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issn 2413-6077. iJMMr 2016 Vol. 2 issue 1

DOI 10.11603/ijmmr.2413-6077.2016.1.6372

Complex approaCh to treatment of subChorioniC 
hematoma in early threatened abortion

S. N. Heryak, N. V. Petrenko, I. Ya. Kuziv, O. Y. Stelmakh,  
N. I. Bagniy, I. V. Korda, V. Yu. Dobryanska, L. V. Bagniy

I. HORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY, TERNOPIL, UKRAINE

Background. Currently, miscarriage is considered to be a multietiological disorder with trombofilic viola-
tions and hormone deficiency as the leading factors. Despite the achievements in treatment of miscarriage, the 
frequency of preterm termination of the wanted pregnancies is still high and the number of perinatal losses is 
significant. Therefore, pathogenetically based therapy, safe for the foetus, is very important in management of 
pregnancy interruption in the first trimester. A proper drugs administration provides optimal concentration of 
active ingredients and fast action. The aim is to improve effectiveness of the early threatened abortion treatment 
in cases of subchorionic hematoma (SCH) by combination of sublingual natural micronized progesterone and 
tranexamic acid 

Objective. We examined 50 pregnant women with early threatened abortion with SCH. We studied system 
of haemostasis, basic hormonal markers and ultrasound criteria of threatened abortion. We compared efficacy 
of treatment between traditional (supportive) therapy (sedation, spasmolytic, haemostatic drug) and combination 
of supportive therapy in combination with tranexamic acid and natural micronized progesterone.

Results. The result of lab tests showed minimal signs of hypercoagulation, hyperfibrinogenemia and platelet 
hyperactivity, a significant β-hCG level decrease and approximate decrease in progesterone and free estriol 
production.

Sonographic examination showed presents of local myometrial hypertonus, deformation of fertilized egg, 
hypoplasia of chorion, low location of fertilized ovum, retarded growth of CRL.

The research proved that combined administration of sublingual micronized progesterone and tranexamic 
acid for the treatment of threatened abortion with SCH has more significant positive effect for pregnancy 
maintenance due to clinical, biochemical, hormonal and ultrasound results if compared with the group which 
underwent supportive therapy.

Conclusions. Complex application of natural micronized progesterone 100 mg three times a day sublin-
gually and 500 mg of Tranexamic acid dissolved in 200 ml normal saline solution improves the dynamics of the 
main hormonal, haemostatic and ultrasound markers of abortion and significantly reduces reproductive losses. 
Tranexamic acid treatment proved a rapid and effective action on hematoma and absence of embryotoxical and 
сoagulopathyc influence. Tranexamic acid does not cause any significant disorders of hemostatic system. This is 
very important at the early gestation because of intravascular coagulation, physiological hypercoagulable con-
dition during pregnancy that can cause microthrombosis and disrupt placentation. On the other hand, it is 
dangerous for the mother’s health because of the increased risk of thrombosis.

KEY WORDS: threatened miscarriage, subhorial hematoma, micronized progesterone, tranexamic 
acid.

Introduction
Currently, miscarriage is considered to be a 

multietiological disorder with trombofilic 
violations and hormone deficiency as the leading 
factors. The problem of early pregnancy loss 
remains urgent because these factors are the 
most common complications without any 

downward tendency [1–4]. According to the 
latest concepts, 80% of all pregnancy losses 
occur at the early stages. One of the first signs 
that threatens the pregnancy is subchorionic 
hematoma (SCH) [5, 6]. It is the most unfortunate 
sign of threatened abortion. It is established that 
the disruption of trophoblast invasion in the 1st 
trimester of pregnancy leads to the advanced 
gestational complications: threatened abortion, 
preeclampsia, preterm delivery, pla cental 
abruption, which increase perinatal, in fant and 

s. n. Heryak et al.

