Tikkanen et al. Journal of Medical Case Reports 2011, 5:418 http://www.jmedicalcasereports.com/content/5/1/418 Page 2 of 4 Placenta Storm flow Figure 1 Ultrasonography findings at gestational week 29 consistent with placenta accreta. thrombocytopenia. A classical uterine incision was used for extraction of the fetus in order to avoid the morbidly adherent low placenta. The internal iliac arteries were catheterized pre-operatively via insertion of balloons to decease peri-operative bleeding. The placenta was left in situ because of placenta previa with severe placenta per- creta. Bilateral uterine artery embolization was per- formed. The total amount of blood loss during the Caesarean section was 300 mL. Our patient then received a single 100 mg dose of intra-muscular metho- trexate. She recovered uneventfully with no complica- tions, and was discharged on the seventh day post- partum. She received prophylactic metronidazole and cephalosporin orally for five days. Our patient returned to the emergency room the next day because of low Placenta Uterus abdominal pain. Her C-reactive protein (CRP) concen- tration was 45 g/L. A pelvic examination showed no sig- nificant findings. She again returned to the emergency room a week later because of recurrent low abdominal pain. Her CRP level was 20 g/L and chorionic gonado- tropin (hCG) concentration was 1828U. Serial periodic serum hCG levels decreased from 1492U to 848U to 562U to 200U over the first four weeks, respectively. Her total intra-uterine placental volume was measured by repeat ultrasound examinations. The placenta shrunk from 900 cm3 on the first examination to 630 cm3 and then to 319 cm3 over four weeks (Figure 3). Ultrasound examination at four weeks showed necrotic areas within the placenta left in situ with heavily vascularized areas next to the bladder and a strong storm flow phenom- enon. Our patient again returned to the emergency room three weeks later (seven weeks from the Caesar- ean section) because of heavy uterine bleeding. Her gen- eral condition was satisfactory, and she received three units of red blood cells and was hospitalized at this time. Her bleeding continued, became more profuse and her condition became unstable, so a decision to perform an emergency laparotomy was made. A laparotomy with emergency hysterectomy was then performed. Her uterus was still relatively large with prominent and bul- ging isthmic portion (Figure 4). The total blood loss during the hysterectomy was 3.7 L. Her uterus was filled by hematoma and placenta previa with deep myometrial invasion (Figure 5). A histopathological examination showed placenta percreta with chorioamnionitis, dilated blood vessels and incomplete involution of the uterus (Figure 6). Our patient recovered uneventfully. She was discharged on the fifth post-operative day in good condition. Figure 2 Operative findings during Caesarean section. Note placenta previa associated with placenta accreta suggestive of placenta percreta. Figure 3 Ultrasonographic findings of placenta accreta left in situ with measurements to estimate the total volume during follow-up.