Diagnosis Of Placental Abruption Research Articles

Association between hospital case volume and maternal adverse events in patients with placental abruption: An analysis using a Japanese national inpatient database.

To clarify the relationship between the prognosis of patients with placental abruption (PA) and the healthcare delivery system using data from a large national inpatient database in Japan. Using the Diagnosis Procedure Combination database, we conducted a retrospective cohort study with the data of patients in almost 1000 hospitals with the primary diagnosis of PA who were hospitalized from April 2014 to March 2021. We divided the hospitals into four groups based on the number of deliveries per month. We performed multilevel logistic regression analysis to analyze the relationship between hospital case volume and maternal end-organ injury (MEOI). Altogether, 8222 patients were included for analysis; among whom, 3575 (44%) were transferred by ambulance. MEOI was noted in 977 patients (12%) with no obvious difference by hospital case volume. Ambulance transfer, age, gestational weeks at admission, delivery on the first day of hospitalization, and history of eclampsia were significantly associated with a higher incidence of MEOI, but the hospital case volume was not. Using a Japanese administrative database, our study shows that hospital case volume was not significantly associated with the severity of maternal illness among patients with PA.

Placental Abruption with Subamniotic Hemorrhage: A Case Report

Background: Subamniotic hemorrhage is a rare lesion with abnormal ultrasonographic findings that is caused by placental abruption. We report the case of a patient with placental abruption who presented with antepartum bleeding in whom the ultrasound findings of subamniotic hemorrhage were detected. This resulted in early diagnosis, leading to a favorable clinical outcome in this patient. Case: A primigravid 35-year-old woman visited the emergency room due to vaginal bleeding at 36 + 4 weeks of gestation. Ultrasound examination revealed a subamniotic hemorrhage that had not been evident on previous antenatal ultrasonography. An emergent cesarean section was performed, and the diagnosis of placental abruption was confirmed. The patient and baby were discharged after an uneventful course in the hospital. Conclusions: Detection of subamniotic hemorrhage by ultrasound helped in achieving an early diagnosis that resulted in prompt intervention against acute placental abruption and ensured favorable clinical outcomes. A thorough ultrasound examination of the placenta should be performed when managing patients with antepartum bleeding.

Couvelaire uterus after external cephalic version

A 30-years-old primiparous woman with 37 weeks of amenorrhoea was admitted to the Obstetric ward with symptoms of ruptured membranes and abdominal pain. The day before she was subjected to an unsuccessful external cephalic version. Transabdominal ultrasonography revealed a breech presentation. The placenta appeared normal. The Cardiotocograph (CTG) showed a nonreassuring pattern with deep variable decelerations. An emergency cesarean section was performed. Intraoperatively, the uterus showed a large intramyometrial hematoma coinciding with the operator`s side of the external cephalic version the previous day. A retroplacental hematoma was evidenced after hysterotomy. The diagnosis of placental abruption and Couvelaire`s uterus was established. The newborn`s 1-minute and 5-minute Apgar scores were 8 and 9, respectively. The postoperative period was good and mother and son are progressing favourably.

