Postpartum hemorrhage (PPH) is a highly challenging obstetric emergency. It is not only one of the leading causes of maternal mortality, but its diagnosis and treatment decisions are also directly related to maternal and infant safety and obstetric medical quality. With the rising proportion of high-risk pregnant and postpartum women – such as cases of preeclampsia complicated with diabetes mellitus and obesity, as well as an increase in complex conditions including pernicious placenta previa and repeat cesarean section – a single treatment modality can no longer address diverse bleeding scenarios.
To this end, the Obstetrics and Gynecology Network specially invited Professor Zhou Wei from Chongqing Maternal and Child Health Hospital to conduct an in-depth discussion on core issues including PPH prevention strategies, the synergistic application of pharmacological and interventional therapies, and individualized intervention for high-risk populations. She shared clinical decision-making thinking from practical practice, providing obstetric medical staff with references that combine theoretical guidance and practical value, and helping to improve the precision and effectiveness of PPH management.
Obstetrics and Gynecology Network: For pregnant and postpartum women with preeclampsia complicated with diabetes mellitus, obesity and other diseases, how should clinicians combine medications (e.g., uterotonics, hemostatic drugs) to achieve the therapeutic goal of rapid hemostasis plus long-term maintenance and reduce the risk of PPH?
Professor Zhou Wei:
Preeclampsia, diabetes mellitus and obesity are all high-risk factors for PPH. The prevention and management of such patients need to cover both preventive and therapeutic aspects.
In the prevention phase, active management of the third stage of labor is the core, and prophylactic use of uterotonics is a proven effective measure. A standard dose of 10 units of oxytocin suffices for ordinary pregnant women, but oxytocin monotherapy has limited efficacy in high-risk patients and requires combination medication.A critical note: ergometrine is contraindicated in patients with preeclampsia – this drug causes intense contraction of both the uterine corpus and cervix, which may induce cerebrovascular accidents.
Prostaglandin preparations are a safer alternative in this context, with carboprost tromethamine (Hemabate) as the first choice. Compared with misoprostol, it has a faster onset, more stable efficacy maintenance, and fewer side effects such as high fever and chills. Therefore, for high-risk patients, oxytocin combined with carboprost tromethamine is recommended for prophylactic medication.
If PPH has already occurred in the patient, the medication regimen should be adjusted for treatment:
- Uterotonics can be administered at an increased dose – a second dose of both oxytocin and carboprost tromethamine is permissible, with the critical caveat that the total daily dose of carboprost tromethamine shall not exceed 8 ampoules (2000 μg).
- Hemostatic drugs should be administered concurrently; tranexamic acid is the first-line choice. It is not an adjuvant drug, but a key medication that significantly reduces PPH-related mortality.
- Contraindications must be screened before medication use – for example, carboprost tromethamine should be used with caution in patients with asthma or severe heart disease.
These conservative treatment measures can effectively prevent PPH, or stop its progression to severe, refractory bleeding, thereby reducing clinical burden and associated risks.
Obstetrics and Gynecology Network: In clinical practice, Hemabate is often used in combination with mechanical measures such as Bakri balloon and uterine compression suturing for repeat cesarean section or pernicious placenta previa cases to prevent and control PPH. What are the specific manifestations of the synergistic mechanism of this combined therapy? How to achieve more efficient hemostasis through complementary effects under different pathophysiological conditions?
Professor Zhou Wei:
The combination of Hemabate (carboprost tromethamine) with mechanical measures including Bakri balloon and uterine compression suturing is centered on achieving hemostasis through the dual effect of active contraction plus passive compression. Its synergistic mechanism can be understood from two aspects: therapeutic principle and complementarity.
In terms of therapeutic principle, the ultimate goal of all modalities is to compress blood vessels and occlude sinusoids:
✅ Hemabate, as a potent uterotonic, acts on contraction receptors in the uterine corpus, lower uterine segment and cervix to induce forced myofibril contraction – this is defined as active contractile compression, and is particularly effective for the lower uterine segment (a common bleeding site in placenta previa).
✅ Uterine compression suturing achieves passive contraction by folding the uterine myometrium; it can compress sinusoids via physical folding even if the uterus has poor spontaneous contractility.
✅ Bakri balloon exerts direct mechanical compression on the bleeding surface through intrauterine water infusion, forming pressure from the inside out.
The key complementarity of the combination lies in this: mechanical measures rely on the uterus’s basic contractile force – without strong uterine contractions, balloon tamponade may cause passive uterine distension and fail to form effective compression. Meanwhile, although uterotonics enhance active contraction, their effect on local compression of extensive bleeding surfaces is limited.
Thus, Hemabate’s active contraction provides the basic tension for mechanical measures, while the passive compression from balloon tamponade or suturing compensates for insufficient local contraction, forming a combined internal and external compression force for hemostasis.
In clinical application, this combined modality adapts to different pathophysiological states:
👉 For bleeding mainly caused by uterine atony: Hemabate is first used to enhance uterine contraction, followed by suturing to strengthen local compression.
👉 For bleeding with extensive surfaces (e.g., pernicious placenta previa): Bakri balloon is first used to control active bleeding, then Hemabate to maintain overall uterine contraction and prevent recurrent bleeding after balloon removal.
This synergy significantly improves hemostasis efficiency and reduces the risk of severe complications.
Expert Profile
Professor Zhou Wei
Chongqing Maternal and Child Health HospitalChief Physician, Professor, Master’s SupervisorDeputy Party Secretary & President, Chongqing Maternal and Child Health Hospital / Women and Children’s Hospital Affiliated to Chongqing Medical University
Academic Positions:Vice President of Chongqing Medical AssociationMember of the Labor Ward Safety and Midwifery Subgroup, Perinatal Medicine Branch of Chinese Medical AssociationVice Chairperson of the Perinatal Integrated Management of Preterm Infants Committee, Chinese Maternal and Child Health AssociationVice Chairperson of the Maternal-Fetal Medicine Committee, Chinese Eugenics Science AssociationEditorial Board Member of Chinese Journal of Practical Gynecology and Obstetrics and other academic journals
Editor: Lily
