Emergency Radiology (2019) 26:87–97

https://doi.org/10.1007/s10140-018-1638-3

REVIEW ARTICLE

Placental abruption and hemorrhage—review of imaging appearance

Shaimaa A. Fadl 1 & Ken F. Linnau 2 & Manjiri K. Dighe 1

Received: 26 March 2018 / Accepted: 22 August 2018 / Published online: 29 August 2018
# American Society of Emergency Radiology 2018

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.

Keywords Placenta . Placental abruption . Retroplacental hematoma . Subchorionic hematoma-placental hematoma

Background The term placental abruption (PA, abruptio placentae) is

The placenta plays a crucial role during pregnancy in the ex-
change of nutrients and oxygen between the mother and fetus.
Early placental formation begins when blastocyst adheres to
the myometrium. The outer trophoectoderm layer of the blas-
tocyst differentiates into trophoblasts, which are responsible
for formation of the chorionic villi. Initially, the chorionic villi
cover the entire gestational sac. Successively, the trophoblasts
rapidly proliferate at the site near the decidua basalis and form
the chorion frondusum which is the early placenta, while the
remaining placenta close to the amnion progressively atro-
phies and called the smooth chorion. The chorionic plate re-
fers to the fetal side of the placenta, and the basal plate refers
to the maternal side of the placenta [1].
* Shaimaa A. Fadl
sfadl@uw.edu
1
Department of Radiology, University of Washington Medical Center,
1959 NE pacific St., Seattle, WA 98195, USA
2
Department of Radiology, Harborview Medical Center, University of
Washington, 325, 9th Avenue, Harborview Medical Center,
Seattle, WA 98104, USA
used to refer to partial or complete detachment of the placenta
from the underlying myometrium before the expected delivery
time. Most articles in the literature do not specify as to during
which weeks of gestation should the term be used [2–7]; how-
ever, a few papers used the specific term Babruption^ when
this separation is after the 20th week of gestation [8]. In gen-
eral, placental abruption is more common after 16 weeks of
gestation [5] and encompasses placental or periplacental
hemorraghe. The highest reported incidence for abruption is
from 24th to 26th weeks of gestation, after which PA inci-
dence drops with advancing gestational age [7].
Placental abruption complicates 0.4–1% of pregnancies [2,
4]. Risk factors for placental abruption include smoking,
multiparity, thrombophilia, chronic and gestational hyperten-
sion, premature rupture of membranes (PROM), prior history
of placental abruption, in vitro fertilization (IVF), alcohol con-
sumption, and drug use (such as cocaine). A prior history of
placental abruption represents a strong risk factor increasing
the risk by 10 to 30 times. Most common other risk factors are
smoking and maternal hypertension [2, 4].
Placental abruption is associated with maternal, fetal, and
neonatal increased morbidity and mortality. Disseminated in-
travascular coagulopathy (DIC), uncontrolled blood loss, or
risk of hysterectomy are known maternal complications of
abruption. Fetal complications include intrauterine growth
88 Emerg Radiol (2019) 26:87–97

restriction (IUGR), non-reassuring fetal heart rate (NFHR),

and fetal demise. Neonatal complications include premature
delivery and neonatal death [3].
The diagnosis of placental abruption is usually clinically
established based on the presence of abdominal pain, vaginal
bleeding, uterine tenderness, or tetanic contractions along with
NFHR [3].
Antepartum bleeding is hemorrhage during late pregnancy
before delivery of the baby. The most common etiologies of
antepartum bleeding include placental abruption and placenta
previa. Less common etiologies include vasa previa (frequent-
ly after amniotomy) and other sources of bleeding from the
vulva, vagina, or cervix [9]. Antepartum bleeding is not spe-
cific for PA and occurs in 13–25% of abruption cases. The
association of bleeding and abnormal fetal heart rate is present
in one third of the cases of placental abruption [4].
We did a PubMed search for articles in English containing
the keywords Bplacental abruption^ and Babruptio placentae^
for the years 1955 to 2018. The reference lists of included
manuscripts were searched for additional articles to be included
in this review. In this structured review article, we review the
normal placental morphology on imaging followed by
discussing the imaging appearance of placental abruption on
different imaging modalities. We address placental abruption
in specific situations such as trauma. We will discuss the clinical
importance of subchorionic hematomas in the first trimester.

