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Fadl 2018
Fadl 2018
https://doi.org/10.1007/s10140-018-1638-3
REVIEW ARTICLE
Abstract
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.
and third trimester. MRI is usually not performed during the first
trimester due to fetal safety concerns. From second trimester
onwards, the normal placenta is slightly hyperintense relative to
the underlying myometrium on T2-weighted images (T2WI) and
slightly hypointense on T1-weigted images (T1WI). During ear-
ly gestational age, the normal placenta is relatively homogenous.
On gestational progression and particularly after 24 weeks, mul-
tiple septae between the lobules start to become conspicuous,
leading to increased heterogeneity [13]. Normal myometrium is
typically tri-layered on T2WI with a heterogeneous hyperintense
middle layer of vascular channels with inner and outer thinner
hypointense layers. The uterine blood vessels may appear as
areas of flow void within the myometrium on T2WI. Normal
myometrium may have variable thickness on MR, since it be-
comes thinner with increasing gestational age and may appear
thinner if there are specific sites of compression, such as adjacent
to the osseous structures [13].
Imaging appearance of placental abruption can be classified Fig. 3 Illustrative drawing of placental hematomas. a Retroplacental
based on the location of the hematoma (Fig. 3) as hematoma (A) is located behind the basal plate and elevates the placenta
retroplacental (Fig. 4), marginal subchorionic (Fig. 5), (P) from the underlying myometrium (M). b Marginal subchorionic he-
preplacental (Fig. 6), and intraplacental [8]. matoma (B) is located peripherally behind the placental margin and ex-
tends behind the chorion. c Preplacental hematoma (C) is located anterior
Retroplacental hematoma is located behind the basal plate to the placenta above the chorionic plate behind the amnion (blue line)
and usually results from disruption of small arterioles. and usually limited by the umbilical cord (UC). d Intraplacental hemato-
Retroplacental hematoma size correlates with fetal prognosis, ma (D) is bleeding inside the placenta (P)
Emerg Radiol
Ultrasound
Fig. 5 Subchorionic hematoma. Longitudinal gray-scale ultrasound im-
age shows large hypoechoic collection (arrows) which is elevating the
chorionic membranes (arrowheads) and extends behind the placenta Ultrasound remains the initial modality of choice for placental
which is beyond the image borders. The placenta (P) is located anteriorly assessment despite its low sensitivity in the detection of
Emerg Radiol
placental abruption [14]. The low sensitivity of ultrasound is thickened or progressive rapidly thickening of the placenta
due to the fact that acute and subacute hematomas can be on ultrasound as these findings may indicate an occult placen-
isoechoic to placental tissue. Additionally, small marginal he- tal abruption requiring alerting the obstetrician about the pos-
matomas are often inconspicuous. Moreover, blood may have sibility of placental abruption.
escaped to the vagina rather than collecting around the placen-
ta at the time of ultrasound. Despite low sensitivity (as low as
Imaging pitfalls
24%), imaging findings when present are highly specific for
abruption (92–96%) [4]. Ultrasound has high positive predic-
Mimics of placental hematomas include myometrial contrac-
tive value 88 to 100% and a low negative predictive value
tions, which have similar appearance as retroplacental hemato-
from 14 to 53% [17, 18]. Ultrasound findings of placental
ma. Color Doppler flow allows differentiation since hematomas
abruption include detection of hematomas. Periplacental he-
lack internal vascularity [14]. Placental chorioangioma may
matomas have variable sonographic appearance depending on
mimic hematoma or focal placental infarction on gray-scale so-
hematoma age, ranging from hyperechoic, isoechoic to
nography; but the focal bulging of the chorioangioma along the
echolucent [19]. Acute or subacute hematomas usually have
fetal placental surface and the presence of internal vascularity on
subtle appearance since they may have echogenicity similar to
color Doppler images help in differentiation [20] (Fig. 8). It may
or slightly higher than the adjacent placenta, while chronic
be challenging to distinguish infarcted chorioangioma from he-
hematomas usually are hypoechoic or echolucent. An ultra-
matoma, in which case comparison with older ultrasounds may
sound maneuver has been described to identify acute and sub-
show the internal vascularity of the chorioangioma [21].
