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Placenta accreta spectrum

Nature Reviews Disease Primers volume 11, Article number: 40 (2025) Cite this article

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Abstract

Placenta accreta spectrum is an increasingly common placental-related disorder diagnosed at birth when the placenta cannot be fully detached manually from the uterine wall, often requiring a surgical removal. Following a worldwide increase in caesarean delivery rates, more than 90% of cases are now found in patients with a history of caesarean delivery and an anterior low-lying placenta or a placenta previa. Accreta placentation is not a consequence of an inherently more aggressive cancer-like trophoblast but of a loss of the normal physiological cell signalling and physical regulatory mechanisms in the scar tissue, with higher-than-normal maternal blood velocity entering the intervillous space of the placenta, distortion of the corresponding lobules and a loss of the physiological site of detachment from the uterine wall. If unsuspected at the time of delivery, attempts to manually remove accreta tissue are often associated with major and sometimes uncontrollable bleeding. Patients with a high probability of placenta accreta spectrum at birth can be generally identified by prenatal ultrasonography, permitting management by a multidisciplinary team. Owing to the high risk of intraoperative and postpartum haemorrhage and damage to other pelvic organs, placenta previa accreta presents a management challenge, particularly in healthcare systems with limited resources. Involving the pregnant patient and their family in preparation for delivery reduces psychological morbidity associated with complex obstetric surgery. Standardized reporting protocols are essential to develop new management strategies. Further research is required to characterize the complex cellular changes at the uteroplacental interface in placenta accreta spectrum.

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Fig. 1: Placenta accreta spectrum classification.
Fig. 2: Accreta placentation is driven by villous development inside a myometrial scar.
Fig. 3: Placentation in the lower uterine segment scar areas of a previous caesarean delivery.
Fig. 4: Intraoperative view of the lower uterine segment at 36 weeks of gestation in a pregnancy that has been complicated by placenta accreta spectrum.
Fig. 5: Preoperative transabdominal ultrasonography of the lower uterine segment at 36 weeks of gestation in a pregnancy that has been complicated by placenta accreta spectrum at birth.
Fig. 6: Management algorithm for PAS.

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Authors and Affiliations

  1. EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, UK

    Eric Jauniaux

  2. Division of Developmental Biology and Medicine, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester and Maternal and Fetal Health Centre, St Mary’s Hospital, Manchester, UK

    John D. Aplin & Carolyn J. P. Jones

  3. Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Karin A. Fox

  4. Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA

    Yalda Afshar

  5. Department of Obstetrics and Gynecology, Kasr Al Ainy School of Medicine, University of Cairo, Cairo, Egypt

    Ahmed M. Hussein

  6. Loke Centre for Trophoblast Research, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK

    Graham J. Burton

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  1. Eric Jauniaux
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  2. John D. Aplin
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  3. Karin A. Fox
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  6. Carolyn J. P. Jones
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Contributions

Introduction (E.J., J.D.A. and C.J.P.J.); Epidemiology (E.J. and A.M.H.); Mechanisms/pathophysiology (J.D.A., E.J., Y.A., C.J.P.J. and G.J.B.); Diagnosis, screening and prevention (E.J., Y.A. and A.M.H.); Management (K.A.F., A.M.H. and E.J.); Quality of life (K.A.F.); Outlook (E.J. and K.A.F); overview of the Primer (E.J. and G.J.B.).

Corresponding author

Correspondence to Eric Jauniaux.

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Competing interests

Y.A. is funded by the Burroughs Wellcome Fund, the Society for Maternal Fetal Medicine/American Association of Obstetricians and Gynecologist Foundation, and the Reproductive Scientist Development Program by the Eunice Shriver National Institute of Child Health and Development. The other authors declare no competing interests.

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Nature Reviews Disease Primers thanks D. A. Carusi, S. L. Collins, S. Matsubara, S. Miller and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Caesarean delivery

A surgical technique used to deliver one or more babies through an incision of the uterine wall.

Caesarean scar defect

(CSD). A defect of the myometrium that develops following incomplete closure of the incision of caesarean section.

Caesarean scar ectopic pregnancy

(CSEP). The development of a pregnancy following the implantation of the blastocyst inside a CSD.

Cytotrophoblast

The progenitor cells forming the inner layer of the trophoblast epithelium of the placental villus and the cell columns that anchor placental villi to the decidua.

Decidua

The transformed endometrial layer during pregnancy, which provides nutrition support to the early placenta and fetus and regulates trophoblast migration.

Extravillous trophoblast

(EVTs). Differentiated trophoblastic cells that detach from cytotrophoblast columns of the anchoring villus and migrate through the decidua down to the inner third of the myometrium.

Lower uterine segment

(LUS). A part of the uterus between the cervix and the thicker upper uterine segment that undergoes circumferential dilatation during labour.

Placenta increta

A placenta with one or more lobule(s) where the villous tissue is abnormally attached inside a myometrial scar area of the uterine wall.

Placental lobules

The globular arrangement of placental villi centred over the opening of a spiral artery.

Placenta previa

The placenta developing inside the LUS with the lower placenta edge <2 cm from the internal os of the uterine cervix at any gestation after 16 weeks.

Residual myometrial thickness

The thickness of the uterine wall of a CSD between the placenta and the serosa of the uterus.

Spiral arteries

The terminal arterial branches of the uterine arteries which vascularize the endometrium during the menstrual cycle and supply blood to the intervillous space of the placenta during the second and third trimesters of pregnancy.

Uterine atony

An obstetric complication characterized by the failure of the uterus to contract effectively after childbirth.

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Jauniaux, E., Aplin, J.D., Fox, K.A. et al. Placenta accreta spectrum. Nat Rev Dis Primers 11, 40 (2025). https://doi.org/10.1038/s41572-025-00624-3

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