Postpartum hemorrhage is one of the obstetric critical emergencies. Its diagnosis and treatment level are directly related to maternal and infant safety, and it has become a key focus in current obstetric and gynecological clinical practice. To further promote academic exchanges in this field and help obstetric and gynecological colleagues improve their diagnostic and treatment capabilities, Obstetrics and Gynecology Network specially invites Professor Gao Jinsong from Peking Union Medical College Hospital, Chinese Academy of Medical Sciences to focus on the key points of perinatal health care for special groups such as elderly pregnant women and multiple pregnancies, and elaborate on the standard emergency management of complications including placental abruption and postpartum hemorrhage. This interview aims to provide practical decision-making ideas for obstetric medical staff, enhance the accuracy and effectiveness of treatment, and ensure maternal and infant safety.

Obstetrics and Gynecology Network:

What key points require special attention in perinatal health care for special groups such as elderly pregnant women and multiple pregnancies?

Professor Gao Jinsong:

Currently, the proportion of pregnant women with high-risk factors is on the rise, among which the number of elderly pregnant women has increased significantly. Perinatal health care classifies pregnant and puerperal women into four risk levels: green, yellow, orange, and red, based on risk factors. Elderly pregnant women fall into the yellow category, indicating general risk with an increased tendency; those over 40 years old are classified as orange, with higher risks.

☞ Three main manifestations of increased risks in elderly pregnant women:

Elevated risk of medical and surgical comorbidities: Higher incidence of internal diseases such as diabetes and hypertension, which significantly increases pregnancy risks.

Increased risk of pregnancy complications: Including gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), leading to a marked rise in maternal risks.

Increased fetal risks: The incidence of fetal chromosomal abnormalities (e.g., Down syndrome) is significantly higher than in younger pregnant women. Additionally, due to the higher prevalence of maternal comorbidities and complications, the risks of preterm birth and fetal growth and development abnormalities also increase accordingly.

Therefore, it is recommended that elderly pregnant women undergo prenatal examinations and delivery in tertiary hospitals or maternal and child health hospitals with rescue capabilities.

The incidence of twin pregnancies has reached 3% or higher due to the increasing age of pregnant women and the application of in vitro fertilization (IVF) technology. All complications and comorbidities of twin pregnancies (e.g., preterm birth, diabetes, HDP) carry higher risks than singleton pregnancies.

Furthermore, special types of twin pregnancies such as monochorionic diamniotic (MCDA) twins and monochorionic monoamniotic (MCMA) twins may be complicated by fetal-specific conditions including twin-twin transfusion syndrome (TTTS), selective fetal growth restriction (sFGR), and intrauterine fetal demise (IUFD) of one twin. Pregnant women with twin pregnancies should also undergo prenatal examinations and delivery in hospitals equipped with diagnostic and therapeutic capabilities in accordance with perinatal health care requirements.

Obstetrics and Gynecology Network:

What standard emergency management measures are usually adopted clinically when obstetric complications (such as placental abruption and postpartum hemorrhage) occur? How should pregnant women and their families cooperate?

Professor Gao Jinsong:

Placental abruption is the most common cause of antepartum hemorrhage, while postpartum hemorrhage is the most common cause of postpartum hemorrhage. Both require high attention.

☞ Emergency management and cooperation for placental abruption

Patients with hypertensive disorders of pregnancy, diabetes, autoimmune diseases, and fetal growth restriction are at higher risk of placental abruption. For this high-risk group, enhanced monitoring and self-monitoring guidance are necessary, including daily blood pressure monitoring and attention to early symptoms such as abdominal pain, vaginal bleeding, and persistent uterine contractions. Once abnormalities occur, timely medical consultation is required to avoid increased risk of intrauterine fetal death due to acute and severe conditions.

Medical staff should conduct adequate health education and comprehensive management of patients' comorbidities. When receiving patients with unexplained abdominal pain, vaginal bleeding, and abnormal fetal heart rate, vigilance for placental abruption and timely diagnosis are essential. It is particularly important to note that placental abruption is mainly diagnosed clinically and cannot be fully relied on ultrasonography, to avoid delayed treatment due to excessive dependence on examinations.

☞ Emergency management and cooperation for postpartum hemorrhage

Postpartum hemorrhage is the most common complication in obstetrics, which can lead to severe maternal complications and is also the leading cause of maternal death.

The treatment of postpartum hemorrhage is based on two core principles:

Etiological treatment targeting causes such as uterine atony, placental factors, soft tissue trauma of the birth canal, and coagulopathy;

Rescue of hemorrhagic shock in patients with excessive blood loss. Both must be carried out simultaneously, and neither can be neglected. During the rescue, close monitoring of the patient's vital signs and management of subsequent complications such as infection are required.

