American Journal of Obstetrics and Gynecology vol:187 issue:5 pages:1416-23
Deep placentation in the human requires physiologic transformation of the spiral arteries into uteroplacental vessels. This process involves the inner myometrial segment (junctional zone) of the spiral arteries and is effected by trophoblast invasion of the vessel wall, resulting in complete loss of the arterial structure and deposition of fibrinoid and fibrous tissues. Absent or inadequate physiologic changes in the junctional zone spiral arteries limits placental blood flow in pregnancies complicated by preeclampsia and fetal growth restriction. The cause of defective deep placentation is still unknown, although it is often attributed to impaired trophoblast function and migration. However, trophoblast invasion is preceded by decidual remodeling of maternal tissues, a process that is initiated in the endometrium but extends into the junctional zone. This review examines the mechanisms that control decidualization and subsequent trophoblast invasion in normal and abnormal pregnancies. The possibility that disruption of the decidual process in the secretory phase of the menstrual cycle triggers a cascade of events resulting in failed deep placentation is explored.