Placenta percreta is a rare finding in the first trimester and is often associated with severe maternal morbidity. Herein we describe a case of placenta percreta with occult uterine rupture in the first trimester in a patient with a history of two previous cesarean deliveries. Imaging was concerning for placenta accreta. Following onset of acute abdominal pain, she underwent exploratory laparoscopy, which was negative for overt uterine scar dehiscence. She ultimately underwent total abdominal hysterectomy at 14 weeks following severe bleeding, with intraoperative and histologic findings consistent with placenta percreta with dehiscence of the anterior lower uterine segment below the level of, and obscured by the vesicouterine peritoneum.

    Bleeding and severe abdominal pain in the first trimester in the context of prior uterine instrumentation should always prompt evaluation of the scar, by imaging in a stable patient, and by direct visualization if necessitated. However, maintenance of clinical suspicion for uterine scar dehiscence is warranted in patients at high risk even in the absence of direct visualization intra-operatively.