975

Subchorionic Bleeding in Threatened Abortion:

Sonographic Findings and Significance

Steven R. Goldstein Bala R. Subramanyam B. Nagesh Raghavendra Steven C. Horii Susan Hilton

Fifty-six p a t i e n t s w i t h clinical 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 six patients, fetal cardiac activity 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 of g e s t a t i o n , a n d fetal d e a t h w a s c o n f i r m e d in all six cases. In t h e o t h e r 5 0 p a t i e n t s , fetal c a r d i a c activity 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 , subchorionic bleeding w a s present in various degrees, appearing sonographically as an extrachorionic crescentic anechoic or c o m p l e x collection. T h e final 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 fetal c a r d i a c activity w a s as 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 bleeding, 1 0 0 % of the pregnancies progressed t oterm; inthe presence of subchorionic 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 , subchorionic bleeding is a n i m p o r t a n t factor affecting t h e o u t c o m e of gestations in patients with clinical threatened abortion.

S p o n t a n e o u s a b o r t i o n 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 l o s s 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 . T h e s y m p t o m s o f e a r l y p r e g n a n c y f a i l u r e , t h a t is, u t e r i n e b l e e d i n g and contractions, occur in u p t o 2 5 % o f all

pregnancies. The more common causes include threatened abortion, sponta neous abortion (complete or incomplete), missed abortion, and blighted ovum. The less c o m m o n causes have include ectopic used pregnancy in t h e and hydatidiform of mole.

Several

investigators

sonography

evaluation

threatened and

abortion and

have c o m p a r e d

the features and

sensitivity of s o n o g r a p h y

v a r i o u s h o r m o n a l a s s a y s . O f t h e s o n o g r a p h i c f a c t o r s u s e d in t h e

assessment

a n d p r o g n o s i s of f e t a l v i a b i l i t y in e a r l y p r e g n a n c y , t h e p r e s e n c e a n d s i g n i f i c a n c e of s u b c h o r i o n i c bleeding have r e c e i v e d s c a n t a t t e n t i o n . W e s t u d i e d p r o s p e c t i v e l y the presence, sonographic appearance, and natural history of subchorionic activity,

b l e e d i n g o n s e q u e n t i a l s c a n s , c o r r e l a t i n g it w i t h f e t a l m o t i o n , c a r d i a c and the long-term prognosis.

Subjects and Methods

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 o f 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
Received February 7, 1983; accepted after

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 o f gestation o r less w e r e e x c l u d e d b e c a u s e fetal m o t i o n a n d fetal heart activity c o u l d n o t be detected reliably. Sonography w a s performed with contact B-mode scanners a n d linear-array or sector real-time scanners. All patients w e r e s c a n n e d within 4 8 hr after t h e onset of s y m p t o m s . The following s o n o g r a p h i c f a c t o r s w e r e evaluated: (1) size, shape, outline, a n d c o n t e n t s of the gestational sac; (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 bleeding (i.e., c r e s c e n t i c fluid collection between t h e gestational s a c a n d t h e uterine wall); a n d (3) fetal motion a n d fetal c a r d i a c activity. Patients with viable fetuses b u t with s u b c h o r i o n i c bleeding were r e e v a l u a t e d at 7 - t o 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 u n t i l t h e s u b c h o rionic 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 fetal viability o r until 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 pregnancy w a s determined by clinical follow-up a n d dilatation and 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 t o d e l i v e r y in v i a b l e c a s e s .

revision July 1 8 ,1 9 8 3 . P r e s e n t e d at t h e a n n u a l m e e t i n g of t h e A m e r i can Roentgen Ray Society, Atlanta, April 1 9 8 3 . 'Department New Ave., York of O b s t e t r i c s and Gynecology, 5 3 0 First

University

Medical Center,

N e w York, NY 1 0 0 1 6 . Address reprint re

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 of R a d i o l o g y , N e w Y o r k University Medical Center, N e w York, N Y 1 0 0 1 6 .

AJR 1 4 1 : 9 7 5 - 9 7 8 , November 1 9 8 3
0361-803X/83/1415-0975 American Roentgen Ray Society

976

GOLDSTEIN

ET

AL.

