Materiały źródłowe

• #1 Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging

  https://www.repository.cam.ac.uk/items/36fa310b-fef0-4a48-b055-6c13014adcc1

  Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. […] The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium. […] The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. […] Correlation of pathological and clinical findings with prenatal imaging is essential to improve screening, diagnosis, and management of placenta accreta spectrum, and standardized protocols need to be developed.

• #2 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In a normal pregnancy, the placenta anchors to decidualized endometrium. The abnormal invasion of placental trophoblasts into the uterine myometrium is called placenta accreta. Based on the degree of myometrial invasion, it is considered a spectrum of disorders, encompassing placenta accreta, placenta increta, and placenta percreta. Placenta accreta spectrum (PAS) disorders are associated with increased maternal morbidity and mortality. Therefore, these patients should be cared for by an interprofessional team. […] Placenta accreta spectrum (PAS) disorders are most commonly associated with a history of a previous cesarean section. This is likely due to the abnormal placentation secondary to the loss of decidua in the cesarean section scar. However, other risk factors are associated with placenta accreta, including advanced maternal age and multiparity. Placenta previa is present in approximately 80% of placenta accreta cases. Placenta accreta has also been linked to other types of uterine surgery, such as myomectomy, uterine curettage, hysteroscopic surgery, prior endometrial ablation, uterine embolization, and pelvic irradiation.

• #3 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  ABSTRACT: Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. […] The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Several studies suggest that disruptions within the uterine cavity cause damage to the endometrialmyometrial interface, thereby affecting the development of scar tissue and increasing the likelihood of placenta accreta.

• #4 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  ABSTRACT: Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. […] The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Several studies suggest that disruptions within the uterine cavity cause damage to the endometrialmyometrial interface, thereby affecting the development of scar tissue and increasing the likelihood of placenta accreta.

• #5 ACOG SMFM Obstetric Care Consensus #7: Placenta Accreta Spectrum – SMFM Publications and Clinical Guidelines

  https://publications.smfm.org/publications/266-acog-smfm-obstetric-care-consensus-7-placenta-accreta/

  Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. […] The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. […] Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. […] The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). […] Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum.

• #6 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In typical placentation, trophoblast invasion stops at the spongiosus layer of the decidua. There are many theories as to why placenta accreta may occur. One leading theory is that in patients with prior uterine surgeries, the spongiosus layer of the decidualized endometrium may not be present. Therefore, the typical stop signal is absent. Furthermore, cytotrophoblasts must also reach the spiral arterioles before differentiation into placenta tissue may occur. However, uterine scars have a relative lack of vasculature. It is important to note that, although rare, placenta accreta can occur in nulliparous women and women without prior uterine surgery.

• #7 Placenta Accreta Spectrum Disorder: Definitions and Management – The ObG Project

  https://www.obgproject.com/2017/03/16/placenta-accreta-optimal-time-deliver/

  In normal circumstances, the trophoblast stops invading the uterus when Nitabuch’s layer is reached in the decidua. In cases of accreta, the trophoblast invades the myometrium due to a deficient or damaged Nitabuch’s layer. Placenta accreta occurs within a spectrum of disorders now referred to as ‘Placenta Accreta Spectrum’ (formerly ‘Morbidly Adherent Placenta’) […] The mainstay of antenatal diagnosis is ultrasound. Note: Absence of ultrasound findings does not mean the patient does not have accreta | Clinical risk factors should be weighted equally compared to sonographic findings (Grade 1A) […] MRI has sensitivities (75%-100%) and specificities (65%-100%) approaching that of ultrasound, but has not been shown to improve the diagnostic accuracy of accreta compared to ultrasound (Grade 1B).

• #8

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  Placenta accreta spectrum (PAS) disorders present a significant clinical challenge, characterized by abnormal placental adherence to the uterine wall secondary to uterine scarring. […] Normal placentation depends on tightly regulated extravillous trophoblast invasion into the decidua, spiral artery remodeling, interactions with the extracellular matrix, and immune modulation. Uterine scarring disrupts this balance, creating an environment deficient in key regulatory signals required for coordinated implantation and decidualization. […] In PAS, the loss of inhibitory decidual cues and deficient boundary limits permits unrestrained trophoblast into the abnormal decidual environment. Dysregulated signaling, along with an inflammatory milieu in scarred tissues, exacerbates abnormal placental development.

• #9

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  The pathogenesis involves an interplay of molecular, cellular, and structural mechanisms that result in unregulated extravillous trophoblast invasion and abnormal placental development and subsequently adherence at specific sites of the placental-myometrial interface. […] The loss of decidual inhibitory signals disrupts the physical and molecular barriers of the endometrial-myometrial interface and, combined with the inflammatory milieu in scarred tissues, amplifies the invasive capacity of trophoblasts. […] Excessive fibrinoid deposition is a hallmark of PAS. […] In PAS, abnormal accumulation of fibrinoid material contributes to pathologic anchoring of the placenta to the uterine wall, which becomes a window into our ultrasound screening markers for PAS. […] Under normal conditions, extravillous trophoblasts remodel spiral arteries to convert them into low-resistance, high-capacity vessels that support adequate blood flow to the placenta. In PAS, the physiologic transformation of spiral arteries is incomplete or absent.

• #10 Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging – PubMed

  https://pubmed.ncbi.nlm.nih.gov/28599899/

  Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. […] The main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. […] The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium.

• #11 Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging – PubMed

  https://pubmed.ncbi.nlm.nih.gov/28599899/

  Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. […] The main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. […] The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium.

• #12 Prepare for the unanticipated: Placenta accreta spectrum

  https://www.contemporaryobgyn.net/view/prepare-for-the-unanticipated-placenta-accreta-spectrum

  Myometrial healing is also not completely regenerative, and the resulting fibrinous tissue is weaker, less elastic, and more prone to injury. As such, in many cases where there is a uterine scar, there is a degree of dehiscence of the scar, particularly as the lower uterine segment elongates in the third trimester, that also plays into PAS pathology. PAS severity clinically results from the interplay among the scar defect, proximity of placenta tissue to this defect, and lost myometrial thickness. Due to altered placental structure in PAS-affected regions, the uteroplacental circulation is altered, resulting in high-velocity maternal blood flow entering the intervillous spaces, termed lacunae.

