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Hemorrhage During Pregnancy

Sonography and MR Imaging

¹ Both authors: Radiology Department, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215.

View larger version (45K): [in a new window]   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.

View larger version (52K): [in a new window]   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.

View larger version (48K): [in a new window]   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.

View larger version (117K): [in a new window]   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.

View larger version (127K): [in a new window]   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.

View larger version (130K): [in a new window]   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).

View larger version (124K): [in a new window]   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).

View larger version (154K): [in a new window]   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.

View larger version (140K): [in a new window]   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.

View larger version (128K): [in a new window]   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).

View larger version (87K): [in a new window]   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.

View larger version (101K): [in a new window]   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.

View larger version (102K): [in a new window]   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.

View larger version (141K): [in a new window]   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.

View larger version (151K): [in a new window]   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).

View larger version (154K): [in a new window]   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.

View larger version (122K): [in a new window]   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).

View larger version (131K): [in a new window]   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.

View larger version (106K): [in a new window]   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.

View larger version (146K): [in a new window]   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.

View larger version (123K): [in a new window]   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.

View larger version (133K): [in a new window]   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])

View larger version (131K): [in a new window]   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.

View larger version (109K): [in a new window]   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.

View larger version (105K): [in a new window]   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.

View larger version (131K): [in a new window]   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.

View larger version (135K): [in a new window]   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).

View larger version (130K): [in a new window]   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.

View larger version (134K): [in a new window]   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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