Placenta accreta is associated with a significant increase in maternal and perinatal morbidity and mortality. It is also associated with complications, which will end up with a cesarean hysterectomy, blood transfusions, sepsis, and other surgical complications. It is defined as the penetration of the trophoblast tissues through the decidua basalis into the underlying myometrium. [1] The incidence of placenta accreta varies between studies. One study done in the United States in 2016 revealed a higher incidence of 1 in 272 [2] . Other studies revealed the incidence of placenta accreta to be 4.3 per 10,000 patients, and a study done in Mania, Egypt, showed the incidence of 9 per 1000 patients [3] [4] .

Among the risk factors for placenta accreta is an increase in the rates of previous scars [5] . Other risk factors that are associated with placenta accreta include increased maternal age, a previous history of placenta previa, grand multiparity, smoking, and chronic hypertension [4] . The diagnosis of placenta accreta can be made during prenatal times by taking a proper history and performing a physical examination. Risk factors can be identified in the early prenatal period. Ultrasound is the first-line tool for placenta accreta diagnosis and can be done in the first, second, and third trimesters. MRI is another emerging investigation used to diagnose placenta accreta [6] - [8] .

Timing of delivery is important to patients with suspected placenta accreta to reduce fetal and maternal morbidity and mortality. The decision to deliver a patient with placenta accreta will always depend on the risk factors and ultrasound results identified during the prenatal period. Increased gestation age for the patient with placenta accreta is associated with increased complications during delivery. Several studies recommended that a patient with placenta accreta should be planned for delivery at the GA of 35 + 0 and 36 + 6 weeks [9] .

Caesarian hysterectomy is the management of choice and the Golden method for the unplanned delivery of placenta accreta. It is associated with significant blood loss and possible surgical complications, so preoperative care should be done before the operation [10] . Apart from caesarian hysterectomy, conservative management can also be done for the patient with placenta accreta by leaving the entire placenta or part of the placenta in the uterus to control bleeding [11] . Above all, Methotrexate can be used as part of the medical management of placenta accreta [12] .

A 34 years G8 P4 + 3 at a gestation age of 40 weeks, with a history of three previous scars comes with presenting complaints of per vaginal bleeding for the past four hours, diagnosis of placenta previa was made on a clinical basis and bed sound obstetric ultrasound, the patient was prepared for caesarian section and a female baby scored 7 - 10 weighted 2.2 kg was delivered and found also was placenta accrete were by it was difficulty in repairing uterus due to excessive bleeding and finally total hysterectomy was done. The patient recovered well in the ward and was discharged on 3/11/2024 in good condition.

Alert, moderately pale, not dyspneic, not cyanotic, not dehydrated, has no palpable lymph nodes.

Three previous scars with placenta praevia.

In the theater, the procedure was done:

Findings:

Abnormal placentation is a major cause of maternal morbidity and mortality worldwide. It is associated with maternal complications such as life-threatening maternal hemorrhage, large-volume blood transfusion, and peripartum hysterectomy [13] . Those complications occurred to our patient; she bled a lot and ended up with a total hysterectomy. Placenta accreta is defined as the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium; the degree of invasion into the myometrium is <50% [1] .

The incidence of placenta accreta continued to increase as time went on, and it is likely to be related to the increased rate of caesarian sections [1] . One study done in the United States in 2016 revealed a higher incidence of 1 in 272. Other studies showed the incidence of placenta accreta to be 4.3 per 10,000 patients, and a study done in Mania, Egypt, showed the incidence to be 9 per 1000 patients [2] - [4] .

Among the risk factors for placenta accreta is a previous caesarian section, and the risk increases as the number of caesarian sections increases. Literature reported that the rate of placenta accreta spectrum has risen from 0.24% in women with one previous cesarean delivery to 6.74% for women with five or more cesarean deliveries [14] . Our patient had three previous scars, so according to the literature, she had a >0.57% chance of having placenta accreta. Other risk factors for placenta accreta include a history of having placenta previa, a history of having submucosal myoma, Prior curettage, advanced maternal age, grand multiparity, smoking, and a history of chronic hypertension [4] . A prior history of placenta accreta has also been found to be a major risk factor for further placenta accreta.

Diagnosis of placenta accreta in our patient was made post total hysterectomy, where the placenta was found adhered to the uterus. We delayed diagnosing placenta accreta to our patient because she didn’t do any prenatal obstetrics ultrasound, and she had three previous scars, which are the risk factor for placenta accreta.

Literature suggested that placenta accreta should be considered in all patients with a previous history of placenta previa, patients with a history of previous caesarian section, and previous uterine surgery [4] . Our patient presented with three previous scars that are risk factors for placenta accreta. For all patients with risk factors for placenta accreta, the literature suggested that they should undergo a routine antenatal ultrasound. It was not done to our patients and led to delayed diagnosis. The reason for not doing routine prenatal ultrasounds was being unaware of the importance of prenatal ultrasounds. Tanzania antenatal care guidelines recommend at least 2 free antenatal ultrasounds for all pregnant women to ensure early diagnosis of placenta accreta and other obstetrics conditions.

An antenatal ultrasound will help in knowing the position of the accreta and the timing for delivery [6] . Currently, the recommended type of ultrasound is three-dimensional Doppler ultrasound, and sometimes Magnetic Resonance imaging to add some missing information [7] [8] [15] .

Our patient was managed by caesarian hysterectomy, which was emergent, but the literature suggested that if the diagnosis is known, it is better to manage the patient by planned operation to avoid complications that may arise intraoperatively. This was not done to our patient because it was not diagnosed earlier. It is also suggested that planned caesarian sections should be done between 34+ and 36 + 6 gestation age because as the gestation age increases, the chances of complication also increase. Our patient was late because she was operated on at 40 GA [16] .

Apart from hysterectomy, conservative management can also be done in patients who aim to preserve their fertility. This is done by leaving the entire placenta or part of it or removing the placenta accreta niche to control bleeding. It was not done to our patient because she didn’t need more children; she had four children at the time of the operation. This method is associated with a lot of complications, including postpartum hemorrhage, post-operative intravascular coagulopathy, and infection, and may require laparotomy. Conservative management is used together with adjuvant methotrexate, though its role is unknown [11] [12] [17] .

Placenta accreta is becoming an increasingly common complication of pregnancy. The reason for the rate increase is the increase in rates of the caesarian sections. Prenatal diagnosis was found to be a key factor in Planning for the counseling, treatment, and outcome of women with placenta accreta. Cesarean hysterectomy is the gold standard and probably the preferable treatment. Conservative management should only be used in highly selected cases.

The authors acknowledge all the frontline healthcare workers who participated in the management of this case. We also thank the members of the Department of Obstetrics and Gynecology and the theater team for their support.

Written informed consent was obtained from the patient for publication in this case report.

Augustino Maufi managed the patient and drafted the manuscript; Daniel Shishi, Martin Adriano, Abduel Mdee, Emmanuela Hope, and Stella Ntobisangu managed the patient and contributed to manuscript writing, and they critically reviewed and contributed to the manuscript. All authors read the final draft of the manuscript and approved publication.