acute preplacental hematomas. Gently pushing the transducer
on the hematoma shows some mobility or softness in the he-
matoma, which is not present in the normal adjacent placental Computed tomography
tissue. This phenomenon has been termed Bjello effect^ of
hematoma. Preplacental or subamniotic hematoma may be Placental assessment with CT is usually performed in the set-
associated with mass effect on the placental cord insertion ting of trauma, when CT is performed for assessment of ma-
and consequently result in ischemia and abnormal umbilical ternal injuries. When systemic evaluation of the placenta is
cord Doppler signal with increased risk of fetal demise [14]. done on CT, the reported sensitivity in detection of placental
Additionally, a thickened placenta with rounded bulging and abruption is as high as 100%. The reported contrast-enhanced
heterogeneous echotexture along with loss of the placental- CT (CECT) specificity is ranging from 56 to 86% [12, 22].
myometrial interface can also be present (Fig. 7). The radiol- On contrast enhanced CT, placental abruption may present
ogist should be attuned to the presence of an abnormally as partial or full thickness area of low attenuation, which usu-
ally forms acute angles with the myometrium (Figs. 9 and 10).
Detection of the placental hematoma is challenging on non-
contrast CT, because hematoma may have the same attenua-
tion as the placenta. Abnormal elevation of the placental edge
should raise concern of the presence of undermining hemato-
ma. Placental hemorrhage can cause intra-amniotic hemor-
rhage. Any hematoma affecting the intrauterine membranes
can disperse into the amniotic cavity and appear as
Fig. 7 Placental abruption on ultrasound at 28 weeks gestation. Fig. 8 Placental chorioangioma. Longitudinal color Doppler ultrasound
Longitudinal gray-scale ultrasound demonstrates thick heterogeneous image shows an exophytic, slightly hypoechoic mass (arrows) along the
placenta (arrows) with anechoic areas (arrowhead). Three hours after chorionic surface of the placenta (P) with internal vascularity
ultrasound the patient started to have vaginal bleeding (arrowheads)
Emerg Radiol
Fig. 9 Placental abruption TAPS 2a. Contrast-enhanced CT a axial and b Fig. 10 Placental abruption TAPS 3. Contrast-enhanced CT a axial and b
coronal reformat images show non-geographic areas of low attenuation sagittal reformat images show non-enhancement of most of the placental
(arrows) forming acute angles (arrowheads) with the myometrium. The tissue (white arrows) denoting devascularization with few remaining en-
overall remaining normally enhancing placental tissue (*) is > 50% hancing islands of placental tissue (black arrowheads)
dependently layering increased density and heterogeneity of Venous lakes can be easily distinguished on ultrasound as
the amniotic fluid [8, 23]. hypoechoic areas with internal echoes on gray-scale im-
ages and low velocity flow on color Doppler images
(Fig. 12) [1]. Additionally, myometrial contraction can
Imaging pitfalls be misinterpreted as an area of large placental perfusion
defect. However, myometrial contraction is usually bulg-
Challenges in the diagnosis of placental abruption on CT ing and has obtuse angles with the myometrium without
include physiological age-related changes of the placental an undermining hematoma [12]. Circumvallate placenta
parenchyma resulting in heterogeneous CT enhancement (Fig. 13) may mimic subchorionic hematoma. Evaluating
with areas of decreased enhancement and increased pla- CT images in axial, sagittal, and coronal planes and cor-
cental surface indentation, which may mimic abruption relating with ultrasound often allows differentiation:
(Fig. 11). Identification of the free edge of the placental shelf is
Maternal venous lakes can be misread as areas of per- characteristic for circumvallate placenta, a finding which
fusion defects; correlation with ultrasound can be useful. is not seen with subchorionic hematoma [1].
Emerg Radiol
transient and have the characteristic low T2WI signal of the during first trimester ultrasound with an incidence up to
uterine smooth muscle [13]. 22% [26]. Spontaneous resolution of subchorionic hemor-
rhage by the end of the second trimester occurs in approx-
imately 70% of the cases. Some hematomas persist
Placental and periplacental hemorrhage throughout the pregnancy and are associated with poor
in specific clinical settings pregnancy outcomes [27].
