AJR 2001; 176:607-615
© American Roentgen Ray Society
Hemorrhage During Pregnancy
Sonography and MR Imaging
Isabelle Trop1 and
Deborah Levine
1
Both authors: Radiology Department, Beth Israel Deaconess Medical Center, 330
Brookline Ave., Boston, MA 02215.
Received April 3, 2000;
accepted after revision August 4, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Address correspondence to D. Levine.
Introduction
Vaginal bleeding is the most frequent indication for first-trimester
sonography. In the presence of a live embryo, the most frequently encountered
sonographic finding is a subchorionic hematoma. Bleeding in the second and
third trimesters is less common. Bleeding restricted by the placenta, the
amniotic or chorionic membranes, or both has characteristic sonographic
features that are important to recognize because the prognosis varies with
location. Bleeding within the fetus is uncommon. This pictorial essay presents
the varied sonographic and MR imaging manifestations of bleeding throughout
pregnancy.
Hemorrhage Related to the Placenta and Intrauterine Membranes
Separation of the placenta from the myometrium where it is implanted causes
bleeding. When only the margin of the placenta is separated, it is called a
marginal subchorionic hematoma (Fig.
1A,1B,1C).
When the bleeding is behind the placenta, it is termed a retroplacental bleed.
The term "abruption" (abruptio placentae) is typically reserved
for premature placental separation occurring after 20 weeks. Subamniotic
bleeding is a collection anterior to the placenta and limited by the umbilical
cord (Fig.
1A,1B,1C).
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Fig. 1A. —Drawings show classification of hematomas in and around
placenta. P = placenta, red = hematoma, blue line = amnion, pink line =
chorion. Retroplacental bleeding is found behind placenta.
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Fig. 1B. —Drawings show classification of hematomas in and around
placenta. P = placenta, red = hematoma, blue line = amnion, pink line =
chorion. Subchorionic bleeding dissects chorion and endometrium; when such
bleeding involves margin of placenta, it is called marginal subchorionic
hematoma.
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Fig. 1C. —Drawings show classification of hematomas in and around
placenta. P = placenta, red = hematoma, blue line = amnion, pink line =
chorion. Subamniotic hemorrhage is contained within amnion and chorion and
thus extends anteriorly to placenta but is limited by reflection of amnion on
placental insertion site of umbilical cord. Subamniotic bleeding is rare.
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In early pregnancy, a hypoechoic collection is often seen adjacent to the
gestational sac (Fig. 2A); when
small, this collection is physiologic. Subchorionic hematomas manifest as
crescentic collections lifting the chorionic membrane (Figs.
2B,
3A,3B,
and 4). Depending on the time
elapsed since the bleeding, the collection will have variable echotexture; it
will be hyperechoic initially, with decreasing echotexture over time
[1]. Most hematomas gradually
decrease in size on follow-up
[2]. A marginal subchorionic
hematoma can mimic a twin gestational sac
(Fig. 2B). Subchorionic
bleeding dissecting around the endometrial cavity
(Fig. 4) should be
distinguished from chorioamniotic separation. Occasionally, prominent basal
veins may mimic subacute hemorrhage (Fig.
5).
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Fig. 2A. —Subchorionic bleeding in fetus at 5.5 weeks' gestational age.
Transverse transvaginal sonogram reveals intrauterine gestational sac with
yolk sac. Note small amount of blood (arrow) adjacent to gestational
sac.
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Fig. 2B. —Subchorionic bleeding in fetus at 5.5 weeks' gestational age.
Transvaginal sagittal sonogram obtained 2 weeks after A because of
vaginal bleeding shows subchorionic hematoma (arrow) with debris.
Collection could be mistaken for second gestational sac with embryonic
demise.
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Fig. 3A. —Marginal subchorionic hematoma in 30-year-old woman with
spotting at 15 weeks' gestational age. Transabdominal transverse sonogram of
uterus shows heterogeneous collection of blood (arrow) lifting margin
of placenta (arrowheads).
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Fig. 3B. —Marginal subchorionic hematoma in 30-year-old woman with
spotting at 15 weeks' gestational age. Transabdominal transverse sonogram
shows hematoma in potential space between chorion (short solid arrow)
and endometrium (long arrow). Note specular reflector of thin amnion
(open arrow).
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Fig. 4. —Distinction between subchorionic hematoma and unfused amnion
in patient with vaginal bleeding at 13 weeks' gestational age. Transabdominal
sagittal sonogram of uterus reveals subchorionic hematoma (H) extending
posteriorly around chorion (arrows) and lifting edge of anterior
placenta (P). Appearance should not be confused with that of unfused amnion.