AJR:141, November

1983

Fig. 2.A,

T r a n s v e r s e s o n o g r a m a t 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 .

Results

t i o n w a s a n e c h o i c in s e v e n p a t i e n t s a n d c o n t a i n e d i n t e r n a l e c h o e s in t h r e e . T h e c o l l e c t i o n w a s n o t a s s o c i a t e d with retroplacental h e m a t o m a , b u t w a s b e l i e v e d to represent

In six of 5 6 p a t i e n t s e v a l u a t e d , t h e g e s t a t i o n a l s a c w a s p o o r l y d e f i n e d a n d d i s t o r t e d , a n d no f e t a l h e a r t m o t i o n w a s detected. This was consistent with missed abortion, which w a s c o n f i r m e d in all six c a s e s . In t h e o t h e r 5 0 p a t i e n t s , t h e fetal a g e w a s d e t e r m i n e d b y c r o w n - r u m p l e n g t h a n d b i p a r ietal d i a m e t e r . T h e f e t a l a g e w a s 9 - 1 0 w e e k s in 3 0 p a t i e n t s , 1 1 - 1 2 w e e k s in 1 3 p a t i e n t s , 1 3 - 1 4 w e e k s in f o u r p a t i e n t s , a n d 1 5 - 1 6 w e e k s in t h r e e . In t h e s e p a t i e n t s t h e g e s t a t i o n a l s a c w a s n o r m a l a n d f e t a l h e a r t a c t i v i t y w a s p r e s e n t . Of these 5 0 patients, 10 ( 2 0 % ) also had subchorionic bleeding, which w a s seen sonographically as an extrachorionic c r e s centic fluid collection located b e t w e e n the gestational sac a n d t h e u t e r i n e wall ( f i g s . 1 - 3 ) . T h e f l u i d c o l l e c t i o n a p p e a r e d t o b e g i n n e a r t h e e d g e of t h e p l a c e n t a , e x t e n d i n g t o v a r i o u s distances from the placenta. The extrachorionic fluid collec

subchorionic bleeding. T h e final 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 4 0 p a t i e n t s w i t h n o e v i d 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 , t h e p r e g n a n c y p r o g r e s s e d to t e r m in all 4 0 ( 1 0 0 % ) . In t h e 1 0 p a t i e n t s w i t h s u b c h o r i o n i c b l e e d ing, eight ( 8 0 % ) s h o w e d gradual resolution of t h e fluid collection over 4 - 7 w e e k s ; there w a s c o n t i n u e d fetal g r o w t h and viability, and the p r e g n a n c i e s c o n t i n u e d to term (figs. 1 a n d 2 ) . In t w o p a t i e n t s ( 2 0 % ) , t h e f l u i d c o l l e c t i o n p e r s i s t e d a n d f e t a l d e a t h o c c u r r e d 2 1 - 3 0 d a y s a f t e r t h e initial s o n o g r a p h i c e x a m i n a t i o n ( f i g . 3 ) . T h e a p p r o x i m a t e v o l u m e of t h e f l u i d c o l l e c t i o n w a s 4 0 - 1 6 0 m l . T h e r e w a s no c o r r e l a t i o n b e t w e e n t h e v o l u m e of t h e c o l l e c t i o n a n d t h e final o u t c o m e . Of t h e 1 0 p a t i e n t s w i t h s u b c h o r i o n i c b l e e d i n g , six w e r e at

AJR:141, November

1983

SONOGRAPHY

OF SUBCHORIONIC

BLEEDING

977

9 - 1 0 w e e k s of g e s t a t i o n ( o n e n e g a t i v e o u t c o m e ) , t h r e e at 1 1 - 1 2 w e e k s ( o n e n e g a t i v e o u t c o m e ) , a n d o n e at weeks. 13-14