Unpredictable Placental Abruption: Case Series

Background: The diagnosis of placental abruption is primarily clinical, but findings from imaging, laboratory, and postpartum pathologic studies can be used to support the clinical diagnosis. In patients with classic symptoms, fetal heart rate abnormalities, intrauterine fetal demise, and/or disseminated intravascular coagulation strongly support the clinical diagnosis and indicate extensive placental separation. In a few cases, placental separation has not been recognized and was only identified upon cesarean section as an incidental finding. Objectives: To describe the clinical presentations and pregnancy outcomes of placental abruption cases that are not diagnosed before cesarean delivery, termed “unpredictable placental abruption” and also cases diagnosed before cesarean delivery, termed “predictable placental abruption”. Methods: A retrospective analysis of 100 cases of placental abruption was identified by cesarean delivery at Tu Du hospital from September 2018 to May 2019. Clinical variables were compared between the unpredictable and predictable groups. The unpredictable group consists of cases that are not diagnosed before cesarean delivery, while the predictable cases were identified placental separation before cesarean delivery. The maternal and fetal outcomes were also studied. Results: In 100 cases of placental, abruption by gross clinical examination of the placenta at the time operation revealed that, 33% were unpredictable. Placental abruption attributed to maternal complications included one case of total hysterectomy (1%) with no cases of disseminated intravascular coagulation (DIC), shock or maternal death; specifically, this case of total hysterectomy appeared with predictable one. There were two cases of stillbirths. Among the 98 live neonates, 15 cases (14.7%) experienced severe birth asphyxia resulting in eight neonatal deaths; two of which were caused by heart disease and necrotizing enterocolitis. Sixty-three neonates were delivered prematurely (61.74%), with mean gestational age of 34.64 ± 3.32 weeks. Among the 33 unpredictable cases, there were no stillbirths but 60.6% and 12.1% experienced moderate and severe asphyxia, respectively. All unpredictable cases had obvious indications of cesarean section but the basic symptoms and signs of acute placental abruption included the onset of preterm labor, unspecified intrapartum hemorrhage, hypertonic uterine contractions and fetal distress for emergency caesarian section; however there were also cases where there were no symptoms and signs. Conclusions: Unpredictable placental abruption cases—not suspected of having abruption, termed—“concealed” or “chronic” placental abruption, may have variable clinical manifestations and better pregnancy outcomes.

Clinical analysis and classification of placental abruption

Objective To investigate the diagnosis, treatment, and maternal and fetal outcomes of placental abruption. Materials and methods We recruited 585 cases of placental abruption from the Women and Children’s Hospital Affiliated to Xiamen University between January 2012 and December 2017. Cases were categorized into four groups (class 0–III) according to the clinical guidelines published by the Obstetrics and Gynecology Branch of the Chinese Medical Association. We then compared clinical data and auxiliary examinations across the four groups. Results The differences were statistically significant (p < .01) among the four groups of placental abruption with regard to the incidence of an abnormal ultrasound finding. Positive ultrasound signs were evident in 6.4% of the patients categorized as class 0 and 100.0% of patients categorized as class III. Monitoring showed that fetal heart rate (FHR) was abnormal in class II patients with placental abruption; patients in class III showed no fetal heart sounds. Cesarean section was carried out for 26.6%, 75.1%, 65.2%, and 47.1% of patients in classes 0, I, II, and III, respectively. The rate of cesarean section for classes I and II was the highest, while the lowest rate occurred for class 0. Postpartum hemorrhage occurred in 2.5%, 9.3%, 15.2%, and 29.4% of patients across the four groups, DIC occurred in 0.0%, 1.3%, 2.3%, and 23.5% of cases, and perinatal death occurred in 1.0%, 1.3%, 7.6%, and 100.0% of cases, respectively. The highest incidence of postpartum hemorrhage was in class III (29.4%) and the lowest was in class 0 (2.5%). The highest incidence of DIC was in class III (23.5%) and the lowest was in class 0 (0.0%). The highest incidence of neonatal asphyxia was in class II (34.1%) and the lowest was in class 0 (10.1%). Regarding perinatal death, the highest incidence was in class III (100.0%) and the lowest was in class 0 (1.0%). These data showed significance differences when compared across the four groups of patients (p < .01). Conclusions We recommend that the diagnosis of placental abruption should consider risk factors, clinical features, FHR monitoring, and dynamic ultrasound monitoring. Early diagnosis and treatment can improve maternal and infant prognosis.

Are maternal and neonatal outcomes different in placental abruption between women with and without preeclampsia?

IntroductionPlacental abruption is a serious pregnancy complication that causes maternal and neonatal mortality and morbidity. Whether maternal and neonatal outcomes differ between patients who concurrently presented with preeclampsia and those who did not, have not been fully investigated. MethodsA total number of 158 patients with placental abruption were included. Of them, 66 concurrently had preeclampsia. Maternal and neonatal characteristics including delivery weeks, time of onset and birthweight as well as the grade of placental abruption were collected and analysed. ResultsThe time at diagnosis of placental abruption in patients who concurrently presented preeclampsia was significantly earlier than that in patients who did not. The number of patients with grade III placental abruption was significantly higher in patients who concurrently presented with preeclampsia, compared to patients who did not. The odds ratio of an increase in grade III placental abruption in patients who concurrently presented preeclampsia was 5.27 (95%CL: 2.346, 12.41), compared to patients who did not. The numbers of infants who were born pre-term and the numbers of stillbirth/neonatal deaths as well as the number of fetal distress were significantly higher in patients who concurrently presented with preeclampsia, compared to patients who did not. The fetal birthweight was significantly lower in patients who concurrently presented with preeclampsia compared to patients who did not. DiscussionOur study demonstrates that women with preeclampsia experiencing placental abruption had worse maternal, fetal and neonatal outcomes, compared to women experiencing placental abruption alone.

