Uterine Preservation Following Catastrophic Hemorrhage From an Undiagnosed First-Trimester Placenta Increta: A Case Report and Review of the Literature

Placenta accreta spectrum (PAS) in the first trimester is a rare but potentially fatal condition. Preoperative diagnosis during early pregnancy remains extremely challenging, particularly in individuals with a previous cesarean delivery. We describe the case of a 35-year-old woman (gravida 3, para 2) with two prior cesarean deliveries who presented at eight weeks of gestation for the management of a missed abortion. Despite her high-risk status, PAS was not suspected on initial ultrasound. Medical induction with misoprostol resulted in sudden massive hemorrhage and hemorrhagic shock 12 hours later. An emergency dilation and curettage (D&C) was unsuccessful in controlling the bleeding. The patient was stabilized with immediate exploratory laparotomy, which revealed a 4 × 4 cm placenta increta. Hemostasis was achieved through bilateral internal iliac and uterine artery ligation, excision of the placental mass, and repair of the uterine defect, allowing for uterine preservation and a smooth postoperative course. This report underscores the significant risk of catastrophic hemorrhage from previously unrecognized PAS in patients with prior cesarean deliveries and highlights a critical diagnostic gap in early pregnancy care. It demonstrates that while fertility-sparing surgery is achievable with rapid intervention, greater emphasis should be placed on prevention through enhanced preoperative risk assessment and optimized imaging protocols for high-risk patients.