ABSTRACT The association between etio-pathogenesis of morbidly adherent placenta (MAP) or placenta cretas and adenomyosis has never been described in medical literature. Contrary to the believe that MAP is due to direct invasion of trophoblastic tissues into the adjacent normal myometrium due to prior uterine surgeries, this article describes how pre-existence of adenomyosis acts as a precursor for the development of placenta cretas. It elucidates how prior uterine traumas such as surgeries, repeated childbirths and endometritis cause endometrial tissues to invade the myometrium as a result of disruption of decidua basalis. The invaded endometrial tissues cause hyper-plasia and hypertrophy of surrounding myometrium to form the clinical entity called adenomyosis. The over-expression of bcl-2 oncogene in the endometrium causes inhibition of apoptosis of endometrial cells removing the barrier of trophoblastic tissues to invade the myometrium to form MAP. This hypothesis is based on the similarity of their clinical perspectives, similar pathological description of the two disease entities and their common molecular components. Both diseases increase with age; more in women older than 35 years and also in those with history of previous endometrial traumas such as surgeries, childbirth and endometritis. Both diseases also share common pathological factors and molecular components due to absence of deciduas basalis and over-expression of bcl-2 oncoprotein gene, inhibition of cell apoptosis and failure to find genetic abnormalities such as mutations of K-ras, P53 or LOH. An ongoing study looking at uterine specimens from cesarean hysterectomies and pelvic MRI evaluation of patients with retained placentas to prove that pre-existing adenomyosis may be a precursor to the development of morbidly adherent placenta is near to conclusion.
Cite this paper
Enakpene, C. and Muneyyirci-Delale, O. (2012) Association between etiopathogenesis of morbidly adherent placenta and adenomyosis. Open Journal of Obstetrics and Gynecology, 2, 321-324. doi: 10.4236/ojog.2012.23067.
 Rokitansky, K. (1860) Ueber uterus-neubildung. Aerzte zu Wien Ztschr K Gesellsch, 16, 577.
 Von Recklinghausen, F. (1896) Die adenomyoma die uterus und tuberwandung ihne abkunft von resten des wolffschen korpeus. August Hirschwald, Berlin.
 Atzori, E., Tronci, C. and Sionis, L. (1996) Transvaginal ultrasound in the diagnosis of diffuse adenomyosis. Gynecologic and Obstetric Investigation, 42, 39-41.
 Vercellini, P., Cortesi, I., De Giorgi, O., et al. (1998) Transvaginal ultrasound versus uterine needle biopsy in the diagnosis of diffuse adenomyosis. Human Reproduction, 13, 2884-2887. doi,10.1093/humrep/13.10.2884
 Ascher, S.M., Arnold, L.L., Patt, R.H., et al. (1994) Adenomyosis, prospective comparison of MRI and trans-vaginalsonography. Radiology, 190, 803-806.
 Bazot, M., Darai, E., Rouger, J., et al. (2002) Limitations of transvaginalsonography for diagnsosis of adenomyosis with histopathological correlation. Ultrasound in Obstetrics & Gynecology, 20, 605-611.
 Benson, R.C. and Sneeded, V.D. (1958) Adenomyosis, a reappraisal of symptomatology. American Journal of Obstetrics & Gynecology, 76, 1044-1061.
 Vercellini, P., Ragni, G., Trespidi, L., et al. (1993) Adenomyosis, a deja vu? Obstetrical & Gynecological Survey, 48, 789-794. doi,10.1097/00006254-199312000-00004
 MCelin, T.W. and Bird, C.C. (1974) Adenomyosis of the uterus. Obstetrics and Gynecology Annual, 3, 425.
 Owolabi, T.O. and Strickler, R.C. (1977) Adenomyosis a neglected diagnosis. Obstetrics & Gynecology, 50, 424-427.
 Pavlik, R.M. (1995) Adenomyosis, an ignored uterine disease. Nursing Practitioner, 20, 32-43.
 Plater, F. (1937) Quoted in Surgery. Obstetrics & Gynecology, 64, 178.
 Gielchinsky, Y., Rojansky, N., Faouliotis, S.T. and Ezra, Y. (2002) Placenta accrete-summary of 10 years, a survey of 310 cases. Placenta, 23, 210-214.
 ACOG committee on obstetric practice (2002) ACOG committee opinion number 266 January 2002, placenta accrete. Obstetrics & Gynecology, 99, 169-170.
 Morken, N.H. and Henriksen, H. (2001) Placenta percreta two cases and review of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology, 100, 112-115. doi,10.1016/S0301-2115(01)00422-5
 Benirschke, K. and Kaufmann, P. (2000) Pathology of the human placenta. 4th Edition, Springer, New York.
 Thompson, J.R. and Davion, R.J. (1986) Adenomyosis of the uterus, an enigma. Journal of the American Medical Association, 78, 305-307.
 Panganamamula, U.R., Harmanli, O.H., Isik-Akbay, E.F., et al. (2004) Is prior uterine surgery a risk factor for adenomyosis? Obstetrics & Gynecology, 104, 1034-1038.
 Matsumoto, Y., Iwasaka, T., Yamasaki, F. and Sugimori, H. (1999) Apoptosis and ki-67 expression in adenomyotic lesions and the corresponding eutopic endometriosis. Obstetrics & Gynecology, 94, 71-77.
 Miller, D.A., Chollet, J.A. and Goodwin, T.M. (1997) Clinical risk factors for placenta previa-placenta accreta. American Journal of Obstetrics & Gynecology, 177, 210-214. doi,10.1016/S0002-9378(97)70463-0
 Tantbirojn, P., Crum, C.P. and Parast, M.M. (2008) Pathophysiology of placenta creta, the role of decidua and extravilloustrophoblast. Placenta, 29, 639-645.
 Kong, T.Y. and Abdul Rahman, H. (1997) Bcl-2 expression delays postpartum involution of pregnancy-induced vascular changes in the human placenta bed. International Journal of Gynecological Pathology, 16, 138-142.
 Ueki, K., Kumagai, K., et al. (2004) Expression of apoptosis related protein in adenomyotic uteri treated with danazol and GnRh agonists. International Journal of Gynecological Pathology, 23, 248-258.
 Rabinovici, J. and Stewart, E.A. (2006) New interventional techniques for adenomyosis. Best Practice and Research Clinical Obstetrics and Gynecology, 20, 617-636.
 Muneyyirci-Delale, O., Chandrareddy, A., Battala, N., et al. (2008) Norethindrone acetate in the medical management of adenomyosis. Obstetrics and Gynecology, 111, 29S.