Maternal Death Due to Placenta Percreta: A Case Report Study

Maternal Death Due to Placenta Percreta: A Case Report Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Maternal Death Due to Placenta Percreta: A Case Report Study Zoya Hadinejad, Masumeh Hashemi Amrei, Hassan Talebi, Mohammad Shadman, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7979244/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Feb, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted 14 You are reading this latest preprint version Abstract Introduction: Abnormal placental adhesion is often associated with severe life-threatening bleeding, which requires emergency hysterectomy around parturition. Abnormal adhesions of the placenta are essential causes of maternal death due to bleeding during pregnancy or after parturition. Patient Presentation : A 39-year-old patient with G 2 P 1 IUFD 1 , who had a history of hypothyroidism and IUFD in the 24th week of pregnancy, had undergone a hysterotomy with classical incision.The patient with a gestational age of 36W+4D called emergency 911, complaining of pain and sweating, and was taken to the maternity Ward of hospital.The patient was triage level 1 with features of restlessness, headache, cold sweat, cephalic, no bleeding , discharge and contractions in the examination. The possibility of placenta accreta was raised in the MRI, and the emergency cesarean section was performed at 12:35. About 3-4 liters of blood due to uterine rupture before the C/S was removed after opening the abdomen. A baby was born in thick meconium with an Apgar score of 2.10 in 5 minutes. Approximately 20% of the placenta had a decollement, and there was a tear of about 4-5 cm in front of the fundus of the uterus in the place of the previous classic incision.The patient suffered cardiac arrest three times, and finally, despite the measures taken, resuscitation was not successful, and Patient expired . Conclusion: Today, placentas with abnormal adhesions are increasing due to frequent use of C/S and abnormal uterine incisions. One of the ways to reduce this critical complication is to avoid C/S without indication. Placenta percreta pregnancy mortality gynecological emergencies Introduction Placenta percreta is described as a full-thickness invasion of the myometrium by placental tissue in the placenta accreta spectrum (PAS), sometimes extending to the pelvic organs and adjacent vessels, and compromising them. The term .”placenta percreta" was first used in 1950 ( 1 )Placenta accreta has become a significant cause of maternal mortality ( 2 ). PAS is clinically diagnosed when the placenta fails to separate from the uterus after delivery ( 3 ).This abnormal adherence of the placenta to the myometrium occurs when a defect in the decidua allows chorionic villi to invade the myometrium. Women with a previous cesarean delivery are seven times more likely to have subsequent PAS ( 3 ). Population-based studies have shown a significant increase in the incidence of PAS, which now appears to affect 1.7 to 4.6 per 10,000 deliveries ( 4 )،, likely due to the increased use of cesarean section in the past 30 years( 5 ). .PAS is responsible for adverse maternal outcomes at delivery ( 6 ) and identifying the type of PAS allows for optimal management of women and childbirth so that delivery can be planned in a center with expertise in managing surgical PAS and reducing surgical complications. The aim of this study is to report a case of maternal death following a diagnosis of placenta percreta and to prevent the recurrence of such events." Case Presentation "The 39-year-old G 2 P 1 deceased patient with a history of one stillbirth at 36 weeks of gestation was married 3 years ago. A homemaker with an 8th-grade education, she had underlying conditions of hypothyroidism and diabetes, for which she had been receiving treatment for the past 4 years. Her first pregnancy, 2 years prior, resulted in an intrauterine fetal demise (IUFD) at 21 weeks, followed by a classical cesarean section. She also reported a previous myomectomy. With the approval of her gynecologist, she became pregnant again. At 21 weeks of gestation, while visiting her mother, she presented to a health center. Fetal tests and screenings were performed, and she was seen by a midwife and a physician. All routine in-person care was provided, including referrals to a gynecologist and an endocrinologist. Due to her advanced maternal age (over 35), a referral to a cardiologist was also made. All consultations were unremarkable. The mother gained 2 kilograms in the past three months, leading to a referral to a nutritionist. She was educated about danger signs by the midwife. Given the mother's risk factors, she was referred to a high-risk pregnancy clinic. An ultrasound raised suspicions of placenta previa, prompting an MRI. The possibility of placental adhesion was not confirmed and ruled out. The mother was advised to receive the COVID-19 vaccine but declined due to concerns about fetal harm (fear of another stillbirth) and opted to postpone vaccination until after delivery. At 25 weeks of gestation, she was referred to a tertiary care hospital by her private gynecologist due to itching and abnormal liver