Ultrasonographic findings of placental abruption observed on superb microvascular imaging.

OBJECTIVE: To demonstrate ultrasound pathological findings of placental abruption (PA) detected using a new Doppler method: superb microvascular imaging (SMI). CASE REPORT: The patient was a pregnant woman with dark brown vaginal discharge at 32 + 4 weeks of gestation. Conventional ultrasound revealed an exophytic heterogeneous area measuring 3 cm, between the placenta and myometrium. SMI showed no minor blood flow inside the area. A diagnosis of marginal sub-chorionic hematoma was made. On the seventh day of hospitalization, SMI showed pulsation of blood flow in the inter-villous space and fetal blood flow in the villous trees. Due to an increase in the frequency of uterine contractions, an emergency cesarean section was performed. Histopathological examination showed hematomas beneath the decidual tissue, and the decidual layer was undamaged. The inter-villous space was preserved. CONCLUSION: SMI can contribute to a more accurate PA diagnosis that may lead to timely administration of obstetric intervention.

Assessment of placental abruption with diffusion-weighted imaging.

AIM: To investigate whether placental abruption without fetal distress could be assessed by apparent diffusion coefficient (ADC) values in magnetic resonance imaging (MRI). METHODS: We conducted a retrospective case-control study at a single center. ADC values at the lesions of placental abruption in the abruption group (n = 8) were compared to those in the control group (n = 32). In the abruption group, ADC values at the sites of abruption were also compared to those at the nonabruption sites within the same placenta. RESULTS: The ADC values in the placental area above the abruption site in the abruption group showed lower values than those in the control group when the slice containing the umbilical cord insertion site was set as the reference, and those values were compared in each corresponding slice. Compared with average ADC values, those above the abruption site in the abruption group were also significantly lower than those in the control group (p < 0.001). Furthermore, ADC values at the area above abruption were lower than those at the nonabruption area of all planes in the abruption group. CONCLUSIONS: ADC values at the lesions above the placental abruption site were reduced compared to those in the normal placenta and those in the nonabruption area. Thus, it would be helpful to understand the pathophysiology of placental abruption in expectant management, although further investigations would be needed.

Attenuation imaging as a new ultrasonographic application for identifying placental haematoma.

We present a case in which attenuation imaging (ATI), a recently developed ultrasonographic application, facilitated the diagnosis of preplacental and postplacental haematoma. Placental abruption is a serious condition that affects the prognosis of infants and is difficult to diagnose. Ultrasonography is the primary imaging modality that complements the clinical findings in the diagnosis; however, its sensitivity is low, and improved diagnostic accuracy is desired. Here, we found that placental haematomas on the placental fetal surface observed at 19 weeks of gestation were indistinct from placental parenchyma in B-mode ultrasonographic imaging. In ATI, the placental parenchyma was colour-mapped, but the haematoma portion was not, which helped identify the haematoma. ATI, which also colour-maps uniform tissues, did not colour-map vessels within the placenta. ATI has a breakthrough potential for improving the diagnosis of placental abruption.

Incidental sonographic finding of a concealed placental abruption leading to delivery at 37 weeks' gestation.

Placental abruption occurs clinically in approximately 1% of births although placental pathology assessment suggests a higher incidence. Ultrasound rarely plays a role in the diagnosis or clinical management of patients with suspected placental abruption. A patient with an incidental sonographic finding of a large concealed abruption at 36 weeks' gestation, led to induction of labor. This case and the established association of increased stillbirth with placental abruption among patients of advanced maternal age, suggest that at term, following sonographic findings of abruption, consideration should be given to elective delivery of these patients even in the absence of clinical symptomatology.

Assessment of Acute Obstetrical Needs and the Potential Utility of Point-Of-Care Ultrasound in the North East Region of Haiti: A Cross-Sectional Study.

Background: Point-of-care ultrasound (POCUS) implemented through task shifting to nontraditional users has potential as a diagnostic adjuvant to enhance acute obstetrical care in resource-constrained environments with limited access to physician providers. Objective: This study evaluated acute obstetrical needs and the potential role for POCUS programming in the North East region of Haiti. Methods: Data was collected on all women presenting to the obstetrical departments of two Ministry of Public Health and Population (MSPP)-affiliated public hospitals in the North East region of Haiti: Fort Liberté Hospital and Centre Medicosocial de Ouanaminthe. Data was obtained via retrospective review of hospital records from January 1 through March 31, 2016. Trained personnel gathered data on demographics, obstetrical history, diagnoses, clinical care and outcomes using a standardized tool. Diagnoses a priori, defined as those diagnoses whose detection could be assisted with POCUS, included multi-gestations, non-vertex presentation, cephalopelvic disproportion, placental abruption, placenta previa, spontaneous abortions, retained products and ectopic pregnancy. Results: Data were collected from 589 patients during the study period. Median maternal age was 26 years and median gestational age was 38 weeks. The most common reason for seeking care was pelvic pain (85.2%). Sixty-seven (11.5%) women were transferred to other facilities for higher-level care. Among cases not transferred, post-partum hemorrhage, infant mortality and maternal mortality occurred in 2.4%, 3.0% and 0.6% of cases, respectively. There were 69 cases with diagnoses that could have benefited from POCUS use. Between sites, significantly more cases had the potential for improved diagnostics with POCUS at Fort Liberté Hospital (19.8%) than Centre Medicosocial de Ouanaminthe (8.2%) (p < 0.001). Conclusion: Acute obstetrical care is common and POCUS has the potential to impact the care of obstetrical patients in the North East region of Haiti. Future programs evaluating the feasibility of task shifting and the sustainable impacts of acute obstetric POCUS in Haiti will be important.

