Review
Obstetrics
The “Great Obstetrical Syndromes” are associated with disorders of deep placentation

https://doi.org/10.1016/j.ajog.2010.08.009Get rights and content

Defective deep placentation has been associated with a spectrum of complications of pregnancy including preeclampsia, intrauterine growth restriction, preterm labor, preterm premature rupture of membranes, late spontaneous abortion, and abruptio placentae. The disease of the placental vascular bed that underpins these complications is commonly investigated with targeted biopsies. In this review, we critically evaluate the biopsy technique to summarize the salient types of defective deep placentation, and propose criteria for the classification of defective deep placentation into 3 types based on the degree of restriction of remodeling and the presence of obstructive lesions in the myometrial segment of the spiral arteries.

Section snippets

The study of the placental bed: the beginning

The study of the placental bed began in the late 1950s by 2 independent groups of investigators who used different biopsy techniques. Dixon and Robertson,9 working in Jamaica, obtained biopsy samples at the time of cesarean delivery with the use of biopsy forceps. At the time of hysterotomy, biopsy samples were obtained under direct visualization from the implantation site after delivery of the placenta. Using curved scissors, the investigators obtained a disk that was approximately 1 cm in

Spiral artery remodeling

After the physiological changes of the spiral arteries in the placental bed were identified, it was postulated that they resulted from the destructive action of trophoblast on the vascular musculature and the elastic membrane. However, it was soon observed that changes associated with trophoblast invasion were preceded by edema of the wall, disintegration of the elastic elements, and changes in smooth muscle cells, such as rounding of the nucleus, the loss of myofibrils and dense bodies, and

Obstetrical syndromes associated with defective deep placentation

More than 50 years after the original observations, it has become clear that disorders of deep placentation occur in a broader range of clinical complications of pregnancy than initially thought. This underscores the importance of this disorder because it is present in virtually every major obstetrical syndrome.

Comment

Defective deep placentation is associated with a spectrum of obstetrical syndromes that include preeclampsia, IUGR, preterm labor with intact membranes, preterm PROM, abruptio placentae, and spontaneous mid-trimester abortion. We propose that disorders of deep placentation are characterized by (1) the degree of restriction of physiologic transformation of the spiral arteries and (2) the presence of arterial lesions in the JZ myometrium of the placental bed.

The degree and extent of physiologic

Acknowledgments

We thank Giuseppe Benagiano and Jan J. Brosens for useful comments.

References (78)

  • A. King et al.

    Placental vascular remodeling

    Lancet

    (1997)
  • S.D. Smith et al.

    Evidence for immune cell involvement in decidual spiral arteriole remodeling in early human pregnancy

    Am J Pathol

    (2009)
  • R. Matijevic et al.

    Spiral artery blood flow in the central and peripheral areas of the placental bed in the second trimester

    Obstet Gynecol

    (1995)
  • M.W. Aardema et al.

    Uterine artery Doppler flow and uteroplacental vascular pathology in normal pregnancies and pregnancies complicated by pre-eclampsia and small for gestational age fetuses

    Placenta

    (2001)
  • M. Hanssens et al.

    Renin-like immunoreactivity in uterus and placenta from normotensive and hypertensive pregnancies

    Eur J Obstet Gynecol Reprod Biol

    (1998)
  • T.Y. Khong et al.

    On an anatomical basis for the increase in birth weight in second and subsequent born children

    Placenta

    (2003)
  • J.M. Roberts et al.

    The two stage model of preeclampsia: variations on the theme

    Placenta

    (2009)
  • T. Chaiworapongsa et al.

    Evidence supporting a role for blockade of the vascular endothelial growth factor system in the pathophysiology of preeclampsiaYoung Investigator Award

    Am J Obstet Gynecol

    (2004)
  • I. Brosens et al.

    The physiological response of the vessels of the placental bed to normal pregnancy

    J Pathol Bacteriol

    (1967)
  • I.A. Brosens et al.

    The role of the spiral arteries in the pathogenesis of preeclampsia

    Obstet Gynecol Annu

    (1972)
  • T.Y. Khong et al.

    Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small-for-gestational age infants

    BJOG

    (1986)
  • E. Ball et al.

    Late sporadic miscarriage is associated with abnormalities in spiral artery transformation and trophoblast invasion

    J Pathol

    (2006)
  • H.G. Dixon et al.

    A study of the vessels of the placental bed in normotensive and hypertensive women

    J Obstet Gynaecol Br Emp

    (1958)
  • M. Renaer et al.

    [Spiral arterioles in the decidua basalis in hypertensive complications of pregnancy.]

    Ned Tijdschr Verloskd Gynaecol

    (1963)
  • I. Brosens

    The placental bed [thesis]

    (1965)
  • J.D. Boyd et al.

    The human placenta

    (1970)
  • R. Pijnenborg et al.

    The pattern of interstitial trophoblastic invasion of the myometrium in early human pregnancy

    Placenta

    (1981)
  • S.C. Robson et al.

    Endovascular trophoblast invasion and spiral artery transformation: the ”two wave” theory revisited

    Placenta

    (2001)
  • E.P.Y. Kam et al.

    The role of trophoblast in the physiological change in decidual spiral arteries

    Hum Reprod

    (1999)
  • I. Brosens et al.

    The anatomy of the maternal side of the placenta

    J Obstet Gynaecol Br Cwth

    (1966)
  • G. Gerretsen et al.

    Morphological changes of the spiral arteries in the placental bed in relation to pre-eclampsia and fetal growth retardation

    BJOG

    (1981)
  • T. Frusca et al.

    Histological features of uteroplacental vessels in normal and hypertensive patients in relation to birthweight

    BJOG

    (1989)
  • J.W. Meekins et al.

    A study of placental bed spiral arteries and trophoblast invasion in normal and severe pre-eclamptic pregnancies

    BJOG

    (1994)
  • S. Sagol et al.

    The comparison of uterine artery Doppler velocimetry with the histopathology of the placental bed

    Aust N Z J Obstet Gynaecol

    (1999)
  • K. Guzin et al.

    The relation of increased uterine artery blood flow resistance and impaired trophoblast invasion in pre-eclamptic pregnancies

    Arch Gynecol Obstet

    (2005)
  • J. Espinoza et al.

    Normal and abnormal transformation of the spiral arteries during pregnancy

    J Perinat Med

    (2006)
  • W.B. Robertson et al.

    The pathological response of the vessels of the placental bed to hypertensive pregnancy

    J Pathol Bacteriol

    (1967)
  • I. Brosens et al.

    Fetal growth retardation and the arteries of the placental bed

    BJOG

    (1977)
  • P.M. Zeek et al.

    Vascular changes in the decidua associated with toxemia of pregnancy

    Am J Clin Pathol

    (1950)
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    Supported, in part, by the Division of Intramural Research of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health/Department of Health and Human Services.

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