Analysis of misssed diagnosis and misdiagnosis of 1 212 cases with placental abruption

Objective: To investigate the risk factors and clinical manifestations of placental abruption, and to analyze the causes of missed diagnosis and misdiagnosis. Methods: A retrospective analysis was conducted in 135 584 women who delivered in Women's Hospital, School of Medicine, Zhejiang University from January 2005 to December 2015. The diagnosis of placental abruption was made in 1 212 cases. According to the consistency of prenatal and postnatal diagnosis, they were divided into 3 groups. (1) The diagnosis was consistent prenatally and postnatally in 715 cases(58.99%, 715/1 212) as the diagnosis group. (2) In 312 cases (25.74%, 312/1 212), the diagnosis was made after birth as the missed diagnosis group. (3) In 185 cases (15.26%, 185/1 212), the diagnosis was made prenatally but excluded after birth as the misdiagnosis group. The disease classification was made, and the risk factors, clinical manifestations, lab results, the time of termination and perinatal outcomes were recorded in the 3 groups. The reasons of missed diagnosis and misdiagnosis were analyzed. Results: (1) In the 1 212 cases, the diagnosis of placental abruption was confirmed in 1 027 cases, with the incidence of 0.76% (1 027/135 584). The rate of missed diagnosis was 30.38% (312/1 027), and the rate of misdiagnosis was 0.14% (185/134 557) . (2) There were significant differences in the degree of placental abruption among the 3 groups (P<0.05). (3)Significant differences were found among the 3 groups regarding the ratio of hypertensive disorders, trauma, induced labor and advanced maternal age (all P<0.05). (4) There were statistically significant differences among the 3 groups regarding the incidence of vaginal bleeding, persistent abdominal pain and uterine tenderness, bloody amniotic fluid, increased uterine tension and stillbirth (all P<0.05). (5) There was no significant difference in the rate of abnormal fetal heart rate mornitoring among the 3 groups (P=0.22). The differences were statistically significant among the 3 groups when regarding the incidence of abnormal ultrasound finding and abnormal blood coagulation (P<0.01), with the highest incidence of abnormal ultrasound in the diagnosis group (68.1%) and the highest incidence of abnormal coagulation in the misdiagnosis group (24.9%). (6)There was statistically significant difference among the 3 groups when comparing the ratio of termination of pregnancy within 24 hours (P=0.01). (7) There were statistically significant differences among the 3 groups when the ratios of postpartum hemorrhage, DIC, neonatal asphyxia and perinatal death were compared (all P<0.05). The highest incidence of postpartum hemorrhage was in the diagnosis group (17.9%) and the lowest was in the misdiagnosis group (5.4%). The highest incidence of DIC was in the diagnosis group (3.9%) and the lowest was in the misdiagnosis group (0). The highest incidence of neonatal asphyxia was in the diagnosis group (30.6%) and the lowest was in the misdiagnosis group (7.6%). And for perinatal death, the highest incidence was in the diagnosis group (12.6%), the lowest was in the misdiagnosis group (2.2%). Conclusions: Placental abruption could be misdiagnosed when depending on risk factors, such as trauma. And it could be missed diagnosis during the induction of labor. Uterine contraction, abnormal fetal heart rate mornitoring, abnormal ultrasound and abnormal coagulation function are important in the diagnosis of placental abruption.

