From Etiopathology to Management of Accreta Placentation

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

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.

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.