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Article

Clinical Utility of Sonography in


the Diagnosis and Treatment of
Placental Abruption

Chris Glantz, MD, MPH, Leslie Purnell, MD

Objective. To determine the sensitivity and specificity of sonography for detection of placental abrup-
tion and whether sonographic results correlate with management or outcome. Methods. We identi-
fied 149 consecutive patients who underwent sonography at 24 weeks gestational age or later for
ruling out abruption or vaginal bleeding. Obstetric and neonatal data were obtained from the hospi-
tal perinatal database. Sonographic results, pathologic reports, and hospital charts were reviewed.
Sonographic sensitivity, specificity, and positive and negative predictive values were calculated, and
regression was used to determine independence of associations. Results. Of the 149 patients, 17
(11%) had sonographic evidence of abruption, and 32 (21%) had evidence of abruption at delivery.
As the scan-to-delivery interval decreased, the positive predictive value increased and the negative pre-
dictive value decreased. Of 55 patients who gave birth within 14 days of sonography, 8 (15%) had
scans consistent with abruption, and 29 (53%) had abruption at delivery; the sensitivity, specificity, and
positive and negative predictive values of sonography were 24%, 96%, 88%, and 53%, respectively.
Positive sonographic findings were univariately associated with 2- to 3-fold greater subsequent tocol-
ysis, betamethasone use, duration of hospitalization, follow-up sonograms, preterm delivery, low birth
weight, and neonatal intensive care unit admission. All but low birth weight and neonatal intensive
care unit admission remained independently significant after adjustment for gestational age (P < .05).
Conclusions. Sonography is not sensitive for detection of placental abruption, but a positive finding
is associated with more aggressive management and worse neonatal outcome. Key words: abrup-
tion; management; outcome; sensitivity; sonography; specificity.

Abbreviations

T
CI, confidence interval; NPV, negative predictive value; hird-trimester placental abruption complicates
OR, odds ratio; PPV, positive predictive value
less than 1% of pregnancies but is associated with
increased risk of preterm delivery and fetal death
when it does occur.1 The clinical diagnosis usual-
ly is based on bleeding, abdominal pain, and contrac-
tions, but sonography often is performed in an attempt to
Received March 18, 2002, from the Department of visualize the extent of subchorionic or retroplacental
Obstetrics and Gynecology, University of Rochester
School of Medicine, Rochester, New York. Revision hematoma. When blood easily can drain through the
requested April 4, 2002. Revised manuscript accept- cervix, however, no hematoma would be expected to be
ed for publication April 9, 2002. visualized. It is unclear how frequently sonography visu-
Presented as a poster at the 2002 American
Institute of Ultrasound in Medicine Annual alizes clots in cases of abruption and, if clots are visual-
Convention, Nashville, Tennessee, March 1013, ized, whether management and outcome change as a
2002. result. Much of the literature on the subject is more than
Address correspondence and reprint requests to
Chris Glantz, MD, MPH, 601 Elmwood Ave, Box 20 years old. The purpose of this study was to estimate
668, Rochester, NY 14642. the sensitivity, specificity, positive predictive value (PPV),

2002 by the American Institute of Ultrasound in Medicine J Ultrasound Med 21:837840, 2002 0278-4297/02/$3.50
Sonography in Placental Abruption