enzymes, with a suspected diagnosis of obstetric cholestasis. She was subsequently admitted to the hospital." "At 28 weeks and 4 days, a non-routine ultrasound (for placental adhesion) was requested by the midwife. At 32 weeks, the rural health center midwife assessed the mother for thromboembolism. The midwife also evaluated and noted inadequate weight gain (weight loss) during pregnancy. Due to suspected COVID-19 symptoms, she was referred to a perinatologist who prescribed diphenhydramine and did not require hospitalization. The mother was provided with necessary education and referred to an infectious disease specialist. Betamethasone injections were started from 29 weeks. She was also taking iron, vitamin D, prenatal multivitamins, calcium, and levothyroxine. At 35 weeks and 6 days, the health visitor conducted a 35–37 weeks pregnancy assessment and referred her to the rural health center midwife. The midwife provided care, assessed the inadequate weight gain (weight loss) during pregnancy, and screened for cardiomyopathy at 35–37 weeks. Following up, the pregnant mother had a prenatal check-up at the provincial women's hospital the day before. She was prescribed enoxaparin 6000 units once daily and insulin 8 units once daily. The heart referral was normal and there were no issues. On the morning of the 36th week of pregnancy, at 10:43 AM, the emergency medical team was called by the deceased's family. The 911 team arrived at 11 AM and, given the patient's symptoms of sweating, abdominal pain, weakness, and restlessness, initiated necessary measures such as checking vital signs, administering IV fluids, and monitoring for shock. At 11:22 AM, the mother was transferred to the hospital emergency room. Suspecting uterine rupture, she was taken to the operating room and underwent a cesarean section. A cardiology consultation at 12:10 PM revealed EF = 50–55% and bradycardia in the fetus. Due to hemodynamic shock, a central venous line (CVL) placement, blood transfusion, and normal saline were requested." "At 12:35 PM, after a catheterization (no urine), the patient was transferred to the operating room with two green IV lines and connected to monitoring. A cesarean section was performed by the on-call gynecologists. Upon opening the abdomen, 3–4 liters of blood were found, indicating a uterine rupture that had occurred prior to the cesarean section. In the operating room, one IV line was green and the other was pink. Upon entering the operating room, vital signs were BP = 100/50, P = 105, SPO2 = 100% The patient was placed under general anesthesia. A female infant with thick meconium was born with Apgar scores of 10/0 at 1 minute and 10/2 at 5 minutes. The placenta was 20% detached and there was a 4–5 cm laceration in the anterior fundus of the uterus at the site of the previous classical incision. Following the cesarean section, the patient experienced a drop in blood pressure and SPO2 = 75% necessitating interventions by the anesthesiologist. CPR was initiated and after 10 minutes and the administration of 4 doses of epinephrine, the patient recovered. During this time, the uterus was completely closed and approximately 1.5 liters of dark blood was evacuated. To control uterine atony, methylergometrine, prostaglandin F2α, and misoprostol were administered. The surgical team was called to check the internal organs and assess for potential bleeding. After extensive abdominal lavage, the abdomen was closed and a drain was placed. A cardiologist was present in the operating room throughout the procedure. The patient received 4.5 liters of IV fluids and 2 units of packed red blood cells in the operating room. Due to low pH in the ABG, 2 vials of sodium bicarbonate were administered. A central venous line (CVL) was placed by the surgical resident." "At 14:10, the patient experienced another cardiac arrest. CPR was performed for approximately 5 minutes for the second time, and 3 doses of epinephrine were administered. At 14:30, after stabilization, the patient was transferred to the ICU B under the close monitoring of the anesthesia, cardiology, obstetrics, and surgery teams. A 20 Fr. femoral sheath was placed by the surgical resident. An echocardiogram was performed again by the cardiologist. At 14:35, the patient developed bradycardia, and CPR was performed again. Drug orders were carried out under the supervision of the anesthesiologist. The operating room anesthesiologist was also present in the ICU. At 15:00, the patient recovered. 3 units of packed red blood cells and 2 units of fresh frozen plasma (FFP) were administered to the patient. At 16:20, the patient coded again, and after resuscitation efforts, the patient recovered at 16:20. 