Subchorionic Bleeding

9 7 5

Subchorionic Bleeding in Threatened Abortion: Sonographic Findings and Significance

Steven R. Goldstein 1

Bala R. Subramanyam 2

B. Nagesh Raghavendra 2

Steven C. Horii 2

Susan Hilton 2

F i f t y - s i x p a t i e n t s w i t h c l i n i c a l t h r e a t e n e d a b o r t i o n w e r e e v a l u a t e d b y s o n o g r a p h y . In s i x p a t i e n t s , f e t a l c a r d i a c a c t i v i t y w a s a b s e n t a t o r b e y o n d 9 w e e k s o f g e s t a t i o n , a n d f e t a l d e a t h w a s c o n f i r m e d in a l l s i x c a s e s . In t h e o t h e r 5 0 p a t i e n t s , f e t a l c a r d i a c a c t i v i t y w a s p r e s e n t a t o r b e y o n d 9 w e e k s o f g e s t a t i o n . In 1 0 ( 2 0 % ) o f t h e s e 5 0 p a t i e n t s , s u b c h o r i o n i c b l e e d i n g w a s p r e s e n t i n v a r i o u s d e g r e e s , a p p e a r i n g s o n o g r a p h i c a l l y a s a n e x t r a c h o r i o n i c c r e s c e n t i c a n e c h o i c o r c o m p l e x c o l l e c t i o n . T h e f i n a l o u t c o m e in t h e 5 0 p a t i e n t s w i t h f e t a l c a r d i a c a c t i v i t y w a s a s f o l l o w s : In t h e a b s e n c e o f s u b c h o r i o n i c b l e e d i n g , 1 0 0 % o f t h e p r e g n a n c i e s p r o g r e s s e d t o t e r m ; i n t h e p r e s e n c e o f s u b c h o r i o n i c b l e e d i n g t h e p o s i t i v e o u t c o m e w a s r e d u c e d t o 8 0 % . In a d d i t i o n t o s i g n s o f f e t a l l i f e o n s o n o g r a p h y , s u b c h o r i o n i c b l e e d i n g is a n i m p o r t a n t f a c t o r a f f e c t i n g t h e o u t c o m e o f g e s t a t i o n s in p a t i e n t s w i t h c l i n i c a l t h r e a t e n e d a b o r t i o n .

S p o n t a n e o u s abo r t i on is a c o m m o n c a u s e of r e p r o d u c t i v e loss a n d o c c u r s in

a b o u t 1 5 % - 2 0 % of d o c u m e n t e d p r e g n a n c i e s . The s y m p t o m s of ear ly p r e g n a n c y

fa i lu re , that is, u ter ine b leed ing and c o n t r a c t i o n s , o c c u r in up to 2 5 % of all

p r e g n a n c i e s . T h e more c o m m o n c a u s e s i nc l ude t h r e a t e n e d a b o r t i o n , s p o n t a ­

neous abo r t i on ( comp le te or i ncomp le te ) , m i ssed a b o r t i o n , and b l i gh ted o v u m .

The less c o m m o n c a u s e s i nc lude ec top i c p r e g n a n c y a n d hyda t i d i f o rm mole .

Severa l inves t iga to rs have used s o n o g r a p h y in the eva lua t ion of t h r e a t e n e d

abo r t i on and have c o m p a r e d the fea tu res a n d sens i t iv i ty of s o n o g r a p h y and

va r ious ho rmona l assays . Of the s o n o g r a p h i c f ac to r s used in the a s s e s s m e n t

a n d p rognos i s of fe ta l v iabi l i ty in ear ly p r e g n a n c y , the p r e s e n c e and s i gn i f i cance

of subcho r i on i c b leed ing have rece ived scan t a t ten t i on . W e s tud ied p rospec t i ve l y

t he p r e s e n c e , s o n o g r a p h i c a p p e a r a n c e , a n d na tura l h is to ry of s u b c h o r i o n i c

b leed ing on sequent ia l s cans , co r re la t i ng it w i th fe ta l m o t i o n , ca rd i ac ac t iv i ty ,

and the l ong - te rm p r o g n o s i s .

Subjects and Methods

R e c e i v e d F e b r u a r y 7 , 1 9 8 3 ; a c c e p t e d a f t e r r e v i s i o n J u l y 1 8 , 1 9 8 3 .

P r e s e n t e d a t t h e a n n u a l m e e t i n g o f t h e A m e r i ­c a n R o e n t g e n R a y S o c i e t y , A t l a n t a , A p r i l 1 9 8 3 .

