Postpartum hemorrhage (PPH), as one of the critical obstetric emergencies, its diagnosis and treatment level are directly related to maternal and infant safety, and it is also a key focus in current obstetric and gynecological clinical practice. To further promote academic exchange in this field and assist obstetric and gynecological colleagues in improving their diagnosis and treatment capabilities, Obstetrics and Gynecology Network specially invites Professor Zhang Lijuan from Shengjing Hospital of China Medical University to analyze multi-dimensional assessment methods for early identification of PPH, share prevention and control strategies for preterm-related hemorrhage and management approaches for PPH complicated with immune factors. 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:
In the early identification of postpartum hemorrhage, besides traditional methods for assessing blood loss, which clinical indicators (such as dynamic monitoring of vital signs, laboratory tests, etc.) do you think can more accurately judge the severity of the condition? What common misunderstandings are likely to occur in primary hospitals during the identification process?
Professor Zhang Lijuan:
Early identification of postpartum hemorrhage is crucial for its diagnosis and treatment. Sudden massive hemorrhage is easy to be valued and diagnosed early, while slow and continuous minor hemorrhage and hematomas are often overlooked. To accurately judge the severity of the condition, the core lies in the correct assessment of blood loss, with the following key points to note ☟:
1. Core Logic of Blood Loss Assessment
Do not only focus on the absolute value of blood loss, but also consider the percentage of blood loss relative to total blood volume and the patient’s underlying diseases (such as anemia, hypertensive disorders of pregnancy, heart disease). Such patients have reduced tolerance and compensatory capacity for blood loss. The blood volume of non-pregnant women is 70ml/kg, which increases to 100ml/kg in the third trimester of pregnancy. For example, a 50kg pregnant woman has a blood volume of approximately 5000ml, and bleeding of 1500ml (accounting for 20%~30%) may lead to shock; while a 90kg pregnant woman with 1500ml of bleeding (accounting for about 15%) may have no obvious discomfort.
2. Clinical Assessment Methods and Indicators
Limitations of traditional assessment methods: Clinically, visual estimation, measurement methods (weighing method, volumetric method, area method), shock index (SI), hemoglobin determination, and vital signs monitoring are commonly used. However, a single method tends to underestimate blood loss, so multi-dimensional comprehensive assessment is required, with simultaneous attention to bleeding rate (an important indicator reflecting the severity of the condition).
Dynamic monitoring of vital signs: Changes in vital signs are intuitive early warning signals. In the early stage of hemorrhage, blood pressure usually does not change significantly, but the pulse may rise to >100 beats per minute; when blood loss reaches 30% of blood volume, symptoms such as increased respiratory and pulse rates, decreased blood pressure, reduced urine output, restlessness, and even lethargy will occur. Dynamic monitoring within 2 hours after delivery should be strengthened.
Shock Index (SI): Calculated as heart rate ÷ systolic blood pressure. The normal SI for adults is 0.5-0.7, and for pregnant women is 0.7-0.9. When SI=1, the estimated blood loss is about 1000ml (accounting for 20% of blood volume); when SI=1.5, the blood loss is about 1500ml (30%); when SI=2, the blood loss is >2500ml (≥50%).
2022 FIGO "30-30 Rule": When hematocrit decreases by 30%, hemoglobin decreases by 30%, systolic blood pressure decreases by 30%, and heart rate increases by 30%, the blood loss reaches 30% of the total blood volume.
Laboratory tests: In the early stage of postpartum hemorrhage, hemoglobin in routine blood tests cannot accurately reflect the actual blood loss. Arterial blood gas analysis should be performed in a timely manner to obtain real-time data on hemoglobin, lactic acid, and pH value; meanwhile, PT, APTT, fibrinogen, D-dimer, and thromboelastography should be completed. Among them, fibrinogen <2g/L is an independent risk prediction indicator for severe postpartum hemorrhage, and coagulation function tests can also provide a basis for transfusion of blood components.
3. Core Principles
Abandon the single visual estimation method, comprehensively consider clinical manifestations, vital signs, and laboratory tests, and follow the "Four Early Principles"—early call for help and team rescue, early assessment and dynamic monitoring, early etiology-based hemostasis, and early volume resuscitation and component transfusion.
