What is the management plan for a subchorionic hemorrhage in an In Vitro Fertilization (IVF) pregnancy?

Management of Subchorionic Hemorrhage in IVF Pregnancy

For subchorionic hemorrhage (SCH) in IVF pregnancy, perform serial ultrasound examinations at 7-day intervals until bleeding ceases or the hematoma resolves, with enhanced surveillance including umbilical artery Doppler studies and antenatal fetal testing, particularly for medium-to-large hematomas. 1, 2

Initial Assessment and Documentation

• Obtain transvaginal ultrasound to document the location of the SCH relative to the placenta, measure hematoma size (classify as small, medium, or large), and confirm fetal cardiac activity using M-mode ultrasound or video clips 1, 3
• Avoid pulsed Doppler ultrasound in the first trimester due to potential bioeffects on the developing embryo 1, 3
• Obtain quantitative beta-hCG level and complete blood count to assess for anemia and trend hormone levels 1, 3
• Check blood type and screen if not already on file, particularly to identify Rh-negative patients who will require anti-D immunoglobulin (50 μg for first trimester bleeding) 1, 3

IVF pregnancies have a significantly higher frequency of SCH (22.4%) compared to spontaneous pregnancies (11%), with frozen-thawed embryo transfer, parity ≥1, and blastocyst transfer being specific risk factors. 4

First Trimester Management Protocol

• Schedule serial ultrasound examinations at 7-day intervals until bleeding ceases, the subchorionic hematoma disappears, or pregnancy outcome is determined 1, 3
• Prognosis is favorable when fetal cardiac activity is present 1, 3
• Consider bed rest during active bleeding, as retrospective data suggests fewer spontaneous abortions (9.9% vs 23.3%) and higher term pregnancy rates (89% vs 70%) in women who adhered to bed rest, though this lacks randomized trial evidence 5

Risk Stratification by Hematoma Size

Large hematomas carry the highest risk and require the most intensive monitoring. 6

• Small SCH: Monitor with standard 7-day interval ultrasounds; generally favorable prognosis 6
• Medium SCH: Associated with significantly higher rates of placental abruption and early pregnancy loss compared to controls; requires closer surveillance 6
• Large SCH: Significantly increased risk of first trimester vaginal bleeding, early pregnancy loss, intrauterine growth restriction (IUGR), placental abruption, and preterm delivery before 37 weeks; these patients require hospitalization consideration and blood transfusion readiness if hemodynamically unstable 2, 6

Second and Third Trimester Management

• Perform umbilical artery Doppler studies for all second and third trimester SCH cases 7, 2
• Implement serial growth ultrasounds to monitor for IUGR, which occurs more frequently with SCH 2, 6
• Consider antenatal fetal testing, particularly if the SCH is large or required maternal blood transfusion 2
• Monitor for signs of hemodynamic instability in large SCH requiring hospitalization, with consideration of blood transfusion if significant blood loss occurs 7

Special Considerations for Anticoagulated Patients

If the patient is on anticoagulation (relevant for some IVF patients with thrombophilia):

• Immediately discontinue direct oral anticoagulants (DOACs) and switch to low molecular weight heparin 7, 1
• Provide early obstetric review and enhanced fetal monitoring, including detailed first trimester scan (11-13+6 weeks) and anomaly scan (18-23 weeks) 1

Common Pitfalls to Avoid

• Do not confuse early first trimester SCH with normal decidual bleeding or other placental abnormalities like subamniotic hematomas 1
• Do not overlook Rh status—failure to administer anti-D immunoglobulin can lead to alloimmunization 1
• Do not assume small hematomas are benign—even small SCH in IVF pregnancies warrant serial monitoring given the higher baseline risk in this population 4, 6
• Do not use pulsed Doppler for cardiac activity assessment in the first trimester; use M-mode instead 1, 3

Prognostic Factors

Unfavorable outcomes correlate with:

• Larger relative and absolute size of the hematoma 8, 6
• Severity of vaginal bleeding 8
• Increasing hematoma size on follow-up examination 8
• Presence of pain 8

The outcome is not significantly correlated with echogenicity of the hematoma, presence of placental margin elevation, gestational age, maternal age, gravidity, or parity 8