' D e p a r t m e n t o f O b s t e t r i c s a n d G y n e c o l o g y , N e w Y o r k U n i v e r s i t y M e d i c a l C e n t e r , 5 3 0 F i r s t A v e . , N e w Y o r k , N Y 1 0 0 1 6 . A d d r e s s r e p r i n t r e ­q u e s t s t o S . R. G o l d s t e i n ( S u i t e 5 E ) .

d e p a r t m e n t o f R a d i o l o g y , N e w Y o r k U n i v e r s i t y M e d i c a l C e n t e r , N e w Y o r k , N Y 1 0 0 1 6 .

F i f t y - s i x p a t i e n t s b e t w e e n 9 a n d 1 6 w e e k s of g e s t a t i o n w i t h s y m p t o m s of l o w e r a b d o m i n a l c r a m p y p a i n a n d v a g i n a l b l e e d i n g w e r e e v a l u a t e d s o n o g r a p h i c a l l y . P a t i e n t s at 8 w e e k s of g e s t a t i o n o r less w e r e e x c l u d e d b e c a u s e fe ta l m o t i o n a n d fe ta l h e a r t a c t i v i t y c o u l d no t be d e t e c t e d r e l i a b l y .

S o n o g r a p h y w a s p e r f o r m e d w i t h c o n t a c t B - m o d e s c a n n e r s a n d l i n e a r - a r r a y o r s e c t o r r e a l - t i m e s c a n n e r s . Al l p a t i e n t s w e r e s c a n n e d w i t h i n 4 8 h r a f te r t h e o n s e t of s y m p t o m s . T h e f o l l o w i n g s o n o g r a p h i c f a c t o r s w e r e e v a l u a t e d : (1 ) s i ze , s h a p e , o u t l i n e , a n d c o n t e n t s of t h e g e s t a t i o n a l s a c ; (2 ) t h e p r e s e n c e o r a b s e n c e of s u b c h o r i o n i c b l e e d i n g ( i . e . , c r e s c e n t i c f l u i d c o l l e c t i o n b e t w e e n t h e g e s t a t i o n a l s a c a n d t h e u t e r i n e wa l l ) ; a n d (3) fe ta l m o t i o n a n d fe ta l c a r d i a c a c t i v i t y . P a t i e n t s w i t h v i a b l e f e t u s e s b u t w i t h s u b c h o r i o n i c b l e e d i n g w e r e r e e v a l u a t e d at 7- to 1 0 - d a y i n t e r v a l s . R e p e a t s o n o g r a m s w e r e o b t a i n e d unt i l t h e s u b c h o ­r i o n i c b l e e d i n g r e s o l v e d w i t h c o n t i n u e d feta l v i a b i l i t y o r unt i l t h e f e t u s w a s n o n v i a b l e . T h e o u t c o m e of e a c h p r e g n a n c y w a s d e t e r m i n e d b y c l i n i c a l f o l l o w - u p a n d d i l a t a t i o n a n d c u r e t t a g e in n o n v i a b l e c a s e s , a n d b y c l i n i c a l f o l l o w - u p to d e l i v e r y in v i a b l e c a s e s .

AJR 141 :975 -978 , November 1983 0 3 6 1 - 8 0 3 X / 8 3 / 1 4 1 5 - 0 9 7 5 © A m e r i c a n R o e n t g e n R a y S o c i e t y

9 7 6 G O L D S T E I N ET A L . A J R : 1 4 1 , N o v e m b e r 1 9 8 3

F i g . 2 .—A, T r a n s v e r s e s o n o g r a m at 9 w e e k s o f g e s t a t i o n . C r e s c e n t i c e x t r a c h o r i o n i c f l u i d c o l l e c t i o n (arrows) w i t h o n e e d g e n e a r p l a c e n t a . B, A t 1 2 w e e k s o f g e s t a t i o n . P a r t i a l r e s o l u t i o n o f f l u i d a n d c o n t i n u e d f e t a l g r o w t h . C, A t 1 5 w e e k s o f g e s t a t i o n . T o t a l r e s o l u t i o n o f f l u i d a n d c o n t i n u e d f e t a l v i a b i l i t y .

