Occult placenta accreta: the missing link in the diagnosis of abnormal placentation

Placenta creta (accreta, increta, or percreta) is a clinically symptomatic condition, usually diagnosed histologically on hysterectomy specimens. At a minimum, focal absence of decidua is the histological finding for this condition; however, excessive amounts of extravillous trophoblasts were recently documented on hysterectomy specimens. The histological finding of basal plate myometrial fibers (BPMF) without intervening decidua in spontaneously delivered placentas, which we term occult placenta accreta (OPA), is not infrequent, even in clinically asymptomatic cases. To prove that OPA is a missing link between normal placental implantation and clinical placenta accreta, CD146 immunohistochemical stains were performed on 25 sections of OPA (study group) and 25 placental sections without BPMF (control group). Implantation-site intermediate trophoblast (ISIT) cell number, thickness, and density were compared between the study and control groups. The ISIT micrometry thickness and cell number at BPMF sites were statistically significantly higher in OPA than in control group and same OPA placentas away from BPMF. There were no statistically significant differences in ISIT density. Therefore, although asymptomatic, OPA features the same histopathology as clinical placenta accreta and may share same pathogenesis, which may include decidual deficiency, abnormal trophoblast/decidua interaction, and/or hypoxia.