Diagnosis of Placental Abruption: Relationship Between Clinical and Histopathological Findings

Abstract

Despite intensive investigation, it is unclear whether the diagnosis of placental abruption should be based on established clinical criteria or histopathological findings. Although the vast majority of placental abruption cases appear to have a chronic etiology, it also remains speculative as to whether abruption is an acute or chronic process. The aim of the present multicenter, case-control study was to assess the concordance between clinical and histopathological diagnostic indicators of placental abruption. A secondary aim was to investigate acute and chronic histological lesions associated with clinical abruption. The clinical and histologic criteria for abruption were compared using data obtained from the New Jersey-Placental Abruption Study. The study subjects, 162 women with a confirmed clinical diagnosis of placental abruption, were matched with 173 controls without placental abruption. Criteria for the clinical diagnosis of placental abruption included painful vaginal bleeding accompanied by nonreassuring fetal status, uterine hypertonicity, evidence of clinically significant retroplacental bleeding, or clot(s) or placental abruption diagnosed on prenatal ultrasound. The pathological criteria for a diagnosis of abruption included hematoma with or without recent or old infarctions, foci of villous compression, fibrin deposition, and hemosiderin-laden histiocytes in cases with older hematomas. Histologic lesions were grouped as acute or chronic histologic lesions. Acute lesions included chorioamnionitis, funisitis, acute deciduitis, meconium-stained membranes associated with amnion necrosis and pigmented macrophages, villous stromal hemorrhage, and villous edema. Chronic lesions included chronic deciduitis, maternal floor decidual necrosis, decidual vasculopathy, placental infarction, villous mal-development with delayed or accelerated maturation, hemosiderin deposition, intervillous thrombosis, and villitis. Of the 162 clinically diagnosed cases, only 30.2% (n = 49) were confirmed as placental abruption based on gross or histological findings, whereas the specificity for a histologic confirmation of abruption was 100%. Among clinically diagnosed cases, the most common indication for a clinical diagnosis of abruption was evidence of retroplacental clot(s) or bleeding (77.1%). Two chronic lesions, placental infarction and decidual vasculopathy, were significantly associated with abruption, but no acute lesions were significantly associated with abruption. The investigators conclude from these finding that there is poor concordance between the clinical and pathological diagnosis of placental abruption. The diagnosis of abruption should be based on clinical criteria such as evidence of retroplacental bleeding or clot(s), ultrasound visualization of abruption, or painful vaginal bleeding accompanied by either nonreassuring fetal status or uterine hypertonocity.