7 units of platelets and 1 unit of packed red blood cells were administered at 16:25. At 16:55, the patient coded again. Resuscitation efforts were repeated, and due to uterine atony, the obstetrics team 1 and 2 performed a hysterectomy during the resuscitation. The surgeon was also present. The hysterectomy was completed at 17:35, and the patient recovered at 17:40. "Two units of packed red blood cells and 4 units of fresh frozen plasma were infused during surgery. A repeat internal medicine consultation was performed at 17:15, requesting consultations from hematology and nephrology. An emergency ultrasound was performed at 17:45. The kidneys appeared normal in shape and corticomedullary echogenicity, with no stones or hydronephrosis. A small amount of fluid was seen in the Morrison's pouch. The bladder was empty and contained a catheter, and due to the hysterectomy and dressing, further examination of the hypogastric region and pelvis was not possible. A pulmonary consultation was performed telephonically by the gynecologist. A nephrology consultation was performed telephonically with the central hospital, and it was decided that the patient would undergo dialysis after stabilization. The cardiologist recommended cautious administration of fluids and blood products. A hematology consultation was performed telephonically by the internal medicine specialist, and the patient was ordered to receive one ampule of calcium in 10 cc of normal saline over 10 minutes. Further instructions were to be given after the results of PT, PTT, FDP, D-dimer, and fibrinogen tests were available. An infectious disease consultation was performed at 18:00, and clindamycin and gentamicin were started for the patient. At 18:30, the patient coded again, and unfortunately, resuscitation efforts were unsuccessful. The anesthesiologist declared the end of resuscitation efforts at 19:00. Discussion and Conclusion Placenta accreta spectrum (PAS) is a potentially life-threatening condition ( 7 ). Given the increasing rate of cesarean sections worldwide, the likelihood of developing PAS over time will increase. Therefore, clinicians should be aware of the diagnostic challenges and management issues associated with this condition. This is a heterogeneous condition associated with high maternal mortality rates and poses unique challenges in its diagnosis and management. To date, the rarity of this condition, coupled with a lack of high-quality evidence and the absence of a standardized approach to reporting PAS cases for ultrasound, clinical, and pathological diagnosis, have been the main challenges to a deep understanding of this condition ( 8 , 9 ) . The depth of placental invasion is one of the main factors influencing maternal outcomes. Therefore, in order to identify the best strategies for managing PAS, it is crucial to accurately assess the degree of invasion at the time of delivery, classify women accordingly, and establish a precise correlation between prenatal imaging, intraoperative aspects, and pathological findings when comparing data from different studies ( 10 ). With timely diagnosis and the application of multidisciplinary management, morbidity and mortality of such conditions are reduced. Due to the relative rarity of this condition, and given the ethical issues associated with randomized controlled trials, there are still no high-quality studies on the management of PAS disorders. As a result, various strategies for managing PAS have been described, with some physicians opting for a traditional radical approach and others suggesting a conservative approach. It has been shown that when care is provided in a tertiary center, maternal morbidity is significantly reduced. A tertiary center is typically a referral hospital that can provide a multidisciplinary team with significant experience in managing the most aggressive forms of PAS, offering both prenatal diagnosis and preoperative planning. Declarations Ethics approval and consent to participate: Because the patient had died, it was not possible to obtain consent. However, the patient's family gave oral consent to the publication of the medical procedures performed and the patient's medical history to the High Risk Maternal Mortality Committee of Mazandaran University of Medical Sciences. This Article is Case Report and we don't have a clinical trial registration number for that. Consent for publication; not applicable. Availability of data and material: The patient's medical records and the performed clinical procedures are available. Competing interests: The authors declare no competing interests. Funding; The authors have not declared a specific grant for this research from any funding. Authors' contributions: writing and editing of the manuscript (M.H) , (H.T) and (M.Sh) and revisions the results conducted by: (Y. S) and (Z.H). All authors read and approved the final manuscript. Acknowledgements : Hereby, the members of the death committee of Mazandaran University of Medical Sciences are thanked for their cooperation in publishing information about the patient. References Pain FA, Dohan A, Grange G, Marcellin L, Uzan-Augui J, Goffinet F, et al. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand. 2022;101(10):1135–45. Sentilhes L, Goffinet F, Kayem G. Management of placenta accreta. Acta Obstet Gynecol Scand. 2013;92(10):1125–34. Jauniaux E, Burton GJ. Placenta accreta spectrum: a need for more research on its etiopathogenesis. BJOG: Int J Obstet Gynecol. 2018;125(11):1449–50. Kayem G, Seco A, Beucher G, Dupont C, Branger B, Crenn Hebert C, et al. Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study. BJOG: Int J Obstet Gynecol. 2021;128(10):1646–55. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLoS ONE. 2016;11(2):e0148343. Ayati S, Vahidroodsari F, Talebian M. Maternal death due to placenta percreta with bladder involvement: a case report. Tehran Univ Med J. 2011;69(6). Morlando M, Collins S. Placenta accreta spectrum disorders: challenges, risks, and management strategies. Int J Women's Health. 2020:1033–45. Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA, Tikkanen M. FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management. International Journal of Gynecology & Obstetrics; 2018. Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E. FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynecol Obstet. 2018;140(3):291–8. Shamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol. 2015;212(2):218. e1-. e9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Feb, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 14 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers agreed at journal 08 Nov, 2025 Reviews received at journal 05 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers invited by journal 03 Nov, 2025 Editor assigned by journal 31 Oct, 2025 Submission checks completed at journal 31 Oct, 2025 First submitted to journal 29 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The term .\u0026rdquo;placenta percreta\" was first used in 1950 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)Placenta accreta has become a significant cause of maternal mortality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). PAS is clinically diagnosed when the placenta fails to separate from the uterus after delivery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).This abnormal adherence of the placenta to the myometrium occurs when a defect in the decidua allows chorionic villi to invade the myometrium. Women with a previous cesarean delivery are seven times more likely to have subsequent PAS (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Population-based studies have shown a significant increase in the incidence of PAS, which now appears to affect 1.7 to 4.6 per 10,000 deliveries (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)،, likely due to the increased use of cesarean section in the past 30 years(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). .PAS is responsible for adverse maternal outcomes at delivery (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and identifying the type of PAS allows for optimal management of women and childbirth so that delivery can be planned in a center with expertise in managing surgical PAS and reducing surgical complications. The aim of this study is to report a case of maternal death following a diagnosis of placenta percreta and to prevent the recurrence of such events.\"\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e\"The 39-year-old G\u003csub\u003e2\u003c/sub\u003eP\u003csub\u003e1\u003c/sub\u003e deceased patient with a history of one stillbirth at 36 weeks of gestation was married 3 years ago. A homemaker with an 8th-grade education, she had underlying conditions of hypothyroidism and diabetes, for which she had been receiving treatment for the past 4 years. Her first pregnancy, 2 years prior, resulted in an intrauterine fetal demise (IUFD) at 21 weeks, followed by a classical cesarean section. She also reported a previous myomectomy. With the approval of her gynecologist, she became pregnant again.\u003c/p\u003e\u003cp\u003eAt 21 weeks of gestation, while visiting her mother, she presented to a health center. Fetal tests and screenings were performed, and she was seen by a midwife and a physician. All routine in-person care was provided, including referrals to a gynecologist and an endocrinologist. Due to her advanced maternal age (over 35), a referral to a cardiologist was also made. All consultations were unremarkable. The mother gained 2 kilograms in the past three months, leading to a referral to a nutritionist. She was educated about danger signs by the midwife. Given the mother's risk factors, she was referred to a high-risk pregnancy clinic. An ultrasound raised suspicions of placenta previa, prompting an MRI. The possibility of placental adhesion was not confirmed and ruled out.\u003c/p\u003e\u003cp\u003eThe mother was advised to receive the COVID-19 vaccine but declined due to concerns about fetal harm (fear of another stillbirth) and opted to postpone vaccination until after delivery. At 25 weeks of gestation, she was referred to a tertiary care hospital by her private gynecologist due to itching and abnormal liver enzymes, with a suspected diagnosis of obstetric cholestasis. She was subsequently admitted to the hospital.\"\u003c/p\u003e\u003cp\u003e\"At 28 weeks and 4 days, a non-routine ultrasound (for placental adhesion) was requested by the midwife. At 32 weeks, the rural health center midwife assessed the mother for thromboembolism. The midwife also evaluated and noted inadequate weight gain (weight loss) during pregnancy. Due to suspected COVID-19 symptoms, she was referred to a perinatologist who prescribed diphenhydramine and did not require hospitalization. The mother was provided with necessary education and referred to an infectious disease specialist. Betamethasone injections were started from 29 weeks. She was also taking iron, vitamin D, prenatal multivitamins, calcium, and levothyroxine.