Corresponding author: Svitlana Heryak, Department of 
Obstetrics and Gynecology No 2, I. Horbachevsky Ternopil State 
Medical University, 1 Maidan Voli, Ternopil, Ukraine, 46001
Tel.: +380352254891
E-mail: heryak@tdmu.edu.ua

International Journal of Medicine and Medical Research 
2016, Volume 2, Issue 1, p. 9–12
copyright © 2016, TSMU, All Rights Reserved



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ISSN 2413-6077. IJMMR 2016 Vol. 2 Issue 1

maternal mortality. The protective func tion of 
the immune system at the early stages of ges-
tation such as the suppression of natural killer 
cells in the endometrium, mother’s blocking 
fac tors production is provided by diffe rent mostly 
hormonal dependent mechanisms; their disor-
ders lead to defects of implantation, SCH and 
can cause early pregnancy termination [3, 7].

The endometrium and decidua contain a 
huge number of immune system cells, all of them 
are able to secrete cytokines. Main cyto kines that 
are secreted in the body inhibit the embryo 
development, proliferation and deve lop ment of 
normal trophoblast. They affect the embryo, both 
directly and indirectly, depending on the intensity 
of secretion and differentiation of target tissues 
[6]. Cytokine cascade can be triggered by in-
fectious agent and by endogenous factors 
(hypoxia, hormones, etc.) as well. Per sis tent viral 
bacterial infection, neuroen docrine disorders, 
chromosomal ab nor malities, the toxic effects, 
stress and envi ronment are also etio logical fac-
tors of early abortion [8, 9]. Despite the achieve-
ments in treatment of mis carriage, the frequency 
of preterm termination of the wan ted pregnancies 
is still high and the number of perinatal losses is 
significant. Therefore, pathogenetically based 
therapy, safe for the foetus, is very important in 
management of pre gnancy interruption in the 
first trimester. A proper drugs administration 
provides optimal concentration of active in-
gredients and fast action.

The aim is to improve effectiveness of the 
early threatened abortion treatment in cases 
of subchorionic hematoma by combination of 
sublingual natural micronized progesterone 
and tranexamic acid. 

Materials and Methods
The examination of 50 pregnant women 

was conducted at the Department of Gynae-
cology of Ternopil Regional Perinatal Centre 
“Mother and Child”. They received treatment 
for threatened abortion in gestational age from 
8 to 12 weeks. All women were diagnosed with 
SCH by means of ultrasound. 

To exclude infection as an etiological factor 
of abortion, bacteriological research of TORCH 
and sexually transmitted infections were con-
ducted. All patients had negative results of the 
tests for these infections.

System of haemostasis was evaluated by 
determination of platelet and aggregation time, 
prothrombin index (PI), thrombin clotting time, 
activated partial thromboplastin time (APTT), 
fibrinogen concentration. 

Basic hormonal markers of abortion were 
also studied: the concentration of free estriol 
and progesterone by radioimmunoassay me-
thod, sets made by company “SORIN” (France), 
and radioisotope sets Amerlayt made by inter-
national company Amersham. β-subunit of 
human chorionic gonadotropin (β-hCG) con-
cen tration was determined by immune fluo-
rescence analysis with time resolution (test 
system Delfiya, Wallac, Perkinelmer) (according 
to the manufacture standard protocol of test 
systems). 

To determine efficacy of the proposed com-
plex of therapeutic measures, all the pregnant 
were tested with transvaginal ultrasound on 
the 14th day of the treatment.

The pregnant of the 1st group (n=25; the 
comparison group) received supportive thera-
py – sedation, spasmolytic, haemostatic drug. 
The pregnant of 2nd group (n=25), together with 
supportive therapy, received tranexamic acid 2 
ml (500 mg) dissolved in 200 ml normal saline 
solution intravenously till the arrest of bleeding 
and natural micronized progesterone 100 mg 
three times a day sublingually. The control group 
consisted of 20 healthy pregnant women without 
any symptoms of threatened abor tion.

Results and Discussion
The evaluation of plasma-coagulation and 

vascular-platelet hemostasis showed minimal 
signs of hypercoagulation, hyperfibrinogenemia 
and platelet hyperactivity if compared with the 
women with physiological pregnancy. This 
suggests a thrombophilia as an etiopathogenetic 
factor of early abortion with SCH in the exa-
mined women.

