Author Information
Naykodi P *, Bharti S**, Samant PY***.
(* Senior Resident, ** Junior Resident, *** Additional Professor, Department of Gynecology and Obstetrics, Seth GS Medical College and KEM Hospital, Mumbai, India.)
(* Senior Resident, ** Junior Resident, *** Additional Professor, Department of Gynecology and Obstetrics, Seth GS Medical College and KEM Hospital, Mumbai, India.)
Abstract
Intraplacental hematoma is a rare entity. A pregnancy with such hematomas can result in serious hemodynamic changes in the placental and fetal circulation resulting in adverse perinatal outcomes. We present a rare case of intraplacental hematoma with intrauterine growth restriction (IUGR) with feto-placental insufficiency, but with good neonatal outcome.
Introduction
Intraplacental hematoma is associated with pre-eclampsia, second trimester miscarriage, preterm delivery, intrauterine growth restriction and stillbirth.[1-3] Also known as the Kline’s hemorrhage or placental cavernae, intraplacental hematoma is a hemorrhagic area in the parenchyma of the placenta, quite commonly associated with microangiopathy.[4] On ultrasonography, these hematomas are identified in the placental intervillous cavity. We present a case of intrauterine growth restriction and deterioration in the placental and fetal Doppler parameters in a case of intraplacental hematoma.
Case Report
A twenty three year old G2P1L1 with 32 weeks gestation was referred to our hospital with ultrasonography suggestive of intaplacental bleeding. She was registered and had regular followup elsewhere. Her previous pregnancy was uncomplicated and she had a full term delivery. Ultrasonography of 28 weeks was suggestive of intraplacental hematoma of 7.4 x 2.1 x 2.9 cm, and the placenta was located anterior and fundal. One week after this, there was an increase in size of the intraplacental bleed to 5.7 x 6 x 2.5 cm, after which she was referred to our hospital. She continued to perceive good fetal movements. Meanwhile she was given progesterone support and steroid dose was completed. At arrival in our hospital, her pulse rate was 88/ minute and blood pressure was 120/80 mm Hg. Uterine height was 32 weeks with longitudinal lie with cephalic presentation and fetal hearts were regular, at 140 beats per minute.
Hemoglobin was 10.5 gm %, platelet count was 2,80,000/cu mm, INR was 0.89 and fibrinogen was 293 mg %. Liver and renal function test reports were normal. Urine albumin was nil. Ultrasonography at our center was suggestive of single live intrauterine gestation of 30 weeks with estimated fetal weight of 1379 grams with adequate liquor, with asymmetric IUGR with intraplacental hematoma of 9 x 8 x 3 cm. Fetal doppler was suggestive of feto-placental insufficiency with raised umbilical artery S/D ratio of 4, fetal middle cerebral artery and pulsatility index of 1.5 (normal).
Figure 1. Ultrasonography showing hematoma.
A decision of induction of labor with prostaglandin E2 gel was taken in
view of increasing size of intraplacental hematoma with IUGR and
feto-placental insufficiency. She required cesarean section due to
failure of induction, and delivered a female child of 1566 gram with
Apgar score of 8/10. Intraoperatively, liqor was clear. Neonate was
transferred to NICU and was later discharged after a two week stay.
Placenta showed a defect of 6 x 8 cm well organized blood clot with
calcifications (figure 2). The postoperative course was uneventful and
she was discharged on day 6.
Figure 2. Yellow arrow pointing to intraplacental hematoma
Discussion
Intraplacental hematomas are rare entities. While retroplacental hematomas are more common in pregnancies less than 20 weeks gestation, intraplacental hematomas occur at higher gestation.[5] The source of bleeding in the intraplacental hematomas is usually maternal and linked to the trophoblastic activity.[6] Kline’s hemorrhage is intervillous thrombosis. It is also referred to as “Placenta Hohlraum”, (cavity in German) or placental cavernae due to intraregional hemorrhagic areas in the middle of the placental cotyledon. The possible etiologies include thrombophilias, antiphospholipid antibody syndrome, pre-eclampsia and disseminated intravascular coagulopathy.[4] Our patient did not have any of these conditions. Most of the bleeding is of maternal origin. Despite this, these hematomas cause a leak in the fetal circulation resulting in under perfusion and fetal anemia.
The risk of placental insufficiency, intrauterine growth restriction and preterm delivery is more in intraplacental hematoma. However, the risk of intrauterine fetal death is more in cases of retroplacental hematoma.[1] The rapidity of progression of the condition is much lesser in intraplacental hematoma, than in retroplacental hematomas.
The risk of placental insufficiency, intrauterine growth restriction and preterm delivery is more in intraplacental hematoma. However, the risk of intrauterine fetal death is more in cases of retroplacental hematoma.[1] The rapidity of progression of the condition is much lesser in intraplacental hematoma, than in retroplacental hematomas.
Intraplacental bleeding may sometimes cause non immune hydrops fetalis due to fetomaternal hemorrhage, as reported by Parekh et al.[7] Apart from correct timing of delivery, at present there are no treatment options available for the such hematomas. It is suggested that low molecular weight heparin and aspirin may be beneficial in cases of placental infarcts.[8] The intraplacental hematomas are linked to pre-eclampsia, IUGR, intrauterine fetal deaths and abnormal neurodevelopment in the surviving fetuses.[9] The neonate will be followed up for neurodevelopmental delay, but was neurologically normal at discharge.
Conclusion
Fetomaternal risk from intraplacental hematomas is different from that of retroplacental hematoma. Timely diagnosis and investigations can result in good maternal and perinatal outcome.
References
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Naykodi P, Bharti S, Samant PY. Intraplacental Hematoma As A Cause of Fetal Insufficiency. JPGO 2018. Volume 5 No.11. Available from:https://www.jpgo.org/2018/11/intraplacental-hematoma-as-cause-of.html