\u003c/p\u003e\u003cp\u003eAt 35 weeks and 6 days, the health visitor conducted a 35–37 weeks pregnancy assessment and referred her to the rural health center midwife. The midwife provided care, assessed the inadequate weight gain (weight loss) during pregnancy, and screened for cardiomyopathy at 35–37 weeks. Following up, the pregnant mother had a prenatal check-up at the provincial women's hospital the day before. She was prescribed enoxaparin 6000 units once daily and insulin 8 units once daily. The heart referral was normal and there were no issues.\u003c/p\u003e\u003cp\u003eOn the morning of the 36th week of pregnancy, at 10:43 AM, the emergency medical team was called by the deceased's family. The 911 team arrived at 11 AM and, given the patient's symptoms of sweating, abdominal pain, weakness, and restlessness, initiated necessary measures such as checking vital signs, administering IV fluids, and monitoring for shock. At 11:22 AM, the mother was transferred to the hospital emergency room. Suspecting uterine rupture, she was taken to the operating room and underwent a cesarean section. A cardiology consultation at 12:10 PM revealed EF = 50–55% and bradycardia in the fetus. Due to hemodynamic shock, a central venous line (CVL) placement, blood transfusion, and normal saline were requested.\"\u003c/p\u003e\u003cp\u003e\"At 12:35 PM, after a catheterization (no urine), the patient was transferred to the operating room with two green IV lines and connected to monitoring. A cesarean section was performed by the on-call gynecologists. Upon opening the abdomen, 3–4 liters of blood were found, indicating a uterine rupture that had occurred prior to the cesarean section. In the operating room, one IV line was green and the other was pink. Upon entering the operating room, vital signs were BP = 100/50, P = 105, SPO2 = 100% The patient was placed under general anesthesia. A female infant with thick meconium was born with Apgar scores of 10/0 at 1 minute and 10/2 at 5 minutes. The placenta was 20% detached and there was a 4–5 cm laceration in the anterior fundus of the uterus at the site of the previous classical incision.\u003c/p\u003e\u003cp\u003eFollowing the cesarean section, the patient experienced a drop in blood pressure and SPO2 = 75% necessitating interventions by the anesthesiologist. CPR was initiated and after 10 minutes and the administration of 4 doses of epinephrine, the patient recovered. During this time, the uterus was completely closed and approximately 1.5 liters of dark blood was evacuated. To control uterine atony, methylergometrine, prostaglandin F2α, and misoprostol were administered. The surgical team was called to check the internal organs and assess for potential bleeding. After extensive abdominal lavage, the abdomen was closed and a drain was placed. A cardiologist was present in the operating room throughout the procedure. The patient received 4.5 liters of IV fluids and 2 units of packed red blood cells in the operating room. Due to low pH in the ABG, 2 vials of sodium bicarbonate were administered. A central venous line (CVL) was placed by the surgical resident.\"\u003c/p\u003e\u003cp\u003e\"At 14:10, the patient experienced another cardiac arrest. CPR was performed for approximately 5 minutes for the second time, and 3 doses of epinephrine were administered. At 14:30, after stabilization, the patient was transferred to the ICU B under the close monitoring of the anesthesia, cardiology, obstetrics, and surgery teams. A 20 Fr. femoral sheath was placed by the surgical resident. An echocardiogram was performed again by the cardiologist. At 14:35, the patient developed bradycardia, and CPR was performed again. Drug orders were carried out under the supervision of the anesthesiologist. The operating room anesthesiologist was also present in the ICU. At 15:00, the patient recovered. 3 units of packed red blood cells and 2 units of fresh frozen plasma (FFP) were administered to the patient. At 16:20, the patient coded again, and after resuscitation efforts, the patient recovered at 16:20. 7 units of platelets and 1 unit of packed red blood cells were administered at 16:25. At 16:55, the patient coded again. Resuscitation efforts were repeated, and due to uterine atony, the obstetrics team 1 and 2 performed a hysterectomy during the resuscitation. The surgeon was also present. The hysterectomy was completed at 17:35, and the patient recovered at 17:40.