Thymic pathology in placental abruption: an autopsy study of third trimester stillborns in a predominantly African–American population

Objective: Complete placental abruption results rapidly in fetal death through acute asphyxia, and identification of thymic lesions at autopsy may help in confirming this diagnosis. Thymic petechiae are a marker for acute asphyxia, while absence of histologically identifiable acute thymic involution (ATI), which requires several hours to develop, may help in exclusion.Methods: We identified autopsies on 17 3rd trimester stillborns with clinical abruption; 58 stillborns with unexplained demise comprised the control group. Eighty-nine percent of the mothers were African–American. ATI was graded 0–4 (grades 0–1 and 3–4 were combined for analysis), and thymic petechiae were recorded.Results: In the abruption group, ATI grade 0–1 was more frequent than higher grades: 13 (77%) had ATI grade 0–1 compared to 1 (6%) with ATI grade 3–4 (p < 0.001). In contrast, in the control group, ATI grade 3–4 was more frequent than lower grades: 9 (16%) had ATI grade 0–1 compared to 30 (52%) with ATI grade 3–4 (p < 0.001). Thymic petechiae were more frequent in the abruption compared to control group [10 (59%) versus 2 (3%)] (p < 0.001), and were frequently seen with low ATI grade: 10 (83%) had ATI grade 0–1 (p < 0.001).Conclusions: The presence of thymic petechiae and ATI grade 0–1 correlates significantly with a clinical diagnosis of placental abruption.

Is there an association between a history of placental abruption and long-term maternal renal complications?

Objective: To investigate whether patients with a history of placental abruption have an increased risk for subsequent maternal long-term morbidity.Study design: A population-based study compared the incidence of long-term renal morbidity in cohort of women with and without a history of placental abruption. Deliveries occurred during a 25-year period, with a mean follow-up duration of 11.2 years. Renal morbidity included kidney transplantation, chronic renal failure, hypertensive renal disease, etc.Results: During the study period 99 354 deliveries met the inclusion criteria; 1.8% (n = 1807) occurred in patients with a diagnosis of placental abruption. Patients with placental abruption did not have higher cumulative incidence of renal related hospitalizations, using Kaplan–Meier survival curve. During the follow-up period patients with a history of placental abruption did not have higher rate of renal morbidity (0.2% versus 0.1%; OR 1.8; 95% CI 0.6–4.8; p = 0.261). When performing a Cox proportional hazards model, adjusted for confounders such as parity and diabetes mellitus, a history of placental abruption was not associated with renal related hospitalizations (adjusted HR, 1.6; 95% CI, 0.6–4.2; p = 0.381).Conclusion: Placental abruption, even though considered a part of the “placental syndrome” with possible vascular etiology, is not a risk factor for long-term maternal renal complications.

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption

Objective: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption.Materials and methods: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death.Results: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p < 0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p < 0.05).Conclusions: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.

Case report: lethal fetal head injury and placental abruption in a pregnant trauma patient

Fetal trauma in blunt abdominal trauma is uncommon, but traumatic fetal head injury is almost universally fatal to the fetus. Placental abruption is the most common injury to the gravid uterus in trauma, and when the mother survives, it is the most common cause of fetal death. The imaging diagnosis of these conditions may be difficult since there are only three cases reported in the literature of intrauterine skull fractures on plain films [3, 8, 10], ultrasound is in sensitive in the diagnosis of placental abruption [24], and the most sensitive test to diagnose placental abruption is external fetal monitoring with devices that measure uterine tone and contractility and fetal heart rate [23]. The diagnosis of fetal trauma and placental abruption may be made on contrast enhanced CT performed through the abdomen and pelvis of pregnant trauma patients. For these reasons, it is useful for the radiologist interpreting the CT scan to recognize fetal head injuries and placental abruption in pregnant trauma patients.Fig. 7 Axial scans through the bony pelvis demonstrate an unstable pelvic fracture with posterior pelvic ring disruption.There is a zone 2 fracture of the left sacrum and a fracture of the left obturator ring (arrowheads)

