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Cited by 204Maternal and fetal healthcarePregnancy and preeclampsia studiesReproductive System and Pregnancy

New insights into the etiopathology of placenta accreta spectrum

Jauniaux, Eric, Jurkovic, Davor, Hussein, Ahmed M., Burton, Graham J.·2022·American Journal of Obstetrics and Gynecology
DOI 10.1016/j.ajog.2022.02.038
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Abstract

Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner myometrium without interposing decidua to transmural invasion through the entire uterine wall and beyond. These descriptions have prevailed for more than 50 years and form the basis for the diagnosis and grading of accreta placentation. Accreta placentation is essentially the consequence of uterine remodeling after surgery, primarily after cesarean delivery. Large cesarean scar defects in the lower uterine segment are associated with failure of normal decidualization and loss of the subdecidual myometrium. These changes allow the placental anchoring villi to implant, and extravillous trophoblast cells to migrate, close to the serosal surface of the uterus. These microscopic features are central to the misconception that the accreta placental villous tissue is excessively invasive and have led to much confusion and heterogeneity in clinical data. Progressive recruitment of large arteries in the uterine wall, that is, helicine, arcuate, and/or radial arteries, results in high-velocity maternal blood entering the intervillous space from the first trimester of pregnancy and subsequent formation of placental lacunae. Recently, guided sampling of accreta areas at delivery has enabled accurate correlation of prenatal imaging data with intraoperative features and histopathologic findings. In more than 70% of samples, there were thick fibrinoid depositions between the tip of most anchoring villi and the underlying uterine wall and around all deeply implanted villi. The distortion of the uteroplacental interface by these dense depositions and the loss of the normal plane of separation are the main factors leading to abnormal placental attachment. These data challenged the classical concept that placenta accreta is simply owing to villous tissue sitting atop the superficial myometrium without interposed decidua. Moreover, there is no evidence in accreta placentation that the extravillous trophoblast is abnormally invasive or that villous tissue can cross the uterine serosa into the pelvis. It is the size of the scar defect, the amount of placental tissue developing inside the scar, and the residual myometrial thickness in the scar area that determine the distance between the placental basal plate and the uterine serosa and thus the risk of accreta placentation.

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  • The inferior placental ROI is the area where abnormal uterine remodelling from a prior Caesarean section has resulted in abnormal placentation.

    “this is the area where abnormal uterine remodelling from a prior Caesarean section has resulted in abnormal placentation [42]”

    From Radiomics-based prediction of FIGO grade for placenta accreta spectrum (2023) · cites this paper as [42]

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Authors
Jauniaux, E., Jurkovic, D., Hussein, A. M., & Burton, G. J.
Affiliations
  • University College London (GB)
  • Cairo University (EG)
  • University of Cambridge (GB)
Corresponding author
Jauniaux, Eric
ORCID
Venue
American Journal of Obstetrics and Gynecology
Publisher
Elsevier BV
Published
2022-09
Volume
227
Issue
3
Pages
384-391
ISSN
0002-9378 (ISSN-L)
DOI
10.1016/j.ajog.2022.02.038
OpenAlex
W4214843556
Cited by
203
References
83
Citations by year
2026: 63 · 2025: 42 · 2024: 48 · 2023: 47 · 2022: 3
FWCI
9.15
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • American Journal of Obstetrics and Gynecology (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
  • Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
  • Life Sciences › Immunology and Microbiology › Immunology › Reproductive System and Pregnancy
Keywords
placenta accreta spectrum, cesarean scar defect, decidualization, anchoring villi, extravillous trophoblast, placental lacunae, uterine spiral arteries, fibrinoid deposition, uteroplacental interface, placental attachment, placenta percreta
MeSH terms
Cicatrix, Female, Humans, Myometrium, Placenta, Placenta Accreta, Placentation, Pregnancy

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