Background: The indications of emergent termination of pregnancy in placenta accreta spectrum (PAS) include vaginal bleeding, true labor pain or premature rupture of membranes (PROM). Some cases may have atypical presentation as a result of presence of intra-abdominal bleeding rather than vaginal bleeding. Delayed diagnosis of these cases leads to catastrophic complications to both mother and fetus.   
Patients and Methods: This was a case series of patients with PAS who underwent emergent delivery due to atypical presentation by hemoperitoneum with absence of any of the classic symptoms that indicate urgent delivery, including vaginal bleeding, true labor pain or PROM. Hemoperitoneum was diagnosed by finding free fluid in the abdomen or pelvis by ultrasonography. 
Results: Seven patients were included in this study. The atypical presentation included: 1) shortness of breath; 2) chest tightness; 3) vague abdominal pain and discomfort; 4) shoulder pain; 5) repeated vomiting and sweating; 6) syncope; and 7) cardiac arrest. Laparotomy was performed for all patients and variable amounts of intra-abdominal bleeding were found. The cause of bleeding was either rupture of surface vessel of uterovesical neovascularity or minute focal penetration of the placenta. Cesarean hysterectomy was performed in 5 patients while resection of lower uterine segment with uterine preservation was performed in 2 patients. The newborn was living in 6 patients and dead in one patient who had presented by cardiac arrest.
Conclusion: Any patient with PAS who have atypical presentation must be put under observation with close monitoring of the general condition for signs of hypovolemia, and ultrasonography should be performed by expert sonographer for early detection of hemoperitoneum. Confirmation of the diagnosis indicates emergent laparotomy, better via longitudinal incision, considering cesarean hysterectomy as a first line treatment.