A 34-year-old Malay, gravida 4, para 3, Rh-negative woman was referred from a private hospital at 13 weeks owing to accreta suspicion for further management. She had a history of three previous lower segment cesarean sections, and all operations were uneventful. At 5 weeks of pregnancy, she presented with per vaginal bleeding and unresolved suprapubic pain at a private hospital. Her urine pregnancy test was positive, and ultrasound examination showed an empty uterus with evidence of intraperitoneal bleeding. A diagnosis of a ruptured ectopic pregnancy was made. She underwent emergency laparotomy, and hemoperitoneum with clots and fresh 500 ml of bleeding were found. This was due to bleeding from a ruptured vessel of an engorged and swollen left Fallopian tube. Left salpingectomy was performed. Postoperatively, her per vaginal bleeding had stopped, and, on day 3 postoperation, she was discharged from the ward. A week later, she had had obvious morning sickness symptoms; she then returned to her doctor and discovered she had an intrauterine pregnancy with a viable fetus of 7 weeks gestation. The gestational sac was located at the lower part of the uterus; however, there was no suspicion of abnormal placentation at that time. The patient was given 4 weeks until her next appointment. She experienced intermittent minimal per vaginal bleeding associated with suprapubic discomfort during this period. At 12 weeks of gestation, a repeat ultrasound showed that a viable fetus was located at the lower part of the uterus, and the placenta was covering the internal os, which was accompanied by loss of the hypoechoic border between the placenta and uterus; thus, a diagnosis of placenta accreta was made. The patient sought a second opinion from another consultant. Magnetic resonance imaging (MRI) was performed, and the gestational sac was found to occupy the lower half of the uterine cavity. Moreover, superior to the gestational sac was a sizeable heterogeneous lesion, suggestive of a multi-age blood clot occupying the other half of the uterine cavity. The placenta was located at the lower part of the uterus covering the os. She was counseled for a hysterectomy and then was referred to our center. A repeat ultrasound examination revealed similar findings with increased subplacental vascularity at the uterine bladder interface. Per-abdominal examination revealed that the uterus was at 20 weeks gravid uterine size. An elective hysterectomy was decided upon, and the procedure and possible complications were explained to the patient and partner. The patient was started with an intravenous antibiotic because of her prolonged per vaginal bleeding. The challenge in managing the case was in deciding the best approach to minimize the patient’s complications. A large amount of Rh-negative blood is not readily available in our blood bank. If an additional amount is required, a regular donor needs to be called, or Rh-negative blood is collected from another hospital blood bank. The surgery could only be performed after at least 6 pints of blood group O Rh-negative was obtained in preparation for any bleeding intraoperatively. The apprehension was more regarding the adhesion of the uterus to the anterior abdominal wall, the difficulty of separating the urinary bladder, the possible injury to the urinary bladder, and intraoperative bleeding. The transfusion department of our institution managed to gather eight units of a packed cell of Rh-negative blood group O on the operation day. The urology team was on standby during the operation. A midline subumbilical vertical incision was made. There were adhesions between the right anterolateral peritoneal wall with the omentum, the anterior surface of the uterus, and the bowels. Adhesiolysis was carried out slowly. An enlarged uterus was visible, with tortuous vessels on the serosal surface of the lower part. The total hysterectomy was performed successfully. The estimated blood loss was 2 L, with bleeding mainly from the raw areas at the vesicouterine fold. Two pints of the packed cell were transfused intraoperatively. A gross histopathological examination showed that the placenta appeared to extend up to the serosa. It was microscopically confirmed that the chorionic villi invaded the myometrium with an absence of decidual tissue, while no invasion toward or penetration of the serosal layer was found. Our patient recovered uneventfully. She was discharged on the fifth postoperative day in good condition, and she was in excellent health during a follow-up visit 2 weeks later. She was seen again after 1 month: she had no complaints, the wound was healed, and she was discharged from the gynecological clinic.