\u003c/p\u003e\u003cp\u003e\"Two units of packed red blood cells and 4 units of fresh frozen plasma were infused during surgery. A repeat internal medicine consultation was performed at 17:15, requesting consultations from hematology and nephrology. An emergency ultrasound was performed at 17:45. The kidneys appeared normal in shape and corticomedullary echogenicity, with no stones or hydronephrosis. A small amount of fluid was seen in the Morrison's pouch. The bladder was empty and contained a catheter, and due to the hysterectomy and dressing, further examination of the hypogastric region and pelvis was not possible. A pulmonary consultation was performed telephonically by the gynecologist. A nephrology consultation was performed telephonically with the central hospital, and it was decided that the patient would undergo dialysis after stabilization. The cardiologist recommended cautious administration of fluids and blood products. A hematology consultation was performed telephonically by the internal medicine specialist, and the patient was ordered to receive one ampule of calcium in 10 cc of normal saline over 10 minutes. Further instructions were to be given after the results of PT, PTT, FDP, D-dimer, and fibrinogen tests were available. An infectious disease consultation was performed at 18:00, and clindamycin and gentamicin were started for the patient. At 18:30, the patient coded again, and unfortunately, resuscitation efforts were unsuccessful. The anesthesiologist declared the end of resuscitation efforts at 19:00.\u003c/p\u003e"},{"header":"Discussion and Conclusion","content":"\u003cp\u003ePlacenta accreta spectrum (PAS) is a potentially life-threatening condition (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Given the increasing rate of cesarean sections worldwide, the likelihood of developing PAS over time will increase. Therefore, clinicians should be aware of the diagnostic challenges and management issues associated with this condition. This is a heterogeneous condition associated with high maternal mortality rates and poses unique challenges in its diagnosis and management. To date, the rarity of this condition, coupled with a lack of high-quality evidence and the absence of a standardized approach to reporting PAS cases for ultrasound, clinical, and pathological diagnosis, have been the main challenges to a deep understanding of this condition (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eThe depth of placental invasion is one of the main factors influencing maternal outcomes. Therefore, in order to identify the best strategies for managing PAS, it is crucial to accurately assess the degree of invasion at the time of delivery, classify women accordingly, and establish a precise correlation between prenatal imaging, intraoperative aspects, and pathological findings when comparing data from different studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). With timely diagnosis and the application of multidisciplinary management, morbidity and mortality of such conditions are reduced.\u003c/p\u003e\u003cp\u003eDue to the relative rarity of this condition, and given the ethical issues associated with randomized controlled trials, there are still no high-quality studies on the management of PAS disorders. As a result, various strategies for managing PAS have been described, with some physicians opting for a traditional radical approach and others suggesting a conservative approach. It has been shown that when care is provided in a tertiary center, maternal morbidity is significantly reduced. A tertiary center is typically a referral hospital that can provide a multidisciplinary team with significant experience in managing the most aggressive forms of PAS, offering both prenatal diagnosis and preoperative planning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Because the patient had died, it was not possible to obtain consent. However, the patient\u0026apos;s family gave oral consent to the publication of the medical procedures performed and the patient\u0026apos;s medical history to the High Risk Maternal Mortality Committee of Mazandaran University of Medical Sciences. This Article is Case Report and we don\u0026apos;t have a clinical trial registration number for that.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication;\u003c/strong\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The patient\u0026apos;s medical records and the performed clinical procedures are available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding;\u003c/strong\u003e The authors have not declared a specific grant for this research from any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e writing and editing of the manuscript (M.H) , (H.T) and (M.Sh) and revisions the results conducted by: (Y. S) and (Z.H). All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Hereby, the members of the death committee of Mazandaran University of Medical Sciences are thanked for their cooperation in publishing information about the patient.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePain FA, Dohan A, Grange G, Marcellin L, Uzan-Augui J, Goffinet F, et al. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand. 2022;101(10):1135\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSentilhes L, Goffinet F, Kayem G. Management of placenta accreta. Acta Obstet Gynecol Scand. 2013;92(10):1125\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJauniaux E, Burton GJ. Placenta accreta spectrum: a need for more research on its etiopathogenesis. BJOG: Int J Obstet Gynecol. 2018;125(11):1449\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKayem G, Seco A, Beucher G, Dupont C, Branger B, Crenn Hebert C, et al. Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study. BJOG: Int J Obstet Gynecol. 2021;128(10):1646\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBetr\u0026aacute;n AP, Ye J, Moller A-B, Zhang J, G\u0026uuml;lmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990\u0026ndash;2014. PLoS ONE. 2016;11(2):e0148343.