Amnion is thin membrane continuous along anterior placental edge but limited
by umbilical cord insertion; subchorionic bleeding leads to edge of
placenta.
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Fig. 5. —Retroplacental veins mimicking hematoma at 36 weeks'
gestational age. Transverse sonogram of placenta reveals hypoechoic structures
(arrows) behind and at edge of placenta. Slow-moving particles were
seen on real-time imaging. This appearance may mimic hematoma but is caused by
retroplacental veins.
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Correlation between the size of the subchorionic hematoma and the rate of
pregnancy loss is imperfect. In general, small- and moderate-sized
subchorionic hematomas have a better outcome than large ones
[3]. The percentage of
placental detachment is the prognostic factor most strongly associated with
fetal mortality: the frequency of fetal demise is 50% for retroplacental
hematoma versus 7% for marginal subchorionic hematoma
[4].
Abruptio placentae is one of the most serious complications of pregnancy,
accounting for up to 25% of perinatal deaths
[1]. Diagnosis requires a high
index of suspicion because the signs and symptoms are variable, including a
painful tense uterus, vaginal bleeding, premature labor, fetal distress, and
coagulopathy; most episodes remain asymptomatic. Sonographic findings are
negative in most cases, either because of the passage of blood without
accumulation behind the placenta or because of blood being isoechoic with the
placenta. The only evidence of abruption may be the identification of an
abnormally thick placenta [1].
The sensitivity of sonography is low, 2-20%
[2]. The clinical visualization
of a hematoma is important because pregnancies with demonstrable hematoma have
a worse prognosis than when no hematoma can be seen
[1]. MR imaging may
differentiate hematomas of various ages from the placenta (Fig.
6A,6B).
T1-weighted gradient-echo imaging is helpful for this because blood products
in many stages of evolution will appear to have increased signal intensity on
these sequences.
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Fig. 6A. —Abruption versus placenta previa in patient at 30 weeks'
gestational age with placenta previa, bleeding, and pain. Because placenta
previa typically does not cause pain but abruption does, clinical question was
how large a retroplacental clot was present. With large abruption, plan was to
deliver immediately. Transabdominal sagittal sonogram of lower uterine segment
shows placenta previa (p) with subtle increase of echogenicity in clot
(arrow) above endocervical canal (arrowheads).
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Fig. 6B. —Abruption versus placenta previa in patient at 30 weeks'
gestational age with placenta previa, bleeding, and pain. Because placenta
previa typically does not cause pain but abruption does, clinical question was
how large a retroplacental clot was present. With large abruption, plan was to
deliver immediately. Sagittal T1-weighted MR image (TR/TE, 137/4.1; field of
view, 240 x 320; matrix, 128 x 256; flip angle, 80°;
acquisition time, 17 sec) obtained immediately after sonogram shows to better
advantage small clot (solid arrow) above internal os (open
arrow), with most of placenta (P) well attached. Finding allowed patient
to be treated expectantly.
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Intraamniotic Bleeding
Any hematoma affecting the intrauterine membranes can dissect through the
amnion and extend into the amniotic cavity. Primary intraamniotic bleeding
occurs most often after trauma. Of all traumas, abdominal trauma puts the
patient most at risk of bleeding. No adverse effects to the fetus have been
documented in association with intraamniotic bleeding. If intraamniotic
bleeding has occurred, amniocentesis can yield dark brownish or green fluid
caused by blood degradation products (Fig.
7).
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Fig. 7. —Samples of amniotic fluid taken during genetic amniocentesis.
Normal amniotic fluid (left) is clear bright yellow. Dark green or brown
amniotic fluid (right) indicates blood degradation products caused by prior
bleeding. Latter sample was obtained from patient in Figure
3A,3B.
Level of  -fetoprotein in amniotic fluid may be elevated as a result of
bleeding.
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Amniocentesis is the most frequently performed procedure associated with
bleeding in the pregnant patient. Intraamniotic bleeding has been reported in
100% of patients scanned immediately after transplacental amniocentesis
[5]. The amount of bleeding is
less when the placenta is avoided. After cessation of active bleeding, strands
of echogenic material representing fibrin strands can be seen in the amniotic
cavity (Fig. 8A). Clotted
blood may form masses that mimic fetal anomalies
(Fig. 8B). Intraamniotic
fibrin strands must be differentiated from synechiae. A variable appearance of
the fibrin masses or strands on successive examinations will help establish
the diagnosis. After amniocentesis, the hematomas usually resolve in 3-10
weeks [5].
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Fig. 8A. —Fibrin strands seen immediately after genetic amniocentesis
at 17 weeks' gestational age. Transabdominal sonogram shows thin wispy
membrane floating in amniotic fluid (arrow). Immediately before
amniocentesis, fetal sonogram (not shown) did not show any intraamniotic
membranes.
