Author: Bouchra Chahboun, et al.
Cureus, June 22, 2026
Placenta percreta is the most severe form of placenta accreta spectrum, with placental tissue extending through the uterine wall and potentially invading adjacent organs, most commonly the bladder. It can cause catastrophic hemorrhage, shock, organ injury, emergency hysterectomy, and maternal death.
This case describes a 34-year-old woman with a twin pregnancy and two previous cesarean deliveries who underwent emergency cesarean delivery at 25 weeks. Placenta accreta spectrum was suspected on admission, but the degree of invasion was substantially underestimated before surgery. Full-thickness bladder invasion was discovered intraoperatively, and the procedure was complicated by massive hemorrhage and asystolic cardiac arrest.
Patient presentation
The patient presented in active preterm labor with a dichorionic-diamniotic twin pregnancy.
Important risk factors included:
• Two previous cesarean deliveries
• An anterior placenta previa
• Multiple irregular placental lacunae on ultrasound
An ultrasound performed three weeks earlier had not identified placenta accreta spectrum. Repeat imaging on admission raised concern for abnormal placental attachment, but twin gestation and the emergency circumstances prevented accurate assessment of the depth of invasion.
MRI and transfer to a specialized tertiary center were not possible because delivery was urgent.
Preparation
Once placenta accreta spectrum was suspected, the team initiated multidisciplinary preparation involving:
• Obstetrics
• Anesthesiology
• Urology
• Blood bank personnel
• Intensive care services
Cross-matched packed red blood cells, plasma, and platelets were ordered, and the massive transfusion protocol was made immediately available.
Emergency cesarean delivery was initially performed under spinal anesthesia using:
• Hyperbaric bupivacaine 10 mg
• Fentanyl 25 µg
Intraoperative findings
Surgical exploration revealed placenta percreta that was substantially more extensive than anticipated.
Findings included:
• Placental penetration through the uterine wall
• Protrusion of the gestational sac through the right anterolateral uterus
• Active hemorrhage
• Dense placental adherence to the posterior bladder
• Full-thickness bladder-wall invasion
Both twins were delivered promptly and transferred to the neonatal intensive care unit. Reported Apgar scores were 8/9 and 8/10.
Conversion to general anesthesia
Because of worsening hemorrhage and the need for extensive surgery, general anesthesia was induced with:
• Etomidate 0.3 mg/kg
• Rocuronium 1.2 mg/kg
• Fentanyl 2 µg/kg
The trachea was intubated, and a radial arterial catheter and internal jugular central venous catheter were inserted.
The placenta could not be safely separated from the bladder. The surgical team therefore performed:
• Total hysterectomy
• En bloc partial posterior cystectomy
• Bladder reconstruction
• Bilateral ureteral stent placement
• Abdominal packing
Massive hemorrhage and cardiac arrest
The estimated blood loss reached approximately 3,500 mL.
Despite norepinephrine and blood-product resuscitation, the patient developed persistent hypotension followed by progressive bradycardia and asystolic cardiac arrest.
A balanced massive transfusion protocol was used, consisting of:
• Seven units of packed red blood cells
• Seven units of fresh frozen plasma
• Seven units of platelets
Crystalloid administration was deliberately restricted to reduce dilutional coagulopathy.
Cardiopulmonary resuscitation was initiated immediately. The patient received chest compressions and intravenous epinephrine 1 mg.
Return of spontaneous circulation was achieved within approximately one minute.
Vasopressor support was discontinued within 30 minutes, and no further vasopressors were required.
Postoperative recovery
The patient was transferred intubated to the intensive care unit but was hemodynamically stable.
She demonstrated complete neurological recovery within 24 hours based on serial bedside examinations. Neuroimaging was not obtained because recovery was rapid and complete.
Abdominal packing was removed, and she was extubated on postoperative day one.
Her subsequent recovery was uncomplicated, and she was discharged home on postoperative day 10.
Clinical implications
Imaging may identify placenta accreta spectrum but substantially underestimate its severity.
Intraplacental lacunae and placenta previa should raise concern, but they cannot reliably distinguish placenta accreta from increta or percreta or predict bladder invasion.
Any suspicion of placenta accreta spectrum should therefore prompt preparation for the most severe possible presentation, including:
• Massive obstetric hemorrhage
• Emergency hysterectomy
• Bladder or ureteral injury
• Conversion from neuraxial to general anesthesia
• Massive transfusion
• Maternal cardiac arrest
• Postoperative intensive care
The case also demonstrates the importance of having urological expertise immediately available when bladder invasion is possible.
Anesthesia considerations
Neuraxial anesthesia may be reasonable when the patient is initially stable, but teams should be prepared for rapid conversion to general anesthesia if hemorrhage develops or extensive surgery becomes necessary.
Before beginning a suspected placenta accreta spectrum case, the anesthesia team should consider:
• Large-bore intravenous access
• Immediate arterial-line availability
• Rapid central venous access when needed
• Blood products physically available
• Active warming
• Rapid-infusion equipment
• Vasopressors prepared for immediate administration
• Calcium replacement during massive transfusion
• Point-of-care coagulation testing when available
• A clearly assigned cardiac-arrest response plan
The authors believed the arrest was most likely caused by severe hemorrhage and loss of circulating volume. However, the exact mechanism could not be proven because intra-arrest blood gases, complete monitoring records, and laboratory measurements were unavailable.
Surgical considerations
When placental tissue densely invades the bladder, attempts to separate it may produce uncontrollable hemorrhage and urinary-tract injury.
In this patient, total hysterectomy with en bloc partial cystectomy was considered the safest definitive treatment.
Conservative management by leaving the placenta in place may be considered in selected planned cases, but it is generally unsuitable when active hemorrhage, extensive invasion, or hemodynamic instability is present.
Important limitations
This report describes a single patient and cannot establish the best management strategy for every placenta percreta case.
The extent of placental invasion was not confirmed by reported histopathology.
Blood loss was estimated rather than directly measured.
There were no intra-arrest laboratory data, making the precise cause of cardiac arrest uncertain.
Neurological recovery was evaluated clinically without neuroimaging or standardized neuropsychological testing.
Bottom line
Placenta percreta with bladder invasion may be far more extensive than suggested by preoperative ultrasound.
Any suspicion of placenta accreta spectrum should trigger maximum multidisciplinary preparation, including obstetric, anesthesia, urological, transfusion, intensive care, and cardiac-resuscitation resources.
Massive hemorrhage can progress rapidly to cardiac arrest. In this case, immediate CPR, epinephrine, balanced massive transfusion, definitive surgical control, and coordinated multidisciplinary care resulted in rapid return of spontaneous circulation, full neurological recovery, and hospital discharge.
Thank you to Cureus for allowing us to summarize this case report.