and negative predictive value (NPV) of sonogra- duration, follow-up sonograms, preterm deliv-
phy in the diagnosis of placental abruption and ery, low birth weight, and neonatal intensive care
to determine, in women with clinical signs and unit admission (Tables 2 and 3). When multiple
symptoms of abruption, whether management linear and logistic regressions were used to con-
and outcome are different when a hematoma is trol for gestational age at the time of scanning, all
visualized compared with when no hematoma is but low birth weight and neonatal intensive care
apparent. unit admission were independently associated
with positive sonographic findings.
Materials and Methods When a diagnosis of abruption at delivery was
added to the regressions as a dummy variable to
We identified 149 consecutive patients who try to separate the effect of the sonogram on
underwent sonographic evaluation at 24 weeks management from the effect of the actual pres-
gestational age or longer for ruling out abruption ence of abruption, betamethasone use still was
or vaginal bleeding and who gave birth at Strong independently associated with positive sono-
Memorial Hospital from 1994 to 1996. Scanning graphic findings (OR, 7.4; 95% confidence inter-
was performed primarily on Ultramark 9 systems val [CI], 1.343.9; P = .03) to a greater degree than
(Philips Ultrasound, Bothell, WA) by a group of 6 abruption at delivery (OR, 3.5; 95% CI, 1.210.4;
sonographers. Obstetric and neonatal data were P = .03). Adjusting for abruption diagnosis at
obtained from the hospital perinatal database. delivery, there was a trend toward independent
We reviewed sonographic reports, pathologic association of sonographic results with tocolytic
reports, hospital charts, and a subset of images to agent use and preterm delivery (OR for tocolysis,
confirm data validity and to determine whether 2.9, 95% CI, 0.899.4; P = .08; OR for preterm
sonographic findings were associated with man- delivery, 4.4; 95% CI, 0.9919.5; P = .05).
agement and outcome variables. A positive For patients giving birth within 14 days of
sonographic finding was defined as showing a sonography, only tocolysis and betamethasone
subchorionic or retroplacental hematoma. use were univariately associated with positive
Abruption at delivery was defined as a clinical scan results. However, because of fewer patients
diagnosis of placental abruption made at the in this group, power was less than 80% for most
time of delivery, whether by concurrent signs and variables.
symptoms or by examination of the placenta. As the scan-to-delivery interval decreased, PPV
Preterm delivery was delivery before 37 weeks increased and NPV decreased (Table 4). Of 55
gestation, and low birth weight was defined as patients giving birth within 14 days of sonogra-
birth weight less than 2500 g. phy, 8 (15%) had positive scan results (consistent
The sonographic sensitivity, specificity, PPV, with abruption) and 29 (53%) had clinical diag-
and NPV were calculated. We used 2, Fisher noses of abruption at delivery; sensitivity, speci-
exact, Mann-Whitney U, and t tests for compar- ficity, PPV, and NPV of sonography were 24%,
isons (P < .05). Linear and logistic regressions 96%, 88%, and 53%, respectively. For all scans
were used to determine independence of associ- and for those scans limited to within 14 days
ations. Odds ratios (ORs) were calculated from before delivery, neither placental location (ante-
logistic coefficients. Analysis was done with rior versus posterior) nor the stated indication
StatView 5.0 (SAS Institute Inc, Cary, NC) on a for sonography (bleeding versus rule out abrup-
Macintosh G3 computer (Apple Computer, Inc, tion) significantly affected sensitivity, specificity,
Cupertino, CA). PPV, or NPV.

Results Discussion

Of the 149 patients, 17 (11%) had sonographic Despite improvements in sonographic machines
evidence of abruption, and 32 (21%) had a clini- over the years, the diagnostic sensitivity for
cal diagnosis of abruption at delivery (Table 1). abruption has not improved in the past 2
Including all patients, positive sonographic find- decades.2 Only 1 of every 9 sonograms obtained
ings were univariately associated with approxi- to rule out placental abruption revealed evidence
mately 2- to 3-fold greater subsequent tocolysis, of a subchorionic or retroplacental hematoma.
betamethasone use, hospitalization-to-delivery The test had a relatively low yield: sonographic

838 J Ultrasound Med 21:837840, 2002


Glantz and Purnell

Table 1. Clinical Characteristics


Sonographic Findings

Characteristic Positive, n = 17 (11%) Negative, n = 132 (89%) P

Gravidity, median (range) 4 (16) 3 (111) .31


Parity, median (range) 1 (04) 1 (07) .18
Tobacco use, % (n) 41 (7) 30 (40) .36
Cocaine use, % (n) 6 (1) 11 (15) .49
EGA at scan, wk, median (range) 30 (2436) 31 (2441) .53
Scan to delivery, d, median (range) 18 (081) 33 (0126) .15
Hypertension, % (n) 0 (0) 6 (8) .30
Hydramnios, % (n) 24 (4) 13 (17) .23
PROM, % (n) 12 (2) 20 (26) .43
EGA indicates estimated gestational age; and PROM, premature rupture of membranes.

