Background: Placenta accreta spectrum (PAS) disorders are severe obstetric complications associated with abnormal adherence of the placenta to the uterine wall, often leading to massive peripartum hemorrhage and maternal morbidity or mortality. Standard management of PAS involves cesarean hysterectomy, which carries a high risk of intraoperative blood loss and transfusion-related complications. Fibrinogen, a critical coagulation factor, is among the first to reach critical low levels during massive bleeding, and early supplementation may improve hemostatic control. ROTEM-guided studies have shown that fibrinogen levels correlate with clot firmness and that early correction can reduce transfusion requirements. However, evidence regarding the effectiveness of prophylactic fibrinogen administration in obstetric hemorrhage, especially in PAS disorders, remains limited and inconclusive. Methods: A double-blind randomized controlled trial was initiated at AIIMS, New Delhi. Patients with confirmed PAS diagnosis (n=14 in year one) were randomized into two groups to receive either 2g fibrinogen (n=7) or placebo (n=7) at the time of cord clamping. Blood samples were collected at baseline, 15 min post-drug, every 500 ml of blood loss, and 24 hours post-administration to assess hemogram, coagulation profile, and ROTEM parameters. Hemodynamic, intraoperative blood loss, and transfusion data were recorded. Data were analysed using t-tests with p<0.05 as the significance threshold. Results: The fibrinogen group had significantly lower intraoperative blood loss (1950 ± 340.3 ml vs 2342.8 ± 325.9 ml; p=0.047) and transfused pRBC volume (464.3 ± 172.5 ml vs 892.9 ± 349.3 ml; p=0.013) compared to placebo. ROTEM parameters showed significantly improved clot firmness (MCF) and fibrinogen levels from sample 2 to 5 in the fibrinogen group. No significant differences were observed at 24h post-administration. No thromboembolic events or adverse effects were reported in either group. Conclusion: Pre-emptive administration of 2g fibrinogen in PAS patients reduces intraoperative blood loss and transfusion requirement without increasing complications. Findings suggest fibrinogen may be a valuable adjunct in managing PAS-associated hemorrhage and warrant further validation in a larger cohort.