The evaluation of hormonal homeostasis 
showed, that at the early gestational age a 
significant β-hCG level decrease and approxi-
mate decrease in progesterone and free estriol 
production were the diagnostic markers of 
threatened abortion with SCH

The results of ultrasound examination 
showed, that SCH was located in the area of the 
lower chorion in 32 (64%) of the pregnant wo-
men, in the central part – in 18 (36%) pati ents. 
Also sonographic examination showed other 
markers of abortion. So, local myometrial 
hyper tonus was diagnosed in 43 (86%) pregnant 
women, deformation of fertilized egg – in 32 
(64%), hypoplasia of chorion – in 12 (24%), low 
location of fertilized ovum – 8 (16%), retarded 
growth of CRL – in 2 (4%).

The research proved that combined admi-
nistration of sublingual micronized progesterone 

S. N. Heryak et al.



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issn 2413-6077. iJMMr 2016 Vol. 2 issue 1

and tranexamic acid for the treatment of 
threatened abortion with SCH has more sig­
nificant positive effect for pregnancy main­
tenance due to clinical, biochemical, hormonal 
and ultrasound results if compared with the 
group which underwent supportive therapy.

After the symptomatic treatment a spon­
taneous abortion happened in 6 (24%) women, 
missed abortion in – 6 (24%), gestational pro­
cess complicated by hyperemesis gravidarum 
which required additional therapy – in 4 (16%). 
Among 25 women of the 2nd group spontaneous 
abortion occurred in 3 (12%) patients, missed 
abortion – in 1 (4%) woman.

The results of our research have shown that 
in women of the 2nd group the level of platelets 
increased and did not significantly differ from 
the control group findings. In patients of the 1st 
group it was significantly lower than in women 
of the 2nd and control groups. The similar chan­
ges were evidenced in the evaluation of PI.

In 2 weeks of the proposed therapy, the 
level of β­hCG increased in both groups of 
women, but in the 2nd group it did not sig­
nificantly differ from the control group. After 
the treatment the level of free estriol and pro­
gesterone increased and did not significantly 
differ from the control group with the similar 
results.

Symptomatic and complex treatment sig­
nificantly reduced the sonographic signs of 
abortion, but in the 2nd group these changes 
pronounced more positive trend than in the 1st 
group. So, in 18 (72%) pregnant women of the 
2nd group and in 4 (16%) – of the I group (p<0,05) 
there was a complete resumption of SCH, 

hematoma decreased in size in 3 (12%) women 
of each group.

Thus, the prescription of micronized proges­
terone sublingually provides an inhibitory effect 
on the contractile activity of myofibrils, prevents 
the further chorine detachment that leads to 
pregnancy maintenance and prevents repro­
ductive losses.

Our research demonstrates the necessity 
of the inclusion of micronized progesterone in 
100 mg 3 times daily sublingually and tranexamic 
acid 500 mg intravenously to the treatment 
protocol of early threatened abortion with SCH. 
Also this treatment is more effective if compared 
with the traditional supportive therapy (seda­
tion, spasmolytic, haemostatic drug).

Conclusions
1. Complex application of natural micronized 

progesterone 100 mg three times a day sub­
lingually and 500 mg of Tranexamic acid 
dissolved in 200 ml normal saline solution 
improves the dynamics of the main hormonal, 
haemostatic and ultrasound markers of abor­
tion and significantly reduces reproductive 
losses.

2. Tranexamic acid treatment proved a rapid 
and effective action on hematoma and absence 
of embryotoxical and сoagulopathyc influence. 
Tranexamic acid does not cause any significant 
disorders of hemostatic system. This is very 
important at the early gestation because of 
intravascular coagulation, physiological hyper­
coagulable condition during pregnancy that 
can cause microthrombosis and disrupt pla­
centation. On the other hand, it is dangerous 
for the mother’s health because of the in­
creased risk of thrombosis.

References
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нального статусусфетоплацентаного комплексу 
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2. Резніченко ГІ. Профілактика невиношуван­
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Received: 2015-12-01

S. N. Heryak et al.