Tikkanen et al. Journal of Medical Case Reports 2011, 5:418 http://www.jmedicalcasereports.com/content/5/1/418 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Placenta previa percreta left in situ - management by delayed hysterectomy: a case report Minna Tikkanen, Vedran Stefanovic and Jorma Paavonen* Abstract Introduction: Placenta percreta is an obstetric emergency often associated with massive hemorrhage and emergency hysterectomy. Case presentation: We present the case of a 30-year-old African woman, gravida 7, para 5, with placenta percreta managed by an alternative approach: the placenta was left in situ, methotrexate was administered, and a delayed hysterectomy was successfully performed. Conclusions: Further studies are needed to develop the most appropriate management option for the most severe cases of abnormal placentation. Delayed hysterectomy may be a reasonable strategy in the most severe cases. Introduction Placenta accreta (PA) is characterized by abnormal inva- sion of the placenta into the myometrium. PA is defined as superficial invasion, placenta increta as middle layer invasion and placenta percreta as deep invasion, which is the most severe form of PA with an incidence of one in 7000. All three types are collectively known as pla- centa accreta. The incidence of PA has dramatically increased due to increasing Caesarean section rates [1,2]. Although rare, PA is one of the most severe preg- nancy complications. Maternal morbidity and mortality associated with PA is mainly caused by massive obstetric hemorrhage or emergency hysterectomy, and PA is often diagnosed during delivery or immediately post- partum leading to an obstetric emergency [1,3,4]. Stu- dies suggest that antenatal diagnosis may reduce obste- tric hemorrhage-related morbidity [5,6]. Furthermore, in some cases a morbidly adherent PA can be left in situ [7,8]. Such conservative management may allow delayed removal of the placenta to avoid massive hemorrhage during an attempted forced removal of the adherent pla- centa. We describe a case in which placenta percreta * Correspondence: jorma.paavonen@hus.fi Helsinki University Hospital, Department of Obstetrics and Gynecology, Helsinki, Finland was left in situ. Subsequent post-partum hemorrhage was successfully managed by delayed hysterectomy. Case presentation Our patient was a 30-year-old African woman, gravida 7, para 5. Her second screening ultrasound at 21 weeks of gestation showed normal fetal anatomy and placenta previa. She was referred in her 28th gestational week from her antenatal clinic to the University Hospital Out- patients Maternity Clinic because of anemia and mild thrombocytopenia. The first suspicion of placenta accreta or percreta based on pathological ‘storm flow’ on Doppler ultrasound was raised at 29 gestational weeks (Figure 1). Severe placenta accreta was confirmed at 35 gestational weeks both by ultrasonography and MRI. As a premature elective delivery was anticipated, she underwent amniocentesis during the same examina- tion. Her amniotic fluid erythropoietin level was normal and her amniotic fluid lamellar body count was 3, con- sistent with an immature fetal lung maturity profile. Intra-muscular betamethasone was administered using two standard doses of 12 mg 24 hours apart. An elective Caesarean section was performed 10 days later (Figure 2) with simultaneous tubal ligation. The weight of the healthy newborn boy was 3.1 kg. The Caesarean section was performed under general anesthesia due to mild © 2011 Tikkanen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.