As an extremely challenging acute condition in obstetric clinical practice, postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality. The scientificity and timeliness of its diagnosis and treatment decisions are directly related to the bottom line of maternal and infant safety and the quality of obstetric medical services. To this end, Obstetrics and Gynecology Network specially invites Professor Wang Zilian from the First Affiliated Hospital of Sun Yat-sen University to share practical decision-making ideas based on clinical experience, focusing on core issues such as early warning of PPH, coordinated medical and surgical intervention, and individualized management of high-risk groups. This sharing aims to provide reference for obstetric medical staff, help improve the accuracy and effectiveness of treatment, and ensure maternal and infant safety.
Obstetrics and Gynecology Network:
Postpartum hemorrhage is the top cause of maternal death. In recent years, both the central and local governments have been promoting the sinking of PPH treatment technologies to the primary level. In the process of regional promotion, what specific challenges do you think exist? What measures may more effectively promote the regional popularization of standardized primary-level treatment?
Professor Wang Zilian:
Maternal mortality caused by postpartum hemorrhage is a major global issue. In China, with policy support and strengthened primary-level construction, the number of related deaths has continued to decline, but there is still significant room for improvement in remote primary-level hospitals.
1. Challenges in Regional Promotion
Insufficient hardware configuration: PPH treatment requires support from medications, monitoring methods, equipment, and surgical skills. Some primary-level hospitals lack adequate medications and equipment.
Need for improved medical staff skills: Primary-level obstetricians need to enhance their capabilities in precise medication use, identification of high-risk patients, rational application of drugs and equipment, and risk management techniques.
Limited blood supply: Primary-level hospitals with poor medical resources face insufficient blood supply, making it difficult to promptly transfer high-risk patients to hospitals with adequate treatment capabilities, which affects the success rate of rescue.
2. Effective Measures to Promote Standardized Primary-Level Treatment
Strengthen identification of high-risk factors: Obstetric medical staff and institutions should accurately identify PPH high-risk factors from the first trimester and conduct adequate preventive work.
Precise assessment of postpartum blood loss: During childbirth, medical staff must accurately assess blood loss to provide a basis for timely initiation of PPH treatment.
Emphasize application of preventive measures: For uterine atony (the main cause of PPH), preventive measures should be applied promptly. More potent uterotonics can be used for patients with high-risk factors.
Standardize post-hemorrhage management: If medical treatment for hemorrhage is ineffective, treatment measures should be upgraded in a timely manner in accordance with the stepwise principle—starting with basic physical hemostatic methods such as manual uterine compression. If compression fails, minimally invasive device compression (e.g., intrauterine balloon tamponade) can be used. If hemorrhage still cannot be controlled, invasive suture hemostasis (e.g., uterine compression suturing) is indicated for scenarios such as uterine atony and placental abruption.
Enhance targeted drills: Primary-level hospital doctors should conduct regular drills based on local conditions to continuously improve rescue skills.
Obstetrics and Gynecology Network:
How do you think we can help primary-level doctors transition from "guideline-based medication" to "individualized precision medication"? For special populations (e.g., elderly parturients, those with pregnancy complicated by hypertension/diabetes), how to promote the precision of individualized medication? How to optimize medication safety through multidisciplinary collaboration (MDC)?
Professor Wang Zilian:
1. Measures to Achieve the Medication Transition
Clarify drug classification and application timing:
PPH medications are divided into preventive and therapeutic drugs. Basic preventive drugs (e.g., oxytocin, ergot alkaloids—contraindicated in patients with hypertension and heart disease) should be actively administered within 2 hours after delivery. For patients with high-risk factors for uterine atony (e.g., macrosomia delivery, large uterine fibroids, abnormal placental position, polyhydramnios) whose blood loss meets the PPH initiation criteria, therapeutic drugs should be added promptly.
Strengthen refined management capabilities:
Obstetricians must accurately assess each patient’s PPH risk factors and blood loss to avoid delayed treatment due to insufficient evaluation—this is the core basic skill for achieving precision medication.
2. Strategies for Precise Individualized Medication in Special Populations
Pregnancy complicated with hypertension:
Doctors must master the mechanism of action and side effects of uterotonics. Caution should be exercised when using uterotonics that may increase blood pressure, with close monitoring. If necessary, switch to safe uterotonics that do not affect blood pressure.
Pregnancy complicated with diabetes mellitus:
Blood glucose should be closely monitored during childbirth. Metabolic abnormalities caused by poor glycemic control may affect uterine contractions, so glycemic management is crucial. Currently, commonly used clinical uterotonics have minimal impact on blood glucose, but individual drugs may affect blood pressure, requiring precise evaluation.
3. Optimizing Medication Safety Through Multidisciplinary Collaboration
Obstetric medical staff must clearly grasp the pharmacokinetics and mechanism of action of drugs, including onset time, duration, and optimal administration route. For each patient, risk factors should be listed before delivery, a delivery plan and contingency plan formulated, potential scenarios predicted, and corresponding drugs prepared. Through multidisciplinary collaboration, individualized management can be achieved to ensure delivery safety.
Summary
Postpartum hemorrhage is the leading cause of maternal death. The increase in high-risk pregnant women has made single-modality treatment inadequate. Experts point out that regional promotion at the primary level faces challenges such as insufficient hardware, inadequate staff skills, and limited blood supply, which require strengthened high-risk factor identification and other measures. Medication should be classified into preventive and therapeutic categories, with adjustments for special populations. Additionally, principles for hemostasis in scarred uterus, difficulties in early identification of hemorrhage, and medication and coagulation management in amniotic fluid embolism are discussed, providing valuable references for obstetric medical staff.
Expert Introduction
Professor Wang Zilian
First Affiliated Hospital of Sun Yat-sen University
Chief Physician, Professor, Doctoral Supervisor, Vice President of the First Affiliated Hospital of Sun Yat-sen University
Has in-depth research and rich clinical experience in perinatal medicine, especially in high-risk pregnancy, maternal-fetal monitoring, multiple pregnancy, gestational diabetes mellitus, and diagnosis and treatment of pregnancy complicated with internal and surgical diseases. Participated in the formulation of multiple obstetric diagnosis and treatment guidelines.
Has received funding from various projects, including the National Natural Science Foundation of China, National Key R&D Program, Ministry of Health Industry Project, World Diabetes Foundation, Guangdong Provincial Natural Science and Social Development Project, Guangzhou Science and Technology Plan Project, and Sun Yat-sen University 5010 Project. Published numerous academic papers in domestic and international journals.
Recipient of honors such as Excellent Teacher of Guangdong Province, Baogang Excellent Teacher Award of the Ministry of Education, and Distinguished Teacher of Sun Yat-sen University. Has hosted multiple sessions of the "Zhongshan Maternal-Fetal Monitoring Forum," playing an active role in disseminating new obstetric knowledge and concepts.
Editor-in-Charge: Lily
