Tikkanen et al. Journal of Medical Case Reports 2011, 5:418 http://www.jmedicalcasereports.com/content/5/1/418 Caesarean section scar Prominent isthmic portion of uterus Figure 4 Uterine findings during laparotomy. Note Caesarean section scar at uterine fundus and bulging isthmic part with placenta accreta/percreta. Discussion PA causes considerable maternal morbidity and mortal- ity and is the major indication for emergency peri-par- tum hysterectomy. Antenatal confirmation of PA diagnosis is often difficult [3,9,10]. The management is usually an elective cesarean delivery and hysterectomy, Placenta accreta Figure 5 Hysterectomy specimen opened. Note placenta previa percreta left in situ. Page 3 of 4 Placenta Myometrium Figure 6 Histopathological specimen consistent with placenta percreta (magnification 40 ×). but this approach often causes massive hemorrhage and may cause injury of adjacent organs due to the morbidly adherent placenta [8]. Delayed trans-vaginal removal of the placenta has also been described [11]. Some studies suggests that leaving placenta in situ lowers the risk for subsequent hysterectomy and may hence be an option in cases when emergency hysterectomy is considered too risky or fertility needs to be preserved [7,8,12]. We describe a severe case of PA histopathologically defined as placenta percreta in which the placenta was left in situ. Subsequently, our patient had multiple emer- gency room visits and ultimately developed severe post- partum hemorrhage leading to delayed emergency hys- terectomy. This case suggests that in some cases with placenta accreta and percreta, leaving placenta in situ may be an alternative management option allowing delayed hysterectomy. This management option may be safer than primary hysterectomy since delayed hysterect- omy may be easier to perform than emergency hysterect- omy immediately post-partum (due to placental involution and decreased uterine vascularity). We are currently developing a management algorithm for women with an antenatal diagnosis of placenta percreta in which the placenta is left in situ, combined with par- enteral methotrexate and elective delayed hysterectomy (although methotrexate is not used in all maternal-fetal centers in such clinical situations). This is justified based on our experience of other cases of placenta accreta in which the placenta was left in situ. Total placental invo- lution with no complications occurred in only one out of five such cases with the placenta left in situ. Conclusions Placenta percreta is an obstetric emergency often asso- ciated with massive hemorrhage leading to emergency