From Etiopathology to Management of Accreta Placentation

Abstract

Purpose of Review
To review the etiopathology of the different grades of accreta placentation and evaluate its impact on management strategies and outcomes.

Recent Findings
Accreta placentation is essentially the consequence of prior uterine surgery, mainly multiple cesarean deliveries which often result in large scar defects with absence of re-epithelialization by the endometrium. Invasive placentation is associated with high maternal morbidity and if undiagnosed before delivery can lead to massive obstetric hemorrhage leading to maternal death. The clinical symptoms of an adherent placenta accreta are very similar to those of placental retention and the inclusion of both conditions in cohort studies has artificially increased the prevalence of placenta accreta spectrum. Similarly, the damage to the myometrial tissue of the lower uterine segment resulting from multiple cesarean incisions often leads a large area of dehiscence which can be mistaken for placenta percreta.

Summary
The degree of success and main outcomes of the different therapeutic strategies in women presenting with placenta accreta spectrum are related to the grade of placental attachment abnormality. Systematic and prospectively collected clinical data including intended and actual mode of management, complications, and long-term follow-up data are essential to the development of tailored management strategies for the increasing number of women presenting with accreta placentation. The quality of the data reported in the medical literature, and in particular on the accurate diagnosis of the different grades of PAS at birth, is pivotal to improve the management and outcome of this complex obstetric complication.

Full text

ABERRANT PLACENTATION: CONTEMPORARY MANAGEMENT OF PLACENTA ACCRETA (E
JAUNIAUX, SECTION EDITOR)
From Etiopathology to Management of Accreta Placentation
Eric Jauniaux
1
&Graham J. Burton
2
Published online: 20 May 2019
#Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Purpose of Review To review the etiopathology of the different grades of accreta placentation and evaluate its impact on
management strategies and outcomes.
Recent Findings Accreta placentation is essentially the consequence of prior uterine surgery, mainly multiple cesarean deliveries
which often result in large scar defects with absence of re-epithelialization by the endometrium. Invasive placentation is asso-
ciated with high maternal morbidity and if undiagnosed before delivery can lead to massive obstetric hemorrhage leading to
maternal death. The clinical symptoms of an adherent placenta accreta are very similar to those of placental retention and the
inclusion of both conditions in cohort studies has artificially increased the prevalence of placenta accreta spectrum. Similarly, the
damage to the myometrial tissue of the lower uterine segmentresulting from multiple cesarean incisions often leads a large area of
dehiscence which can be mistaken for placenta percreta.
Summary The degree of success and main outcomes of the different therapeutic strategies in women presenting with placenta
accreta spectrum are related tothe grade of placental attachment abnormality. Systematic and prospectively collected clinical data
including intended and actual mode of management, complications, and long-term follow-up data are essential to the develop-
ment of tailored management strategies for the increasing number of women presenting with accreta placentation. The quality of
the data reported in the medical literature, and in particular on the accurate diagnosis of the different grades of PAS at birth, is
pivotal to improve the management and outcome of this complex obstetric complication.
Keywords Placenta accreta .Placenta increta .Placenta percreta .Diagnosis .Management
Introduction
Placenta accreta spectrum(PAS) is a relatively new disorder of
human placentation with only a few publications published in
the modern medical literature during the first half of the twen-
tieth century [1]. Obstetrician Frederick C. Irving and pathol-
ogist Arthur T. Hertig from the Boston Lying-In Hospital were
the first to report in 1937 a cohort of 18 cases of placenta
accreta “vera”or “adherenta”[2]. They described their cases
clinically as “the abnormal adherence of the afterbirth in
whole or in parts to the underlying uterine wall”[2].
Microscopically, they found that the common histological
sign between their cases was “the complete or partial absence
of the decidua basalis”.
Three decades later, Luke et al. were the first to show that
the degree of villous adhesion or invasion is rarely uniform
across the placental bed, and that many cases of PAS present
with both adherent and invasive areas [3•]. They described
accreta placentation as a spectrum of abnormally adherent
and invasive placentation disorders, and highlighted the need
to differentiate between abnormally adherent and abnormally
invasive placentas and report on the lateral extension of the
accreta area. PAS is now graded according to the depth of
This article is part of the Topical Collection on Aberrant Placentation:
Contemporary Management of Placenta Accreta
*Eric Jauniaux
e.jauniaux@ucl.ac.uk
Graham J. Burton
Gjb2@cam.ac.uk
1
EGA Institute for Women’s Health, University College London,
86-96 Chenies Mews, London WC1E 6HX, UK
2
Department of Physiology, The Centre for Trophoblast Research,
Development and Neuroscience, University of Cambridge,
Cambridge, UK
Current Obstetrics and Gynecology Reports (2019) 8:55–63
https://doi.org/10.1007/s13669-019-0261-y
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