From the Guidelines
Management of subchorionic hemorrhage in first trimester pregnancy should primarily involve conservative measures, including restriction of strenuous physical activity and avoidance of sexual intercourse, as there is no specific treatment proven to resolve the condition. According to the American College of Radiology Appropriateness Criteria 1, ultrasound (US) is the primary imaging modality in the evaluation of first trimester vaginal bleeding, and it can help distinguish between different causes of bleeding, including subchorionic hemorrhage.
Key aspects of management include:
- Restricting strenuous physical activity and avoiding sexual intercourse until bleeding resolves
- Not routinely recommending bed rest, as evidence for its benefit is lacking 1
- Considering empirical progesterone supplementation, although this practice remains without strong evidence
- Performing pelvic ultrasound to confirm fetal viability, assess the size and location of the hemorrhage, and rule out other complications
- Serial ultrasounds may be needed to monitor resolution, as recommended by the American College of Radiology Appropriateness Criteria 1
It is essential to counsel patients that while subchorionic hemorrhage increases the risk of miscarriage, particularly with larger hemorrhages, most pregnancies with subchorionic hemorrhage continue normally 1. Patients should be instructed to seek immediate medical attention if they experience heavy bleeding, severe abdominal pain, or signs of infection. Routine follow-up should be scheduled in 1-2 weeks to reassess symptoms and pregnancy status. The use of pulsed methods of Doppler US should generally be avoided in the first trimester when there is a normal, or a potentially normal, intrauterine pregnancy, as stated in the American College of Radiology Appropriateness Criteria 1.
From the Research
Management of Subchorionic Hemorrhage in First Trimester Pregnancy
- The management of subchorionic hemorrhage in the first trimester of pregnancy is crucial to prevent adverse pregnancy outcomes.
- Studies have shown that the size of the hematoma, gestational age, and maternal age are significant factors in determining pregnancy outcome 2, 3.
- A large subchorionic hematoma is associated with an increased risk of spontaneous abortion, with a nearly three-fold increase in risk compared to small and moderate hematomas 3.
- The earlier the subchorionic hemorrhage is detected, the higher the rate of subsequent pregnancy failure, with a significant difference in pregnancy failure rates between hematomas diagnosed at or before 7 weeks and those after 8 weeks 2.
- Ultrasound-detected subchorionic hemorrhage before 22 weeks of gestation is also associated with an increased risk of placental abruption and preterm delivery 4.
- However, the use of 17α-hydroxyprogesterone caproate, a progestin used to prevent preterm birth, is not associated with an increased risk of postpartum hemorrhage 5.
Factors Affecting Pregnancy Outcome
- Size of the subchorionic hematoma: a larger hematoma is associated with a higher risk of spontaneous abortion 3.
- Gestational age: earlier detection of subchorionic hemorrhage is associated with a higher rate of pregnancy failure 2.
- Maternal age: advanced maternal age is associated with a higher risk of spontaneous abortion 3.
- Presence of subchorionic hemorrhage: ultrasound-detected subchorionic hemorrhage before 22 weeks of gestation is associated with an increased risk of placental abruption and preterm delivery 4.
Implications for Clinical Practice
- Close monitoring of pregnancy outcome is necessary for women with subchorionic hemorrhage, especially those with large hematomas or advanced maternal age 2, 3.
- Ultrasound surveillance should be performed regularly to assess the size of the hematoma and fetal well-being 2, 3.
- Women with subchorionic hemorrhage should be counseled about the increased risk of placental abruption and preterm delivery 4.