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Subchorionic Hematoma Volume in the First Trimester and Risk of Spontaneous Abortion

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Subchorionic Hematoma Volume in the First Trimester and Risk of Spontaneous Abortion Subchorionic hematoma volume in the first trimester and risk of spontaneous abortion Volumen del hematoma sub-coriónico en el primer trimestre y riesgo de aborto espontáneo Isabel Benavides-Reyes, MD1, Eduardo Reyna-Villasmil, MD, PhD2, Jorly Mejia-Montilla, MgSc, PhD2, Duly Torres-Cepeda, MD2, Yolimar Navarro-Briceño, MD1, Joel Santos-Bolívar, MD2, Nadia Reyna-Villasmil, MgSc, PhD2, Anny Cuevas-González, MD2, Sandra Wilches-Durán, MgSc3, Modesto Graterol, MgSc, PhD3, 3 3 56 Julio Contreras-Velásquez, MgSc , Marco Cerda, MgSc 1Diagnostic Imaging Department. Maternidad “Dr. Armando Castillo Plaza”. Maracaibo, Venezuela 2Department of obstetrics and Gynecology – Obstetrics “Dr. Nerio Belloso”. Hospital Central “Dr. Urquinaona”. Maracaibo. Venezuela 3Advanced Frontier Studies Research Group (ALEF). Universidad Simón Bolívar, sede Cúcuta, Colombia Short title: Subchorionic hematoma and risk of spontaneous abortion Correspondence to: Dr. Eduardo Reyna-Villasmil. Hospital Central “Dr. Urquinaona” End of Milagros Avenue. Maracaibo, Zulia State. Venezuela. Phone number: 584162605233 e-mail: [email protected] Objective: to establish an association between subchori- Objetivo: Establecer la asociación entre el volumen del onic hematoma volume and risk of spontaneous abortion. hematoma subcoriónico en el primer trimestre y riesgo de aborto espontáneo. Methods: patients with viable intrauterine pregnancy be- tween 6 and 13 weeks were included and with diagnosis Métodos: Se incluyeron pacientes con embarazos intra- Abstract of subchorionic hematoma with or without genital bleed- Resumen uterinos viables entre 6 y 13 semanas y diagnóstico de ing and visible heart rate by ultrasound. Patients were hematoma subcoriónico con o sin sangrado genital y fre- divided into two groups depending on the interruption cuencia cardiaca visible por ultrasonido. Las pacientes fue- or continuity of pregnancy: patients who presented spon- ron posteriormente divididas en dos grupos dependiendo taneous abortion and patients who continued with their de la interrupción o no del embarazo: pacientes que pre- pregnancy after the first trimester. sentaron abortos espontáneos y pacientes que continua- ron con el embarazo más allá de la primera mitad de este. Settings: Maternity “Dr. Armando Castillo Plaza” and Hospital “Dr. Urquinaona”. Maracaibo, Venezuela. Ambiente: Maternidad “Dr. Armando Castillo Plaza” y Hospital Central “Dr. Urquinaona”. Maracaibo, Venezuela. Results: Two hundred patients were selected. The gesta- tional age at the moment of the ultrasound evaluation was Resultados: se seleccionaron 200 pacientes. La edad ges- 9.2 ± 2.0 weeks and the mean value of subchorionic hema- tacional al momento de la evaluación ecográfica de 9,2 ± toma volume was 22.4 ± 12.2 cm3. The rate of spontaneous 2,0 semanas y el volumen promedio del hematoma sub- 3 abortion in the group was 33.5%. Patients who presented coriónico de 22,4 ± 12,2 cm . La tasa de aborto espontá- spontaneous abortion did not show significant differences neo en el grupo de pacientes seleccionadas fue de 33,5%. in the maternal age and gestational age at the moment of Las pacientes que presentaron abortos no presentaron di- the ultrasound evaluation compared to those who contin- ferencias significativas en edad materna y edad gestacio- ued with their pregnancy (p = ns). Patients with spontane- nal al momento de la evaluación ecográfica comparado ous abortion presented higher mean values of subchorionic con las pacientes que continuaron con el embarazo (p = hematoma volume (p = 0.05). Relative risk were significant ns). Las pacientes con abortos presentaron valores prome- for groups who presented hematomas considered big (rela- dio mayores del volumen del hematoma subcoriónico (p tive risk = 1.74; interval confidence 95%, 1.20 – 2.44) and = 0,05). El riesgo relativo fue significativo para los grupos very big (relative risk = 4.19, interval confidence 95%, 2.51 que presentaron hematomas considerados grandes (ries- – 7.02; p < 0.05). go relativo = 1,74; intervalo de confianza 95%, 1,20 - 2,44) y muy grandes (riesgo relativo = 4,19; intervalo de Conclusion: There is an association between the first tri- confianza 95%, 2,51 – 7,02; p < 0,05). mester subchorionic hematoma volume and an increased Conclusión: Existe asociación entre el volumen del hema- risk of spontaneous abortion. toma subcoriónico en el primer trimestre y aumento del Keywords: Subchorionic hematoma; Spontaneous abor- riesgo de aborto espontáneo. tion; Risk; Ultrasound; Pregnancy. Palabras claves: Hematoma subcoriónico; Aborto espon- táneo; Riesgo; Ecografía; Embarazo. Revista Latinoamericana de Hipertensión. Vol. 10 - Nº 3, 2015 ubchorionic hematomas are common ultra- he research was carried out in pregnant women Introduction sound findings that can be associated with during their first trimester. They attended the bleedings of the first trimester of pregnancy, obstetrics emergency of the maternity “Dr. Ar- occurring in 5-25% of all the pregnancies, and normally mando Castillo Plaza” and Hospital “Dr. Urquinaona”, diagnosed accidentally or during the evaluation of patients from July 2013 to November of 2014. The research was 1,2 approved by the Committee of ethics and research of both with bleeding . Many sonographers report the presence Materials and methods or absence of subchorionic hematoma, not only to sup- hospitals and a written consent of patients was obtained. ply an explanation of maternal symptoms but also as a Patients with viable intrauterine pregnancies between 6 3,4 57 forecast sign of the probable result of the pregnancy . and 13 weeks were included with diagnosis of subchorion- These hematomas are generally hypoechoic or anechoic, ic hematoma with or without genital bleeding and visible with elevated areas of the placental edge that separates heart rate by ultrasound. During the research were exclud- the uterine wall from the chorion and may be diagnosed ed patients with multiple pregnancies, not viable pregnan- 5,6 early during the first trimester . cies, presence of pathological conditions such as uterine Subchorionic hematomas usually originate from the pla- fibroids, polyps or congenital anomalies, systemic patholo- centa. The mechanisms that relate them with obstetric gies as endocrinopathies, liver diseases, alterations of the complications may rely on the fact that the bleeding be- coagulation, kidney or autoimmune diseases. Additionally, tween the chorionic membrane and the uterine wall pro- those patients who refused to participate in the research or duces a lot of effects on the development and complica- those whose follow-up was impossible to perform. 7 tions of the pregnancy . In most of the cases, the etiology All patients underwent full interrogation in which were is unknown, but can be associated with pre-existing medi- included medical, surgical and obstetric backgrounds. A cal pathologies such as autoimmune diseases and immu- previous sonogram was asked, made before their inclu- 8,9 nological factors . sion in the research. The gestational age was confirmed There are reports that have described the association of by the date of the last menstrual period and by any ul- the diagnosis of subchorionic hematoma with different trasound evaluation before the exploration, and in case complications during pregnancy10. Some reports have sug- of any discrepancy greater of 7 days between both cal- gested that the hematoma increases the risk of alterations culations, the result of this last was used. The ultrasound of the intrauterine growth, causes premature abruption of evaluation was performed exclusively by an investigator ® the placenta, premature break of membranes, preeclamp- and with the same Ultrasound (General Electric Logiq sia and preterm delivery11. However, other researchers Pro 3) with 3.5 transducers and 5 Mhz in real time, in have not confirmed these facts12,13. There are controver- longitudinal, oblique, and transverse plans to have a bet- sies about the possible association of different secondary ter appreciation of the hematoma. All patients with living obstetric pathologies of subchorionic hematoma with the embryos or fetuses and subchorionic hematomas were re- number of pregnancies, volume of subchorionic hema- evaluated in intervals of 7 to 10 days, repeating the evalu- toma, maternal age, gestational age at the moment of ation until the resolution of the subchorionic hematoma, the diagnosis and the frequency of abortions1,2,14,15, but an interruption of pregnancy or that it exceeds 20 weeks. the association between the volume of the subchorionic Subchorionic hematoma is defined as hypoechoic or hematoma and the risk of spontaneous abortion has not anechoic areas, with elevated areas and free of echoes yet been completely established. between the chorionic membrane and the myometrium. The objective of this research was to establish the associa- The volume of the hematoma was estimated by measur- tion between the volume of the subchorionic hematoma ing the following diameters: transverse, anteroposterior in the first quarter of pregnancy and the risk of spontane- and maximum longitudinal and multiplying these values 3 ous abortion. by 0.52 and expressed in cubic centimeters (cm ). The 0.52 correction factor is used to correct the shape of the hematoma, as suggested by Stabile and collaborators16. The patients were divided in two groups depending on the interruption or continuity of pregnancy: patients that presented abortions and patients who continued with their pregnancy more beyond the
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