4. Common Misunderstandings in Primary Hospitals
Underestimating blood loss: Relying on visual estimation or weighing method, especially insufficient judgment of non-massive, slow, and continuous hemorrhage, leading to delayed treatment.
Neglecting vital signs monitoring: Inadequate dynamic monitoring of indicators such as heart rate, blood pressure, and urine output, missing early signs of hemorrhage.
Ignoring early laboratory tests: Due to limited manpower and equipment, failure to timely perform blood gas analysis and coagulation function tests, resulting in delayed transfusion of blood components and missed opportunities for condition judgment and treatment.
Hesitant treatment decisions: Failing to quickly initiate effective rescue measures in the face of early hemorrhage symptoms due to insufficient experience or technical capacity, leading to deterioration of the condition.
Obstetrics and Gynecology Network:
For pregnant women with high-risk factors for preterm birth, how can we reduce the risk of postpartum hemorrhage through risk assessment and intervention during pregnancy? What are the key differences in hemorrhage prevention and management between preterm delivery and term delivery?
Professor Zhang Lijuan:
Preterm birth is divided into spontaneous preterm birth and therapeutic preterm birth. Individualized management should be carried out based on high-risk factors, and the core differences in postpartum hemorrhage management between preterm and term delivery should be clarified.
1. High-Risk Factors for Preterm Birth
Including a history of spontaneous preterm birth/mid-trimester miscarriage, short cervical length during pregnancy, history of cervical surgery, abnormal maternal age (too young/too old), abnormal body mass index (too low/too high), abnormal interpregnancy interval (too short/too long), multiple pregnancy, polyhydramnios, assisted reproductive technology conception, genital tract infection, uterine malformation, first-trimester vaginal bleeding, hypertensive disorders of pregnancy, pregnancy complicated with anemia, placenta accreta spectrum disorders (PAS), etc. Multiple factors may overlap.
2. Prenatal Risk Assessment and Intervention Measures
Preventing anemia: Especially for women with multiple pregnancies, hemoglobin should be maintained at ≥110g/L. Anemia weakens uterine smooth muscle contractility, delays sinus closure after placental separation, increases blood loss; at the same time, it reduces blood loss tolerance and increases infection risk, which in turn aggravates uterine subinvolution, forming a vicious cycle.
For patients with a history of recurrent spontaneous preterm birth/mid-trimester miscarriage: Such patients have a significantly increased risk of preterm birth and miscarriage in subsequent pregnancies. Tocolytic agents (nifedipine, atosiban, progesterone, magnesium sulfate) may be used during pregnancy, which increases the risk of intrapartum uterine atony; some patients require cervical cerclage, and failure to remove the suture in a timely manner when labor starts is prone to cause soft tissue laceration and postpartum hemorrhage. Intervention measures include: timely removal of cerclage suture, routine blood preparation before delivery, active use of uterotonics after delivery, and careful examination of cervical integrity and soft tissue laceration.
For underweight patients (low BMI): Prenatal nutritional guidance should be strengthened to actively prevent anemia. Due to the small total blood volume of these patients, even if the blood loss does not reach 1000ml, they may experience shock symptoms such as tachycardia, hypotension, oliguria, and restlessness. Detailed monitoring of blood loss and vital signs is required, and the depth of soft tissue laceration should be focused on after delivery.
For patients with hypertensive disorders of pregnancy: Such patients are high-risk groups for preterm birth and postpartum hemorrhage. Especially when blood pressure is poorly controlled, complicated with liver function abnormalities, thrombocytopenia, HELLP syndrome, or placental abruption, systemic vasospasm and vascular endothelial injury are likely to occur, leading to disseminated intravascular coagulation (DIC) and coagulation dysfunction. At the same time, uterine muscle cell edema causes uterine atony; and the use of prostaglandin preparations is limited, further increasing the risk of hemorrhage. Intervention measures include: stable blood pressure control during the perinatal period (target <140/90mmHg), vigilance against dilutional anemia and coagulation dysfunction caused by massive postpartum fluid replacement, and timely initiation of postpartum hemorrhage treatment.
For patients with placenta accreta spectrum disorders (PAS): Such patients need to terminate pregnancy at 34-37 weeks, which is prone to iatrogenic preterm birth, and the peroperative bleeding risk is extremely high. Preoperatively, placental MRI and ultrasound should be completed to clarify the placental location and degree of accreta; multidisciplinary consultation should be organized, blood and plasma should be prepared in advance, and intraoperative hemostasis plans (such as balloon tamponade, uterine artery ligation, special suture techniques) should be formulated.
