Jauniaux, E; Hecht, JL; Elbarmelgy, RA; Elbarmelgy, RM; Thabet, MM; Hussein, AM; (2022) Searching for placenta percreta: a prospective cohort and systematic review of case reports. American Journal of Obstetrics and Gynecology , 226 (6) 837.e1-837.e13. 10.1016/j.ajog.2021.12.030.

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Abstract

BACKGROUND: Placenta percreta is described as the most severe grade of placenta accreta spectrum (PAS) and accounts for a quarter of all cases of PAS reported in the literature. OBJECTIVE: We investigated the hypothesis that placenta percreta which has been described clinically as placental tissue invading through the full thickness of the uterus, is a heterogeneous category with most cases due to primary or secondary uterine abnormality rather than an abnormally invasive form of placentation. STUDY DESIGN: We have evaluated the agreement between the intra-operative findings using the International Federation of Gynecology and Obstetrics (FIGO) classification with the postoperative histopathology diagnosis in a prospective cohort of 101 consecutive singleton pregnancies presenting with a low-lying/placenta previa, a history of at least one prior cesarean delivery (CD) and ultrasound signs suggestive of PAS. A systematic literature review of case reports of placenta percreta which included histopathologic findings and gross images was also performed. RESULTS: Samples for histologic examination were available in 80 out of 101 cases of the cohort which were managed by hysterectomy or partial myometrial resection. Microscopic examination showed evidence of PAS in 65 cases (creta n= 9; increta n=56) of these cases. Observer A and observer B graded as percreta 44 (43.5%) and 54 (53.5%) of the 101 cases included in the cohort, respectively. There was a moderate agreement between observers. Eleven out of the 36 cases that showed no evidence of abnormal placental attachment at delivery and/or microscopic examination were classified as percreta by both observers. The systematic literature review identified 41 case reports of placenta percreta with gross images and the presenting symptomatology suggesting that the majority of these cases were the consequence of a uterine rupture. The microscopic descriptions were heterogeneous and all demonstrated histology of placenta creta rather than percreta. CONCLUSION: Our study supports the concept that placenta accreta is not an invasive disorder of placentation, but the consequence of a primary or secondary uterine pathology and found no histologic evidence supporting the existence of a condition where the villous tissue penetrates the entire uterine wall including the serosa and beyond.

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