Normal placental morphology

Ultrasound Fig. 1 Normal placenta on ultrasound. a Transverse gray-scale ultra-

Initially around 6 weeks of gestational age, the placenta ap-
pears as an echogenic rind-like structure surrounding the an-
echoic gestational sac best seen on transvaginal ultrasound
(TVUS) (Fig. 1a). By the 10th week of gestation, a focal
echogenic thickening of the echogenic rind is seen. By the
end of the first trimester, the intervillous flow can be detected
on color Doppler. At the beginning of the second trimester
around 14th to 15th weeks of gestation, a well-formed normal
placenta is seen and appears hyperechoic relative to the un-
derlying myometrium with a hypoechoic subplacental or
retroplacental zone, also referred to as subplacental space or
retroplacental complex (Fig. 1b) [10, 11].
Computed tomography
On contrast enhanced computed tomography (CT) (Fig. 2),
during the first trimester, the normal placenta appears as a
homogenous enhancing rind around the gestation sac that is
not clearly distinguished from the underlying myometrium
[12]. Sometimes, small subchorionic hemorrhage may be seen
as a hypodense area adjacent to the placenta and is due to a
sound image through the uterus shows gestational sac (GS) with thick
hyperechoic rind (arrow) representing normal placenta at 6 weeks gesta-
tion. b Longitudinal color Doppler ultrasound image through the uterus
shows normal placenta (P) at 18 weeks gestation. The retroplacental
hypoechoic zone (arrows) is located between the homogenous placenta
and the myometrium containing the uterine vessels (arrowheads)
small amount of hemorrhage seen during early placentation.
On progression to the second trimester, there is increased pla-
cental heterogeneity and placental cotyledon formation.
Placental cotyledons are discoid units separated from the de-
cidua basalis by placental septa that form towards the end of
the second trimester. These units appear as lobules with fetal
placental surface indentations. Placental maturation continues
through the third trimester with increased visualization of the
chorionic plate indentations on the fetal side and venous lakes
on the maternal side of the placenta [12].
Magnetic resonance imaging
Magnetic resonance imaging (MRI) with a magnetic field
strength of 3 Tesla or less is considered safe during the second
Emerg Radiol (2019) 26:87–97 89

Fig. 2 Normal placenta on CT.

Axial contrast-enhanced CT of
the pelvis a at 6 weeks gestation
shows eccentric gestational sac
(arrows) without definite visible
placental tissue. b CT at 9 weeks
gestation shows an enhancing
rind around the gestational sac
corresponding to the placental
tissue (arrows). c CT at 16 weeks
gestation shows placenta with
slightly heterogeneous
enhancement (arrows). d CT at
24 weeks gestation shows
placenta (P) with more
heterogeneous appearance and
placental surface indentation
(arrows)

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].

