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Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of Gestation in Singlet

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Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of Gestation in Singlet Obstetrics: Original Research Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of 10/03/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3oaxD/vH2r75sSQQDNjZrr3KH+LcwFQox2jirv34XnUs= by https://journals.lww.com/greenjournal from Downloaded Gestation in Singleton Pregnancies Downloaded Mackenzie N. Naert, BA, Alberto Muniz Rodriguez, BA, Hanaa Khadraoui, BA, Mariam Naqvi, MD, from and Nathan S. Fox, MD https://journals.lww.com/greenjournal OBJECTIVE: To assess the association of first-trimester not differ between the groups. On univariable analysis, subchorionic hematomas with pregnancy outcomes after subchorionic hematoma was not associated with any 20 weeks of gestation in women with singleton preg- pregnancy outcomes at more than 20 weeks of gestation, nancies. including gestational age at delivery, preterm birth, birth by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3oaxD/vH2r75sSQQDNjZrr3KH+LcwFQox2jirv34XnUs= METHODS: We conducted a retrospective cohort study weight, birth weight less than the 10th percentile for of all women with singleton pregnancies presenting for gestational age, gestational hypertension, preeclampsia, prenatal care before 14 weeks of gestation over a 3-year placental abruption, intrauterine fetal death at more than period at a single obstetric practice. All patients under- 20 weeks of gestation, cesarean delivery, blood transfu- went routine first-trimester ultrasound examinations. We sion, and antepartum admissions. On regression analysis compared rates of adverse pregnancy outcomes at more including subchorionic hematoma, vaginal bleeding, and than 20 weeks of gestation in women with and without gestational age at ultrasound examination, vaginal bleed- a subchorionic hematoma on the initial ultrasound examination, excluding women with pregnancy loss ing was independently associated with preterm birth at before 20 weeks of gestation. less than 37 weeks of gestation and birth weight less than RESULTS: From January 2015 to December 2017, a total the 10th percentile. Subchorionic hematoma was not of 2,172 women met the inclusion criteria for the study, independently associated with pregnancy outcomes. This 389 (17.9%) of whom had a subchorionic hematoma study had 80% power to detect a 5% absolute difference (mean largest diameter 2.161.4 cm). Women with sub- in the frequency of preterm birth; that is, from 10% to chorionic hematomas had their first ultrasound examina- 15%. tion at earlier gestational ages (8 5/7 vs 9 6/7 weeks, CONCLUSION: In singleton pregnancies, a first- P, .001) and were more likely to have vaginal bleeding trimester subchorionic hematoma is not associated with at the time of the ultrasound examination (31.9% vs adverse pregnancy outcomes at more than 20 weeks of 7.9%, P,.001). Maternal age, race, use of in vitro fertil- gestation. ization, body mass index, and medical comorbidities did (Obstet Gynecol 2019;134:863–8) DOI: 10.1097/AOG.0000000000003487 on 10/03/2019 From the Icahn School of Medicine at Mount Sinai, New York, Touro College of Osteopathic Medicine, Harlem, and Maternal Fetal Medicine Associates, PLLC, ubchorionic hematomas are commonly observed New York, New York. Son ultrasound examination during the first trimes- Each author has confirmed compliance with the journal’s requirements for ter. The reported incidence varies widely, from as low authorship. as 0.46% to as high as 39.5%.1–3 Although a study of Corresponding author: Mackenzie N. Naert, BA, Icahn School of Medicine at 451 singleton pregnancies with subchorionic hemato- Mount Sinai, New York, NY 10028; email: [email protected].. Financial Disclosure mas showed that subchorionic hematoma is not inde- The authors did not report any potential conflicts of interest. pendently associated with pregnancy loss before 20 weeks of gestation,4 the data are conflicting regarding © 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. the association between subchorionic hematoma and ISSN: 0029-7844/19 adverse outcomes later in pregnancy. VOL. 134, NO. 4, OCTOBER 2019 OBSTETRICS & GYNECOLOGY 863 © 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. A large systematic review found that subchorionic ultrasound report. Subchorionic hematoma was hematomas were associated with an increased risk of defined as a crescent-shaped, echo-free area between stillbirth, placental abruption, and preterm birth,5 and the chorionic membrane and the myometrium.2 other studies have found associations with low birth We reviewed each woman’s computerized medical weight,6,7 