• #13 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  ABSTRACT: Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. […] The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrialmyometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Several studies suggest that disruptions within the uterine cavity cause damage to the endometrialmyometrial interface, thereby affecting the development of scar tissue and increasing the likelihood of placenta accreta.

• #14 Pathophysiology of Placenta Accreta Spectrum Disorders: A Review of Current Findings.

  https://www.repository.cam.ac.uk/items/148e7369-c8d9-40cf-a9f7-ea2853237770

  Current findings continue to support the concept of a biologically defective decidua rather than a primarily abnormally invasive trophoblast. […] Prior cesarean sections increase the risk of placenta previa and both adherent and invasive placenta accreta, suggesting that the endometrial/decidual defect following the iatrogenic creation of a uterine myometrium scar has an adverse effect on early implantation. […] Preferential attachment of the blastocyst to scar tissue facilitates abnormally deep invasion of trophoblastic cells and interactions with the radial and arcuate arteries. […] Subsequent high velocity maternal arterial inflow into the placenta creates large lacunae, destroying the normal cotyledonary arrangement of the villi.

• #15

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  The pathogenesis involves an interplay of molecular, cellular, and structural mechanisms that result in unregulated extravillous trophoblast invasion and abnormal placental development and subsequently adherence at specific sites of the placental-myometrial interface. […] The loss of decidual inhibitory signals disrupts the physical and molecular barriers of the endometrial-myometrial interface and, combined with the inflammatory milieu in scarred tissues, amplifies the invasive capacity of trophoblasts. […] Excessive fibrinoid deposition is a hallmark of PAS. […] In PAS, abnormal accumulation of fibrinoid material contributes to pathologic anchoring of the placenta to the uterine wall, which becomes a window into our ultrasound screening markers for PAS. […] Under normal conditions, extravillous trophoblasts remodel spiral arteries to convert them into low-resistance, high-capacity vessels that support adequate blood flow to the placenta. In PAS, the physiologic transformation of spiral arteries is incomplete or absent.

• #16 New insights into the etiopathology of placenta accreta spectrum

  https://ouci.dntb.gov.ua/en/works/42YNNAj7/

  Placenta accreta spectrum (PAS) is one of the major causes of maternal morbidity and mortality worldwide with increasing incidence. PAS refers to a group of pathological conditions ranging from the abnormal attachment of the placenta to the uterus wall to its perforation and, in extreme cases, invasion into surrounding organs. […] Decidual deficiency, abnormal vascular remodeling in the maternal–fetal interface, and excessive invasion by extravillous trophoblast (EVT) cells contribute to its onset. However, the mechanisms and signaling pathways underlying such phenotypes are not fully understood, partly due to the lack of suitable experimental animal models. […] This review details early placental development in mice, with a focus on the approaches of PAS modeling. Additionally, the strengths, limitations and the applicability of each strategy and further perspectives are summarized to provide the theoretical foundation for researchers to select appropriate animal models for various research purposes. This will help better determine the pathogenesis of PAS and even promote possible therapy.

• #17 Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging – PubMed

  https://pubmed.ncbi.nlm.nih.gov/28599899/

  Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. […] The main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. […] The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium.

• #18 Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging

  https://www.repository.cam.ac.uk/items/36fa310b-fef0-4a48-b055-6c13014adcc1

  Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. […] The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium. […] The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. […] Correlation of pathological and clinical findings with prenatal imaging is essential to improve screening, diagnosis, and management of placenta accreta spectrum, and standardized protocols need to be developed.

• #19 Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel | Modern Pathology

  https://www.nature.com/articles/s41379-020-0569-1

  The formulation of a microscopic definition of PAS was controversial. There was some concern of PAS overdiagnosis in the absence of myometrial invasion, as the decidual layer may normally vary in thickness across the placental bed. […] An altered pattern of EVT has been described in PAS. EVT is normally present in the basal plate, decidua, and inner myometrium, but deeper infiltration of the uterine wall is seen in PAS.

• #20 The Underlying Molecular Mechanisms of the Placenta Accreta Spectrum: A Narrative Review

  https://www.mdpi.com/1422-0067/25/17/9722

  This review aims to describe the molecular mechanisms driving PAS by exploring the pathological signaling pathways implicated in this disease. […] The physiopathological features of the PAS involve a complex interplay of factors, including abnormal placentation, uterine scarring, and impaired decidualization. […] The developmental behavior of severity in this spectrum comprises complex mechanisms, highlighting abnormal placentation, which allows trophoblast invasion to myometrium involving cellular differentiation, proliferation, and invasion in conjunction with growth factors and receptors. […] In this regard, the chemokine CXCL12 and its receptors, CXCR4 and CXCR7, are known to play pivotal roles in the invasion process of trophoblast cells. […] The mechanisms underlying the excessive invasion of trophoblasts in patients diagnosed with PAS present an upregulation of CXCL12 and CXCR4/CXCR7 in extravillous trophoblastic cells in a dose-dependent manner, increasing their proliferative capabilities at higher expressions, and contributing to the invasion into the uterine wall.

• #21

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  The pathogenesis involves an interplay of molecular, cellular, and structural mechanisms that result in unregulated extravillous trophoblast invasion and abnormal placental development and subsequently adherence at specific sites of the placental-myometrial interface. […] The loss of decidual inhibitory signals disrupts the physical and molecular barriers of the endometrial-myometrial interface and, combined with the inflammatory milieu in scarred tissues, amplifies the invasive capacity of trophoblasts. […] Excessive fibrinoid deposition is a hallmark of PAS. […] In PAS, abnormal accumulation of fibrinoid material contributes to pathologic anchoring of the placenta to the uterine wall, which becomes a window into our ultrasound screening markers for PAS. […] Under normal conditions, extravillous trophoblasts remodel spiral arteries to convert them into low-resistance, high-capacity vessels that support adequate blood flow to the placenta. In PAS, the physiologic transformation of spiral arteries is incomplete or absent.