Types of placental abruption

Imaging appearance of placental abruption can be classified
based on the location of the hematoma (Fig. 3) as
retroplacental (Fig. 4), marginal subchorionic (Fig. 5),
preplacental (Fig. 6), and intraplacental [8].
Retroplacental hematoma is located behind the basal plate
and usually results from disruption of small arterioles.
Retroplacental hematoma size correlates with fetal prognosis,
Fig. 3 Illustrative drawing of placental hematomas. a Retroplacental
hematoma (A) is located behind the basal plate and elevates the placenta
(P) from the underlying myometrium (M). b Marginal subchorionic he-
matoma (B) is located peripherally behind the placental margin and ex-
tends behind the chorion. c Preplacental hematoma (C) is located anterior
to the placenta above the chorionic plate behind the amnion (blue line)
and usually limited by the umbilical cord (UC). d Intraplacental hemato-
ma (D) is bleeding inside the placenta (P)
90
Fig. 4 Retroplacental hematoma. Longitudinal color Doppler ultrasound
image shows large slightly hypoechoic hematoma (arrows) behind the
placenta (P)
where hematoma size larger than 50 ml or more than 50%
placental detachment predicts poor fetal outcome [14].
Marginal subchorionic hematoma is located peripherally be-
hind the basal plate elevating the placental edge and extends
behind the chorion. Preplacental hematoma is less common
and located behind the amnion above the chorionic plate and
usually limited by the umbilical cord [10]. Intraplacental
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
which is beyond the image borders. The placenta (P) is located anteriorly
Emerg Radiol (2019) 26:87–97
Fig. 6 Preplacental hematoma at 19 weeks gestation. Longitudinal gray-
scale ultrasound image demonstrates large crescentic hemorrhage
(arrows) between the placenta (P) and the membranes (arrowhead)
hematoma is bleeding in the intervillous space of the placenta.
This uncommon condition can occur either primary or second-
ary to large retroplacental hematoma dispersing through the
intervillous spaces [15]. Intraplacental hematoma carries a
higher risk of adverse maternal and fetal outcomes than
retroplacental hematoma. Rounded intraplacental and
retroplacental hematomas can also result as a consequence
of disruption of the vasculopathic decidual arterioles [16].
Annath et al. [3] in their retrospective study classified pla-
cental abruption as mild or severe placental abruption based
on associated morbidity and mortality. They considered
abruption as Bsevere^ when at least one maternal, fetal, or
neonatal complication occurred. Two thirds of placental
abruption cases are associated with fetal or maternal conse-
quences. Maternal complications include need for cesarean
sections, need for blood transfusion, disseminated intravascu-
lar coagulation (DIC), hypovolemic shock, hysterectomy, re-
nal failure, and death. Fetal complications include NFHR,
intrauterine fetal growth restriction (IUGR), or intrauterine
fetal death (IUFD). Neonatal complications include neonatal
death, preterm delivery related complications, and small-for-
gestational age (SGA) births [3].
Placental abruption can also be classified based on the pres-
ence or absence of vaginal bleeding as revealed versus concealed
[14]. The Brevealed abruption^ term is used when the bleeding
tracks between the membranes and escapes to the vagina, while
the Bconcealed abruption^ term is used when the blood accumu-
lates behind the placenta without vaginal bleeding.
Imaging findings of placental-related
bleeding
Ultrasound
Ultrasound remains the initial modality of choice for placental
assessment despite its low sensitivity in the detection of
Emerg Radiol (2019) 26:87–97
placental abruption [14]. The low sensitivity of ultrasound is
due to the fact that acute and subacute hematomas can be
isoechoic to placental tissue. Additionally, small marginal he-
matomas are often inconspicuous. Moreover, blood may have
escaped to the vagina rather than collecting around the placen-
ta at the time of ultrasound. Despite low sensitivity (as low as
24%), imaging findings when present are highly specific for
abruption (92–96%) [4]. Ultrasound has high positive predic-
tive value 88 to 100% and a low negative predictive value
from 14 to 53% [17, 18]. Ultrasound findings of placental
abruption include detection of hematomas. Periplacental he-
matomas have variable sonographic appearance depending on
hematoma age, ranging from hyperechoic, isoechoic to
echolucent [19]. Acute or subacute hematomas usually have
subtle appearance since they may have echogenicity similar to
or slightly higher than the adjacent placenta, while chronic
hematomas usually are hypoechoic or echolucent. An ultra-
sound maneuver has been described to identify acute and sub-
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
tissue. This phenomenon has been termed Bjello effect^ of
hematoma. Preplacental or subamniotic hematoma may be
associated with mass effect on the placental cord insertion
and consequently result in ischemia and abnormal umbilical
cord Doppler signal with increased risk of fetal demise [14].
Additionally, a thickened placenta with rounded bulging and
heterogeneous echotexture along with loss of the placental-
myometrial interface can also be present (Fig. 7). The radiol-
ogist should be attuned to the presence of an abnormally
Fig. 7 Placental abruption on ultrasound at 28 weeks gestation.
Longitudinal gray-scale ultrasound demonstrates thick heterogeneous
placenta (arrows) with anechoic areas (arrowhead). Three hours after
ultrasound the patient started to have vaginal bleeding
91
thickened or progressive rapidly thickening of the placenta
on ultrasound as these findings may indicate an occult placen-
tal abruption requiring alerting the obstetrician about the pos-
sibility of placental abruption.
Imaging pitfalls
Mimics of placental hematomas include myometrial contrac-
tions, which have similar appearance as retroplacental hemato-
ma. Color Doppler flow allows differentiation since hematomas
lack internal vascularity [14]. Placental chorioangioma may
mimic hematoma or focal placental infarction on gray-scale so-
nography; but the focal bulging of the chorioangioma along the
fetal placental surface and the presence of internal vascularity on
color Doppler images help in differentiation [20] (Fig. 8). It may
be challenging to distinguish infarcted chorioangioma from he-
matoma, in which case comparison with older ultrasounds may
show the internal vascularity of the chorioangioma [21].
Computed tomography
Placental assessment with CT is usually performed in the set-
ting of trauma, when CT is performed for assessment of ma-
ternal injuries. When systemic evaluation of the placenta is
done on CT, the reported sensitivity in detection of placental
abruption is as high as 100%. The reported contrast-enhanced
CT (CECT) specificity is ranging from 56 to 86% [12, 22].
On contrast enhanced CT, placental abruption may present
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. 8 Placental chorioangioma. Longitudinal color Doppler ultrasound
image shows an exophytic, slightly hypoechoic mass (arrows) along the
chorionic surface of the placenta (P) with internal vascularity
(arrowheads)
92
Fig. 9 Placental abruption TAPS 2a. Contrast-enhanced CT a axial and b
coronal reformat images show non-geographic areas of low attenuation
(arrows) forming acute angles (arrowheads) with the myometrium. The
overall remaining normally enhancing placental tissue (*) is > 50%
dependently layering increased density and heterogeneity of
the amniotic fluid [8, 23].
Imaging pitfalls
Challenges in the diagnosis of placental abruption on CT
include physiological age-related changes of the placental
parenchyma resulting in heterogeneous CT enhancement
with areas of decreased enhancement and increased pla-
cental surface indentation, which may mimic abruption
(Fig. 11).
Maternal venous lakes can be misread as areas of per-
fusion defects; correlation with ultrasound can be useful.
Emerg Radiol (2019) 26:87–97
Fig. 10 Placental abruption TAPS 3. Contrast-enhanced CT a axial and b
sagittal reformat images show non-enhancement of most of the placental
tissue (white arrows) denoting devascularization with few remaining en-
hancing islands of placental tissue (black arrowheads)
Venous lakes can be easily distinguished on ultrasound as
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
be misinterpreted as an area of large placental perfusion
defect. However, myometrial contraction is usually bulg-
ing and has obtuse angles with the myometrium without
an undermining hematoma [12]. Circumvallate placenta
(Fig. 13) may mimic subchorionic hematoma. Evaluating
CT images in axial, sagittal, and coronal planes and cor-
relating with ultrasound often allows differentiation:
Identification of the free edge of the placental shelf is
characteristic for circumvallate placenta, a finding which
is not seen with subchorionic hematoma [1].
Emerg Radiol (2019) 26:87–97 93

