Definition/General
Introduction:
Retroplacental hematoma represents placental abruption (abruptio placentae)
It involves premature separation of normally implanted placenta
It results in hemorrhage behind the placental mass
It is a major obstetric emergency.
Origin:
Results from decidual vessel rupture
Spiral artery bleeding into decidua basalis
Maternal vascular disease
Trauma or sudden pressure changes
Cocaine use
Leads to placental separation.
Classification:
Classified by severity: Grade 0 (asymptomatic), Grade 1 (mild), Grade 2 (moderate), Grade 3 (severe)
By extent: Partial vs complete
By location: Central vs marginal
Acute vs chronic.
Epidemiology:
Incidence approximately 0.5-1% of pregnancies
Maternal mortality 1-5%
Perinatal mortality 10-50%
More common in third trimester
Risk increases with maternal age and parity.
Clinical Features
Presentation:
Sudden onset severe abdominal pain
Vaginal bleeding (may be concealed)
Uterine tenderness and rigidity
Fetal distress
Maternal shock
Disseminated intravascular coagulation.
Symptoms:
Severe, constant abdominal pain
Dark red vaginal bleeding
Nausea and vomiting
Dizziness and weakness
Shortness of breath
Decreased fetal movements
Back pain radiating.
Risk Factors:
Hypertensive disorders
Previous abruption (10-fold increased risk)
Trauma
Cocaine or tobacco use
Multiparity
Advanced maternal age
Thrombophilia
Uterine abnormalities.
Screening:
Continuous fetal monitoring
Complete blood count
Coagulation studies (PT, PTT, Fibrinogen)
Ultrasound (limited sensitivity)
Blood type and crossmatch
Kleihauer-Betke test.
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Gross Description
Appearance:
Dark red blood clot adherent to maternal surface
Cup-shaped depression on maternal surface
Variable size
Fresh or organized clot
Overlying placental infarction.
Characteristics:
Firm, dark red hematoma
Adherent to decidua basalis
Well-circumscribed
Overlying placental pallor
May be laminated (repeated episodes)
Organization varies with time.
Size Location:
Size correlates with clinical severity
Located at maternal surface
May be central or marginal
Partial or complete placental involvement
Depth varies.
Multifocality:
Usually single large hematoma
May have multiple areas
Extension beyond initial site
Confluent bleeding areas
Chronic cases may show multiple episodes.
Microscopic Description
Histological Features:
Acute hemorrhage with intact red blood cells
Decidual necrosis
Spiral artery rupture
Overlying villous infarction
Organization with time
Fibrin deposition.
Cellular Characteristics:
Fresh red blood cells
Decidual cell death
Neutrophilic infiltrate
Hemosiderin-laden macrophages (chronic)
Fibroblasts (organizing)
Vessel wall necrosis.
Architectural Patterns:
Disrupted decidual architecture
Vessel rupture sites
Overlying villous changes
Fibrin mesh formation
Granulation tissue (chronic)
Scar formation.
Grading Criteria:
Grade 1: <20% placental separation
Grade 2: 20-50% separation
Grade 3: >50% separation
Based on extent of separation and clinical severity.
Immunohistochemistry
Positive Markers:
Fibrin (fibrin deposition)
CD68 (macrophages)
Factor VIII (vessel damage)
Smooth muscle actin (vessel walls)
CD34 (endothelial damage).
Negative Markers:
Cytokeratin (in necrotic areas)
hCG (trophoblast viability)
Infectious organism stains
Complement (typically).
Diagnostic Utility:
Confirms hemorrhagic nature
Assesses vessel damage
Rules out other lesions
Evaluates organization
Demonstrates decidual necrosis.
Molecular Subtypes:
Acute abruption
Chronic abruption
Marginal abruption
Central abruption
Concealed abruption.
Molecular/Genetic
Genetic Mutations:
Thrombophilia mutations predispose
Factor V Leiden
Prothrombin mutation
MTHFR variants
Protein C/S deficiencies
Antithrombin deficiency.
Molecular Markers:
Coagulation factors
D-dimer (elevated)
Fibrinogen (decreased in DIC)
Platelet count
Kleihauer-Betke (fetal-maternal hemorrhage)
Genetic testing for thrombophilia.
Prognostic Significance:
Severity correlates with outcomes
Maternal mortality risk
Fetal death risk
Recurrence risk 5-15%
Long-term maternal complications
DIC development.
Therapeutic Targets:
Immediate delivery (severe cases)
Blood product replacement
DIC management
Maternal stabilization
Thrombophilia treatment
Prophylaxis in future pregnancies.
Differential Diagnosis
Similar Entities:
Subchorionic hematoma
Placenta previa bleeding
Uterine rupture
Marginal sinus rupture
Cervical lesions
Vasa previa.
Distinguishing Features:
Retroplacental: Behind placental mass
Retroplacental: Severe pain
Subchorionic: Membrane location
Previa: Painless bleeding
Rupture: Uterine wall defect.
Diagnostic Challenges:
Clinical diagnosis primarily
Ultrasound limitations
Concealed hemorrhage
Distinguishing from other bleeding
Severity assessment.
Rare Variants:
Chronic abruption
Concealed abruption
Marginal abruption
Combined with previa
Couvelaire uterus.
Sample Pathology Report
Template Format
Sample Pathology Report
Complete Report: This is an example of how the final pathology report should be structured for this condition.
Specimen Information
Placenta with retroplacental hematoma measuring [dimensions] involving [percentage]% of maternal surface
Diagnosis
Retroplacental Hematoma (Placental Abruption)
Classification
Classification: Grade [1/2/3] placental abruption with [partial/complete] separation
Histological Features
Shows acute hemorrhage with decidual necrosis and overlying villous infarction
Severity Assessment
Severity: Grade [1/2/3] based on [percentage]% placental separation
Vascular Changes
Shows [spiral artery rupture/vessel necrosis] with associated decidual damage
Placental Effects
Overlying placenta shows [infarction/ischemic changes] in [percentage]% of tissue
Clinical Correlation
Findings consistent with clinical presentation of [severity] abruption with [maternal/fetal] complications
Final Diagnosis
Retroplacental Hematoma, Grade [1/2/3], with [extent] placental separation and [clinical outcomes]