• #22

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  High-velocity blood flow through unremodeled arteries generates shear stress and mechanical damage, resulting in lacunar formation and thrombosis. These hemodynamic disturbances compromise placental function, increasing the risk of adverse pregnancy outcomes. […] At its core, PAS pathophysiology is rooted in the interplay of uterine scarring, decidual dysfunction, extracellular matrix remodeling, vascular abnormalities, and dysregulated trophoblast invasion.

• #23 The Underlying Molecular Mechanisms of the Placenta Accreta Spectrum: A Narrative Review

  https://www.mdpi.com/1422-0067/25/17/9722

  This review aims to describe the molecular mechanisms driving PAS by exploring the pathological signaling pathways implicated in this disease. […] The physiopathological features of the PAS involve a complex interplay of factors, including abnormal placentation, uterine scarring, and impaired decidualization. […] The developmental behavior of severity in this spectrum comprises complex mechanisms, highlighting abnormal placentation, which allows trophoblast invasion to myometrium involving cellular differentiation, proliferation, and invasion in conjunction with growth factors and receptors. […] In this regard, the chemokine CXCL12 and its receptors, CXCR4 and CXCR7, are known to play pivotal roles in the invasion process of trophoblast cells. […] The mechanisms underlying the excessive invasion of trophoblasts in patients diagnosed with PAS present an upregulation of CXCL12 and CXCR4/CXCR7 in extravillous trophoblastic cells in a dose-dependent manner, increasing their proliferative capabilities at higher expressions, and contributing to the invasion into the uterine wall.

• #24 The role of angiogenic factors in the pathogenesis of placenta accreta spectrum in women with placenta previa – Makukhina – Obstetrics and Gynecology

  https://edgccjournal.org/0300-9092/article/view/249475

  Objective: To investigate the contribution of angiogenic factors to the pathogenesis of placenta accreta spectrum (PAS) in women with placenta previa to identify additional biomarkers of abnormal placental invasion. […] Women with PAS had lower expression of Flt-1 in chorionic villi than those without PAS.

• #25 Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum | Scientific Reports

  https://www.nature.com/articles/s41598-022-24869-0

  Our results also suggest a greater predictive value of second trimester markers relative to third trimester markers. Proteins within the second trimester panel are more specific to cellular invasion and angiogenesis functions than those in the third trimester panel. […] In the second trimester, canonical pathway analyses demonstrate over-representation of processes related to blood cell function and oxygenation, including iron homeostasis and erythropoietin signaling. Dysregulation in these processes may indicate subclinical bleeding evidenced by presence of placental lakes on ultrasound, inflammation, and/or anemia in second trimester PAS. […] In the third trimester, similar analyses characterized abnormal innate and adaptive immune cell and IL-15 signaling. Immunoglobulins and complement factors are involved in multiple implantation and placentation processes which may be abnormal in PAS.

• #26

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  The pathogenesis involves an interplay of molecular, cellular, and structural mechanisms that result in unregulated extravillous trophoblast invasion and abnormal placental development and subsequently adherence at specific sites of the placental-myometrial interface. […] The loss of decidual inhibitory signals disrupts the physical and molecular barriers of the endometrial-myometrial interface and, combined with the inflammatory milieu in scarred tissues, amplifies the invasive capacity of trophoblasts. […] Excessive fibrinoid deposition is a hallmark of PAS. […] In PAS, abnormal accumulation of fibrinoid material contributes to pathologic anchoring of the placenta to the uterine wall, which becomes a window into our ultrasound screening markers for PAS. […] Under normal conditions, extravillous trophoblasts remodel spiral arteries to convert them into low-resistance, high-capacity vessels that support adequate blood flow to the placenta. In PAS, the physiologic transformation of spiral arteries is incomplete or absent.

• #27

  https://journals.lww.com/greenjournal/fulltext/9900/biology_and_pathophysiology_of_placenta_accreta.1245.aspx

  The pathogenesis involves an interplay of molecular, cellular, and structural mechanisms that result in unregulated extravillous trophoblast invasion and abnormal placental development and subsequently adherence at specific sites of the placental-myometrial interface. […] The loss of decidual inhibitory signals disrupts the physical and molecular barriers of the endometrial-myometrial interface and, combined with the inflammatory milieu in scarred tissues, amplifies the invasive capacity of trophoblasts. […] Excessive fibrinoid deposition is a hallmark of PAS. […] In PAS, abnormal accumulation of fibrinoid material contributes to pathologic anchoring of the placenta to the uterine wall, which becomes a window into our ultrasound screening markers for PAS. […] Under normal conditions, extravillous trophoblasts remodel spiral arteries to convert them into low-resistance, high-capacity vessels that support adequate blood flow to the placenta. In PAS, the physiologic transformation of spiral arteries is incomplete or absent.

• #28 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  The pathogenesis of PAS includes the formation of an abnormally firm and deep attachment to the uterine wall by the placenta. […] In addition, there may be an absence of the decidua basalis and incomplete development of the Nitabuch’s layer. […] Women experience higher morbidity with placenta percreta compared to placenta accreta and increta. […] In cases of placenta percreta, where the uterus is deeply penetrated into and through the myometrium to the bladder or rectum, it is highly advised to avoid any attempts of removing the placenta. […] Leaving the placenta in situ, not removing it after childbirth, has been part of the conservative management of PAS discussed later.

• #29 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  The pathogenesis of PAS includes the formation of an abnormally firm and deep attachment to the uterine wall by the placenta. […] In addition, there may be an absence of the decidua basalis and incomplete development of the Nitabuch’s layer. […] Women experience higher morbidity with placenta percreta compared to placenta accreta and increta. […] In cases of placenta percreta, where the uterus is deeply penetrated into and through the myometrium to the bladder or rectum, it is highly advised to avoid any attempts of removing the placenta. […] Leaving the placenta in situ, not removing it after childbirth, has been part of the conservative management of PAS discussed later.