The depiction of subchorionic hematoma on imaging dur-
Subchorionic hemorrhage during early pregnancy ing early pregnancy is associated with increased risk of spon-
(first trimester) taneous abortion, placental abruption, and preterm delivery
[26, 28–30]. The overall rate of spontaneous miscarriage with
Subchorionic hematomas separate the chorion from the subchorionic hematoma in the first trimester is 9.3% [31]. In a
decidua during early pregnancy. The detection of recent systematic review [29], the risk of early and late preg-
subchorionic hematoma is a frequent incidental finding nancy loss was found to double when subchorionic hematoma
Emerg Radiol
Fig. 15 Myometrial contraction on MRI. Sagittal MRI T2WI image Vanishing twin or blighted ovum in a twin pregnancy is a
shows focal myometrial thickening which has low T2 signal (arrows) at
the subplacental region mimicking a placental hematoma. It was transient
sonographic mimic of subchorionic hemorrhage.
and disappeared later during the exam which is compatible with focal Chorioamniotic separation may also be mistaken for
myometrial contraction. P = placenta, F = fetus subchorionic hematoma. The placental (chorion) and fetal
(amniotic) membranes usually fuse and become indistinguish-
is present. Subchorionic hematoma during early pregnancy is able between 12 and 16 weeks of gestation. The unfused
also associated with increased risk of placental abruption [19, membranes of choriamniotic separation can be shown
29]. Bennet et al. [19] retrospectively collected 516 patients
with first trimester bleeding in whom a subchorionic hemato-
Table 2 Traumatic Abruption Placenta Scale (TAPS): CT-based placen-
ma and a viable fetus had been identified. They classified the tal enhancement grading system [37]
patients based on hematoma size and gestational and maternal
ages. They graded the hematoma size (Table 1) into small, Grade Placental Imaging findings Management
enhancement
medium, and large. They found that there is increased rate of
pregnancy loss with increasing size of the hematoma. They 0 100 Homogenous high Normal clinical
concluded that the fetal outcome is dependent on the hemato- attenuation evaluation
ma size, advancing maternal age, and earlier gestational age in 1 > 50% Geographic areas of
first trimester patients with vaginal bleeding [19]. low attenuation
representing normal
On ultrasound, subchorionic hematoma is usually a cres-
variants such as
centic, hypoechoic or sonolucent area behind the chorion [32] venous lakes,
(Fig. 16). Detachment of the placental margin can be seen in cotyledons,
some cases and represents a weak risk factor for pregnancy age-related insignifi-
cant small placental
loss [31]. The size of the hematoma in relation to the gesta-
infarcts.
tional sac circumference should be documented in the radiol- 2a > 50% Full thickness areas of Extended clinical
ogy report as it correlates with the rate of pregnancy loss [19]. low attenuation. observation with
Cesarean section if
clinical symptoms
Table 1 First trimester subchorionic hematoma ultrasound and signs of
classification based on the hematoma size [19] abruption
Subchorionic hematoma size Based on the circumferential 2b 25–50% Contiguous or full
separation from the chorion thickness areas of
low attenuation.
3 < 25% Large areas of
Small < 1/3
contiguous or full
Moderate 1/3–2/3 thickness areas of
Large > 2/3 low attenuation.
Emerg Radiol
sonographically during early pregnancy as free-floating thin in complex cases. Radiologists need to be familiar with the
membranes surrounding the fetus. In distinction to normal appearance of the placenta as it evolves during the
chorioamniotic separation, subacute subchorionic hematoma pregnancy in order to establish the diagnosis of placental
will elevate the chorion. abruption. Although management may be expectant, the pres-
The detection of subchorionic hematoma allows risk strat- ence of placental hematoma is generally associated with in-
ification of pregnant patients. Management of subchorionic creased risk for mother and child.
hematoma is always expectant [28].
Compliance with ethical standards
Traumatic placental abruption
Conflicts of interests The authors declare that they have no conflicts of
interest.
Trauma complicates 3–8% of pregnancies [33]. Blunt trauma
is more common than penetrating trauma. Most common
causes of trauma in pregnant patients are motor vehicle
crashes, falls, and domestic violence [22]. Placental abruption References
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