in the intertwin membrane cleft, where the 2 placentas fuse.
Sagittal endovaginal scan of a dichorionic-diamniotic twin pregnancy in the 13th week of gestation in a 45-year-old woman. An empty gestation sac mimics a subchorionic collection (red arrow). Also note the transient uterine contraction (yellow arrow).
Sagittal endovaginal scan of the uterus in a 29-year-old woman in 9th week of gestation demonstrates nonfusion and separation of chorion and amnion.
Transverse endovaginal scan in a 29-year-old woman in 21st week of gestation demonstrates intra-amniotic hemorrhage as fine echoes dispersed in the amniotic fluid.
Sagittal gray-scale endovaginal scan (top) of the uterus in a 16-year-old mother in 25th week of gestation demonstrates a hypoechoic area adjacent to the lower edge of the placenta; this finding suggests a small subchorionic hematoma. However, color Doppler scan (bottom) at the same level confirms that this finding represents prominent vessels mimicking a subchorionic hematoma.
Sagittal endovaginal gray-scale scan in a 21-year-old woman in 33rd week of pregnancy demonstrates prominent retroplacental vessels mimicking a retroplacental hematoma.
Color Doppler scan in a 21-year-old woman in 33rd week of pregnancy demonstrates prominent retroplacental vessels mimicking a retroplacental hematoma.
 
 
 
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