Successful outcome after spontaneous first trimester intra-amniotic haematoma and early preterm premature rupture of membranes

Abstract

A spontaneous intra-amniotic haematoma is a rare cause of preterm premature rupture of the membranes (PPROM) but can have significant fetal and maternal consequences. It has previously been reported to occur in the second and third trimesters but not in an earlier gestation. We present a case that presented acutely in the first trimester of pregnancy, which leads to early PPROM at 15 weeks and spontaneous preterm delivery at 28 weeks of gestation. There were no maternal complications during the pregnancy.

Background

Intra-amniotic haematoma, in the absence of trauma or amniocentesis, is a very rare event. It is thought to occur due to either a subchorionic or subamniotic haematoma which dissects through the amnion and into the amniotic cavity. A few case reports of spontaneous intra-amniotic haematoma occurring in the second and third trimesters describe significant maternal compromise, threatened preterm labour, and the intra-amniotic haematoma mimicking fetal abnormalities or as an incidental finding. We report a case of acute intra-amniotic haematoma detected in the first trimester leading to early preterm premature rupture of membranes (PPROM) and subsequent preterm delivery with a good maternal and neonatal outcome.

Case presentation

A 30-year-old Caucasian gravida 2 para 0 was referred for fetal medicine specialist assessment at 14+1 weeks of gestation due to detection of an anechoic area (41×30×26 mm) within the maternal isthmus of the uterus during the first trimester ultrasound examination (12+0 weeks) for combined screening (1:2700 Down syndrome risk, β human chorionic gonadotropin 1.08 MoM and pregnancy-associated plasma protein-A 0.46 MoM) (figure 1). The patient had attended hospital 3 days earlier with vaginal bleeding and abdominal pain, where the ultrasound examination of the fetus and uterus showed no abnormality.

Figure 1.

Intra-amniotic haemorrhage resembling an organised blood clot.

Transvaginal ultrasound was performed due to the poor image quality transabdominally. The fetal growth velocity was normal, the bowel was echogenic but there were no other fetal structural abnormalities or soft markers were detectable. Floating within the amniotic fluid attached to the superior end of the placenta was an area of heterogeneous echogenicity (45×37×28 mm), which resembled an organised blood clot within the amniotic sac (figures 2 and 3). This area moved with the placenta, while Doppler studies revealed no active blood flow within it. The patient was advised of the risks of further bleeding, PPPROM and subsequent preterm birth.

Figure 2.

Intra-amniotic haemorrhage resembling an organised blood clot within the amniotic sac adjacent to the fetal head.

Figure 3.

Intra-amniotic haemorrhage resembling an organised blood clot.

Follow-up was planned for 3 weeks later, however, she attended hospital 6 days later describing a brown vaginal discharge and wetness. A speculum examination allowed visualisation of pooling liquor in the posterior fornix on Valsalva. An ultrasound scan confirmed oligohydramnios, a live fetus and the previously observed blood clot (now 30×37×22 mm). Based on the history of ‘wetness’, findings on speculum examination and oligohydramnios, a diagnosis of PPROM was made in accordance with National Institute for Health and Care Excellence guidelines,¹ and the patient was counselled about the possible maternal and neonatal outcomes. The couple declined termination of pregnancy. The patient was commenced on erythromycin 500 mg BD for 10 days. Active management using antibiotics after PPROM is our departmental policy in discussion with parents, even when PPROM occurs this early, with the aim of preventing infection and delay delivery. In addition, she was offered serial weekly outpatient monitoring for maternal and fetal well-being.

