Lessons learned from a case of placenta previa totalis complicated by placenta accreta spectrum: Importance of timely decision-making

Introduction and clinical importance: Placenta previa (PP) is characterized by abnormal placental placement in the lower uterine segment, obstructing the cervical opening. Placenta previa totalis (PPT) occurs when the placenta completely covers the internal cervical os. This condition can lead to placenta accreta spectrum (PAS), where the placenta adheres abnormally to the uterine wall, complicating separation. PAS is reported in approximately 0.2 % of pregnancies.

Case presentation: This report concerns a case of a 28-year-old woman at 35 weeks gestation presented with painless vaginal bleeding and contractions. She had a history of five cesarean sections. Ultrasound revealed PPT with suspected placenta percreta, alongside multiple false knots and blood lakes in the placenta. A vertical uterine incision allowed for the delivery of a 2700-g male fetus, with APGAR scores of 9/10 and 10/10. Following massive hemorrhage, an abdominal hysterectomy was performed. The patient was discharged on postoperative day four in stable condition, and the infant was also discharged healthy.

Clinical discussion: PAS poses significant maternal risks, necessitating early diagnosis and meticulous surgical planning. Management strategies, including feeder vessel ligation and conservative approaches, aim to minimize hemorrhage. Hysterectomy remains a critical intervention in cases of uncontrollable bleeding, with postoperative care focused on hemodynamic stabilization and pain management.

Conclusion: This paper emphasizes effective communication, timely decision-making, and adherence to massive hemorrhage protocols in managing obstetric emergencies like PAS. In addition, routine screening during second-trimester ultrasounds for high-risk pregnancies and further prospective clinical trials are needed to enhance diagnostic and management strategies.