Escalation management model for postpartum hemorrhage treatment

For patients unresponsive to conventional uterotonic therapy and uterine massage, more effective hemostatic measures such as intrauterine balloon tamponade, uterine artery embolization (UAE), and surgical suturing should be adopted. If bleeding cannot be controlled and threatens the patient's life, hysterectomy should be considered. Accurate assessment of blood loss is crucial in the diagnosis of postpartum hemorrhage. It is recommended to use precise measurement tools such as blood collection pads for timely diagnosis and to avoid delayed treatment due to inaccurate assessment.

Obstetrics and Gynecology Network:

What are the differences between common prenatal screening and diagnostic technologies (such as Down syndrome screening, non-invasive prenatal testing (NIPT), and amniocentesis)? Which populations are they suitable for?

Professor Gao Jinsong:

Down syndrome screening and NIPT are prenatal screening technologies, not diagnostic methods. They are mainly used to screen for fetal chromosomal abnormalities (especially trisomy 21) and identify potentially affected fetuses in the general population. Patients with positive screening results must undergo further confirmation through prenatal diagnostic technologies such as chorionic villus sampling (CVS), amniocentesis, or umbilical vein puncture.

Technical differences and applicable populations

1. Prenatal screening technologies (Down syndrome screening, NIPT)

Both are screening methods for preliminary risk assessment of fetal chromosomal abnormalities but cannot provide a definitive diagnosis.

They are mainly suitable for the general population to evaluate the risk of fetal chromosomal abnormalities (e.g., trisomy 21). For elderly pregnant women (maternal age ≥ 35 years at delivery), amniocentesis for prenatal diagnosis was previously recommended. With the popularization of NIPT, more patients now choose this technology. However, it is necessary to fully inform patients of the advantages and disadvantages of each technology and allow them to make autonomous choices.

2. Prenatal diagnostic technologies (e.g., amniocentesis)

Including CVS, amniocentesis, and umbilical vein puncture, these are definitive diagnostic methods that can confirm the presence of fetal chromosomal abnormalities and other genetic diseases.

☞ Applicable to the following populations:

(1) Patients with positive prenatal screening results, who require definitive diagnosis through these technologies;

(2) Patients with a family history of specific genetic diseases or a history of delivering abnormal fetuses: Prenatal counseling and genetic evaluation should be conducted first. Some patients are not suitable for prenatal screening and are advised to undergo direct prenatal diagnosis;

(3) Patients with abnormal fetal ultrasonography results: Prenatal screening is not recommended to rule out genetic diseases, and direct prenatal diagnosis should be performed.

In addition to detecting fetal chromosomal diseases, prenatal diagnosis can currently identify other genetic conditions such as fetal microdeletion and microduplication syndromes, as well as gene mutations. The appropriate technology should be selected based on the patient's specific circumstances and needs. Both prenatal screening and diagnostic results must be consulted and interpreted by qualified professional doctors.

Summary

Postpartum hemorrhage is the leading cause of maternal death. The rising proportion of high-risk pregnant and puerperal women has made single treatment methods insufficient to meet clinical needs. Experts point out that primary hospitals face challenges such as insufficient hardware facilities, lack of medical staff skills, and limited blood supply guarantee in promoting postpartum hemorrhage rescue. It is necessary to strengthen the identification and management of high-risk pregnant and puerperal women. In terms of medication, it is essential to distinguish between preventive and therapeutic drugs, and adjust medication regimens for special populations. Additionally, the principles for managing bleeding in scarred uterus, difficulties in early identification of postpartum hemorrhage, and medication strategies and coagulation function management during amniotic fluid embolism (AFE) are discussed. This interview provides references for obstetric medical staff in clinical practice, helping to improve the level of postpartum hemorrhage rescue and ensure maternal and infant safety.

Expert Introduction

Professor Gao Jinsong

✿ Director of the Obstetric Center, Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences

✿ Doctor of Medicine (M.D.), Chief Physician, Doctoral Supervisor

✿ Expertise: Perinatal health care, management of high-risk pregnancies, treatment of obstetric comorbidities and complications.

✿ Has presided over multiple national, provincial, and institutional-level scientific research projects, and published more than 100 professional articles.

✿ Current positions: Member of the Obstetrics Group, Gynecological Branch of the Chinese Medical Association; Member of the Preterm Birth and Preterm Infant Group, Perinatal Medicine Branch of the Chinese Medical Association; Vice Chairman of the Perinatal Nutrition and Metabolism Professional Committee, China Maternal and Child Health Association; Standing Committee Member of the Perinatal Medicine Branch of the Beijing Medical Association; Standing Committee Member of the Obstetrics and Gynecology Branch of the Beijing Medical Association, etc.

✿ Editorial Board Member of Journal of Reproductive Medicine, Peking Union Medical College Journal, and Maternal Fetal Medicine; Corresponding Editorial Board Member of Chinese Medical Journal.

Editor-in-Charge: Lily