normal cases, the chorionic and amniotic m e m b r a n e s may be s e p a r a t e d and the potential space between the two m e m b r a n e s o b l i t e r a t e at a b o u t 1 6 w e e k s of g e s t a t i o n . In c h o r i o a m n i o t i c s e p a r a t i o n , r u p t u r e of t h e a m n i o n w i t h p r e s e r v a t i o n of t h e c h o r i o n r e s u l t s in e x t r a v a s a t i o n of a m n i o t i c fluid into t h e p o t e n t i a l s p a c e b e t w e e n a m n i o n a n d c h o r i o n . S o n o g r a p h i c a l l y , c h o r i o a m n i o t i c s e p a r a t i o n a p p e a r s as a fluid c o l l e c t i o n o u t l i n i n g a t h i n , f r e e - f l o a t i n g m e m b r a n e t h a t c o m p l e t e l y s u r r o u n d s t h e f e t u s , e x t e n d i n g o v e r the f e t a l s u r f a c e of t h e p l a c e n t a o r i n v o l v i n g a p a r t of t h e u t e r i n e c a v i t y r e m o t e f r o m t h e p l a c e n t a [ 9 ] . It is d e t e c t e d i n c i d e n t a l l y d u r i n g r o u t i n e o b s t e t r i c s o n o g r a p h y a n d is n o t a s s o c i a t e d w i t h v a g i n a l b l e e d i n g o r a b d o m i n a l c r a m p 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 , t h e r e f o r e , t h e f i n d i n g of t h i c k m e m b r a n e is m o r e l i k e l y to r e p r e s e n t b l e e d i n g . Blighted twin p r e g n a n c y also can be associated with an intrauterine m e m b r a n e , and may appear sonographically as a s e c o n d s a c , a s e p t a l d i v i s i o n of t h e a m n i o t i c c a v i t y , or a crescentic fluid collection outlining the sac [ 1 0 ] . Since the c r e s c e n t i c fluid c o l l e c t i o n s e e n in b l i g h t e d t w i n p r e g n a n c y is s o n o g r a p h i c a l l y s i m i l a r t o t h a t s e e n in o u r c a s e s of s u b chorionic bleeding, a clear differentiation between the two c o n d i t i o n s m a y n o t a l w a y s be p o s s i b l e . In o u r s e r i e s , c o n s i d e r i n g o n l y t h e s o n o g r a p h i c d e t e c t i o n of fetal c a r d i a c a c t i v i t y at or b e y o n d 9 w e e k s of g e s t a t i o n , 9 6 % of t h e p r e g n a n c i e s p r o g r e s s e d to t e r m , a n d t h e r e s u l t s w e r e s i m i l a r to t h o s e p r e v i o u s l y r e p o r t e d . H o w e v e r , w h e n 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 bleeding was i n c l u d e d in t h e p r o g n o s t i c a t i o n , t h e final o u t c o m e of t h e p r e g n a n c i e s w a s d i f f e r e n t . S p e c i f i c a l l y , in t h e 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 , t h e o u t c o m e w a s f a v o r a b l e in 1 0 0 % of c a s e s ; w h e n s u b c h o r i o n i c bleeding was present, the 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 to 8 0 % . In o u r s e r i e s , t h e r e w a s no c o r r e l a t i o n b e t w e e n t h e v o l u m e of t h e h e m o r r h a g e a n d t h e final o u t c o m e . In c o n c l u s i o n , s u b c h o r i o n i c b l e e d i n g c a n b e d e t e c t e d o n an extrachorionic crescentic fluid collection associated with a