Nonfetal Imaging During Pregnancy: Placental Disease.

Placenta is a vital organ that connects the maternal and fetal circulations, allowing exchange of nutrients and gases between the two. In addition to the fetus, placenta is a key component to evaluate during any imaging performed during pregnancy. The most common disease processes involving the placenta include placenta accreta spectrum disorders and placental masses. Several systemic processes such as infection and fetal hydrops can too affect the placenta; however, their imaging features are nonspecific such as placental thickening, heterogeneity, and calcifications. Ultrasound is the first line of imaging during pregnancy, and MR imaging is reserved for problem solving, when there is need for higher anatomic resolution.

MRI in pregnancy: Indications and practical considerations.

There is a constantly evolving knowledgebase regarding the safety of MRI in pregnant patients, as well as the safety of gadolinium administration, given potential fetal risks. This review provides an overview of national and international recommendations for patient screening and safety by trimester, evaluates the most recent literature regarding administration of gadolinium in pregnant patients, and discusses technical requirements when imaging pregnant patients. A protocol for imaging pregnant patients is provided, and multiple common indications for MRI in pregnancy are discussed. Level of Evidence 5. Technical Efficacy Stage 5. J. Magn. Reson. Imaging 2019;49:621-631.

Placental abruption and hemorrhage-review of imaging appearance.

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.

Imaging findings of concealed intra-amniotic hemorrhage in the setting of placenta previa and placenta accreta spectrum disorder.

Placental abruption is an important cause of feto-maternal hemorrhage, with significant impact on both fetal and maternal mortality. In most cases, it presents with abdominal pain and vaginal bleeding. However, vaginal bleeding may be absent with concealed intra-amniotic hemorrhage, as in cases with placenta previa, hence confounding this diagnosis. In such cases, imaging studies may be obtained to evaluate for abdominal pain in pregnancy; hence, radiologists should be aware of the ultrasound and magnetic resonance (MR) imaging appearance of intra-amniotic hemorrhage. This includes presence of markedly echogenic amniotic fluid on US. Hemorrhage signal intensity on MR imaging varies with the duration of bleeding. In acute to subacute cases, it will present as T1 isointense and T2 hypointense amniotic fluid. This case is the first report of MR imaging findings of acute concealed intra-amniotic hemorrhage.

Ultrasonographic prediction of antepartum deterioration of growth-restricted fetuses after late preterm.

AIM: To examine the predictive value of ultrasound parameters for antepartum non-reassuring fetal status (NRFS) in fetal growth restriction (FGR) cases after late preterm. METHODS: Retrospective review of singleton FGR cases before 37 weeks gestation who delivered after 34 weeks gestation was performed. The association between ultrasound parameters that was assessed from 34 to 36 weeks gestation and the development of antepartum NRFS that was diagnosed by nonstress test and biophysical profile was analyzed by using multivariate Cox proportional hazards analyses. RESULTS: A total of 214 patients were included in final data analyses. Antepartum NRFS occurred in 23 cases (10.7%) including five cases of placental abruption. Lower standard deviation (SD) of estimated fetal weight (EFW), lower cerebroplacental ratio (CPR) and the presence of oligohydramnios were independently associated with antepartum NRFS. The prevalence of antepartum NRFS was highest (50.4%) in the group of EFW ≤-2.5 SD with CPR ≤1.45. CONCLUSION: Ultrasound parameters of lower SD of EFW, lower CPR and oligohydramnios were predictive for antepartum NRFS in FGR after late preterm.

Core curriculum case illustration: placental abruption.

This is the 33rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC .

Placental abruption leading to hysterectomy.

A 32-year-old multigravid patient at 21 weeks gestation presents with major concealed placental abruption and subsequent fetal demise. During an eventually failed misoprostol regime aiming for vaginal delivery she develops severe disseminated intravascular coagulopathy. Subsequent hysterotomy reveals Couvelaire uterus with major haemorrhage and requires subtotal hysterectomy for haemostasis. This case highlights the severity of the systemic response to abruption and fetal demise in utero and the multifactorial nature of its management.

