Prognosis of Very Large First-Trimester Hematomas

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1 Case Series Prognosis of Very Large First-Trimester Hematomas Juliana Leite, MD, Pamela Ross, RDMS, RDCS, A. Cristina Rossi, MD, Philippe Jeanty, MD, PhD Objective. The aim of this study was to evaluate the outcome of pregnancies complicated by very large hematomas in the first trimester. Methods. Between January 2001 and January 2006, 8085 patients between 5 and 14 weeks gestation underwent routine first-trimester ultrasonographic examinations at our practice. Of these, 30 patients had a very large (>50% of the gestational sac) intrauterine hematoma. These 30 patients were further classified according to pregnancy outcome (normal or adverse), maternal age, vaginal bleeding, crown-rump length, gestational age at diagnosis of the hematoma, and position and location of the hematoma. P <.05 was considered statistically significant. Results. Six patients were excluded (4 were still pregnant, and 2 were lost to follow-up), leaving 24 patients eligible for analysis, of which 11 (46%) had adverse outcomes and 13 (54%) had normal outcomes. The group with adverse outcomes had a significantly lower gestational age at diagnosis than the second group (7 weeks [range, weeks] versus 8.4 weeks [range, weeks]; P =.0227), but crown-rump length, vaginal bleeding, and position and location of the hematoma were similar. Conclusions. Very large hematomas were associated with adverse outcome in 46% of the pregnancies. Vaginal bleeding was not associated with a poor prognosis. Neither position nor location of the placental hematoma was related to the outcome; however, when the hematoma was diagnosed at an early gestational age, the outcomes were worse. Key words: intrauterine hematoma; ultrasonography; vaginal bleeding. Received May 17, 2006, from Inner Vision Women s Ultrasound, Nashville, Tennessee USA (J.L., P.R., P.J.); and Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy (A.C.R.). Revision requested June 19, Revised manuscript accepted for publication June 20, Address correspondence to Juliana Leite, MD, c/o Philippe Jeanty, Inner Vision Women s Ultrasound, 2201 Murphy Ave, Suite 203, Nashville, TN USA. Intrauterine hematomas are common ultrasonographic findings that may be associated with firsttrimester bleeding. First-trimester bleeding occurs in 5% to 25% of all pregnancies, and the incidence of intrauterine hematomas has been reported to be 4% to 22%, mainly associated with vaginal bleeding. 1 3 The etiology of intrauterine hematomas remains unclear. Intrauterine hematomas are diagnosed by ultrasonography either incidentally or during the evaluation of patients with first-trimester bleeding. The hematomas usually are hypoechoic, crescent-shaped areas separating the uterine wall and the chorion by the American Institute of Ultrasound in Medicine J Ultrasound Med 2006; 25: /06/$3.50

2 Prognosis of Very Large First-Trimester Hematomas Intrauterine hematomas in the first trimester of pregnancy have been described as risk factors for adverse maternal and neonatal complications, including preeclampsia, spontaneous abortion, fetal growth restriction, and preterm delivery 4,5 ; however, the association between the size of the hematoma and the adverse outcome remains unclear. 3 5 The objective of our study was to evaluate the outcome of pregnancies complicated by very large first-trimester hematomas. Materials and Methods This study was performed between January 2001 and January All women with a very large first-trimester hematoma (see definition below) who were seen in our unit were considered eligible for participation. The inclusion criteria were as follows: single intrauterine live pregnancy, gestational age between 5 and 14 weeks, and the detection of a very large hematoma. Patients with multiple pregnancies, nonviable or nonvisible embryos, and pathologic features, including fibroids, polyps, and uterine malformations, and those who underwent elective termination of pregnancy were excluded. Hematoma was defined as a collection below the placenta or fetal membranes that was assessed as a mostly crescent-shaped image (Figures 1 6). Figure 1. Sonogram of a very large hematoma detected at 6 weeks. Figure 2. Sonogram of a very large hematoma detected at 6 weeks. The size of the hematoma was then compared with the size of the gestational sac during the examination and classified as small (<20% of the gestational sac), medium (20% 50% of the gestational sac), or large (>50% of the gestational sac). Only the last category was included in this study. The patients were further classified according to gestational age at the diagnosis of the hematoma, crown-rump length, maternal age, vaginal bleeding, position and location of the hematoma, and pregnancy outcome (normal or adverse). Figure 3. Sonogram of a subchorionic hematoma detected at 1442 J Ultrasound Med 2006; 25:

3 Leite et al Figure 4. Sonogram of a subchorionic hematoma detected at Gestational age was calculated on the basis of the last menstrual period or the first ultrasonographic measurements. When a discordance of at least 1 week between the last menstrual period and the echographic measurement was detected, the ultrasonographically derived gestational age was used for analysis. The location of the hematoma was described as anterior, posterior, fundal, or covering more than 1 site. The position was described in regard to the placental site as being subchorionic (located between the chorion and the uterine wall, external to the chorion laeve), retroplacental (behind the placenta, external to the chorion frondosum), or both. Ultrasonographic examinations were performed transvaginally with an Acuson 128XP or Acuson Sequoia system (Siemens Medical Solutions, Mountain View, CA) or a Voluson 730 system (GE Healthcare, Milwaukee, WI). Adverse outcomes were defined as spontaneous abortion, preterm delivery, or premature rupture of membranes. Normal outcomes were healthy, full-term deliveries. Patients were assigned to either group: group 1 was the adverse outcome, and group 2 was the normal outcome. For each patient, maternal age, gestational age at diagnosis of a hematoma, fetal crown-rump length, vaginal bleeding, and location and position of the hematoma were recorded. When serial scans were performed, only the first examination was considered for the analysis. Data on subsequent ultrasonographic scans were obtained from the ultrasound department s database. Further outcome information was collected by review of the medical records. Figure 5. Sonogram of a very large hematoma detected at Figure 6. Sonogram of a very large hematoma detected at 9 weeks. J Ultrasound Med 2006; 25:

4 Prognosis of Very Large First-Trimester Hematomas Statistical analysis was performed with GraphPad InStat version 3.00 (GraphPad Software, Inc, San Diego, CA); Fisher and Mann-Whitney tests were applied for categorical and quantitative variables, respectively. The level of significance was set below P =.05. Results During the study period between January 2001 and January 2006, 8085 patients in our practice underwent routine first-trimester ultrasonographic examinations. Of these, 30 met entry criteria and were enrolled in the study; however, 4 were excluded because they were still pregnant at the time of analysis, and 2 were lost to follow-up. Therefore, 24 patients were eligible for the study, of which 11 (46%) had adverse outcomes and 13 (54%) had normal outcomes. Of the 11 patients with adverse outcomes, 1 had a premature rupture of membranes, 8 had a firsttrimester miscarriage, and 2 had a secondtrimester loss (at 16 and 22 weeks, respectively). Maternal age did not differ between the groups (group 1, 32 ± 1.66 years; group 2, ± 1.27 years; P =.4688). The median gestational ages at the first ultrasonographic examination were 7 weeks (range, weeks) in the adverse outcome group and 8.4 weeks (range, weeks) in the normal outcome group. There was a significant difference between the two groups (P =.0227; Figure 7). Figure 7. Gestational age at the first ultrasonographic examination in the adverse outcome and in normal outcome groups. There was a significant difference between the two groups (P =.0227). The median crown-rump lengths were ± and ± 7.65 mm in groups 1 and 2, respectively (P =.1372). Vaginal bleeding occurred in 16 (66%) patients, of which 8 (73%) were in group 1 and 8 (61%) were in group 2. There was no significant difference between the two groups (P =.6792). In the adverse outcome group, the hematoma was located in only 1 site (anterior, posterior, cervical, or fundal) in 8 (73%) patients. In the normal outcome group, those same locations occurred in 9 (69%) patients. The hematoma covered more than 1 site in 3 (27%) and 4 (31%) patients in the adverse and normal outcome groups, respectively. There were no significant differences between the two groups (P >.9). In group 1, the position of the hematoma was subchorionic or retroplacental in 8 (73%) patients (adverse outcome) and both subchorionic and retroplacental in 3 (27%) patients. In group 2 (normal outcome), the hematoma was subchorionic or retroplacental in 11 (85%) patients and both subchorionic and retroplacental in 2 (15%) patients. The data are summarized in Table 1. There were no significant differences between the two groups (P =.63). Discussion Intrauterine hematoma is a common finding in first-trimester scans. The clinical implication of an intrauterine hematoma during the first trimester of pregnancy is not completely clear. Some authors have reported an association with spontaneous abortion and other adverse pregnancy outcomes such as preeclampsia, placental abnormalities, and preterm delivery. 4,5 Maternal age, vaginal bleeding, and gestational age at the time of the diagnosis are possible outcome factors in pregnancies complicated by a hematoma in the first trimester. 1,2,6 Maternal age is considered an independent risk factor for adverse outcome because there is a strong correlation with chromosomal and structural fetal anomalies. Our results did not demonstrate a significant correlation between adverse outcomes and advanced maternal age. The gestational age at diagnosis was related to spontaneous abortion. 2 The group with an adverse outcome had a significantly lower gestational age at diagnosis 1444 J Ultrasound Med 2006; 25:

5 Leite et al Table 1. Correlation Between the Different Parameters and Outcome Parameter Adverse Outcome Normal Outcome P Patients (n = 24), n (%) 11 (46) 13 (54) Age, y, mean ± SD 32 ± ± Median gestational age at diagnosis (range), y 7 ( ) 8.4 (6.2 14).0227* Crown-rump length, mm, mean ± SD ± ± Bleeding, n (%) 8 (73) 8 (61).6792 Location, n (%) Anterior/cervical/fundal 8 (73) 9 (69) All 3 (27) 4 (31) >.9 Position, n (%) Subchorionic/retroplacental 8 (73) 11 (85) Both 3 (27) 2 (15).63 *Significant at P <.05. than the group with a normal outcome. Interestingly, there was no correlation between vaginal bleeding and the adverse outcomes. Another controversial issue is the association between the size of the hematoma and subsequent pregnancy complications. 6 8 There are different classifications for the size of the hematoma. The hematoma can be classified as small, medium, or large according to the size relative to the gestational sac. 1 Another option is to measure the volume of the hematoma. Volumes are estimated by measuring the anteroposterior, longitudinal, and transverse diameters and multiplying these values by (the ellipsoid formula). 1 Because the hematoma may wrap around the gestational sac, the ellipsoid formula would overestimate the size. In our study, we decided to use the size of the hematoma relative to the gestational sac because this method is simple and well established and has been the method described in most previous reports. In the future, direct 3-dimensional volume measurements will provide a more precise estimate. The limitations of our study include the size of our sample. Our study was a 5-year study in which 8085 patients were evaluated. During this period, only 30 cases of first-trimester large hematomas were detected. The patients in our study may not be representative of all patients with large first-trimester hematomas because our unit accepts emergency cases only during the day, and that is the reason we decided not to calculate the incidence of the hematomas in our population because we could underestimate the number. In conclusion, our study suggests that the presence of a very large first-trimester hematoma is associated with a 46% risk of adverse pregnancy outcome (spontaneous abortion and premature rupture of membranes). Only an early gestational age at diagnosis may be considered a risk factor for poor outcomes. References 1. Nagy S, Bush M, Stone J, Lapinski RL, Gardo S. Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol 2003; 102: Maso G, D Ottavio G, Seta F, Sartore A, Piccoli M, Mandruzzato G. First-trimester intrauterine hematoma and outcome of pregnancy. Obstet Gynecol 2005; 105: Bennett GL, Bomley B, Lieberman E, Benacerraf B. Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 1996; 200: Johns J, Hyett J, Jauniaux E. Obstetric outcome after threatened miscarriage with and without a hematoma on ultrasound. Ultrasound Obstet Gynecol 2003; 102: Jauniaux E, Johns J, Burton GJ. The role of ultrasound imaging in diagnosing and investigating early pregnancy failure. Ultrasound Obstet Gynecol 2005; 25: Sharma G, Kalish RB, Chasen ST. Prognostic factors associated with antenatal subchorionic echolucencies. Am J Obstet Gynecol 2003: 189: Falco P, Zagonari S, Gabrielli S, Bevini M, Pilu G, Bovicelli L. Sonography of pregnancies with first-trimester bleeding and a small intrauterine gestational sac without a demonstrable embryo. Ultrasound Obstet Gynecol 2003; 21: Mäkikallio K, Tekay A, Jouppila P. Effects of bleeding on uteroplacental, umbilicoplacental and yolk-sac hemodynamics in early pregnancy. Ultrasound Obstet Gynecol 2001; 18: J Ultrasound Med 2006; 25:

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