Fig. 11 Placental surface indentation. Sagittal CT reformation image

shows indentations (arrows) along the placental (P) fetal surface

Magnetic resonance imaging

MR images have intrinsic high soft tissue contrast in-

creasing the sensitivity for detection of the hematoma
(Fig. 14), particularly in a retroplacental location. MRI
can accurately depict placental-related hemorrhage with
a reported high sensitivity 95–100% and high specificity
of 100% [24].
MRI allows to distinguish hematomas from other
causes of antepartum bleeding, such as vasa previa,
degenerated uterine fibroid, cervical pathology, and pla-
cental tumors [25]. Moreover, MRI helps to determine the
age of the blood products based on MR signal character- Fig. 12 Placental venous lakes. a Coronal CT reformat image shows
istics of h emoglobin on T1WI and T 2WI [24 ]. hypodense non-enhancing areas (arrows) within the placenta (P) which
Consequently, placental bleeding can be categorized into are concerning for preplacental hematoma. b Color Doppler image show
slow flow in the corresponding areas (arrows) within the placenta (P)
hyperacute, acute, early subacute, late subacute, and indicative of normal placental venous lakes
chronic hematomas. Acute or early subacute placental he-
matomas are considered unstable hematomas with higher
risk of rapid progression or rebleeding, which may require highly sensitive in detecting acute ischemia and can easily
change in management. Typically, acute hematomas are identify hematomas [24, 25].
hypointense on T2WI and hyperintense on T1WI.
Diffusion-weighted images (DWI) showing restricted dif-
fusion and susceptibility artifact on T1-gradient echo im- Imaging pitfalls
ages are helpful for hematoma detection [24, 25].
Placental abruption is usually a combination of ischemia Focal thickening of the myometrium caused by uterine con-
and hemorrhage; therefore, T2-weighted half-Fourier tractions can be identified and may deform the placental shape
RARE and true FISP are useful sequences, which are if it occurs subplacental (Fig. 15). Uterine contractions are
94
Fig. 13 Partial circumvallate placenta mimicking placental abruption. a
Axial contrast-enhanced CT image shows an elevated placental edge
(arrow) along the left lateral aspect of the placenta (P). b Sagittal CECT
reformation image shows the placental ridge (arrows) running longitudi-
nally and correspond to the elevated placental edge
transient and have the characteristic low T2WI signal of the
uterine smooth muscle [13].
Placental and periplacental hemorrhage
in specific clinical settings
Subchorionic hemorrhage during early pregnancy
(first trimester)
Subchorionic hematomas separate the chorion from the
decidua during early pregnancy. The detection of
subchorionic hematoma is a frequent incidental finding
Emerg Radiol (2019) 26:87–97
Fig. 14 Subchorionic hematoma within the cervix at 24 weeks gestation
in a patient with worsening abdominal pain. MRI a sagittal T2W image
and b axial T1WI show heterogeneous high T1 and high T2 signal
hematoma (arrows) within the lower uterine segment and extending to
the cervix which is located outside the membranes (arrowheads). The
placenta (P) is located anteriorly
during first trimester ultrasound with an incidence up to
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
throughout the pregnancy and are associated with poor
pregnancy outcomes [27].
The depiction of subchorionic hematoma on imaging dur-
ing early pregnancy is associated with increased risk of spon-
taneous abortion, placental abruption, and preterm delivery
[26, 28–30]. The overall rate of spontaneous miscarriage with
subchorionic hematoma in the first trimester is 9.3% [31]. In a
recent systematic review [29], the risk of early and late preg-
nancy loss was found to double when subchorionic hematoma
Emerg Radiol (2019) 26:87–97 95

