Case notes
A 33-year-old woman, 5 days into week 17 of her sixth pregnancy was treated in the Emergency Department with heavy vaginal bleeding. Placenta accreta had already been suspected based on a 15-week ultrasound image ( Figure 1 ). Her obstetric history included 2 term births, 2 preterm births, and 1 induced abortion or miscarriage; she had 4 living children. Three of her previous deliveries were by cesarean delivery.
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Conclusions
The patient’s condition was stabilized; after prognostic counseling, she opted for pregnancy termination. Her initial desire for future fertility led to a discussion regarding the safest option: dilation and evacuation (D&E), planned placental retention, or gravid hysterectomy. Magnetic resonance imaging, which was obtained for surgical planning, showed thinning of the lower uterine segment and likely placental accreta/increta ( Figure 2 ). This discovery altered the treatment plan, and she underwent a total gravid hysterectomy with a finding of uterine dehiscence at the time of bladder flap dissection ( Figure 3 ). The pathology report confirmed complete placenta previa and percreta. The patient recovered without incident.
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