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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 17
| Issue : 4 | Page : 816-819 |
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Perinatal outcome of subchorionic hemorrhage in early pregnancy vaginal bleeding
Manisha Gupta, Neelima Agarwal, Alpana Agrawal
Department of Obstetrics and Gynaecology, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India
| Date of Submission | 17-Jan-2022 |
| Date of Decision | 17-Jan-2022 |
| Date of Acceptance | 12-Oct-2022 |
| Date of Web Publication | 10-Feb-2023 |
Correspondence Address:
Prof. Manisha Gupta
R 14/22 Rajnagar, Ghaziabad, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_17_22
Introduction: First-trimester vaginal bleeding is an early indicator of underlying placental pathology and is a causative factor for adverse perinatal outcome. Although subchorionic hemorrhage is quite prevalent ,but outcomes have not been studied in the ongoing pregnancies. Hence, we aimed to study the outcome in pregnancies with subchorionic hemorrhage presenting with vaginal bleeding in up to 20 weeks of pregnancy. Methodology: The present study was an observational study conducted over a period of 1 year. A sample size of 230 patients presenting with threatened abortion within 20 weeks of gestation and who fulfilled the inclusion criteria were recruited in the study. A routine ultrasound examination was done to analyze the presence of subchorionic hemorrhage, and the outcomes of such pregnancies were studied. Results: Total 230 subjects presented with bleeding in early pregnancy with gestational age of <20 weeks on ultrasound examination; 31 (13.4%) patients were found to have subchorionic hemorrhage. The present study showed that women with subchorionic hematoma had a significantly higher rate of complications. Conclusion: There is an increased risk of adverse outcome in pregnancy with subchorionic hemorrhage.
Keywords: Perinatal outcome, subchorionic hemorrhage, threatened abortion, vaginal bleeding
How to cite this article:
Gupta M, Agarwal N, Agrawal A. Perinatal outcome of subchorionic hemorrhage in early pregnancy vaginal bleeding. J Datta Meghe Inst Med Sci Univ 2022;17:816-9 |
| Introduction | |  |
The occurrence of bleeding in early pregnancy is a cause for stress and anxiety to the mother and treating obstetrician regarding the outcome of pregnancy. About 50% of cases of first-trimester bleeding end in miscarriage within 20 weeks of gestation[1] and those women who remain pregnant have an increased risk of developing other complications later in pregnancy.[2] Bleeding in early pregnancy results in influx of maternal blood in placenta, which leads to rise in oxygen tension and release of reactive oxygen species as a byproduct of aerobic respiration. A paucity of antioxidants leads to an imbalance, which results in adverse pregnancy outcomes. The outcome of early pregnancy bleeding is likely to be affected by cause of bleeding, gestational age at the time of bleeding, and amount of bleeding.
Ultrasonography is an important modality for the confirmation of diagnosis and also for predicting the outcome in cases of threatened abortion. Apart from ascertaining the viability, the presence of subchorionic hemorrhage, which is associated with 4%–33% rate of miscarriage,[3] can also be diagnosed. In 18%–39% of the women presenting with threatened miscarriage, a subchorionic or retroplacental hematoma can be seen on ultrasound.[4] One of the most studied and reported adverse outcomes with subchorionic hematoma is miscarriage.
With this background, we aimed to assess the outcome in pregnancies with subchorionic hemorrhage presenting with vaginal bleeding in up to 20 weeks of pregnancy.
| Methodology | | |
The present study was an observational study conducted over a time period of 1 year from September 2019 to September 2020 in a tertiary care hospital in Ghaziabad. Antenatal patients presenting with bleeding before 20 weeks of gestation who met the inclusion and exclusion criteria were recruited in the study.
Inclusion criteria
- No hormonal contraception use
- Spontaneous conception
- Singleton pregnancy
- Sure of dates.
Exclusion criteria
- History of any chronic medical illness
- Addictions such as tobacco or drug abuse
- Extrauterine, nonviable, or molar pregnancy
- Congenital uterine anomalies
- Pelvic tumors
- Local cervical and vaginal lesions causing bleeding
- Bleeding disorders.
Approval from the ethical committee of the institution was obtained before conducting the study (F No. SU/2019/1296(9), Dated September 3, 2021). After explaining the purpose and procedures of the study, written informed consent was taken from all participants before recruitment in the study. The subjects were assured of their confidentiality.
A detailed history was taken including age, parity, duration of onset of bleeding, amount of blood loss, and its association with pain. Clinical, systemic, and gynecological examination was done for each patient. Routine and special investigations such as ultrasound (pelvis/transvaginal) were done to confirm fetal viability, subchorionic hematoma, and placental localization. The diagnostic criteria for threatened miscarriage were based on documented fetal cardiac activity on ultrasound with a history of vaginal bleeding in the presence of a closed cervix and gestational age at 20 weeks or less. All subjects with the presence of subchorionic hemorrhage were followed throughout the pregnancy and their perinatal outcome was studied.
