Perioperative management of placenta accreta spectrum after early pregnancy loss

Objective: We explore the continuum between the two diagnoses of c-section scar pregnancy (CSP) and early placenta accreta spectrum (PAS), the role of pelvic magnetic resonance imaging (MRI) as a diagnostic aide, interventions to reduce morbidity and mortality, and surgical considerations of a robotic-assisted total laparoscopic hysterectomy for definitive management of an early pregnancy loss impacted by CSP/PAS. Case(s): A thirty-six-year-old pregnant female with seven prior cesarean sections presents with life-threatening vaginal bleeding after an early pregnancy loss at home. In the hospital, pelvic ultrasound demonstrates a retained placenta, and MRI further reveals findings concer-ning for a new diagnosis of CSP and early PAS. After medical stabilization and multidiscipliary treating planning, she underwent uterine ar-tery embolization followed by robotic-assisted total laparoscopic hysterectomy. She was discharged on postoperative day one and recovered well. Final pathology confirmed placental invasion through the endo-myometrium with uterine serosa only overlying the attached placenta consistent with a diagnosis of an abnormal placentation disorder. Conclusion: Here we describe a severe presentation of early PAS after an early pregnancy loss and the role of MRI and multidisciplinary collaboration in successful management. Discussion between minimally invasive gynecology, maternal-fetal medicine, and radiology speci-alists is critical in management of a c-section scar pregnancy and placenta accreta spectrum disorder. MRI has an emerging and important independent role in visualizing critical anatomy and surgical planning.