Understanding decidual vasculopathy and the link to preeclampsia: A review

Preeclampsia is the archetype of a spectrum of clinical disorders related to abnormal placental development or function, characterized by placental histological lesions. Among those lesions, decidual vasculopathy is a term used to describe lesions of maternal spiral arteries, which are encountered on placental examination in about half of the women with preeclampsia. The morphological features of the lesions include perivascular lymphocytic infiltration, fibrinoid necrosis and foam cell incorporation within the vessel wall. Due to the resemblance of the latter characteristic to atherosclerosis, they are alternatively termed acute atherosis. Decidual vasculopathy correlates with worse maternal and neonatal outcomes, as well as placental pathology. In this article, we review the available literature on decidual vasculopathy and address the pitfalls in histological analysis of the lesions, including the varying definitions of the lesions and sample collection methods. We also discuss the current evidence on the etiology of the lesions and propose a novel hypothesis linking the three etiological pathways to the formation of decidual vasculopathy and, ultimately, the emergence of the heterogeneous group of placental dysfunction disorders, known as the great obstetric syndromes. •Decidual vasculopathy are lesions of maternal spiral arteries consisting of perivascular lymphocytic infiltration, fibrinoid necrosis and foam cells, which are present in about half of the woman with preeclampsia.•Decidual vasculopathy is underestimated with current protocols of placental analysis.•Decidual vasculopathy is potentially initiated by an immunological mismatch, resulting in perivascular lymphocytic infiltration of spiral arteries.•The presence of additional maternal factors (e.g. abnormal cardiovascular profile) or placental factors (abnormal spiral artery remodeling) determines the development of the additional morphological features of decidual vasculopathy.•The intertwined triad of maternal, fetal and placental factors culminate into clinical disease.