• #30 The Underlying Molecular Mechanisms of the Placenta Accreta Spectrum: A Narrative Review

  https://www.mdpi.com/1422-0067/25/17/9722

  Placenta accreta spectrum (PAS) disorders are characterized by abnormal trophoblastic invasion into the myometrium, leading to significant maternal health risks. […] The condition is most associated with previous cesarean deliveries and increases in chance with the number of prior cesarians. […] This review explores genetic expression and key regulatory processes, such as apoptosis, cell proliferation, invasion, and inflammation, focusing on signaling pathways, genetic expression, biomarkers, and non-coding RNAs involved in trophoblastic invasion. […] Understanding genetic expression and non-coding RNAs is crucial for unraveling PAS complexities. […] In addition, aberrant signaling pathways like Notch, PI3K/Akt, STAT3, and TGF-β offer potential therapeutic targets to modulate trophoblastic invasion.

• #31 The Underlying Molecular Mechanisms of the Placenta Accreta Spectrum: A Narrative Review

  https://www.mdpi.com/1422-0067/25/17/9722

  Inflammation is another mechanism involved in the PAS since an interaction exists between the trophoblast and the uterine tissue, resulting in the exacerbated release of proinflammatory mediators. […] The invasive trait of trophoblastic cells has been related to YKL-40 enhancer activity since it is overexpressed both in PAS samples and in vitro using HTR8/SVneo cells, promoting proliferation, migration, and invasion, but also inhibiting apoptosis through the activation of the Akt/MMP9 signaling pathway. […] Overall, this review highlights the importance of interdisciplinary care, early diagnosis, and a comprehensive understanding of the molecular underpinnings of PAS.

• #32 Integration of transcriptome and proteome profiles in placenta accreta reveals trophoblast over-migration as the underlying pathogenesis | Clinical Proteomics | Full Text

  https://clinicalproteomicsjournal.biomedcentral.com/articles/10.1186/s12014-021-09336-8

  The adhesion-related signature increased in the transcriptome and proteome based on the KEGG and GO pathway analyses in the placenta accreta group, demonstrating that trophoblast invasion plays a critical role in the development of placenta accreta. […] Our study further demonstrates over-invasion of trophoblasts in the pathogenesis of placenta accreta. […] To clarify the function of MeCP2, PODN and ApoD, si-MeCP2, si-PODN, and si-ApoD, or their negative controls were transfected into HTR-8/SVneo cell lines. […] Furthermore, the cell experiments confirmed the functions of MeCP2, PODN, and ApoD in trophoblast migration and invasion.

• #33 The Role of CXCR2, MMP-2, and MMP-9 in the Pathogenesis of Placenta Accreta: A Molecular Expression Study

  https://www.mdpi.com/1648-9144/61/3/461

  CXCR2 overexpression in PASD is likely to result in higher levels of immunostaining expression compared with the control (normal pregnancy). CXCR2 expression has a role in increasing trophoblast invasion, vascular remodeling, and neovascularization. […] The currently existing explanation concerning the cause of PASD is that a malfunction in the interface between the endometrium and myometrium results in the inability of the uterine scar area to undergo normal decidualization, hence permitting deeper infiltration of trophoblasts. […] Matrix metalloproteinases are a class of enzymes that include zinc (Zn) and require calcium for their activity. They play a role in breaking down the ECM. MMP-2 has a function in wound healing by speeding up the movement of cells, whereas MMP-9 is produced by keratinocytes at the forefront of the wound to enhance cell movement and the process of re-epithelialization.

• #34 The Role of CXCR2, MMP-2, and MMP-9 in the Pathogenesis of Placenta Accreta: A Molecular Expression Study

  https://www.mdpi.com/1648-9144/61/3/461

  The expression level of CXCR2 immunostaining in placental and uterine tissues of patients with PASD was significantly different from patients without PASD. The expression level of MMP-2 immunostaining in placental and uterine tissues of patients with PASD was not significantly different from patients without PASD. The MMP-9 immunostaining expression level of PASD patients was significantly different from that of patients without PASD in uterine tissue, but not in placental tissue.

• #35 Research on the expression of MRNA-518b in the pathogenesis of placenta accreta

  https://www.europeanreview.org/article/16743

  To investigate the expression of micro ribonucleic acid miR-518b and its regulatory role in the pathogenesis of placenta accreta. […] The high expression of miR-518b may lead to the development of placenta accreta through upregulating the transcription and protein expression of downstream VEGF and OPN, providing insights for the future therapy against the pathogenesis of placenta accreta.

• #36 The Underlying Molecular Mechanisms of the Placenta Accreta Spectrum: A Narrative Review

  https://www.mdpi.com/1422-0067/25/17/9722

  Inflammation is another mechanism involved in the PAS since an interaction exists between the trophoblast and the uterine tissue, resulting in the exacerbated release of proinflammatory mediators. […] The invasive trait of trophoblastic cells has been related to YKL-40 enhancer activity since it is overexpressed both in PAS samples and in vitro using HTR8/SVneo cells, promoting proliferation, migration, and invasion, but also inhibiting apoptosis through the activation of the Akt/MMP9 signaling pathway. […] Overall, this review highlights the importance of interdisciplinary care, early diagnosis, and a comprehensive understanding of the molecular underpinnings of PAS.

• #37 The Role of CXCR2, MMP-2, and MMP-9 in the Pathogenesis of Placenta Accreta: A Molecular Expression Study

  https://www.mdpi.com/1648-9144/61/3/461

  The pathogenesis of placenta accreta spectrum disorder (PASD) is influenced by the inflammatory process. Therefore, the examination of biomarkers related to the inflammatory process, namely matrix metalloproteinase (MMP) and CXC motif chemokine receptor 2 (CXCR2), is expected to bring researchers to a bright spot regarding the pathogenesis of PASD. This study analyzes the role of CXCR2, MMP-2, and MMP-9 in the pathogenesis of PASD. […] While the mechanical factors, such as previous cesarean delivery and surgical history, have been extensively studied, the molecular mechanisms underlying PASD remain underexplored. Recent advances in the understanding of placental biology suggest that inflammatory processes may play a critical role in the development of this condition. […] The biomarker CXCR2 is involved in trophoblast invasion, neovascularization, and vascular remodeling processes.

