What is the management and treatment for a patient with subchorionic hemorrhage?

Management of Subchorionic Hemorrhage

Subchorionic hemorrhage (SCH) requires conservative management with close monitoring, as there is no proven specific treatment that alters outcomes, though bed rest may reduce spontaneous abortion rates. 1, 2

Definition and Diagnosis

• SCH is diagnosed by ultrasound imaging, appearing as a collection of blood between the chorion and uterine wall 1
• SCH can occur in any trimester but presents differently based on gestational age 1
• Initial symptoms typically include vaginal bleeding and/or uterine contractions 3

Risk Factors

• Known risk factors include maternal coagulation factor deficiencies and anticoagulation therapy 1
• Women on direct oral anticoagulants (DOACs) should be switched to alternative anticoagulation if pregnancy is planned or immediately if pregnancy is discovered 4

Management Approach

First Trimester SCH

• Bed rest is recommended during active bleeding episodes, as studies show it may reduce spontaneous abortion rates (9.9% vs 23.3%) and increase term delivery rates (89% vs 70%) 2
• Early ultrasound examination should be performed to:
  • Assess fetal viability
  • Evaluate for evidence of subchorionic/retroplacental bleeding 4
  • Measure the size of the hematoma (larger hematomas may have worse prognosis) 1, 3

Pharmacological Management

• Progesterone therapy may be beneficial:
  • Dydrogesterone (40 mg/day) has shown promise in reducing abortion rates in women with SCH (7% abortion rate with treatment) 5
  • The immunomodulatory effect of progesterone helps maintain pregnancy by supporting a T helper-2 cytokine balance 5

Monitoring Protocol

• Serial ultrasound examinations at 7-day intervals until:
  • Bleeding ceases
  • Subchorionic hematoma disappears
  • Pregnancy outcome is determined 2
• For second and third trimester SCH:
  • Serial growth ultrasounds
  • Umbilical artery Doppler studies
  • Antenatal fetal testing, particularly if the SCH is large or maternal blood transfusion is required 1

Prognosis and Complications

• SCH is associated with increased risk of:
  • Spontaneous abortion (17.6% vs 8.9% in controls; OR 2.18) 6
  • Stillbirth (1.9% vs 0.9%; OR 2.09) 6
  • Placental abruption (3.6% vs 0.7%; OR 5.71) 6
  • Preterm delivery (13.6% vs 10.1%; OR 1.40) 6
  • Preterm premature rupture of membranes (3.8% vs 2.3%; OR 1.64) 6
• Persistent SCH with symptoms until delivery is particularly concerning:
  • May result in spontaneous abortion (13.6%)
  • High rate of premature labor (77.3%)
  • Only 9.1% reach full-term delivery 3

Special Considerations

• For women on anticoagulants who develop SCH:
  • If on DOACs, discontinue immediately and switch to low molecular weight heparin 4
  • Early obstetric review and fetal monitoring are essential 4
• For large SCH requiring hospitalization:
  • Monitor for signs of hemodynamic instability
  • Consider blood transfusion if significant blood loss occurs 1
  • Tocolysis may be attempted but has limited success in preventing premature delivery in cases of persistent SCH 3

Common Pitfalls

• Failing to provide adequate follow-up monitoring, as SCH can persist for weeks (average duration of bleeding: 28.8 ± 19.1 days) 2
• Overlooking the need for serial ultrasound monitoring to assess hematoma resolution 2
• Underestimating the risk of adverse outcomes even after bleeding has stopped, as SCH is associated with later pregnancy complications 6