A 25 year-old primigravida patient was referred from a nearby health center to HEAL Africa Hospital, a multidisciplinary tertiary hospital for management of an acute abdomen at 33-weeks gestation. Her chief complaint was severe abdominal pain associated with each fetal movement for a period of 1 week prior to admission at the referring health center. Among other undocumented treatments, the patient had been managed with spasmolytics and hematinics but without relief of her pain. On August 30, 2019, when the patient’s condition worsened, the decision was made to transfer her for further care. She reported to the emergency unit of the hospital on the same date at 21h30. Her first and second trimesters had been uncomplicated. She had received antenatal care in a nearby clinic where she was treated with antihelmintics, iron and folic acid supplementation, as well as prophylactic anti-malarials, according to recommended standards. The patient had not had an obstetrical ultrasound. There was no history of any symptoms suggestive of sexually transmitted diseases such as vaginal discharge or genital ulcers. about the duration of her cycle, she typically bled for 3 days per cycle and denied pain or passage of clots during menstruation. Dates of her last normal menstrual period were unknown. Past medical history was notable for malaria with two prior admissions to a nearby clinic. There was no history of chronic illnesses such as hypertension, diabetes mellitus, asthma or sickle cell disease, and the patient did not take any medications on an ongoing basis. She had never been tested for HIV. She had never undergone myomectomy or any other surgical procedures and did not have a history of blood transfusion. There was no history of involvement in road traffic or other accidents. On social history, the patient was the third born in a family of five children. Her parents and siblings were alive and healthy. There was no family history of chronic illnesses. The patient was a married housewife and did not smoke cigarettes or drink alcohol. In summary, this was a healthy 25-year old primigravida who was admitted with a one-week history of severe abdominal pain associated with fetal movements at 33- weeks gestation in an otherwise uncomplicated pregnancy. On physical examination, the patient was noted to be ill-appearing. Vitals signs were as follows: heart rate of 99 beats per minute, blood pressure of 120/69, respiratory rate was 22 breaths per minute, oxygen saturation of 98% on room air and temperature of 36.90 C. The patient’s pulse was regular and of normal volume. Apex beat was noted in the 5th intercostal space with normal S1 and S2 on auscultation. Chest expansion was symmetrical and breath sounds were normal with bilateral good air entry. The abdomen was symmetrical but tense without surgical scars. Striae gravidarum and a linea nigra were visible. There was marked tenderness on abdominal palpation, particularly in the peri-umbilical area and associated with each fetal movement. Palpation of the liver, spleen, and kidneys was limited due to the patient’s tenderness. Fundal height was not well delineated but was estimated at 28/40 weeks. There were no palpable contractions but marked abdominal tenderness was noted during fetal movement. Fetal parts were not easily palpable through the abdominal wall. Additionally, fetal presentation and fetal lie were not easily appreciated on physical exam. A regular fetal heart of 148 beats per minute was auscultated in the mesogastrium. Examination of the vulva and vagina were normal. The cervix was long, posterior, and not excitable. The os was closed. No abnormal discharge was noted. Diagnosis of an acute abdomen in the third trimester of pregnancy was made and acute peritonitis was suspected. Differential diagnosis included appendicular or other bowel perforation. The patient was admitted to hospital. An emergency ultrasound showed a single viable pregnancy at 33-weeks gestation with a low-lying placenta and oligoamnios. Initial hemoglobin was 8.1 g/dl with a hematocrit of 22.6%. After intravenous access was obtained, intravenous fluids and initial pain management were started. The patient was counselled and consented for an emergency laparotomy. She was taken to operating theatre and was given general anesthesia with endotracheal intubation. Both an obstetrician and a general surgeon scrubbed for the case. A sub-umbilical incision was made and then extended above the umbilicus. On entering the abdominal cavity, a huge reddish mass was identified. Fetal parts were visible through the membranes delineating the mass. There was minimal meconium stained amniotic fluid around the baby. Upon digital opening of the mass, a live 2000 g female baby in longitudinal lie with the head in the maternal pelvis was delivered [Fig. ]. APGAR scores were 8, 6, and 9 at 1, 5 and 10 min respectively. The baby was immediately taken to neonatology for thorough screening by the paediatrics team and was found to be healthy with no congenital abnormalities. Careful exploration of the abdomen revealed a placenta implanted on the greater omentum and on the small bowel mesentery [Fig. ]. There was no plane of cleavage and any manoeuver to remove the placenta was susceptible to bleeding. It was decided to leave the placenta in place. Membranes were stripped and the umbilical cord was cut near its placental insertion. The patient remained hemodynamically stable throughout the surgery and no complications were noted. However, she did receive one unit of whole blood transfusion. The patient was admitted to the post-partum ward after she was fully awake and was started on parenteral antibiotics and analgesics for 3 days, after which she was transitioned to oral treatment. Patient was also started on hematinics. Weekly ultrasounds were planned as well as serial quantitative beta-HCG measurements to evaluate the status of the placenta. The patient remained stable in the post-operative period. Her first post-partum ultrasound showed an intra-abdominal placenta in the hypogastric region extending to the left and right iliac fossas with evidence of vascularisation on Doppler. Partial placental detachment was noted with two pouches of encapsulated peri-placental hematoma having maximal diameters of 9.39 cm and 6.78 cm each. The anteverted, anteflexed and empty uterus was well visualized and the serum beta – HCG was > 1500 IU/ml. In the second post-operative week, the patient did not have any major complaints. Ultrasound again demonstrated an intra-abdominal placenta in the hypogastrium, above the uterus, with an encapsulated peri-placental hematoma of 8.41 cm in the longest diameter. The uterus remained empty, anteverted, anteflexed. Serum beta–HCG returned at 653.9 IU/ml. The patient continued to make a good recovery and the baby appeared to be healthy. The mother was discharged home on prophylactic antibiotics for 1 week with a planned follow up at the end of post-partum week 6.