Initial Management of Subchorionic Hematoma
For subchorionic hematoma, the initial management approach should be conservative in hemodynamically stable patients, with close monitoring for complications, while surgical intervention should be reserved for cases with hemodynamic instability, expanding hematoma, or severe neurological deficits that fail to improve with conservative measures. 1
Assessment and Diagnosis
- CT scan with IV contrast is the preferred imaging modality for diagnosing suspected retroperitoneal bleeding, including subchorionic hematoma, to accurately identify the location, size, and potential source of bleeding 1
- MRI can be useful for differentiating between blood and underlying neoplasm, and for characterizing bleeding acuity by identifying acute versus chronic blood 1
- The ratio of the hematoma to the gestational sac is an important prognostic factor - when this ratio exceeds 35%, there is a 4.5-fold increased risk of pregnancy loss 2
Management Based on Hemodynamic Status
For Hemodynamically Stable Patients
- Implement conservative management with close monitoring 1
- Provide adequate analgesia for pain control 1
- Monitor hemoglobin levels regularly to assess for continued bleeding 1
- Apply the principles of rest, ice, compression, and elevation (RICE) to limit further bleeding and reduce inflammation 1, 3
- For pregnant patients with subchorionic hematoma, bed rest and close monitoring are recommended 4, 5
For Hemodynamically Unstable Patients
- Secure large-bore intravenous access (8-Fr central access is ideal in adults) 1
- Administer high FiO2 and actively warm the patient and all transfused fluids 1
- Obtain baseline blood tests including full blood count, coagulation studies, and cross-match 1
- Initiate blood product resuscitation with warmed blood and blood components 1
- Consider invasive blood pressure monitoring for patients with significant comorbidities 1
- Perform immediate intervention (surgery or angioembolization in selected situations) for patients with no or transient response to resuscitation 6
Interventional Approaches
- Ultrasound-guided aspiration may be considered for large hematomas causing significant pain or functional impairment 1, 3
- Percutaneous drainage can be attempted for accessible collections that are causing significant symptoms 1
- Arterial embolization should be considered if active bleeding is identified on imaging 1
- For symptomatic hematomas with significant mass effect, surgical intervention may be necessary 6
Special Considerations for Pregnancy-Related Subchorionic Hematoma
- In pregnancy, subchorionic hematoma is associated with adverse outcomes including preterm birth, preterm prelabor rupture of membranes, fetal growth restriction, and fetal demise 4
- Serial growth ultrasounds, umbilical artery Doppler studies, and antenatal fetal testing should be considered, particularly if the hematoma is large 4
- Tocolysis may be needed but has limited success in preventing premature delivery in cases of persistent subchorionic hematoma with symptoms 7
- For pregnant patients with subchorionic hematoma, monitoring should continue throughout pregnancy as persistent hematomas with clinical symptoms are likely to result in abortion or premature labor 7
Monitoring and Follow-up
- Serial hemoglobin measurements to detect ongoing bleeding 1
- Once bleeding is controlled, standard venous thromboprophylaxis should be commenced as patients rapidly develop a prothrombotic state 1
- Patients should be advised to seek urgent medical attention if they develop new-onset severe back or leg pain, lower limb motor weakness or sensory disturbance, urinary or fecal incontinence, urinary retention, perineal sensory disturbance, nausea and vomiting, or fever 6