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAyati S, Vahidroodsari F, Talebian M. Maternal death due to placenta percreta with bladder involvement: a case report. Tehran Univ Med J. 2011;69(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorlando M, Collins S. Placenta accreta spectrum disorders: challenges, risks, and management strategies. Int J Women's Health. 2020:1033\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAllen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA, Tikkanen M. FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management. International Journal of Gynecology \u0026amp; Obstetrics; 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E. FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynecol Obstet. 2018;140(3):291\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol. 2015;212(2):218. e1-. e9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Placenta percreta, pregnancy mortality, gynecological emergencies","lastPublishedDoi":"10.21203/rs.3.rs-7979244/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7979244/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e Abnormal placental adhesion is often associated with severe life-threatening bleeding, which requires emergency hysterectomy around parturition. Abnormal adhesions of the placenta are essential causes of maternal death due to bleeding during pregnancy or after parturition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Presentation\u003c/strong\u003e: A 39-year-old patient with G\u003csub\u003e2\u003c/sub\u003eP\u003csub\u003e1\u003c/sub\u003eIUFD\u003csub\u003e1\u003c/sub\u003e, who had a history of hypothyroidism and IUFD in the 24th week of pregnancy, had undergone a hysterotomy with classical incision.The patient with a gestational age of 36W+4D called emergency 911, complaining of pain and sweating, and was taken to the maternity Ward of hospital.The patient was triage level 1 with features of restlessness, headache, cold sweat, cephalic, no bleeding , discharge and contractions in the examination. The possibility of placenta accreta was raised in the MRI, and the emergency cesarean section was performed at 12:35. About 3-4 liters of blood due to uterine rupture before the C/S was removed after opening the abdomen. A baby was born in thick meconium with an Apgar score of 2.10 in 5 minutes. Approximately 20% of the placenta had a decollement, and there was a tear of about 4-5 cm in front of the fundus of the uterus in the place of the previous classic incision.The patient suffered cardiac arrest three times, and finally, despite the measures taken, resuscitation was not successful, and Patient expired\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eToday, placentas with abnormal adhesions are increasing due to frequent use of C/S and abnormal uterine incisions. One of the ways to reduce this critical complication is to avoid C/S without indication.\u003c/p\u003e","manuscriptTitle":"Maternal Death Due to Placenta Percreta: A Case Report Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 12:00:09","doi":"10.21203/rs.3.rs-7979244/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-14T19:24:22+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"31129774647771393348072352897320687488","date":"2025-11-13T03:10:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70500526739709142109770152687681140850","date":"2025-11-13T02:22:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T10:32:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16310717438964236056339682741530611368","date":"2025-11-11T08:30:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50567426082882119895057286893896277295","date":"2025-11-10T19:48:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76776348879708457358299587338186007715","date":"2025-11-10T18:56:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29305268933508824067532934366607037236","date":"2025-11-08T18:52:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T21:04:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71811710196455501570657972498242685348","date":"2025-11-05T21:02:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-03T20:30:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-31T16:34:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-31T16:32:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-10-29T11:19:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1efe3754-6c23-4b9f-8522-38519a0f1f26","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T16:00:59+00:00","versionOfRecord":{"articleIdentity":"rs-7979244","link":"https://doi.org/10.1186/s12245-025-01104-x","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2026-02-19 15:57:16","publishedOnDateReadable":"February 19th, 2026"},"versionCreatedAt":"2025-11-13 12:00:09","video":"","vorDoi":"10.1186/s12245-025-01104-x","vorDoiUrl":"https://doi.org/10.1186/s12245-025-01104-x","workflowStages":[]},"version":"v1","identity":"rs-7979244","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7979244","identity":"rs-7979244","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}