• #38 The Role of CXCR2, MMP-2, and MMP-9 in the Pathogenesis of Placenta Accreta: A Molecular Expression Study

  https://www.mdpi.com/1648-9144/61/3/461

  The pathogenesis of placenta accreta spectrum disorder (PASD) is influenced by the inflammatory process. Therefore, the examination of biomarkers related to the inflammatory process, namely matrix metalloproteinase (MMP) and CXC motif chemokine receptor 2 (CXCR2), is expected to bring researchers to a bright spot regarding the pathogenesis of PASD. This study analyzes the role of CXCR2, MMP-2, and MMP-9 in the pathogenesis of PASD. […] While the mechanical factors, such as previous cesarean delivery and surgical history, have been extensively studied, the molecular mechanisms underlying PASD remain underexplored. Recent advances in the understanding of placental biology suggest that inflammatory processes may play a critical role in the development of this condition. […] The biomarker CXCR2 is involved in trophoblast invasion, neovascularization, and vascular remodeling processes.

• #39 The Role of CXCR2, MMP-2, and MMP-9 in the Pathogenesis of Placenta Accreta: A Molecular Expression Study

  https://www.mdpi.com/1648-9144/61/3/461

  CXCR2 overexpression in PASD is likely to result in higher levels of immunostaining expression compared with the control (normal pregnancy). CXCR2 expression has a role in increasing trophoblast invasion, vascular remodeling, and neovascularization. […] The currently existing explanation concerning the cause of PASD is that a malfunction in the interface between the endometrium and myometrium results in the inability of the uterine scar area to undergo normal decidualization, hence permitting deeper infiltration of trophoblasts. […] Matrix metalloproteinases are a class of enzymes that include zinc (Zn) and require calcium for their activity. They play a role in breaking down the ECM. MMP-2 has a function in wound healing by speeding up the movement of cells, whereas MMP-9 is produced by keratinocytes at the forefront of the wound to enhance cell movement and the process of re-epithelialization.

• #40 Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum | Scientific Reports

  https://www.nature.com/articles/s41598-022-24869-0

  Our results also suggest a greater predictive value of second trimester markers relative to third trimester markers. Proteins within the second trimester panel are more specific to cellular invasion and angiogenesis functions than those in the third trimester panel. […] In the second trimester, canonical pathway analyses demonstrate over-representation of processes related to blood cell function and oxygenation, including iron homeostasis and erythropoietin signaling. Dysregulation in these processes may indicate subclinical bleeding evidenced by presence of placental lakes on ultrasound, inflammation, and/or anemia in second trimester PAS. […] In the third trimester, similar analyses characterized abnormal innate and adaptive immune cell and IL-15 signaling. Immunoglobulins and complement factors are involved in multiple implantation and placentation processes which may be abnormal in PAS.

• #41 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In a normal pregnancy, the placenta anchors to decidualized endometrium. The abnormal invasion of placental trophoblasts into the uterine myometrium is called placenta accreta. Based on the degree of myometrial invasion, it is considered a spectrum of disorders, encompassing placenta accreta, placenta increta, and placenta percreta. Placenta accreta spectrum (PAS) disorders are associated with increased maternal morbidity and mortality. Therefore, these patients should be cared for by an interprofessional team. […] Placenta accreta spectrum (PAS) disorders are most commonly associated with a history of a previous cesarean section. This is likely due to the abnormal placentation secondary to the loss of decidua in the cesarean section scar. However, other risk factors are associated with placenta accreta, including advanced maternal age and multiparity. Placenta previa is present in approximately 80% of placenta accreta cases. Placenta accreta has also been linked to other types of uterine surgery, such as myomectomy, uterine curettage, hysteroscopic surgery, prior endometrial ablation, uterine embolization, and pelvic irradiation.

• #42 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In a normal pregnancy, the placenta anchors to decidualized endometrium. The abnormal invasion of placental trophoblasts into the uterine myometrium is called placenta accreta. Based on the degree of myometrial invasion, it is considered a spectrum of disorders, encompassing placenta accreta, placenta increta, and placenta percreta. Placenta accreta spectrum (PAS) disorders are associated with increased maternal morbidity and mortality. Therefore, these patients should be cared for by an interprofessional team. […] Placenta accreta spectrum (PAS) disorders are most commonly associated with a history of a previous cesarean section. This is likely due to the abnormal placentation secondary to the loss of decidua in the cesarean section scar. However, other risk factors are associated with placenta accreta, including advanced maternal age and multiparity. Placenta previa is present in approximately 80% of placenta accreta cases. Placenta accreta has also been linked to other types of uterine surgery, such as myomectomy, uterine curettage, hysteroscopic surgery, prior endometrial ablation, uterine embolization, and pelvic irradiation.

• #43 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In a normal pregnancy, the placenta anchors to decidualized endometrium. The abnormal invasion of placental trophoblasts into the uterine myometrium is called placenta accreta. Based on the degree of myometrial invasion, it is considered a spectrum of disorders, encompassing placenta accreta, placenta increta, and placenta percreta. Placenta accreta spectrum (PAS) disorders are associated with increased maternal morbidity and mortality. Therefore, these patients should be cared for by an interprofessional team. […] Placenta accreta spectrum (PAS) disorders are most commonly associated with a history of a previous cesarean section. This is likely due to the abnormal placentation secondary to the loss of decidua in the cesarean section scar. However, other risk factors are associated with placenta accreta, including advanced maternal age and multiparity. Placenta previa is present in approximately 80% of placenta accreta cases. Placenta accreta has also been linked to other types of uterine surgery, such as myomectomy, uterine curettage, hysteroscopic surgery, prior endometrial ablation, uterine embolization, and pelvic irradiation.

