If an abruption occurs in a posteriorly located placenta, the only presenting symptom may be:

• A. A hard uterus
• B. Massive vaginal bleeding
• C. Severe back pain
• D. Fetal distress

Answer: (C)

When placental abruption happens, blood collects between the placenta and the uterine wall, and the symptoms depend on where the placental separation occurs. If the placenta is located toward the back of the uterus (posterior placenta), the separation and the resulting hematoma are often felt as pain in the back rather than as vaginal bleeding. Blood can remain trapped behind the placenta, so heavy vaginal bleeding may be minimal or absent, leaving back pain as the prominent or even sole symptom. The uterus may still be tender and contractions may occur, but the hallmark in this posterior location is the severe back pain that patients may report without obvious external bleeding. Other signs like a hard, rigid uterus or fetal distress can occur, but they aren’t required for the presentation when the placenta is posterior; back pain without significant bleeding can be the sole presenting symptom.