Postpartum hemorrhage (PPH) is an extremely challenging acute emergency in clinical obstetrics. 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 the quality of obstetric care. With the rising proportion of high-risk pregnant and lying-in women – such as preeclampsia complicated with diabetes and obesity, and the increasing number of complex cases including pernicious placenta previa and repeat cesarean section – a single treatment method can hardly address diverse bleeding scenarios. For this reason, Obstetrics and Gynecology Network specially invited Professor Gao Yan from Sichuan Maternal and Child Health Hospital to conduct an in-depth discussion on core issues including PPH prevention strategies, the synergistic application of pharmacotherapy and interventional therapy, and individualized intervention for high-risk populations. She shared clinical decision-making thinking in practical practice, providing obstetric medical staff with a reference that combines theoretical guidance and practical value, and helping to improve the accuracy and effectiveness of PPH treatment.
Obstetrics and Gynecology Network:
When managing severe PPH requiring multidisciplinary collaboration, what are the key considerations and priority strategies in clinical decision-making regarding the application sequence of pharmacotherapy and vascular interventional therapy (e.g., uterine artery embolization)?
Professor Gao Yan:
Postpartum hemorrhage is a common obstetric disease, and severe PPH is even one of the major causes of maternal death. The core of clinical management is to first identify the cause of bleeding. PPH is mainly caused by four factors, commonly referred to as the Four Ts:Tone (uterine atony), Tissue (placental factors such as incomplete placental delivery), Trauma (soft birth canal laceration), and Thrombin (coagulation factor deficiency).
Among them, uterine atony accounts for more than 80% of PPH cases, so interventions targeting this factor are the priority.
In terms of treatment strategies, pharmacotherapy is the first-line option. We require all obstetric departments to be equipped with uterotonic drugs. Oxytocin is routinely administered after fetal delivery, and potent uterotonics such as carboprost tromethamine, ergometrine, carbetocin, and misoprostol are kept on standby. Taking carboprost tromethamine as an example, the interval between two injections should be at least 15 minutes, and the maximum daily dose shall not exceed 8 ampoules. These drugs are highly accessible, and a PPH emergency kit is usually prepared clinically for quick access.
Pharmacotherapy and vascular interventional therapy are not contradictory and can be performed simultaneously in some cases, but the application of interventional therapy must meet specific conditions:
In clinical practice, pharmacotherapy is usually adopted first: after PPH is detected in the delivery room or operating room, medical staff immediately administer uterotonic drugs and observe the effect. If hemostasis is successful, no further intervention is needed; if pharmacotherapy fails, interventional therapy or surgical treatment is then considered.
Vascular intervention, as a conservative treatment method, is only applicable in hospitals with the required conditions.
Indications: Various refractory PPH unresponsive to conservative treatment (including uterine atony, placental factors, birth canal injury, etc.).
Contraindications: Puerperae with unstable vital signs or who are unfit to be moved; disseminated intravascular coagulation (DIC) complicated with bleeding in other organs; severe cardiac, hepatic, renal and coagulation dysfunction; and patients allergic to contrast media.
If interventional conditions are not available or the situation is emergency, laparotomy will be selected, such as uterine compression suturing, uterine vessel ligation, and hysterectomy in extreme cases.
In addition, treatment decisions should be combined with the cause of bleeding: residual placenta should be removed promptly for placental factors; lacerations should be sutured as soon as possible for birth canal injury; and coagulation factors should be supplemented targetedly for coagulation disorders.
Obstetrics and Gynecology Network:
When guiding junior doctors in managing PPH, how do you strengthen their ability to predict PPH risks (e.g., early identification of high-risk signals, accurate assessment of bleeding volume) and cultivate their emergency decision-making thinking through teaching methods such as simulation drills and case reviews?
Professor Gao Yan:
For the management of PPH, we particularly emphasize the predictability and risk assessment ability of junior doctors, and help them establish standardized clinical thinking through systematic training.
In terms of the training system, we intervene from the pregnancy period: strengthen the screening of high-risk factors during pregnancy and standardized health care, enabling doctors to detect potential risks that may lead to intrapartum bleeding as early as possible; use a PPH High-Risk Assessment Form before delivery, which includes high-risk factors such as macrosomia, polyhydramnios, placenta previa, placenta accreta, and multiple pregnancy, to complete risk prediction before entering the delivery room.
After entering the delivery room or operating room, the team will take corresponding measures according to the high-risk assessment form: midwives and medical staff jointly decide the number of venous accesses to be established and whether to conduct blood cross-matching in advance; hemostatic drugs are prepared in advance, and if high-risk factors exist, potent uterotonics such as carboprost tromethamine are immediately administered after fetal delivery.
In terms of specific skill training, we focus on two aspects:
To strengthen these abilities, we conduct simulation drills and case reviews, allowing junior doctors to familiarize themselves with the process in a non-emergency state. Adequate advance preparation can avoid chaos when actual bleeding occurs, and ensure that medical staff are "ready to respond, capable of acting, and effective in treating".
Expert Profile
Professor Gao Yan
Sichuan Maternal and Child Health Hospital
Member of the Party Committee, General Branch Secretary, Recipient of the Special Government Allowance of the State Council, Postdoctoral and Master Supervisor, Director of Maternal Health Department / Chief of Obstetrics
Academic Affiliations
Editor-in-Charge: lily