Male Fetal Sex is Associated With Earlier Onset of Placental Abruption

Despite clear evidence that there is overrepresentation of male fetal sex in cases with placental abruption, prior studies have not investigated possible differential outcomes between female and male infants following abruption. This population-based case-control study investigated possible sex-related differences in short-term morbidity in cases with placental abruption. Data on pregnancy, delivery, and perinatal outcomes were collected from the Finnish Hospital Discharge Register and the Medical Birth Register for all women with a diagnosis of placental abruption between 1987 and 2005. A total of 4081 women with singleton pregnancy and placental abruption were matched with 12,752 controls without placental abruption by maternal age, parity, year of birth, and hospital district area. The final analysis included 3688 cases and 12,695 controls with live-born infants. The primary study outcome measure was placental abruption. There was a significant male sex overrepresentation in the placental abruption cases compared with the controls (cases: 0.548 vs. controls: 0.516, P = 0.001). Male fetuses in the placental abruption group were born earlier than female fetuses (P = 0.018). Cases were born earlier than the controls, and were also associated with lower birth weight, more frequent growth restriction, as well as lower Apgar scores and pH values (all comparisons, P < 0.001). Compared with controls, newborn infants in the abruption group more often needed special care, respirator treatment, intravenous antimicrobials, and phototherapy (all comparisons, P < 0.001). No difference occurred in perinatal outcomes between female and male infants in the placental abruption group. These findings show that placental abruption was more common and occurred earlier in pregnancy with male fetal sex compared with females but other short-term outcomes of the newborns were similar. Outcomes of newborns in the placental abruption group were worse compared with controls.

Diagnosis of Placental Abruption: Relationship Between Clinical and Histopathological Findings

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.

Diagnosis of placental abruption: relationship between clinical and histopathological findings

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.

Antepartum haemorrhage

The incidence of antepartum haemorrhage (APH) is reported as 3.5% of all pregnancies. It is an important cause of maternal and perinatal mortality. There has been a decline in maternal mortality due to APH due to placenta praevia, but the decline has been marginal in cases of placental abruption. No definite cause can be identified in at least half of cases of APH. The diagnosis of placental abruption is based on clinical presentation and on the examination of the delivered placenta. Major complications resulting from placental abruption require critical care in 5–7% of cases. Mid-pregnancy ultrasound scan is an effective screening tool for the detection of placenta praevia. Ultrasound-based criteria have been developed for managing cases of placenta praevia. The incidence of placenta accreta responsible for APH has increased 10-fold, mainly due to a rise in caesarean section rate. Extraplacental causes of APH can be diagnosed on careful speculum examination.

Assessment of the Prevalence of Placental Abruption in Pregnant Women Referred to Motazedi Hospital, Kermanshah, (2001-2002)

Background & Objectives : To determine the prevalence of placental abruption, due to its maternal & fetal known adverse outcomes, the present survey was carried out on pregnant women referred to the obstetric center of Kermanshah University of Medical Science (Motazedi hospital) in 2001_2002. Materials and Methods: This study was a descriptive one, having surveyed all the inpatient pregnant women with a definite diagnosis of placental abruption. The instruments for gathering data was a checklist containing 32 items about demographic (Age, Job, Education) and gestational (the Age of Pregnancy, Pariety, PROM and Gestational Hypertension) characteristics. Results: In this study, placental abruption was observed in 300 cases out of 14433 with the prevalence of 2.08%. This study shows a significant prevalence of placental abruption in the first and second delivery. 44% of deliveries were preterm and the age of pregnancy was under 37 weeks and 51% of them involved in still birth /dead fetus. Conclusion: According to the findings of the research, the frequency of placental abruption was more than those of the other research, perhaps it is due to the difference in the frequency of the predisposing factors of this problem among other societies. For later studies, it is highly recommended to consider the predisposing factors for placental abruption.