Discussion
Several investigators have studied the sonographic fea t u r e s in c a s e s of t h r e a t e n e d a b o r t i o n a n d c o m p a r e d t h e m w i t h t h e v a r i o u s h o r m o n a l a s s a y s [1 - 7 ] , T h e y f o u n d uni f o r m l y t h a t l o w h o r m o n a l a s s a y s a n d a b s e n c e of f e t a l a c t i v i t y o n s o n o g r a p h y at 9 w e e k s of g e s t a t i o n h a d a 1 0 0 % c o r r e lation w i t h a n e g a t i v e o u t c o m e . T h e r e s u l t s of o u r s t u d y a r e i d e n t i c a l in t h a t a b s e n c e of f e t a l m o t i o n a n d c a r d i a c a c t i v i t y on sonography at or b e y o n d 9 w e e k s of g e s t a t i o n was c o r r e l a t e d w i t h f e t a l d e a t h in all c a s e s . P r e d i c t i o n s of p o s i tive o u t c o m e o n t h e b a s i s of n o r m a l h o r m o n a l a s s a y s a n d s i g n s of f e t a l life o n s o n o g r a p h y at 9 w e e k s of g e s t a t i o n a r e a c c u r a t e in 8 0 % - 9 5 % of c a s e s . T h e r e h a s b e e n n o p r e v i o u s e v i d e n c e to i d e n t i f y c a s e s of t h r e a t e n e d a b o r t i o n at g r e a t e r risk f o r e v e n t u a l n e g a t i v e o u t c o m e in t h e p r e s e n c e of n o r m a l c a r d i a c a c t i v i t y o n s o n o g r a p h y . T h e r e s u l t s of o u r s t u d y i n d i c a t e t h a t in a d d i t i o n to s i g n s of f e t a l life o n s o n o g r a p h y , a s u b c h o r i o n i c f l u i d c o l l e c t i o n 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 of p r e g n a n c y . T h e r e s u l t s of o u r s t u d y a n d t h o s e of o t h e r r e s e a r c h e r s [ 8 ] i n d i c a t e t h a t s u c h a 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 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 in a s i n g l e g e s t a t i o n r e p r e s e n t s s u b c h o r i o n i c b l e e d i n g d u e to p l a c e n t a l s e p a r a t i o n . W e b e l i e v e t h i s is s u p p o r t e d by t h e f a c t t h a t all p a t i e n t s w e r e s y m p t o m a t i c (i.e., h a d v a g i n a l b l e e d i n g ) . A l s o , patients suggests clotted blood. S t i l l , it is c o n c e i v a b l e t h a t m o r e t h a n o n e p r o c e s s m a y b e i n v o l v e d in t h e p a t h o l o g y of t h e s e p a t i e n t s . S p e c i f i c a l l y , t h e s o n o g r a p h i c a p p e a r a n c e of s u b c h o r i o n i c b l e e d i n g s e e n in o u r c a s e s is s o m e w h a t s i m i l a r t o t h a t s e e n w i t h c h o r i o a m niotic s e p a r a t i o n a n d b l i g h t e d t w i n g e s t a t i o n [ 9 , 1 0 ] . In the p r e s e n c e of d e b r i s in t h e f l u i d c o l l e c t i o n of m a n y of t h e

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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.

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 Gynecol 4. W. Scand 1980;59:405-409

Obstet

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 Human chorionic gonadotropin, estradiol, progesterone, prolactin, and B-scan ultrasound m o n i t o r i n g of c o m p l i c a t i o n s in e a r l y p r e g n a n c y . Obstet Gyneco/1981;57:207-214 be

5.

Duff 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 c l i n i c a l j u d g e m e n t . Br J Obstet Gynaecol

tween predictions made by sonar, urinary hormone assays and 1975;82:858-862 abortion Obstet 6. Eriksen Gynecol 7. PS, Philipsen T. Prognosis in t h r e a t e n e d

ACKNOWLEDGMENTS 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 ration.

evaluated by h o r m o n e assays and ultrasound s c a n n i n g . 1980;55:435-438 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 col 1980;55:42-47 of threatened abortion. Br J Obstet

J . Early pregnancy fail Gyne-

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 8. abortion stud Gynecol 9.

REFERENCES 1. H e r 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 1980;55:324-328 2. Duff G B , Evans J J , L e g g e M. A s t u d y of investigations u s e d to 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 t e r t h r e a t e n e d a b o r t i o n . Br Obstet 3. Gynaecol 1980;87:194-198 J

Mantoni M, Pederson JF. Intrauterine hematoma: an ultrasonic study Gynaecol mem JCU 1981;88:47-51 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 branes: sonographic findings and clinical significance. 1982;10:1-8

i e d 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

10.

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 gestation with first trimester bleeding: the blighted twin. diology 1979; 1 3 2 : 1 3 7 - 1 4 2 Ra

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