Between 16 and 18 weeks of gestation, the bleeding and amniotic fluid leakage ceased, fetal growth was appropriate and two pools of amniotic fluid were consistently seen (7 and 1.4 mm). At 20+1 weeks, a detailed anomaly ultrasound examination revealed normal fetal growth and anatomy; the fetal stomach, kidneys and bladder were visualised and fetal movements were observed. Over the following 7 weeks, small pockets of amniotic fluid remained around the fetus, fetal growth continued with normal fetal Doppler studies. At 28+0 weeks, the patient experienced vaginal bleeding and was admitted to hospital where the maternal dexamethasone injection was administered to mature the fetal lungs. Spontaneous preterm labour ensued at 28+2 weeks and she delivered a live baby girl by breech vaginal delivery weighing 1.19 kg with Apgars of 3 at 1 min. The baby was initially intubated for 7 days and required a further 18 days of continuous positive airway pressure but could breathe spontaneously at 3 weeks of age. A chest X-ray showed pulmonary hypoplasia (small lung volume and poor lung expansion). Though initially treated as septic, all neonatal cultures were negative, and antibiotics were stopped after 2 days, and the baby was discharged to her local neonatal unit on day 27.

Histological analysis of the placenta showed florid amnion nodosum consistent with longstanding oligohydramnios, but with no acute inflammation. There were haemosiderin-laden macrophages in the chorion which suggested an amniotic haemorrhage. The cord and membranes looked otherwise normal, with no signs of villitis or intervillositis.

Outcome and follow-up

The child has been seen recently aged 3. She is walking and talking and ahead in all her milestones. The child has not formally had lung function measured and has been susceptible to winter respiratory viruses but otherwise had no other apparent residual respiratory problems. There are no ongoing concerns resulting from her prematurity.

Discussion

Intra-amniotic haemorrhage, unrelated to amniocentesis or trauma, is a very rare event with an unknown incidence, and only a handful of cases are described in the literature (table 1). Intra-amniotic haemorrhage is thought to result from either a subchorionic or subamniotic haematoma which dissects through the amnion and into the amniotic cavity. This bleeding can be either small echogenic particles floating in the amniotic fluid which represent fibrin strands or form a mass which can mimic fetal abnormalities.²

Table 1.

Presenting complaint, ultrasound findings, placental findings, pathology and outcome of 5 cases of intra-amniotic haemorrhage

Author	GA (wks)	Presenting complaint	Ultrasound findings	Placental findings	Outcome
Gilboa et al 3	38	Routine prior to LSCS	‘Sludge’ and a 70×20 mm cylindrical mass	No gross pathology	LSCS–PPH (not related to intra-amniotic haemorrhage)
Ustuner et al 4	20	Raised AFP. Possibility of anterior abdominal wall defect and oligohydramnios	A highly echogenic, partially solid and partially cystic mass measuring 28×30 mm		PPROM miscarriage
Cutillo et al 6	36	Uterine contractions, APH. Maternal anaemia	Real-time rapidly increasing polyhydramnios. Transplacental tear with decreased echogenicity and irregular borders. A freely mobile flap of placental tissue extending from the tear	Placenta circumvalate with blood-stained membranes, extensive intervillous fibrin deposition and focal villous fibrosis	Artificial rupture of membranes revealed dark blood-stained amniotic fluid proceeding to LSCS
Kurata et al 7	32	Uterine contractions, vaginal bleeding and maternal tachycardia and anaemia. Cardiotocogram showed reduced variability. A diagnostic amniocentesis revealed heavily blood-stained amniotic fluid	A clot around the umbilical cord and polyhydramnios	A 150 g old clot was found around the umbilical cord with no signs of abruption. Analysis of the placenta revealed chorioamnionitis	LSCS
Sijanovic et al 8	40	Maternal collapse and weakness. Maternal tachycardia, hypotension and anaemia	A homogeneous echogenic mass measuring 120×80 mm within the amniotic fluid	Fibroid matter at the edge of the placenta	LSCS
Magann et al 5	21	Isogenic irregular mass; similar appearance to gastroschisis	Isogenic irregular mass measuring 7.38×4.95×3.40 cm without any noted colour flow was observed near the fetal umbilicus	A single intervillous haematoma measuring 1 cm was seen within the placenta. A separate organised clot, which was within the membranes, was found to consist of fibrin clots	PPROM at 30 weeks, followed by suspected placental abruption and LSCS

Previously published cases on intra-amniotic haemorrhage.