• #44 Placenta Accreta – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK563288/

  In a normal pregnancy, the placenta anchors to decidualized endometrium. The abnormal invasion of placental trophoblasts into the uterine myometrium is called placenta accreta. Based on the degree of myometrial invasion, it is considered a spectrum of disorders, encompassing placenta accreta, placenta increta, and placenta percreta. Placenta accreta spectrum (PAS) disorders are associated with increased maternal morbidity and mortality. Therefore, these patients should be cared for by an interprofessional team. […] Placenta accreta spectrum (PAS) disorders are most commonly associated with a history of a previous cesarean section. This is likely due to the abnormal placentation secondary to the loss of decidua in the cesarean section scar. However, other risk factors are associated with placenta accreta, including advanced maternal age and multiparity. Placenta previa is present in approximately 80% of placenta accreta cases. Placenta accreta has also been linked to other types of uterine surgery, such as myomectomy, uterine curettage, hysteroscopic surgery, prior endometrial ablation, uterine embolization, and pelvic irradiation.

• #45 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #46 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  Placenta accreta is a pregnancy complication that occurs when the placenta embeds too deep in the uterine wall. […] Abnormalities with the lining of your uterus cause placenta accreta. Your uterine lining can become damaged or scarred from prior uterine surgeries. […] The risk factors for placenta accreta are: Multiple C-sections: People whove had multiple C-sections have a higher risk of developing placenta accreta. This results from scarring of your uterus from the procedures. […] An early diagnosis of placenta accreta is essential because it can allow multiple healthcare providers to become involved in your pregnancy and delivery care. […] Treatment of placenta accreta can vary. If your provider diagnoses it before delivery, theyll monitor you closely for the rest of your pregnancy.

• #47 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #48 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #49 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #50 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #51 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #52 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #53 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  A growing body of evidence has demonstrated that ultrasound is the preferred method of evaluation for placenta accreta spectrum disorders. […] Ultrasound has reported sensitivity 90% and specificity 96% in the diagnosis of PAS. […] The above listed sonographic signs should not be used independently to diagnose PAS, as they individually may have low sensitivity and specificity for PAS. […] The risk factors for PAS include prior cesarean delivery, placenta previa, advancing maternal age, prior uterine surgery, multiparity, endometrial ablation, uterine irradiation and smoking. […] Studies have shown varying sensitivity rates using ultrasound for the prenatal diagnosis of PAS; these sensitivities vary, but range from 70-90%. […] The majority of published guidelines recommend the use of ultrasound for diagnosis of PAS, with magnetic resonance imaging (MRI) use as an adjunct if needed. […] The study concluded that, given the high cost and limited clinical value, MRI should not be routinely used as an adjunct to ultrasound in the detection of PAS. […] Utilizing ultrasound is likely to decrease the rates of misdiagnosis, and decrease utilization of MRI.

• #54 Placenta Accreta Spectrum Program | Riley Children’s Health

  https://www.rileychildrens.org/departments/placenta-accreta-spectrum-program

  The Placenta Accreta Spectrum Program at Riley Children’s Health and Indiana University Health offers specialized care for pregnancies complicated by abnormal placental growth into or beyond the uterine wall. This condition, known as the placenta accreta spectrum (PAS), includes placenta accreta, increta, and percreta, and poses significant risk of life-threatening hemorrhage during childbirth. […] An ultrasound is the primary tool for diagnosing PAS, and it is often performed during the second or third trimester of pregnancy. Magnetic Resonance Imaging (MRI) is also used to provide additional detail and confirm the extent of placental invasion. […] Conservative management: This approach is for mild cases of placenta accreta where thorough imaging and surgical evaluation indicate that the benefits of placental delivery and resection rather than hysterectomy outweigh the risks. It aims to manage the condition while minimizing potential complications safely.

• #55 Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum | Scientific Reports

  https://www.nature.com/articles/s41598-022-24869-0

  Placenta accreta spectrum, or PAS, is characterized by aberrant placentation ranging from abnormal adherence to invasion through the uterine wall and into neighboring pelvic structures. The central pathogenic feature of PAS is that the placenta does not spontaneously separate from the uterus after delivery of the fetus. Therefore, PAS may lead to catastrophic obstetric hemorrhage, emergent hysterectomy, multiorgan failure, and death. As such, PAS is a significant contributor to maternal morbidity and mortality around the world, and its incidence is increasing. Reliable antenatal identification of PAS would allow for transfer to PAS referral institutions where appropriate multidisciplinary delivery care can be provided. Appropriate care at such institutions reduces maternal morbidity from PAS by up to 80%. However, up to half of PAS is undiagnosed prior to delivery. Therefore, improving early- and mid-gestation identification of PAS is critical to the global effort to minimize maternal morbidity.

• #56 Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum | Scientific Reports

  https://www.nature.com/articles/s41598-022-24869-0

  With the dual goals of identifying a clinically useful PAS biomarker, as well as identifying CMP mechanisms of PAS pathogenesis, we conducted a nested casecontrol study to identify CMP-associated protein panels that identify pregnancies complicated by PAS. […] While the pathophysiology of PAS remains unclear, it is likely that aberrations in trophoblast invasion, apoptosis, and angiogenesis are involved. […] Additional proteins identified on the PAS panels described here may also reveal mechanisms of PAS pathogenesis. For instance, H4 has been implicated in apoptosis and is an early marker of cell death. HBG2 comprises fetal hemoglobin, the breakdown products of which are associated with increased oxidative stress. CRAC1 is an extracellular matrix protein associated with matrix disorders and involved in cell proliferation, regeneration and collagen degradation.

• #57 Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum | Scientific Reports

  https://www.nature.com/articles/s41598-022-24869-0

  Our results also suggest a greater predictive value of second trimester markers relative to third trimester markers. Proteins within the second trimester panel are more specific to cellular invasion and angiogenesis functions than those in the third trimester panel. […] In the second trimester, canonical pathway analyses demonstrate over-representation of processes related to blood cell function and oxygenation, including iron homeostasis and erythropoietin signaling. Dysregulation in these processes may indicate subclinical bleeding evidenced by presence of placental lakes on ultrasound, inflammation, and/or anemia in second trimester PAS. […] In the third trimester, similar analyses characterized abnormal innate and adaptive immune cell and IL-15 signaling. Immunoglobulins and complement factors are involved in multiple implantation and placentation processes which may be abnormal in PAS.