The outcome of pregnancy is categorized as abortions and ongoing live pregnancies, where the perinatal outcome was observed.
Perinatal outcome (continuation of pregnancy after 20 weeks)
- Preterm delivery
- Low birth weight (<2500 kg)
- Antepartum hemorrhage
- Intrauterine growth retardation
- Neonatal intensive care unit (NICU) admission
- Full-term birth with a healthy fetus.
The STROBE guidelines were followed when reporting the clinical data.
The data were tabulated and percentages (frequencies) of various parameters was calculated and subjected to statistical test using Chi-square test and t-test wherever applicable. Statistical significance was taken as P ≤ 0.05.
Ethical clearance
Ethical approval for this study (Ethical Committee SU/2019/1296[9]) was provided by the Ethical Committee Santosh Deemed to be University, Uttar Pradesh, on 17 June 2019.
| Results | | |
Total 230 subjects presented with bleeding in early pregnancy with gestational age of <20 weeks. Out of these, 163 (70.8%) patients had live birth and 67 (29.2%) pregnancies ended in abortion. On ultrasound examination, 31 patients were found to have subchorionic hemorrhage. The incidence of subchorionic hemorrhage was observed to be 13.4%.
The outcome of pregnancies complicated with subchorionic hemorrhage was studied and the incidence of women who had abortion after bleeding (70.9%; n = 22) was found to be much higher than who continued pregnancy (29.1%; n = 9). The odds ratio in women who had subchorionic hemorrhage and whose pregnancy ended in abortion was significantly higher (odds ratio: 8.3654, P < 0.0001).
The mean age ± standard deviation was 25.15 ± 4.11 years, where 79.31% of women fell in the age group of 21–30 years. The mean parity of the study group was 1.02±.03.
The mean period of gestation of patients who had subchorionic hemorrhage was 8.64 ± 1.34 weeks [Table 1]. | Table 1: Period of gestation at bleeding with subchorionic hematoma (n=31)
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Most of the women had spontaneous abortions (n = 10), and the different types of abortions are depicted in [Chart 1]. All the women with missed abortion (n = 7) had surgical termination.
Rebleeding after an initial episode of bleeding occurred in 61.27% (n = 19) of cases. Out of these, only n = 2 pregnancies ended in live birth (odds ratio: 5.5, P < 0.05) It includes 10 cases of spontaneous abortion, which occurred after rebleeding.
The current study showed that women with subchorionic hematoma had a significantly higher rate of complications [Table 2]. The incidence of indeterminate APH was higher in the study group. The rate of NICU admissions was higher and statistically significant.
| Discussion | | |
The present study shows that threatened abortion in early pregnancy is an important predictor of adverse perinatal outcome. Compared with women who did not bleed during pregnancy, the risks of various maternal and fetal outcomes were found to be significantly raised.
In the present study, 29.2% of patients with first-trimester bleeding aborted, the mean gestation of which was found to be 8.64 ± 1.34 weeks, which is consistent with many other studies.[5],[6] In contrast to the findings in the present study, subchorionic hemorrhage was not associated with increased pregnancy loss.[7],[8] The timing of bleeding coincides with the timing of shift from luteal production to placental production of progesterone. This causes a slight decrease in progesterone levels, leading to activation of process of vaginal bleeding, resulting in abortion.
Majority of the pregnancy losses in the present study ended in incomplete abortion, which was in contrast to the studies by Hokabaj et al. and Kamble et al.,[6],[9] where the percentage of missed abortion was higher.
The incidence of premature rupture of membranes and preterm labor was increased in the current study. The production of hydroxyl radicals from subchorionic bleeding results in the weakening and subsequent rupture of the amniotic membranes.[2],[3],[10] Subchorionic hematoma forms a nidus for infection, which may cause preterm rupture of membranes.[11]
The risk of abruption and indeterminate APH was ignificantly increased in the current study (P < 0.05) Saraswat et al.,[12] Mulik et al.,[13] Wijesiriwardana et al.,[14],[15]
The limitations of the present study were a relatively small number of the study population. Moreover, the outcome of patients with mild subchorionic hemorrhage who may not report to hospital or come for follow-up will not be known. It is recommended that a bigger sample size may have to be studied.
| Conclusion | | |
The probability of abortion and adverse pregnancy outcome increases in the patients with subchorionic hemorrhage. Early recognition of such pregnant women and classifying them as high-risk pregnancies is important to facilitate decision-making regarding management.
Acknowledgment
We are thankful to all the subjects for participating in the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2]
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