Delayed Catastrophic Uterine Rupture in a Subsequent Pregnancy After Expectant Management of Placenta Accreta Spectrum

Placenta accreta spectrum (PAS) is a serious obstetric disorder involving abnormal placental attachment to the uterine wall and is associated with substantial maternal risk. While cesarean hysterectomy remains the standard treatment, conservative management approaches are emerging as alternatives. Minimal data is currently available regarding the long-term complications of conservative management. We present a case of a patient with a history of conservatively managed PAS who presented 14 years later during a subsequent pregnancy with fundal uterine rupture in the second trimester, highlighting the potential long-term risks associated with uterine sparing approaches. A 39-year-old gravida 6 para 5003 woman presented at 26 weeks of gestation with acute abdominal pain and no fetal cardiac activity. Her history was notable for five prior cesarean deliveries, including a classical cesarean in her G4 pregnancy complicated by PAS. In that pregnancy, she underwent multidisciplinary conservative management, including classical cesarean delivery with the placenta left in situ and uterine artery embolization. Her postoperative course was uncomplicated, with successful uterine preservation. In her G6 pregnancy, due to concern for uterine rupture, decision was made to proceed with stat cesarean section. Upon entry into the abdominal cavity, she had experienced a fundal uterine rupture with complete placental separation. The site of the uterine rupture was able to be repaired, and the uterus was left in situ. This case demonstrates that even when conservative, uterine-sparing management of PAS is pursued with careful patient selection and multidisciplinary planning, adverse outcomes can still occur. It highlights the need for long-term surveillance and further research to clarify the risks, outcomes, and reproductive implications of fertility-preserving approaches.