• #58 The modern concepts of etiology and pathogenesis placenta accreta and prospects of its prediction by molecular diagnostics – Vinitskiy – Obstetrics and Gynecology

  https://journals.eco-vector.com/0300-9092/article/view/247861

  Objective. To conduct a systematic analysis of the data available in the current literature, risk factors, pathogenesis and markers, determined by laboratory diagnostic methods that indicate a placenta accreta. […] Results. There are the basic molecular mechanisms that lead to placenta accreta. It is described risk factors and laboratory markers that allow to diagnose placenta accreta. […] Conclusion. There are many theories that consider the pathogenesis of placenta accrete by many sides. The most common one postulates about the important role of hypoxic factor with reduced vascular component of scar tissue on the uterus. It explains the high prevalence of this disease among women who have a caesarean section that was performed previously. […] A perspective direction is the prediction and diagnosis of placenta accreta by detecting of laboratory markers: some proteins, fetal DNA, mRNA, thereby complementing the instrumental imaging.

• #59 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  Placenta accreta spectrum is considered a high-risk condition with serious associated morbidities; therefore, ACOG and the Society for MaternalFetal Medicine recommend these patients receive level III (subspecialty) or higher care. This level includes continuously available medical staff with appropriate training and experience in managing complex maternal and obstetric complications, including placenta accreta spectrum, as well as consistent access to interdisciplinary staff with expertise in critical care.

• #60 Placenta Accreta Spectrum | ACOG

  https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum

  Placenta accreta spectrum is considered a high-risk condition with serious associated morbidities; therefore, ACOG and the Society for MaternalFetal Medicine recommend these patients receive level III (subspecialty) or higher care. This level includes continuously available medical staff with appropriate training and experience in managing complex maternal and obstetric complications, including placenta accreta spectrum, as well as consistent access to interdisciplinary staff with expertise in critical care.

• #61 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  The pathogenesis of PAS includes the formation of an abnormally firm and deep attachment to the uterine wall by the placenta. […] In addition, there may be an absence of the decidua basalis and incomplete development of the Nitabuch’s layer. […] Women experience higher morbidity with placenta percreta compared to placenta accreta and increta. […] In cases of placenta percreta, where the uterus is deeply penetrated into and through the myometrium to the bladder or rectum, it is highly advised to avoid any attempts of removing the placenta. […] Leaving the placenta in situ, not removing it after childbirth, has been part of the conservative management of PAS discussed later.

• #62 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  The pathogenesis of PAS includes the formation of an abnormally firm and deep attachment to the uterine wall by the placenta. […] In addition, there may be an absence of the decidua basalis and incomplete development of the Nitabuch’s layer. […] Women experience higher morbidity with placenta percreta compared to placenta accreta and increta. […] In cases of placenta percreta, where the uterus is deeply penetrated into and through the myometrium to the bladder or rectum, it is highly advised to avoid any attempts of removing the placenta. […] Leaving the placenta in situ, not removing it after childbirth, has been part of the conservative management of PAS discussed later.

• #63 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  Placenta accreta is a pregnancy complication that occurs when the placenta embeds too deep in the uterine wall. […] Abnormalities with the lining of your uterus cause placenta accreta. Your uterine lining can become damaged or scarred from prior uterine surgeries. […] The risk factors for placenta accreta are: Multiple C-sections: People whove had multiple C-sections have a higher risk of developing placenta accreta. This results from scarring of your uterus from the procedures. […] An early diagnosis of placenta accreta is essential because it can allow multiple healthcare providers to become involved in your pregnancy and delivery care. […] Treatment of placenta accreta can vary. If your provider diagnoses it before delivery, theyll monitor you closely for the rest of your pregnancy.

• #64 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  Placenta accreta is defined as an abnormal invasion of all or part of the placenta into the myometrial wall of the uterus. […] The prenatal diagnosis of PAS is paramount to optimizing management and decreasing morbidity and mortality associated with the disease. […] Undiagnosed PAS can lead to a variety of unfavorable outcomes, including emergent cesarean hysterectomy, disseminated coagulopathy, multi-organ failure, permanent disability and even death. […] When PAS is accurately diagnosed in the prenatal period, this provides the opportunity for a scheduled delivery at a tertiary care center, utilizing a multidisciplinary team with expertise in the management of accreta. […] The resulting evaluation of the placenta requires thorough investigation for accurate diagnoses, and the role of ultrasound in this diagnosis has been well studied and documented.

• #65 Coding for Placenta Accreta Spectrum – Society for Maternal-Fetal Medicine

  https://www.smfm.org/news/coding-for-placenta-accreta-spectrum

  Placenta accreta is defined as an abnormal invasion of all or part of the placenta into the myometrial wall of the uterus. […] The prenatal diagnosis of PAS is paramount to optimizing management and decreasing morbidity and mortality associated with the disease. […] Undiagnosed PAS can lead to a variety of unfavorable outcomes, including emergent cesarean hysterectomy, disseminated coagulopathy, multi-organ failure, permanent disability and even death. […] When PAS is accurately diagnosed in the prenatal period, this provides the opportunity for a scheduled delivery at a tertiary care center, utilizing a multidisciplinary team with expertise in the management of accreta. […] The resulting evaluation of the placenta requires thorough investigation for accurate diagnoses, and the role of ultrasound in this diagnosis has been well studied and documented.

• #66 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  Placenta accreta is a pregnancy complication that occurs when the placenta embeds too deep in the uterine wall. […] Abnormalities with the lining of your uterus cause placenta accreta. Your uterine lining can become damaged or scarred from prior uterine surgeries. […] The risk factors for placenta accreta are: Multiple C-sections: People whove had multiple C-sections have a higher risk of developing placenta accreta. This results from scarring of your uterus from the procedures. […] An early diagnosis of placenta accreta is essential because it can allow multiple healthcare providers to become involved in your pregnancy and delivery care. […] Treatment of placenta accreta can vary. If your provider diagnoses it before delivery, theyll monitor you closely for the rest of your pregnancy.

