The incidence of abnormal placentation, includingplacenta accreta, increta and percreta, ranges from 1in 540 to 1 in 93,000 deliveries [1]. Placenta percreta isdefined as the penetration of trophoblastic tissue intothe myometrium or serosa of the uterus. Severe hem-orrhage may occur with attempts to manually separatethe placenta from the uterus following delivery. The in-creased frequency of cesarean delivery over the past twodecades has resulted in a greater incidence of abnormalplacentation as more women enter into subsequent pre-gnancies with a history of operative deliveries [2]. Thetreatment of abnormal placentation has evolved withtime. We report a case of placenta previa totalis andextensive percreta that was successfully managed withpreservation of the uterus.A 32-year-old woman, gravida 2, para 1, was referredto our hospital at 7 weeks of gestation for evaluation ofan asymptomatic pregnancy within a cesarean scar, asdemonstrated by ultrasound. She had a history of ce-sarean section with an incision in the lower uterine seg-ment. Termination of the pregnancy was recommended.However, the patient decided to continue the pregnancybecause of religious beliefs. The antenatal examinationswere unremarkable with the exception of intermittentpainless vaginal spotting. An ultrasound examinationat 27 weeks of gestation showed the absence of a nor-mal subplacental sonolucent layer and deep invasionof the anterior lower uterine segment by the placenta.Magnetic resonance imaging (MRI) at 32 weeks of ges-tation demonstrated that the placenta occupied theentire lower uterine segment with some obliteration ofthe uteroplacental interface and small serosal interrup-tions of the left posterior wall of the bladder withoutmucosal invasion (Figure 1). The findings were consistentwith a diagnosis of placenta percreta.A classical cesarean section was performed at 34+weeks of gestation, after ultrasound examination indi-cated an adequate fetal body weight. Angioemboli-zation catheters were placed bilaterally through thefemoral arteries on the morning of surgery. At laparot-omy, the previous cesarean scar was nearly completelydehiscent and involved the lower one-third of theuterus. The placenta was visualized beneath a paper-thinmembrane-like peritoneum covering the area of dehis-cence, and engorged blood vessels crossing throughthe membrane were noted (Figure 2). The fetus wasdelivered via breech extraction, and had Apgar scoresof 5 and 9 at 1 and 5 minutes, respectively. The placentawas not removed and was left in place. Immediatelyafter the infant was delivered, bilateral transarterialembolization of the internal iliac arteries using Gelfoamwas performed by radiologists present in the deliveryroom. The embolization technique was done as previ-ously described [3]. The amount of intraoperative bloodloss was approximately 2,000mL. The postoperative
