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Cesarean scar defects encompass a spectrum of separation of the uterine layers that increase risk of uterine rupture during labor and delivery. When coupled with the presence of placenta accreta spectrum, a condition characterized by abnormal adherence to or invasion of the myometrium by the placenta, the risk of life-threatening hemorrhage significantly increases. As rates of cesarean delivery increase, it is important to understand the imaging findings typical of both conditions. We present the case of a 30-year-old patient with a dichorionic, diamniotic twin gestation complicated by uterine window and placenta accreta spectrum.