Diagnosis of placental abruption: relationship between clinical and histopathological findings

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Abstract

Objective

We evaluated the extent to which histologic lesions bearing a diagnosis of abruption conform to a diagnosis based on established clinical criteria. We further examined the profile of chronic and acute histologic lesions associated with clinical abruption.

Methods

Data from the New Jersey-Placental Abruption Study – a multi-center, case-control study – were utilized to compare the clinical and histologic criteria for abruption. The study was based on 162 women with clinically diagnosed abruption and 173 controls. We examined the concordance between clinical indicators for abruption with those of a histopathological diagnosis. The clinical criteria for a diagnosis of abruption included (i) evidence of retroplacental clot(s); (ii) abruption diagnosed on prenatal ultrasound; or (iii) vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity. The pathological criteria for abruption diagnosis included hematoma, fibrin deposition, compressed villi, and hemosiderin-laden histiocytes in cases with older hematomas. Acute lesions included chorioamnionitis, funisitis, acute deciduitis, meconium stained membranes, villous stromal hemorrhage, and villous edema. Chronic lesions included chronic deciduitis, decidual necrosis, decidual vasculopathy, placental infarctions, villous mal-development (delayed or accelerated maturation), hemosiderin deposition, intervillous thrombus, and chronic villitis.

Results

Of clinically diagnosed cases, the sensitivity and specificity for a histologic confirmation of abruption were 30.2% and 100%, respectively. Presence of retroplacental clots remained the single most common finding (77.1%) among clinically diagnosed cases. Among the acute lesions, chorioamnionitis and funisitis were associated with abruption. The only chronic histologic lesion associated with abruption was placental infarctions.

Conclusions

The concordance between clinical and pathologic criteria for abruption diagnosis is poor. The criteria for diagnosing a clinical abruption should include sonographic visualization of abruption, evidence of retroplacental clots, or vaginal bleeding accompanied by nonreassuring fetal status or uterine hypertonicity.

Introduction

Placental abruption, the premature separation of the placenta, is a serious obstetric complication that occurs in about 1–2 per 100 pregnancies [1], [2], [3]. Over half of all pregnancies complicated by abruption deliver preterm [4], [5], [6], and abruption is associated with an array of adverse maternal and fetal outcomes [7], [8], [9]. The etiology of placental abruption remains speculative but is thought to be the consequence of abnormal trophoblast invasion leading to rupture of the spiral arteries and premature separation of the placenta [10].

Despite being an important obstetrical condition, placental abruption lacks a unified diagnostic clinical criterion. Histologic evidence supporting a chronic process that frequently accompanies placental abruption has led researchers to speculate that the condition is the end-result of an underlying chronic process with origins very early in pregnancy, and perhaps even extending to the time of implantation [11], [12]. In the presence of vaginal bleeding accompanied by abdominal pain, uterine contractions, or uterine tenderness [13], placental abruption is first considered in the differential clinical diagnosis. At delivery, old or freshly adherent blood clots are diagnostic of abruption. Some of these placentas, but not all, may have histologic features of placental abruption. Moreover, there have been cases of women diagnosed with placental abruption based on histological markers that showed a clinically unremarkable obstetrical course and outcome [14].

Given these uncertainties surrounding the diagnosis of placental abruption, we sought to determine the concordance between a clinical and histologic diagnosis of placental abruption. Additionally, we evaluated associations between acute and chronic placental lesions and abruption to determine if findings from the placenta might provide some insights as to whether placental abruption is the result of an acute event or a chronic process.

Section snippets

New Jersey-Placental Abruption Study (NJ-PAS)

Women with a clinically diagnosed placental abruption were recruited from either Saint Peters University Hospital (SPUH) or Robert Wood Johnson University Hospital (RWJUH) in New Brunswick, NJ. Subjects were recruited between August 2002 and June 2004 at SPUH and between July 2003 and June 2007 at RWJUH. Placental abruption cases were matched to controls based on their race/ethnicity and parity to those who experienced an otherwise normal delivery. Because the original study was designed to

Results

Of a total of 424 enrolled patients, placental histological examination was completed in 88.2% (n = 374) patients. The study was restricted to those with completed placental examination and women that delivered a singleton birth, leaving a total of 162 abruption cases and 173 controls. One hundred and seventeen patients were enrolled at RWJUH (60% of abruption cases) and 218 patients were enrolled at SPUH (42% of abruption cases). Among the 162 clinically diagnosed abruption cases, 30.2% (n = 49)

Discussion

Despite extensive research, the etiology of placental abruption remains speculative, perhaps, to a large extent the lack of appropriate diagnostic criteria. Our study reveals several important and clinically relevant findings regarding placental abruption: (i) the diagnosis of abruption should be based on clinical criteria, since an examination of the placenta for confirmational purposes is not sensitive; (ii) the diagnostic criteria should include the presence of retroplacental clot(s) or

Funding

This study was funded by the United States National Institutes of Health (R01-HD038902) awarded to Dr. Ananth.

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