• #67 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  However, in severe cases where the placenta is deeply or firmly attached or invading into other organs, a hysterectomy (removal of the uterus) may be the safest option. […] The outlook is generally good when pregnancy care providers diagnose placenta accreta during pregnancy. However, there will be complications associated with preterm labor and a possible hysterectomy. […] Placenta accreta is a potentially life-threatening condition that doesnt typically cause symptoms during pregnancy. However, an early diagnosis via ultrasound and close monitoring can help lower your risk for complications from placenta accreta.

• #68 Placenta Accreta: Types, Risks, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/17846-placenta-accreta

  However, in severe cases where the placenta is deeply or firmly attached or invading into other organs, a hysterectomy (removal of the uterus) may be the safest option. […] The outlook is generally good when pregnancy care providers diagnose placenta accreta during pregnancy. However, there will be complications associated with preterm labor and a possible hysterectomy. […] Placenta accreta is a potentially life-threatening condition that doesnt typically cause symptoms during pregnancy. However, an early diagnosis via ultrasound and close monitoring can help lower your risk for complications from placenta accreta.

• #69 Placenta accreta spectrum – Wikipedia

  https://en.wikipedia.org/wiki/Placenta_accreta_spectrum

  The pathogenesis of PAS includes the formation of an abnormally firm and deep attachment to the uterine wall by the placenta. […] In addition, there may be an absence of the decidua basalis and incomplete development of the Nitabuch’s layer. […] Women experience higher morbidity with placenta percreta compared to placenta accreta and increta. […] In cases of placenta percreta, where the uterus is deeply penetrated into and through the myometrium to the bladder or rectum, it is highly advised to avoid any attempts of removing the placenta. […] Leaving the placenta in situ, not removing it after childbirth, has been part of the conservative management of PAS discussed later.

• #70 Placenta Accreta Spectrum Program | Riley Children’s Health

  https://www.rileychildrens.org/departments/placenta-accreta-spectrum-program

  The Placenta Accreta Spectrum Program at Riley Children’s Health and Indiana University Health offers specialized care for pregnancies complicated by abnormal placental growth into or beyond the uterine wall. This condition, known as the placenta accreta spectrum (PAS), includes placenta accreta, increta, and percreta, and poses significant risk of life-threatening hemorrhage during childbirth. […] An ultrasound is the primary tool for diagnosing PAS, and it is often performed during the second or third trimester of pregnancy. Magnetic Resonance Imaging (MRI) is also used to provide additional detail and confirm the extent of placental invasion. […] Conservative management: This approach is for mild cases of placenta accreta where thorough imaging and surgical evaluation indicate that the benefits of placental delivery and resection rather than hysterectomy outweigh the risks. It aims to manage the condition while minimizing potential complications safely.

• #71 A case series on abnormal placenta accreta spectrum in a rural tertiary care centre – IJOGR

  https://www.ijogr.org/html-article/15922

  Placenta accreta spectrum (PAS) is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. […] The etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leading to failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. […] The most accepted theory is that prior uterine surgery involving the endometrial-myometrial interface leading to defective decidualization in an area of uterine scar, allowing the anchoring villi of the placenta to adhere to the myometrium abnormally and further trophoblast invasion. […] The occurrence of invasive PAS (increta and percreta) may be due to uterine scar cracking partially or completely, which thereby allows the deeper invasion of placental villi(myometrium, serosa, and even beyond). […] The incidence of placenta accreta spectrum disorder with previous LSCS and placenta previa ranges from 0.24% to 0.57%. […] In our study, peripartum hysterectomy remains the main lifesaving procedure over conservative methods for PPH secondary to Abnormal Placental invasion.

• #72 Placenta accreta spectrum (PAS) — prenatal diagnosis and management. The Polish Society of Gynecologists and Obstetricians Guidelines | Huras | Ginekologia Polska

  https://journals.viamedica.pl/ginekologia_polska/article/view/101422

  The delayed consequences of PAS treatment include a need for repeated hospitalisation and additional surgical procedures, as well as the development of persistent psychosocial and emotional problems and deterioration in the quality of life. […] The risk can be reduced, both for a mother and for a foetus, by an early diagnosis and providing patients with specialist care at centres treating patients with pregnancy complicated by placenta accreta spectrum (PAS referral centres).

• #73 Placenta accreta spectrum (PAS) — prenatal diagnosis and management. The Polish Society of Gynecologists and Obstetricians Guidelines | Huras | Ginekologia Polska

  https://journals.viamedica.pl/ginekologia_polska/article/view/101422

  The delayed consequences of PAS treatment include a need for repeated hospitalisation and additional surgical procedures, as well as the development of persistent psychosocial and emotional problems and deterioration in the quality of life. […] The risk can be reduced, both for a mother and for a foetus, by an early diagnosis and providing patients with specialist care at centres treating patients with pregnancy complicated by placenta accreta spectrum (PAS referral centres).

• #74 Placenta Accreta: Symptoms, Risk Factors, & Treatment | University of Utah Health | University of Utah Health

  https://healthcare.utah.edu/womens-health/pregnancy-birth/placenta-accreta

  Placenta accreta is a pregnancy complication. It occurs when the placenta implants into scar tissue instead of healthy tissue in your uterine lining. […] The biggest risk factor for placenta accreta is a prior C-section. Any other surgery that could cause uterine scarring also increases your risk. […] Sometimes, we cant tell how deeply the placenta has grown until delivery. Its important to understand that placenta accreta is a spectrum that ranges from somewhat mild to complex to life-threatening. […] The standard treatment for placenta accreta is to deliver by C-section at 3436 weeks of pregnancy. Our goal is to avoid labor so you dont have heavy bleeding. […] Your treatment plan depends on several factors, including your preferences and whether conservative management is safe for you. Some people who experience heavy bleeding during pregnancy may not be good candidates for conservative management. When possible, however, conservative management can offer patients an alternative that may allow them to preserve their fertility. […] A placenta accreta diagnosis can have significant psychological effects. People with the condition often feel worried throughout their pregnancy. Its common to experience anxiety, depression, or post-traumatic stress after your delivery.

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