Evolución y aspectos ecográficos del desprendimiento crónico de placenta / Evolution and ultrasound aspects of chronic placental abruption

El desprendimiento crónico de placenta se caracteriza por la aparición de un sangrado venoso crónico intra o retroplacentario que produce la separación paulatina de la misma. Es poco frecuente y se puede presentar en pacientes sin factores de riesgo. La imagen ecográfica plantea diagnóstico diferencial con la corioamnionitis. El pronóstico fetal es malo especialmente si se asocia con oligoamnios. Se presentan cuatro casos caracterizados por imagen ecográfica característica, retraso del crecimiento fetal, alteración del Doppler, y confirmación anatomopatológica.

Chronic placental abruption is due to intra or retroplacental insidious bleeding that causes progressive separation from the uterine wall. It is a rare condition and can occur in low risk patients. Chronic abruption imaging poses differential diagnosis with infectious TORCH chorioamnionitis. Fetal prognosis is ominous especially in the presence of oligohydramnios. We present four cases with a common ultrasound appearance, fetal growth restriction, Doppler abnormalities and pathological confirmation.

MRI findings of chronic abruption-oligohydramnios sequence (CAOS): report of three cases.

Chronic abruption-oligohydramnios sequence (CAOS), characterized by chronic vaginal hemorrhage and oligohydramnios, is a rare clinical condition of pregnancy. Because CAOS is associated with preterm delivery and lung injury to the infant, it is a major clinical concern. This report describes three CAOS cases which presented characteristic MRI findings reflecting CAOS pathological mechanisms and pathological findings. First, in all cases, the placenta detached from the uterus at the peripheral portion of the placenta because of placental marginal hematoma. Because the cause of CAOS is presumed to be chronic peripheral separation of the placenta developing from bleeding from the peripheral vein of the placenta, the MRI finding corresponds to the CAOS pathophysiology. Second, the placental marginal hematoma spread extensively along the decidua. This MRI finding can explain the vaginal hemorrhage of CAOS patients. Finally, the amniotic fluid of all patients showed high signal intensity on T1-weighted images, suggesting that amniotic fluid contains blood-derived products. In CAOS patients, chronic venous bleeding engenders the release of blood-derived products into the amniotic cavity. The aspiration of these products might be a cause of lung injury to the fetus. We presented these MRI findings with radiologic-pathologic correlation.

Trauma in pregnant women: assessing detection of post-traumatic placental abruption on contrast-enhanced CT versus ultrasound.

OBJECTIVES: To evaluate detection of post-traumatic placental abruption with contrast-enhanced CT (CECT) and comparison with Ultrasound (US). METHODS: Picture Archive and Date System database at a level-1 trauma center was retrospectively reviewed using keywords pregnancy, trauma, and/or placental abruption over 10 years. CT was compared to US, if performed within 24 h. Two subspecialty-trained radiologists blindly reviewed the studies. Placental features on delivery and pregnancy outcomes were used as reference standard. Lack of adverse pregnancy/fetal outcome was treated as the absence of abruption. RESULTS: CECT was performed in 36 patients, with 27 US within 24 h. There were three complete and eight partial abruptions. Reader sensitivity for CT was 100% for both reviewers; however, specificity was 54.5% and 56.7%. No sonographic abnormality was noted in both partial and complete abruption. Using kappa statistics, inter-observer agreement was low for both CT (0.169) and US (0.078). False-positive reads were from misinterpretation of normal placental structures like cotyledons, age-related infarcts, and marginal sinus of the placenta. CONCLUSIONS: CECT identifies post-traumatic placental abruption with high sensitivity but low specificity for clinically significant abruptions, and performs better than US. Pitfalls from normal placental structures mimicking abruption should be avoided. US markedly underdiagnoses abruption.

Placenta abruption surface and perinatal outcome.

OBJECTIVE: To identify the relationship between the placenta abruption (PA) surface and the perinatal outcome. METHODS: This prospective descriptive study was carried out from 1 February to 30 September 2014. We recruited all women whose delivery was complicated by PA with onset preceded by the presence of active fetal movement. PA surface was assessed by placental examination after delivery. Main outcome measures were gestational age, Apgar score, and location and percentage of PA. Data were analyzed using SPSS 17.0 Fisher's exact test was used for comparison. RESULTS: PA occurred in 47 women (1.3%). Mean gestational age was 36.0 weeks. PA percentages varied between 5% and 60%. Detachment ≥45% was always associated with stillbirth and was significantly observed in central PA (p < 0.0002), while separation of 25-44% was associated with various degrees of neonatal asphyxia. Compared to marginal separation of the placenta, central separation was significantly associated with stillbirth (77.8% versus 10.5%, p < 0.0002) and perinatal death (88.9% versus 13.1%, p < 0.0001). CONCLUSION: PA surface ≥45% was associated with stillbirth. This knowledge can be helpful in identifying the cause of stillbirth when PA is found. Central PA was significantly associated with poor perinatal outcome and PA surface ≥45%. Therefore, its diagnosis calls for rapid intervention.