Background <p>Placenta accreta spectrum (PAS) is a leading cause of catastrophic obstetric hemorrhage. Although cesarean hysterectomy is the standard approach, conservative management is increasingly used to preserve fertility. Evidence from Sub-Saharan Africa remains limited, however. We report a rare Ethiopian case of PAS managed conservatively without hysterectomy and provide a brief review of similar strategies in the literature to contextualize this case.</p> Case presentation <p>A 20-year-old woman (gravida 2 para 1) with no prior uterine surgery underwent cesarean section for prolonged prelabor rupture of membranes and breech presentation at 37 + 2 weeks’ gestation. Intraoperatively, a highly vascular fundal mass extending to the left adnexa suggested PAS. Attempts at placental removal were unsuccessful, but bleeding remained minimal. To preserve fertility, and because advanced PAS surgical management was not available, a conservative approach was adopted and the placenta was left in situ. Postoperative management included antibiotics, uterotonics, and serial methotrexate. The placenta gradually regressed without hemorrhage, sepsis, or need for secondary surgery. At three-year follow-up, the woman remained stable with normal menstruation and intact uterus.</p> Conclusions <p>Placenta in situ management—supported by structured monitoring and methotrexate—can be a safe and feasible option in carefully selected women with PAS, even in low-resource settings. It provides rare, regionally relevant evidence and underscores the need for context-specific PAS protocol to expand fertility- preserving management options where surgical capacity is limited.</p>