R e s u l t s

In s ix of 5 6 pa t ien ts eva lua ted , the ges ta t iona l sac w a s poor ly de f ined and d i s to r t ed , and no fetal hear t mo t ion w a s de tec ted . Th is w a s cons is ten t w i th m issed abo r t i on , w h i c h w a s con f i rmed in all s ix cases . In the o the r 5 0 pa t ien ts , the fetal age w a s de te rm ined by c r o w n - r u m p length and b ipar -ietal d iameter . The feta l age w a s 9 - 1 0 w e e k s in 3 0 pat ien ts , 1 1 - 1 2 w e e k s in 13 pa t ien ts , 1 3 - 1 4 w e e k s in four pa t ien ts , and 1 5 - 1 6 w e e k s in t h ree . In these pa t ien ts the ges ta t iona l sac w a s norma l and fetal hear t act iv i ty w a s p resen t . Of these 5 0 pa t ien ts , 10 ( 2 0 % ) a lso had subcho r i on i c b l eed ing , wh i ch w a s seen sonog raph i ca l l y as an ex t racho r i on i c c r e s ­cent ic f lu id co l l ec t i on loca ted b e t w e e n the ges ta t iona l sac and the u ter ine wal l ( f igs. 1 - 3 ) . The f lu id co l lec t ion a p p e a r e d to beg in near the e d g e of the p lacen ta , ex tend ing to var ious d is tances f rom the p lacen ta . The ex t racho r i on i c f lu id co l l ec ­

t ion w a s anecho i c in seven pa t ien ts and c o n t a i n e d in terna l echoes in t h ree . The co l l ec t i on w a s not assoc ia ted w i th re t rop lacen ta l h e m a t o m a , but w a s be l ieved to rep resen t subcho r i on i c b leed ing .

The f inal o u t c o m e in the 5 0 pa t ien ts w i th fetal ca rd i ac act iv i ty w a s as fo l l ows : In the 4 0 pa t ien ts w i th no ev idence of subcho r i on i c b leed ing , t he p r e g n a n c y p r o g r e s s e d to t e rm in all 4 0 ( 1 0 0 % ) . In the 10 pa t ien ts wi th s u b c h o r i o n i c b l e e d ­ing , e ight ( 8 0 % ) s h o w e d g radua l reso lu t ion of the f lu id co l lec t ion over 4 - 7 w e e k s ; the re w a s c o n t i n u e d fetal g r o w t h and v iabi l i ty , and the p regnanc ies c o n t i n u e d to te rm ( f igs. 1 and 2) . In t w o pa t ien ts ( 2 0 % ) , the f lu id co l l ec t i on pers is ted and fetal dea th o c c u r r e d 2 1 - 3 0 d a y s af ter the init ial s o n o ­g raph ic examina t ion ( f ig . 3 ) . The a p p r o x i m a t e vo l ume of the f lu id co l lec t ion w a s 4 0 - 1 6 0 ml . The re w a s no co r re la t i on be tween the vo l ume of the co l l ec t i on a n d the f inal o u t c o m e . Of the 10 pa t ien ts wi th subcho r i on i c b l eed ing , s ix w e r e at

A J R : 1 4 1 , N o v e m b e r 1 9 8 3 S O N O G R A P H Y OF S U B C H O R I O N I C B L E E D I N G 9 7 7

9 - 1 0 w e e k s of ges ta t ion (one negat ive o u t c o m e ) , th ree at 1 1 - 1 2 w e e k s (one negat ive o u t c o m e ) , and o n e at 1 3 - 1 4 w e e k s .

Discussion

Severa l inves t iga tors have s tud ied the s o n o g r a p h i c f ea ­tu res in cases of t h rea tened abor t ion a n d c o m p a r e d t h e m wi th the va r ious ho rmona l assays [1 - 7 ] , T h e y f ound un i ­fo rm ly that low ho rmona l assays and a b s e n c e of feta l ac t iv i ty on s o n o g r a p h y at 9 w e e k s of ges ta t ion had a 1 0 0 % c o r r e ­lat ion wi th a nega t i ve o u t c o m e . The resu l ts of ou r s tudy are ident ica l in that a b s e n c e of feta l mot ion and ca rd iac ac t iv i ty on s o n o g r a p h y at or b e y o n d 9 w e e k s of ges ta t ion w a s co r re la ted w i th fetal dea th in all cases . P red ic t i ons of p o s i ­t ive o u t c o m e on the bas is of norma l ho rmona l assays and s igns of feta l l ife on s o n o g r a p h y at 9 w e e k s of ges ta t ion are accu ra te in 8 0 % - 9 5 % of cases . The re has been no p rev ious ev idence to ident i fy cases of t h rea tened abo r t i on at g rea te r r isk for eventua l negat ive o u t c o m e in the p r e s e n c e of norma l ca rd iac act iv i ty on s o n o g r a p h y . The resu l ts of our s tudy ind ica te tha t in add i t ion to s igns of feta l l ife on s o n o g r a p h y , a subcho r i on i c f lu id co l l ec t i on is an impor tan t f ac to r a f fec t ­ing the o u t c o m e of p r e g n a n c y .