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Fig. 8B. —Fibrin strands seen immediately after genetic amniocentesis
at 17 weeks' gestational age. Sagittal sonogram of fetus reveals round
echogenic mass (arrow) anterior to fetal abdomen (A); mass was caused
by bleeding and clot formation but mimics anterior abdominal wall mass. Fibrin
strands resolve on follow-up and should not be confused with fetal masses,
amniotic band syndrome, or synechiae.
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Echogenic particles in the amniotic fluid result directly from bleeding
(Fig. 9A). When the fetus
swallows blood, a mass in the stomach may be seen, as has been reported in
1.5% of sonographic studies performed after amniocentesis
[6]
(Fig. 9B). Less commonly,
hyperechoic bowel will be seen (Fig.
10).
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Fig. 9A. —Intraamniotic bleeding and gastric pseudomass in fetus at 21
weeks' gestational age, 2 weeks after transplacental amniocentesis. Transverse
transabdominal sonogram shows echogenic particles floating in amniotic fluid
(arrow) that were not present before amniocentesis. Until third
trimester, echogenic particles in amniotic fluid should raise possibility of
bleeding. Later in pregnancy, particles are most commonly the result of shed
epithelial cells (vernix caseosa).
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Fig. 9B. —Intraamniotic bleeding and gastric pseudomass in fetus at 21
weeks' gestational age, 2 weeks after transplacental amniocentesis. Transverse
sonogram of fetal abdomen shows echogenic material (arrow) in stomach
that results from fetus swallowing echogenic blood particles that resulted
from recent amniocentesis. Gastric pseudomasses resolve on follow-up
examination. To our knowledge, no gastric neoplasms have been reported on
prenatal sonography.
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Fig. 10. —Echogenic fetal bowel at 15 weeks' gestational age in 33-year
old woman with vaginal bleeding. Sonogram revealed subchorionic hemorrhage
(not shown). Sagittal scan through fetal abdomen reveals hyperechoic loops of
bowel (arrow) as echogenic as adjacent bone. Cytomegalovirus titers
and karyotype were normal, and findings of prenatal screening for cystic
fibrosis were negative. Normal bowel echotexture was seen on follow-up 2 weeks
later (not shown).
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Umbilical Cord Hematoma
Most umbilical cord hematomas are iatrogenic, resulting mainly from
amniocentesis and percutaneous umbilical blood sampling. A large hematoma is
more likely to have hemodynamic consequences for the fetus and to be
associated with a worse prognosis.
Cord hematomas initially appear as echogenic masses, with progressive loss
of echogenicity over time, followed by resorption
(Fig. 11). They are most often
seen near the cord insertion into the fetal abdomen or the placental insertion
site. Cord hematoma must be differentiated from anterior abdominal wall
defects and placental masses.
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Fig. 11. —Umbilical cord hematoma immediately after amniocentesis at 17
weeks' gestational age. Gray-scale image of color Doppler sonogram of
umbilical cord shows echogenic mass (arrows) in umbilical cord
deviating vessels. Normal flow was seen in umbilical arteries and vein.
Finding was not present before amniocentesis.
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Bleeding Within the Fetus
Bleeding isolated to the fetus is rare. It may result from a primary fetal
blood dyscrasia, a vascular malformation, trauma, maternal bleeding disorders,
anticoagulants, or antiepileptic drugs. The cause is often undetermined.
Intracerebral Bleeding
Intracerebral hemorrhage usually portends a poor prognosis; many of the
cases reported in the literature resulted in fetal demise
[7]. Intracerebral bleeding
remains a rare occurrence in utero. MR imaging is more sensitive than
sonography in detecting and defining the extent of such bleeding
[8] (Figs.
12A,12B,12C,12D
and
13A,13B,13C).
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Fig. 12A. —Cortical hemorrhage in patient examined at 16 weeks'
gestational age. Transabdominal oblique coronal sonogram of fetal head shows
mild ventriculomegaly with choroid plexus in dependent location. Margins of
lateral ventricular walls are irregular (arrows). Finding suggests
destructive process in periventricular cortical tissue.
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Fig. 12B. —Cortical hemorrhage in patient examined at 16 weeks'
gestational age. Coronal half-Fourier single-shot turbo spin-echo MR images
(TEeff, 60; field of view, 245 x 280; matrix, 192 x
256; flip angle, 130°; acquisition time, 420 msec) show destruction of
brain tissue in right frontal lobe (arrows, B) with focal area
of low signal intensity in right frontal lobe (arrow, C).
