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A life-threatening puerperal uterine perforation and an acute uterine inversion can both be caused by placenta accreta [1,2], but seldom together.A 22-year-old woman, gravida 2, presented in labor to the emergency unit of the Gynecology and Obstetrics Department at 30 weeks of pregnancy with preterm premature rupture of membranes, breech presentation, thick meconium-stained liqueur, and nonlocalization of fetal heart sounds confirmed by ultrasound. Placenta was fundal, approaching the right lateral wall. A dead fetus weighing 1000 g was delivered but not the placenta. The patient was taken to the operating room for manual removal of the retained placenta (MRP). Under anesthesia, a cleavage was felt toward the lower edge of the placenta and separation was attempted. The placenta was delivered with a fleshy piece of tissue attached, possibly myometrium. The patient immediately went into shock. Per-vaginum examination revealed an acute incomplete inversion of the uterus with suspicion of a big rent. Laparotomy was immediately performed with infusion of blood. After uterine reposition per vaginum via the Johnson maneuver, a 5 cmÂ4 cm fundal perforation was discovered. Subtotal hysterectomy was performed, hemostasis was secured, and the patient was discharged on the 10th day. A histopathologic evaluation revealed placenta accreta.Classically, placenta accreta presents with a retained placenta and hemorrhage and postpartum hysterectomy remains the gold-standard treatment. Why uterine inversion occurs is unclear but strong traction on the umbilical cord with fundal placenta, excessive fundal pressure, relaxed uterus, placenta accreta (fundal), short umbilical cord, congenital weakness, or anomalies of the uterus and antepartum use of magnesium sulphate/ oxytocin are known culprits [1].Uterine inversion and retained placenta can both be fatal. Manual removal of the placenta is a standard practice for retained placenta, and uterine perforation following manual removal is very

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