(on USG). The patient reported first to us at 28 weeks for pain abdomen. The patient had right side DJ stenting at 28 weeks gestation for urosepsis due to lower right ureteric obstruction. The patient did not complain of any pain thereafter. Her previous reports and regular ultrasounds were all reported normal. Her first ultrasonography was done at 15 weeks gestation. Her vitals were normal. An abdominal examination revealed generalized tenderness with fetus in breech position and mild scar tenderness, fundal height was term size. FHS was regular. Pelvic examination revealed a long, firm, closed cervix slightly deviated to the patient’s right side. It is extremely rare to first dx abdominal pregnancy at the time of elective caesarean section for another indication. During LSCS, after opening the peritoneum a large sac with full-term live baby in the breech presentation was felt in between the peritoneal sac. It was opened, clear liquor was drained and the baby and a viable female infant were delivered via breech extraction with an Apgar score of 9/9 at 1 and 5 minutes with the weight of 2.65 kg (fig 1). The placenta was adhered to the right uterine wall serosa, posteriorly in the pouch of Douglas, along with the right pelvic wall with omental and bowel attachments (fig 1). A tentative diagnosis of placenta percreta versus concealed placental abruption was made. In view of torrential bleed and massive hemorrhage protocol, the emergency term was alarmed for laparotomy. The decision was made to proceed for hysterectomy and removal of placental tissue due to continuous bleeding after taking consent from attendants and patient herself who was in spinal anesthesia and after that intubated and given general anesthesia. The uterus was exteriorized due to massive bleeding and distortion of anatomy. Total abdominal hysterectomy was performed and excision of most of the placental tissue occupying the right side of pelvic floor adhering to bowel, mesentery and omentum along with multiple feeding vessels which were carefully ligated. Homeostasis was secured some bits of placental tissue was left in situ, which was not bleeding, that was dealt with INJ. Methotrexate (50MG) Intramuscular during the postoperative period. The intra-operatively patient received 4 FFP and 3PRBC. Along with intravascular volume expanders. The estimated blood loss was 1.5litres. The patient was then transferred to ICU for further observation and extubated the following morning. The patient was discharged with the full term healthy female of 2.65 kg on day 4 of surgery.

position and abdominal examination was unremarkable as she reported first to us at 28 weeks gestation [9]. Abdominal pregnancy is often associated with foetal deformities such as facial and cranial asymmetry, joint abnormalities limb deformity and central nervous deformity in about 21% of cases [10]. In our case, there was mild facial and cranial asymmetry (Fig 2) [10]. The most common complication of abdominal pregnancy is bleeding from the placental implantation site which can be massive and life-threatening and is the most common cause of maternal morbidity and mortality as high as 30-40% [4, 11]. The massive hemorrhage that mostly occurs with surgery is due to a lack of constriction of blood vessels after placental separations. The placenta can be attached firmly to the parietal peritoneum, mesentery and bowel [12]. Removing the placenta can result in catastrophic hemorrhage and damage to adjacent structures. The decision to remove or leave the placenta should depend on the extent of the placentation particularly with the bowel and omental involvement as well as on the expertise of the surgeon. Because of increased postoperative morbidity and mortality, it is not advisable to leave the placenta in situ [5]. In our case, massive transfusion protocol was applied as per hospital protocol. While if the placenta is left in situ it may lead to secondary hemorrhage, abscess formation, adhesions, coagulopathy, failure of lactogenesis which can require second surgery and also a longer follow up along with other complications. There can be torrential hemorrhage from the placental separation and rapid surgical action is necessary to save the woman’s life [4]. The various manoeuvre can be used to control bleeding that includes compression of bleeding site, ligating the vascular pedicles, lavage with cold saline and local or systemic coagulation promoting agents. The removal of the organ to which the placenta is attached or adherent like hysterectomy, salpingo-oophorectomy, omentectomy can be justified to control the hemorrhage [4,11]. Abdominal packing can be done for uncontrolled hemorrhage.

In this case, the placenta has adhered to the omentum, mesentery and bowel and on the right pelvic wall along with extension into the POD. The decision was made intraoperatively for hysterectomy to obtain adequate haemostasis along with controlling bleeding from ligating vascular pedicles attached to the omentum, mesentery and

 Fig 4: Gravid uterus & placenta.