findings for these indications usually are normal Approximately 50% of women with clinical
and are positive in only 25% of cases of placental signs suggesting abruption but with negative
abruption that are confirmed at delivery. sonographic findings have evidence of abrup-
Sonography is not sensitive for detecting tion at delivery. Blood having egress to the cervix
abruption, but when a clot is visualized on may drain and thus may not collect under the
sonography, the PPV for abruption at delivery is chorion, so that no blood is visible during
high. The presence of blood in large enough vol- sonography. Such a patient still may be given a
umes to be visible sonographically indicates diagnosis of abruption at delivery based on
retained hemorrhages that may be more likely intrapartum signs and symptoms or placental
to continue to manifest signs and symptoms. In examination. Even if the placenta appears gross-
addition, large collections of blood would be ly normal, a diagnosis of abruption may follow
expected to take longer to resorb or drain and from the classic appearance of vaginal bleeding,
are less likely to fully resolve by the time of deliv- abdominal pain, and uterine hypertonicity.
ery. The sooner delivery occurs after detection As shown in Table 1, there were no significant
of such clots, therefore, the more often abrup- differences in clinical characteristics between
tion will be clinically apparent. The shorter the women with positive and women with nega-
scan-to-delivery interval, the greater the PPV. tive sonographic findings. When a subchorion-
When delivery occurred within 2 weeks of a ic or retroplacental hematoma was identified,
positive sonographic finding, the diagnosis of however, management was more aggressive
placental abruption was confirmed in 100% of than when no hematoma was visualized.
our cases. Women in whom sonography showed intrauter-

Table 2. Obstetric Interventions and Outcome


Sonographic Findings
Intervention or Outcome Positive Negative P

Tocolysis, % (n) 71 (12) 34 (45) .004*


Betamethasone, % (n) 87 (13) 32 (36) <.0001
Hospitalization to delivery, d, median (range) 4 (145) 0 (033) .0001
Follow-up sonogram, % (n) 73 (11) 37 (41) .008
Labor induction, % (n) 18 (3) 24 (32) .55
Cesarean delivery, % (n) 53 (9) 28 (37) .04
EGA at delivery, wk, median (range) 32 (2740) 38 (2442) .02
Postpartum hemorrhage, % (n) 18 (3) 4 (5) .02
EGA indicates estimated gestational age.
*Independently significant after adjustment for EGA at scanning (OR, 4.5; 95% CI, 1.513.6; P = .008).
Independently significant after adjustment for tocolysis and EGA (OR, 15.3; 95% CI, 3.175.2; P = .0008).
Independently significant after adjustment for EGA (regression coefficient, 4.4; P = .008).
Not independently associated with scan result after adjustment for EGA.

J Ultrasound Med 21:837840, 2002 839


Sonography in Placental Abruption

Table 3. Neonatal Outcome


Sonographic Findings

Outcome Positive Negative P


Preterm delivery, % (n) 82 (14) 40 (53) .001
Birth weight, g, mean (SD) 2128 (786) 2682 (936) .01*
Low birth weight, % (n) 76 (13) 34 (45) .0007*
Apgar <7 at 5 min, % (n) 6 (1) 5 (6) .81
NICU admission, % (n) 71 (12) 37 (49) .008*
NICU indicates neonatal intensive care unit.
*Not independently associated with scan result after adjustment for estimated gestational age.

Table 4. Accuracy of Sonography: Sonographic Result Versus Clinical Abruption at Delivery


Scan-to-Delivery Interval, wk

Value All 3 2 1

n 149 67 55 45
Sensitivity, % 28 28 24 23
Specificity, % 93 94 96 100
PPV, % 53 82 88 100
NPV,% 83 59 53 49

ine hematomas more frequently received Previous studies have related outcome to the
betamethasone and tocolytic agents, more com- sonographic appearance or to second-trimester
monly underwent follow-up sonograms, gave scans,35 but this study compared outcomes in
birth at earlier gestational ages, and had higher groups with and without sonographic evidence
frequencies of postpartum hemorrhage. Did the of third-trimester abruption.
positive sonographic findings themselves alter
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840 J Ultrasound Med 21:837840, 2002