The resul ts of our s tudy and those of o ther r esea rche rs [8 ] ind ica te that s u c h a c rescen t i c f lu id co l l ec t i on in pa t ien ts wi th c l in ica l t h rea tened abo r t i on in a s ing le ges ta t ion r e p ­resents subcho r i on i c b leed ing due to p lacen ta l sepa ra t i on . W e bel ieve th is is s u p p o r t e d by the fac t that all pa t ien ts we re symp toma t i c ( i .e. , had vag ina l b leed ing ) . A l so , the p resence of deb r i s in the f lu id co l l ec t i on of many of the pat ients sugges ts c lo t ted b l ood .

St i l l , it is conce i vab le tha t more than one p r o c e s s may be involved in the pa tho logy of these pa t ien ts . Spec i f i ca l l y , t he sonog raph i c a p p e a r a n c e of subcho r i on i c b leed ing seen in our cases is s o m e w h a t s imi lar to that seen w i th c h o r i o a m -niot ic separa t ion and b l igh ted tw in ges ta t ion [9 , 1 0 ] . In

normal cases , the cho r ion i c and amn io t i c m e m b r a n e s may be separa ted and the potent ia l s p a c e b e t w e e n the t w o membranes ob l i te ra te at abou t 16 w e e k s of ges ta t i on . In cho r ioamn io t i c sepa ra t i on , rup tu re of the amn ion w i th p res ­ervat ion of the cho r i on resu l ts in ex t ravasa t ion of amn io t i c f lu id into the potent ia l s p a c e b e t w e e n amn ion a n d c h o r i o n . Sonograph ica l l y , cho r i oamn io t i c separa t i on a p p e a r s as a f lu id co l lec t ion ou t l in ing a th in , f ree- f loa t ing m e m b r a n e that comp le te l y s u r r o u n d s the fe tus , ex tend ing over the fetal su r face of the p lacen ta or invo lv ing a part of the u ter ine cav i ty remote f rom the p lacen ta [9 ] . It is de tec ted inc identa l l y dur ing rout ine obs te t r i c s o n o g r a p h y and is not assoc ia ted wi th vag ina l b leed ing or abdomina l c r a m p s . In pa t ien ts w i th c l in ical t h rea tened abo r t i on , t he re fo re , the f i nd ing of an ex t rachor ion i c c rescen t i c f lu id co l l ec t i on assoc ia ted w i th a th ick m e m b r a n e is more l ike ly to rep resen t b l eed ing .

B l igh ted tw in p r e g n a n c y a lso can be assoc ia ted w i th an in t rauter ine m e m b r a n e , and may appea r sonog raph i ca l l y as a s e c o n d sac, a septa l d iv is ion of the amn io t i c cav i ty , or a c rescen t i c f lu id co l l ec t i on ou t l in ing the sac [ 1 0 ] . S ince the c rescen t i c f lu id co l l ec t i on seen in b l igh ted tw in p r e g n a n c y is sonograph ica l l y s imi lar to tha t seen in our cases of s u b ­chor ion ic b leed ing , a c lear d i f fe ren t ia t ion b e t w e e n the two cond i t i ons may not a lways be poss ib le .

In ou r ser ies , cons ide r i ng on ly the s o n o g r a p h i c de tec t i on of fetal ca rd iac act iv i ty at or b e y o n d 9 w e e k s of ges ta t i on , 9 6 % of the p regnanc ies p r o g r e s s e d to t e rm , and the resu l ts we re s imi lar to those prev ious ly r e p o r t e d . Howeve r , w h e n the p r e s e n c e or a b s e n c e of s u b c h o r i o n i c b leed ing w a s inc luded in the p r o g n o s t i c a t i o n , the f inal o u t c o m e of the p regnanc ies w a s d i f fe ren t . Spec i f i ca l l y , in the a b s e n c e of subcho r i on i c b leed ing , the o u t c o m e w a s favorab le in 1 0 0 % of cases ; w h e n subcho r i on i c b leed ing w a s p resen t , t he posi t ive o u t c o m e w a s r e d u c e d to 8 0 % . In our se r ies , the re w a s no co r re la t ion be tween the vo l ume of the h e m o r r h a g e and the f inal o u t c o m e .