Spontaneous rectus sheath haematoma in pregnancy

A 20-year-old, primiparous, Caucasian woman presented at 32 weeks and 6 days gestation with sudden onset severe left-sided abdominal pain. She denied any history of recent trauma, falls or vaginal bleeding. She had no history of previous abdominal pain in this pregnancy and had booked at 9 weeks gestation. Her booking weight was 96 kg with a body mass index of 39 kg/m2 and her booking haemoglobin was 13.6 g/dl. No relevant past medical or surgical history was noted and so far her pregnancy had been uneventful. Clinically she was very distressed with the pain, was sweaty and had cold extremities. Her pulse was 130/minute, blood pressure was 130/87 mmHg and her temperature was 36.4°C. Abdominal examination revealed marked tenderness in the left upper quadrant of the abdomen over the upper pole of the uterus, which had a symphysiofundal height of 34 cm. Her haemoglobin was 8.8 g/dl, white cell count was 9.1×109/litre, and platelet count was 454×109/litre with a normal clotting screen. The cardiotocograph (CTG) was normal. On ultrasound scan a large haematoma was noted associated with the left uterine wall. This was directly associated with her tenderness. With a presumptive diagnosis of placental abruption a decision was made to perform emergency caesarean section delivery under general anaesthetic. At laparotomy a large rectus sheath haematoma (RSH) was noted. There were no signs of intraperitoneal bleeding and the uterus was 32 weeks in size. Both tubes and ovaries appeared normal. Caesarean delivery was not performed. About 400 ml of blood clot was evacuated from the left rectus muscle. No active bleeding vessels were noted. The peritoneum was closed followed by the rectus sheath after leaving a sub-rectus drain in the haematoma cavity. Postoperatively fetal CTG monitoring remained normal. She did not require blood transfusion. On her second postoperative day her haemoglobin was 9.7 g/dl and the abdominal drain was removed. She was allowed home on the fifth postoperative day on oral ferrous sulphate. At 34 weeks sonographic fetal biometry was on the 50th centile, liquor volume was normal and the haematoma was resolving (size 72 mm × 60 mm × 35 mm). She was seen again at 36 and 38 weeks. At 39 weeks and 2days she presented in spontaneous labour and proceeded to a forceps delivery, for failure to progress, of a 2.81 kg healthy baby. Her 6-week postnatal follow-up scan showed complete resolution of the RSH.

OP11.13: The clinical values of contrast‐enhanced ultrasonography in the diagnosis of placental abruption, placental infarction and placenta increta—a pilot study

OP11.13: The clinical values of contrast‐enhanced ultrasonography in the diagnosis of placental abruption, placental infarction and placenta increta—a pilot study

Value of ultrasonography in the diagnosis of placental abruption.

Placental abruption is a serious cause of fetal mortality. We retrospectively reviewed 24 patients with placental abruption who underwent cesarean section to evaluate ultrasonographic images with reference to the clinical findings and fetal and maternal prognosis. Fourteen of these patients presenting with placental edge separation and persistent hematoma showed a significantly smaller area of abruption, a smaller amount of intraoperative bleeding, a smaller incidence of disseminated intravascular coagulation, and a higher Apgar score as compared to the 10 patients with a thickened placenta. The patients with thickened placenta tended to have a typical clinical presentation, whereas those with placental edge separation and hematoma appeared to have an atypical and mild clinical manifestation. It was concluded that ultrasonography is useful in the diagnosis of mild and atypical placental abruption.

Co-existence of spontaneous rupture of uterine artery and placental abruption

vaginal bleeding with no evidence of prelabour rupture of the membranes. No cause was found to explain her presenting symptoms. Her antenatal period was otherwise uneventful. Her blood group was O Rhesus positive with no antibodies detected at her booking antenatal visit. On admission, she was comfortable without palpable uterine activity. Her abdomen was soft and non-tender. Her blood pressure was 138/77 mmHg with a pulse rate of 103 beats per minute, regular with good volume. A small amount of altered blood was noted on her sanitary towel. An abdominal ultrasound scan showed that the placenta was posterior, not low lying with no evidence of placental separation. A 10◊6◊4 cm intrauterine haematoma described as mixed echogenocity was noted anteriorly and separate from the placenta. Cardiotocogram showed a reactive trace, and the Kleihauer test was negative. Her coagulation screen, platelet count and haemoglobin were normal. On the third day after her admission she suddenly became unwell, appeared clammy and complained of abdominal pain. Her blood pressure was 90/45 mmHg with a pulse rate of 90 beats per minute. Abdominal examination revealed a hard, tender and tense uterus. Cardiotocography showed a baseline fetal heart rate of 120 beats per minute with a baseline variability of less than 5 beats per minute. There was a deceleration to 90 beats per minute lasting for a minute. A clinical diagnosis of placental abruption was made. A cardiotocogram performed 2 hours before her collapse showed a baseline fetal heart rate of 150 beats per minute with baseline variability between 10 and 15 beats per minute. Accelerations were noted throughout the hour-long trace, with no decelerations. Her haemoglobin was 10´6 g/dl, white cell count of 15´9◊10 9 /l,