Treatment Approach for Central Placenta Previa
For central placenta previa, cesarean hysterectomy with the placenta left in situ is the standard treatment approach due to the life-threatening nature of this condition, though conservative management may be considered in carefully selected cases. 1
Initial Assessment and Preparation
- Transvaginal ultrasound is the diagnostic modality of choice for accurate assessment of placenta previa 2
- Digital pelvic examination should be avoided until placenta previa has been excluded to prevent triggering hemorrhage 2
- Women with placenta previa and prior cesarean deliveries should be evaluated for placenta accreta spectrum disorder, which significantly increases morbidity 2
- Delivery should take place at an institution with adequate blood banking facilities and multidisciplinary expertise 2
Surgical Management Algorithm
Standard Approach
- Cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most generally accepted approach 1
- Attempts at forced placental removal often result in profuse hemorrhage and are strongly discouraged 1
- Total hysterectomy is typically required because lower uterine segment or cervical bleeding frequently precludes a supracervical hysterectomy 1
Surgical Technique
- Place patient in dorsal lithotomy positioning to allow for access to the vagina and optimal surgical visualization 1
- Inspect the uterus after peritoneal entry to determine placental location 1
- Make the uterine incision away from the placenta when possible 1
- After delivery of the fetus, if placental removal does not occur with usual maneuvers, rapidly close the uterine incision and proceed with hysterectomy 1
Blood Product Management
- Ensure availability of blood products before surgery 2
- Consider a 1:1:1 to 1:2:4 strategy of packed red blood cells:fresh frozen plasma:platelets for massive transfusion 1
- Close monitoring of volume status, urine output, blood loss, and hemodynamics is critical during surgery 1
Conservative Management Options
In select cases where fertility preservation is desired, conservative approaches may be considered:
Conservative Management (removal of placenta without hysterectomy)
- May be appropriate for patients with focal placental adherence 1
- Manual extraction or surgical excision followed by repair of the resulting defect 1
- Placental removal followed by insertion of a Bakri balloon has been successful in preventing hysterectomy in 84% of cases with placenta accreta spectrum 1
Expectant Management (leaving placenta in situ)
- Considered an investigational approach 1
- The cord is ligated near the placenta and the entire placenta is left in situ 1
- Success rates vary: 78% did not require hysterectomy in the largest series 1
- Median time to placental involution: 13.5 weeks 1
Risks of Conservative/Expectant Management
- Failure rates are higher with more extensive placental attachment (44% in placenta percreta vs. 7% in less extensive defects) 1
- Severe adverse complication rate: 6% overall, with 70% of severe outcomes occurring in the delayed hysterectomy group 1
- Common complications include bleeding (primary cause of failure) and infection/febrile morbidity (28% of patients) 1
- Severe morbidity includes sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, and acute renal failure 1
Important Cautions
- Methotrexate to hasten placental resorption is not recommended due to unproven benefit and possible harm 1
- Conservative management should be considered rare and individualized due to significant risks 1
- Failure of conservative management can lead to catastrophic bleeding requiring emergency hysterectomy 3
- Patients who opt for conservative management should be informed about the possibility of severe bleeding that may ultimately require blood transfusions and hysterectomy 3