AFP, alpha-fetoprotein; LSCS, lower segment caesarean section; PPH, postpartum haemorrhage; PPROM, preterm premature rupture of the membrane.

Gilboa et al presented a case of an incidental finding of intra-amniotic haemorrhage prior to a planned caesarean section with no adverse effect on the mother or neonate.³ Ustuner et al reported a patient at 20 weeks who presented for specialist fetal medicine review with a raised serum alpha-fetoprotein concentration and a normal scan at 18 weeks. In this case, the intra-amniotic haemorrhage mimicked an anterior abdominal wall defect and required a fetal MRI to confirm the diagnosis.⁴ In a similar case that presented at 29 weeks of gestation, the intra-amniotic haemorrhage was misdiagnosed as a gastroschisis, the correct diagnosis being confirmed on MRI.⁵ Intra-amniotic haemorrhage has presented in two cases in the third trimester with uterine contractions, vaginal bleeding and anaemia^{6 7} In one case at 36 weeks, ultrasound imaging revealed real-time rapidly increasing polyhydramnios, and a transplacental tear was visible with a freely mobile flap of placental tissue extending into the amniotic cavity. Pathology examination revealed a circumvallate placenta.⁶ In the second case at 32 weeks, there was a reduced beat to beat variability on the cardiotocogram, and an ultrasound scan showed polyhydramnios and a blood clot around the umbilical cord. Amniocentesis revealed heavily blood-stained amniotic fluid and an immediate caesarean section was performed with a delivery of a healthy neonate. Placental histological analysis revealed chorioamnionitis.⁷ Finally, intra-amniotic haemorrhage has also presented with maternal collapse, tachycardia, hypotension and anaemia at 40 weeks of gestation.⁸ Ultrasound examination showed a live, well-grown fetus with a large intra-amniotic homogenous echogenic mass (120×80 mm). She developed haemorrhagic shock and underwent immediate caesarean delivery. The placental histological examination was normal with no evidence of an abruption, but there was a 20 cm diameter 450 g blood clot detected.⁸

Our case is unique in the literature due to its early gestational age at diagnosis of intra-amniotic haemorrhage and associated PPROM. Though there were no effects to the maternal cardiovascular system, the vaginal bleeding and intra-amniotic blood clot were early signs of the pathology present. The lack of sepsis and chorioamnionitis, both clinically during the pregnancy and on histological analysis of the placenta is the most likely reason that the pregnancy progressed. The haemosiderin-laden macrophages in the chorion confirmed the presence of amniotic haemorrhage, however, the defect in the placenta was not seen, either as it was too small or because it had already sealed up.

Though intra-amniotic haemorrhage is a rare occurrence, its consequences can be severe for both mother and fetus. Its identification at any gestation should be taken seriously and acted on as appropriate for the presenting symptoms and gestational age.

Patient’s perspective.

The initial diagnosis was devastating. We really appreciated the care we received, particularly the time that the team took to talk us through the available evidence on PPROM and its potential consequences. Having that information enabled us to make an informed decision. We felt hugely supported by the fetal medicine team.

The remaining 13 weeks of the pregnancy were very difficult. We learnt to live with a great deal of uncertainty, trying to balance hope with realism. A high-risk pregnancy is an isolating experience, although we were helped and encouraged through this period by family, friends, and the medical team. We also found the support from people online who had had similar experiences very valuable.

Despite a difficult time on the neonatal unit, our daughter is now a bright, lively, funny 3 year old. When we see her running around the park, we remember a conversation with a neonatal consultant shortly before she was born, who told us that in the best-case scenario, she might never be able to run very far. We are amazed and so grateful to have had the outcome we did.

Learning points.

• Spontaneous intra-amniotic haematoma is a rare cause of preterm premature rupture of membranes.

• It can have significant fetal and maternal consequences.

• With appropriate conservative management, a successful outcome is possible.