Because of use of ultrafast sequences, no fetal or maternal sedation was
necessary.
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Fig. 12C. —Cortical hemorrhage in patient examined at 16 weeks'
gestational age. Coronal half-Fourier single-shot turbo spin-echo MR images
(TEeff, 60; field of view, 245 x 280; matrix, 192 x
256; flip angle, 130°; acquisition time, 420 msec) show destruction of
brain tissue in right frontal lobe (arrows, B) with focal area
of low signal intensity in right frontal lobe (arrow, C).
Because of use of ultrafast sequences, no fetal or maternal sedation was
necessary.
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Fig. 12D. —Cortical hemorrhage in patient examined at 16 weeks'
gestational age. Axial fast T1-weighted MR image (TR/TE, 137/4.1; field of
view, 240 x 320; matrix, 128 x 256; flip angle, 80°) reveals
extraaxial high and low signal intensity (arrow), consistent with
blood products. Pregnancy was terminated. (Reprinted from
[9])
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Fig. 13A. —Extraaxial bleeding in fetus at 20 weeks' gestational age.
Axial sonogram of fetal head reveals extraaxial collection of blood (solid
arrow) in posterior fossa, pushing and deforming cerebellum (c).
Dependent echoes (open arrow) are suggestive of clot.
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Fig. 13B. —Extraaxial bleeding in fetus at 20 weeks' gestational age.
Corresponding axial half-Fourier single-shot turbo spin-echo MR image of fetal
head (TEeff, 60; field of view, 225 x 300; matrix, 192
x 256; flip angle, 130°; acquisition time, 13 sec) again show
extraaxial collection in posterior fossa (solid arrow) extending
superiorly, with hypointense focus caused by clot or calcification (open
arrow). This is intratentorial bleeding.
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Fig. 13C. —Extraaxial bleeding in fetus at 20 weeks' gestational age.
Coronal MR image of fetal head also shows subarachnoid blood (curved
arrows). Note midline superior sagittal sinus (straight arrow).
Postnatal imaging (not shown) showed almost complete resolution of
hematoma.
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Fetal Abdominopelvic Hemorrhage
Fetal abdominopelvic hemorrhage may be primary and may secondarily involve
any mass, the most frequent being adrenal (Fig.
14A,14B,14C)
and ovarian (Fig. 15) lesions.
A lesion presenting in a suprarenal location warrants follow-up.
Neuroblastomas present many features similar to those of hematomas, and
resolution over time suggests a benign cause.
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Fig. 14A. —Neuroblastoma with hemorrhage in fetus at 34 weeks'
gestational age referred for evaluation of right suprarenal mass. Coronal
sonogram of fetal abdomen shows complex mass (arrow) above right
kidney (arrowheads). No normal adrenal tissue is identified.
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Fig. 14B. —Neuroblastoma with hemorrhage in fetus at 34 weeks'
gestational age referred for evaluation of right suprarenal mass. Sagittal
oblique half-Fourier single-shot turbo spin-echo MR image of fetus
(TR/TEeff, xx/64; field of view, 320 x 320; matrix, 192
x 256; flip angle, 130°; acquisition time, 13 sec) shows
hyperintense well-demarcated lesion (arrow) above right kidney
(arrowheads).
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Fig. 14C. —Neuroblastoma with hemorrhage in fetus at 34 weeks'
gestational age referred for evaluation of right suprarenal mass. Axial
T1-weighted MR image (TR/TE, 132/4; field of view, 297 x 340; matrix,
112 x 256; flip angle, 80°; acquisition time, 16 sec) through fetal
abdomen shows clear fluid-fluid level (straight arrow) compatible
with intracystic hemorrhage. Cyst is of mixed signal intensities, with higher
signal intensity debris in dependent portion of cyst (curved arrow)
consistent with blood degradation products. CT scan after birth (not shown)
showed hemorrhagic adrenal lesion. Because of increasing size of lesion after
birth, excision was performed when infant was 3 months old. Histology revealed
hemorrhagic neuroblastoma.
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Fig. 15. —Ovarian cyst in female fetus at 34 weeks' gestational age.
Coronal sonogram shows complex cystic mass (arrow) in left abdomen (s
= stomach, b = bladder). Through-transmission is seen posterior to cyst. On
follow-up scans (not shown), cyst size remained the same but hematoma in cyst
decreased in size. Excision was performed when infant was 3 months old, and
pathology revealed intrauterine ovarian torsion.
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Conclusion
This pictorial essay illustrates the sonographic and MR imaging findings of
prenatal hemorrhage. Awareness of the various manifestations of hemorrhage in
pregnancy is important for patient counseling and treatment.
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Introduction
Hemorrhage Related to the...