gestational hypertension,7 preeclampsia,7 record to obtain demographic and baseline clinical and higher rates of cesarean delivery.7 Yet other stud- information. ies have found no increased rate of preterm birth,6 We compared baseline characteristics between stillbirth,6 preeclampsia,5,8 or small-for-gestational- the women with and without subchorionic hematomas age neonates.5,8 Subchorionic hematoma duration using x2 and Student’s t-tests for parametric data and may also affect rates of adverse pregnancy outcomes,3 Fisher’s exact test for nonparametric data, as appro- although the majority of studies did not analyze sub- priate (IBM SPSS for Windows 22.0). Outcomes mea- chorionic hematoma duration and mention this as sured included gestational age at delivery (mean a limitation.7,8 Additionally, many of these studies weeks), preterm birth at less than 34 weeks of gesta- have significant methodologic limitations that reduce tion, preterm birth at less than 37 weeks of gestation, their generalizability. birth weight (mean grams), birth weight less than the In light of the limitations of prior investigations, 10th percentile for gestational age, gestational hyper- the objective of this study was to investigate the tension, preeclampsia, placental abruption, intrauter- association between first-trimester subchorionic ine fetal death at more than 20 weeks of gestation, hematoma and adverse pregnancy outcomes at more cesarean delivery, blood transfusion, and an antepar- than 20 weeks of gestation in unselected women with tum admission. Outcomes were defined clinically at singleton pregnancies. the time of diagnosis according to contemporary guidelines. We compared these outcomes between METHODS women with and without subchorionic hematomas. This was a retrospective cohort study of all women We correlated subchorionic hematoma size and preg- with singleton pregnancies who presented for prenatal nancy outcomes using Pearson’s correlation test. We care before 14 weeks of gestation at a single maternal– performed a multivariable logistic regression to con- fetal medicine practice over a 3-year period between trol for significant differences in baseline characteris- January 2015 and December 2017. All women in our tics between the two groups (P,.05). practice undergo an ultrasound examination at our For the subgroup of women with subchorionic affiliated imaging center at or before their initial visit. hematomas, we also looked at their second-trimester The images are all archived, and formal reports are ultrasound examinations to determine how long the generated. We reviewed the initial ultrasound exam- hematomas persisted. We recorded whether or not the ination performed between 6 0/7 and 13 6/7 weeks of subchorionic hematoma was present during the fol- gestation for each patient. Gestational age was deter- lowing intervals: 14 0/7–17 6/7 weeks of gestation mined by last menstrual period or first-trimester ultra- and 18 0/7–21 6/7 weeks of gestation. We also re- sound examination, or both, per standard guidelines.9 corded the hematoma size by largest diameter and The date of embryo transfer was used to determine volume (length3width3height). We looked at the gestational age of pregnancies resulting from in vitro percentage of hematomas that persisted into the sec- fertilization (IVF). ond trimester, as well as their mean size by volume We excluded pregnancies with multiple gesta- and largest diameter. Lastly, we looked to see whether tions, a vanishing twin, or a fetal heart rate less than subchorionic hematomas that persisted into the sec- 100 beats per minute. We previously have published ond trimester were associated with gestational age at an article regarding the association between first- delivery, birth weight, placental abruption, pre- trimester subchorionic hematoma and pregnancy loss eclampsia, or intrauterine fetal death. at less than 20 weeks of gestation.4The present study This project was approved by the Biomedical was designed to look at pregnancy outcomes after 20 Research Alliance of New York’s Institutional Review weeks of gestation; therefore, we excluded women Board. There was no funding for this study. who had a pregnancy loss at less than 20 weeks of gestation. RESULTS We reviewed each ultrasound report for the A total of 2,586 women presented for prenatal care presence or absence of a subchorionic hematoma, before 14 weeks of gestation with singleton gestations their number and size, and the presence or absence of over the course of the study period, of whom 2,172 vaginal bleeding, which are all routinely noted on the were ultimately included in this analysis (Fig. 1). Of 864 Naert et al Subchorionic Hematomas and Pregnancy Outcomes After 20 Weeks OBSTETRICS & GYNECOLOGY
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