In conc lus i on , subcho r i on i c b leed ing can be de tec ted on

978 GOLDSTEIN ET AL. AJR:141, November 1983

sonography in about 18% of patients with clinical threatened abortion and is an important parameter in their prognosis. Patients with subchorionic bleeding are at greater risk for eventual fetal death even if signs of fetal life are present initially on sonography. We recommend that these patients be scanned serially to determine the final outcome of their gestation.

A C K N O W L E D G M E N T S

W e t h a n k J a n e t L. J a m e s a n d M a r c i R o s a f o r m a n u s c r i p t p r e p a ­r a t i o n .

R E F E R E N C E S

1 . Her t z J B , M a n t o n i M , S v e n s t r u p B. T h r e a t e n e d a b o r t i o n s t u d ­ied b y e s t r a d i o l - 1 7 B in s e r u m a n d u l t r a s o u n d . O b s f e f Gynecol 1 9 8 0 ; 5 5 : 3 2 4 - 3 2 8

2. Duf f G B , E v a n s J J , L e g g e M . A s t u d y o f i n v e s t i g a t i o n s u s e d t o p r e d i c t o u t c o m e of p r e g n a n c y a f te r t h r e a t e n e d a b o r t i o n . Br J Obstet Gynaecol 1 9 8 0 ; 8 7 : 1 9 4 - 1 9 8

3. J o u p p i l a P. C l i n i c a l a n d u l t r a s o n i c a s p e c t s in t h e d i a g n o s i s a n d

f o l l o w - u p of p a t i e n t s w i t h e a r l y p r e g n a n c y f a i l u r e . Acta Obstet Gynecol Scand 1 9 8 0 ; 5 9 : 4 0 5 - 4 0 9

4 . Y u e n B H , L i v i n g s t o n J E , P o l a n d B J , W i t t m a n B K , S y L, C a n n o n W . H u m a n c h o r i o n i c g o n a d o t r o p i n , e s t r a d i o l , p r o g e s t e r o n e , p r o l a c t i n , a n d B - s c a n u l t r a s o u n d m o n i t o r i n g o f c o m p l i c a t i o n s in ear ly p r e g n a n c y . Obstet G y n e c o / 1 9 8 1 ; 5 7 : 2 0 7 - 2 1 4

5. Duf f G B . P r o g n o s i s in t h r e a t e n e d a b o r t i o n : a c o m p a r i s o n b e ­t w e e n p r e d i c t i o n s m a d e b y s o n a r , u r i n a r y h o r m o n e a s s a y s a n d c l i n i c a l j u d g e m e n t . Br J Obstet Gynaecol 1 9 7 5 ; 8 2 : 8 5 8 - 8 6 2

6. E r i k s e n P S , P h i l i p s e n T. P r o g n o s i s in t h r e a t e n e d a b o r t i o n e v a l u a t e d b y h o r m o n e a s s a y s a n d u l t r a s o u n d s c a n n i n g . Obstet Gynecol 1 9 8 0 ; 5 5 : 4 3 5 - 4 3 8

7. J o u p p i l a P, H u h t a n i e m i I, T a p a n a i n e n J . E a r l y p r e g n a n c y f a i l ­u r e : s t u d y b y u l t r a s o n i c a n d h o r m o n a l m e t h o d s . Obstet Gyne-col 1 9 8 0 ; 5 5 : 4 2 - 4 7

8 . M a n t o n i M , P e d e r s o n J F . I n t r a u t e r i n e h e m a t o m a : a n u l t r a s o n i c s t u d y o f t h r e a t e n e d a b o r t i o n . Br J Obstet Gynaecol 1 9 8 1 ; 8 8 : 4 7 - 5 1

9 . B u r r o w s P E , L y o n s E A , P h i l l i p s H J , O a t e s I. I n t r a u t e r i n e m e m ­b r a n e s : s o n o g r a p h i c f i n d i n g s a n d c l i n i c a l s i g n i f i c a n c e . JCU 1 9 8 2 ; 1 0 : 1 - 8

1 0 . F i n b e r g H J , B i r n h o l z J C . U l t r a s o u n d o b s e r v a t i o n s in m u l t i p l e g e s t a t i o n w i t h f i r s t t r i m e s t e r b l e e d i n g : t h e b l i g h t e d t w i n . Ra­diology 1 9 7 9 ; 1 3 2 : 1 3 7 - 1 4 2