Management of Subchorionic Hemorrhage
The management of subchorionic hemorrhage should include bed rest until 48 hours after cessation of bleeding, along with folic acid supplementation and close monitoring with serial ultrasounds. 1 While there are no formal guidelines specifically for subchorionic hemorrhage management, evidence suggests this approach may reduce spontaneous abortion rates and increase term pregnancy rates.
Understanding Subchorionic Hemorrhage
Subchorionic hemorrhage (SCH) is defined as blood accumulation between the chorion and decidua basalis due to separation of these layers. It is:
- Commonly detected on ultrasound as a hypoechoic or anechoic crescent-shaped dark area 2
- Present in approximately 9% of women with first-trimester vaginal bleeding 1
- Associated with potential adverse outcomes, particularly when large or occurring in later trimesters
Diagnosis
- Diagnosis is primarily made by ultrasound imaging 3
- Evaluate for:
- Size of hematoma (larger hematomas >20 cm² have worse prognosis) 4
- Location relative to placenta
- Gestational age at diagnosis
- Presence of active bleeding
Risk Factors
The only established risk factors for SCH include:
- Maternal coagulation factor deficiencies
- Anticoagulation therapy 3
Other potential contributing factors include:
- Autoimmune factors
- Assisted reproductive technology
- Reproductive tract infections 2
Management Approach
Immediate Management
Bed rest: Patients who adhere to bed rest during the duration of vaginal bleeding have significantly fewer spontaneous abortions (9.9% vs 23.3%) and higher rates of term pregnancy (89% vs 70%) compared to those who maintain normal activity 1
Duration of bed rest: Continue until at least 48 hours after cessation of bleeding 4
Folic acid supplementation: Should be provided throughout pregnancy 4
Monitoring:
- Serial ultrasounds at 7-day intervals until bleeding ceases and hematoma resolves 1
- Monitor for signs of worsening (increased bleeding, pain, or expanding hematoma)
For Second and Third Trimester SCH
For SCH diagnosed in later pregnancy:
- Increased surveillance: More frequent prenatal visits and monitoring
- Serial growth ultrasounds: To detect potential fetal growth restriction 3
- Umbilical artery Doppler studies: To assess placental function 3
- Antenatal fetal testing: Particularly if the SCH is large or maternal blood transfusion is required 3
Management of Complications
If complications develop:
Antepartum hemorrhage: Occurs in approximately 7.5% of cases that continue beyond threatened abortion 4
- Assess maternal hemodynamic stability
- Consider hospitalization for monitoring if bleeding is significant
- Blood transfusion may be necessary in severe cases
Preterm labor: Monitor for signs and symptoms
- Consider antenatal corticosteroids if preterm delivery appears imminent
Intrauterine growth restriction: Seen in about 13.2% of pregnancies that continue after threatened abortion with SCH 4
- Implement more frequent growth scans and Doppler studies
Prognosis and Outcomes
Prognosis depends on several factors:
- Size of hematoma: Larger hematomas (>20 cm²) are associated with higher rates of spontaneous abortion 4
- Timing of diagnosis: Second and third-trimester SCH carries higher risks for adverse outcomes 3
- Treatment adherence: Bed rest appears to improve outcomes significantly 1
Potential adverse outcomes include:
- Spontaneous abortion (17-23% depending on management) 1
- Preterm birth
- Preterm premature rupture of membranes (5.66%) 4
- Intrauterine growth restriction (13.2%) 4
- Intrauterine fetal demise (5.66%) 4
Follow-up
- Continue regular prenatal care with increased surveillance
- Repeat ultrasound examinations until resolution of the hematoma
- Monitor for recurrence of vaginal bleeding
- Be vigilant for signs of the complications noted above
While the evidence base for SCH management is not robust, the available data suggests that conservative management with bed rest during active bleeding provides the best outcomes for both mother and fetus.