Central Placenta Previa Management

Initial Assessment and Preparation

The American College of Obstetricians and Gynecologists recommends that women with placenta previa and prior cesarean deliveries should be evaluated for placenta accreta spectrum disorder, which significantly increases morbidity 1
Delivery should take place at an institution with adequate blood banking facilities and multidisciplinary expertise 1

The American College of Obstetricians and Gynecologists recommends cesarean hysterectomy with the placenta left in situ after delivery of the fetus as the most generally accepted approach 2, 3
Attempts at forced placental removal often result in profuse hemorrhage and are strongly discouraged 4
Total hysterectomy is typically required because lower uterine segment or cervical bleeding frequently precludes a supracervical hysterectomy 4

The American College of Obstetricians and Gynecologists recommends ensuring availability of blood products before surgery 1
Consider a 1:1:1 to 1:2:4 strategy of packed red blood cells:fresh frozen plasma:platelets for massive transfusion 4
Close monitoring of volume status, urine output, blood loss, and hemodynamics is critical during surgery 4

The American College of Obstetricians and Gynecologists recommends that conservative approaches may be considered in select cases where fertility preservation is desired, such as patients with focal placental adherence 5
Placental removal followed by insertion of a Bakri balloon has been successful in preventing hysterectomy in 84% of cases with placenta accreta spectrum 5
Expectant management, where the cord is ligated near the placenta and the entire placenta is left in situ, is considered an investigational approach with success rates varying, and a median time to placental involution of 13.5 weeks 5

Failure rates are higher with more extensive placental attachment (44% in placenta percreta vs. 7% in less extensive defects) 6
Severe adverse complication rate: 6% overall, with 70% of severe outcomes occurring in the delayed hysterectomy group 5
Common complications include bleeding and infection/febrile morbidity (28% of patients) 5
Severe morbidity includes sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, and acute renal failure 5

Methotrexate to hasten placental resorption is not recommended due to unproven benefit and possible harm 6
Conservative management should be considered rare and individualized due to significant risks 5

Management decisions for placenta accreta (e.g., choosing expectant versus surgical intervention) must be based on serial β‑hCG monitoring together with clinical evaluation and imaging, rather than on a single β‑hCG level, to accurately assess residual trophoblastic activity and prevent mis‑guided treatment. 7