Fig. 16 Subchorionic hematoma at 7 weeks gestation. Transverse color

Doppler ultrasound image through the uterus shows an avascular
hypoechoic subchorionic hematoma. GS = gestational sac. UT = uterus

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.
96
sonographically during early pregnancy as free-floating thin
membranes surrounding the fetus. In distinction to
chorioamniotic separation, subacute subchorionic hematoma
will elevate the chorion.
The detection of subchorionic hematoma allows risk strat-
ification of pregnant patients. Management of subchorionic
hematoma is always expectant [28].
Traumatic placental abruption
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
is the second most common injury after blunt solid organ
injury in pregnant women. Fetal mortality after emergency
delivery following blunt trauma is 21–25%, presumably due
to placental injury, and abruption [34]. Traumatic placental
abruption is likely due to shear injury with subsequent
devascularization of the placenta.
Although sonography remains the initial imaging modality
of choice [35, 36], Jha et al. [22] found that ultrasound mark-
edly underdiagnosed traumatic placental abruption when
compared to CECT. CECT has high sensitivity in detection
of traumatic placental abruption as described above.
Traumatic placental abruption is often overlooked on CT, par-
ticularly when multiple other organ injuries are present. We
suggest including systematic placental evaluation in a search
pattern checklist during CT evaluation of pregnant trauma
patients. Given that trauma CT of pregnant patients is uncom-
mon, radiologists may not be attuned to placental evaluation,
thereby contributing to the wide range of CT specificity re-
ported in the literature. As placental heterogeneity increases
with gestational age, detection of placental injury becomes
more challenging. For this reason, Saphier et al. [37] proposed
a standardized CT grading system for the evaluation of the
placenta in the setting of trauma, called Traumatic Abruption
Placental Scale (TAPS) (Table 2) (Figs. 9 and 10). In TAPS,
placental injuries are classified based on the placental surface
enhancement to aid in the management of salvageable fetuses
[37, 38]. Fetuses older than 24 weeks who weigh more than
600 g are considered viable with acceptable
neurodevelopmental outcome [39]. On CT, placental enhance-
ment of 50% or less is highly concerning for placental abrup-
tion and delivery at the first NFHR will improve fetal survival
[20, 34].
Conclusion
Initial evaluation of the placenta usually relies on ultrasound.
The role of CT is usually restricted to pregnant trauma pa-
tients, and MRI is most commonly used for trouble shooting
Emerg Radiol (2019) 26:87–97
in complex cases. Radiologists need to be familiar with the
normal appearance of the placenta as it evolves during the
pregnancy in order to establish the diagnosis of placental
abruption. Although management may be expectant, the pres-
ence of placental hematoma is generally associated with in-
creased risk for mother and child.
Compliance with ethical standards
Conflicts of interests The authors declare that they have no conflicts of
interest.
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