Transformation of spiral arteries during pregnancy: pathogenic parallels between preeclampsia and placenta accrete spectrum

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Abstract

Introduction. Spiral artery transformation is a key physiological process of pregnancy that establishes low-resistance uteroplacental blood flow. It involves trophoblast invasion of the vascular wall, replacement of the endothelium, and disruption of the smooth muscle layer, resulting in dilated vessels that lose vasomotor control. Abnormalities of this process have traditionally been associated with preeclampsia; however, current evidence indicates a more complex and heterogeneous pathogenesis. Altered pathways of trophoblast invasion and its interactions with vessels of the uteroplacental region are also of major importance in placenta accreta spectrum (PAS).

Objective. To analyze and compare current evidence on the mechanisms of spiral artery transformation, patterns of trophoblast invasion, and shared pathogenetic pathways in preeclampsia and PAS.

Material and methods. An analytical review of published scientific data on physiological and pathological spiral artery remodeling, molecular mechanisms of trophoblast invasion, angiogenic imbalance, hypoxia, inflammatory responses, matrix metalloproteinase expression, and cell adhesion molecules in preeclampsia and PAS was performed. Morphological, molecular, and pathogenetic findings were comparatively synthesized.

Results. Impaired spiral artery transformation is an important but non-universal mechanism of preeclampsia and appears to be predominantly associated with specific disease phenotypes. In PAS, the absence or deficiency of decidual cells plays a key role, disrupting the physiological regulation of trophoblast invasion and altering the direction of trophoblast cell spread. Under these conditions, trophoblast cells may spread through the myometrium and invade the vascular wall from the adventitial side. Preeclampsia and PAS share several pathogenetic pathways, including hypoxia, disturbances in angiogenic balance, altered expression of matrix metalloproteinases and cell adhesion molecules, and activation of proinflammatory responses. However, trophoblast functional status differs between these conditions: preeclampsia is associated with trophoblast dysfunction, injury, and shedding, whereas in PAS a relatively preserved trophoblast, in the setting of absent or deficient decidual cells, may spread in an unregulated manner into the myometrium.

Conclusion. Preeclampsia and PAS represent distinct clinical and morphological patterns of disturbed interactions among trophoblast, decidual cells, and vessels of the uteroplacental region. Despite differences in the direction and morphological manifestations of invasion, shared molecular and pathogenetic mechanisms support consideration of these conditions within a broader concept of abnormal trophoblast invasion. Further investigation of spiral artery transformation and trophoblast phenotypic plasticity may improve understanding of disease mechanisms and contribute to more accurate diagnosis of placenta-associated pregnancy complications.

About the authors

Natalia V. Nizyaeva

FSBSI “Petrovsky National Research Center of Surgery”

Author for correspondence.
Email: niziaeva@gmail.com
ORCID iD: 0000-0001-5592-5690
SPIN-code: 9893-2630

Head of the Reproduction Pathology Laboratory Research Institute of Human Morphology named after Academician A.P. Avtsyn; Doctor of Medical Sciences

Russian Federation, Abrikosovskiy per., 2, Moscow, 119435

Ekaterina R. Milyutina

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: milyutina.kate@mail.ru
ORCID iD: 0000-0003-2701-0607

Оbstetrician, Pregnancy Pathology Department

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

Marina R. Makhmutova

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: basimova_m@mail.ru
ORCID iD: 0009-0003-6905-6539

Оbstetrician, Pregnancy Pathology Department

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

Elena N. Plakhotina

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: Enp2004@inbox.ru
ORCID iD: 0000-0002-6793-2318
SPIN-code: 4995-4590

Head of the Department of Anesthesiology and Resuscitation, Professor of the Department of Anesthesiology and Resuscitation. Doctor of Medical Sciences

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

Tatyana V. Fokina

FSBSI “Petrovsky National Research Center of Surgery”

Email: tatyana-doc-6@mail.ru
ORCID iD: 0000-0002-2467-7660
SPIN-code: 7107-3500

Senior Researcher of the Laboratory of Reproduction Pathology, Avtsyn research institute of human morphology; Candidate of Medical Sciences

Russian Federation, Abrikosovskiy per., 2, Moscow, 119435

Nataliia A. Gabitova

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: gabitova_nataliya@mail.ru
ORCID iD: 0000-0003-2278-2624
SPIN-code: 4812-3600

Obstetrician-gynecologist, Department of Pregnancy Pathology, State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”; Professor, Department of Obstetrics and Gynecology, Academy of Postgraduate Education, FSBI “Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies of the Federal Medical and Biological Agency of Russia”. Doctor of Medical Sciences

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

Yaroslav I. Adamov

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: Kapral92@mail.ru
ORCID iD: 0009-0004-8063-9783

anesthesiologist-resuscitator of the Department of Anesthesiology and Resuscitation

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

Tamara N. Belousova

State Budget Healthcare Institution of Moscow Region “Vidnovsky Perinatal Center”

Email: Beltamara1@mail.ru
ORCID iD: 0000-0003-3804-7691

Chief Physician; Candidate of Medical Sciences

Russian Federation, Zavodskaya street, 17, Vidnoe, Leninsky district, Moscow region, 142700

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