3. Key Differences in Postpartum Hemorrhage Management Between Preterm and Term Delivery
Risk of uterine atony: Due to the small gestational age, preterm pregnant women are less sensitive to oxytocin and prostaglandins than term pregnant women, and the risk of uterine atony is higher. The use of uterotonic drugs should be strengthened during and after delivery.
Standards for uterine palpation assessment: After term delivery, a clearly defined uterine fundus located two fingers below the umbilicus indicates good uterine contraction; however, for preterm pregnant women who deliver at 30 weeks or earlier, even if the uterine fundus height is similar to the above, vigilance against poor uterine contraction is required, and comprehensive judgment should be made in combination with other indicators.
Obstetrics and Gynecology Network:
For parturients with a history of recurrent spontaneous abortion (RSA) complicated with immune factors, how to balance the management of immune-related issues while conducting hemostatic treatment when postpartum hemorrhage occurs? What potential therapeutic contradictions may exist?
Professor Zhang Lijuan:
Recurrent spontaneous abortion (RSA) refers to the loss of two or more consecutive pregnancies before 28 weeks of gestation with the same spouse. Immune factors are important etiologies. It is necessary to balance hemostasis and immune management in the treatment of postpartum hemorrhage, while addressing potential therapeutic contradictions.
1. Association Between Immune Factors and Postpartum Hemorrhage
Common immune-related diseases include antiphospholipid syndrome (APS), systemic lupus erythematosus (SLE), Sjögren's syndrome, undifferentiated connective tissue disease, rheumatoid arthritis, etc. Abnormal immune system can lead to: imbalance of immune tolerance at the maternal-fetal interface, affecting trophoblast function; formation of microthrombi in the placenta, increasing the risk of miscarriage, preterm birth, fetal growth restriction (FGR), and hypertensive disorders of pregnancy; increased risk of placental adhesion; increased bleeding risk due to the use of anticoagulant drugs during pregnancy; imbalance of immune tolerance at the maternal-fetal interface and enhanced oxidative stress, weakening uterine muscle contractility, and further increasing the incidence of postpartum hemorrhage.
2. Prenatal Stratified Management
Stratification should be carried out based on the patient’s previous adverse pregnancy and childbirth history, antiphospholipid antibody profile (type and titer), and other autoimmune antibodies (type and titer), and targeted treatment should be implemented, including antiplatelet therapy (such as low-dose aspirin, usually discontinued at 36 weeks or 1 week before delivery), anticoagulant therapy (such as low-molecular-weight heparin, prophylactic dose discontinued 12 hours before delivery, therapeutic dose discontinued 24 hours in advance), anti-inflammatory and anti-immune therapy.
3. Strategies for Balancing Postpartum Hemorrhage Treatment and Immune Management
Prevention and control of hemorrhage: If the patient needs emergency termination of pregnancy due to sudden labor or obstetric factors, aspirin or low-molecular-weight heparin may still be in use, which increases the risk of hemorrhage; if cesarean section is performed, general anesthesia also increases the probability of hemorrhage. Uterotonics such as oxytocin and prostaglandins should be used prophylactically during delivery and surgery to ensure thorough hemostasis during surgery. If necessary, abdominal and subfascial drainage should be indwelled to monitor and prevent postoperative intra-abdominal hemorrhage, subfascial hemorrhage, and subcutaneous hematoma.
Prevention of immune disease recurrence: Postpartum hemorrhage and surgical stress are prone to induce recurrence or exacerbation of autoimmune diseases. If the patient has used glucocorticoids during pregnancy, the dose should be increased during delivery to prevent adrenal insufficiency and acute onset of the disease; at the same time, close monitoring of blood pressure and blood glucose is required to alert to the risk of infection caused by high-dose hormones. Prophylactic use of antibiotics should be considered if necessary, and multidisciplinary team (MDT) consultation should be carried out for collaborative diagnosis and treatment.
4. Potential Therapeutic Contradictions
Contradiction between anticoagulant drugs and bleeding risk: Anticoagulant therapy is needed during pregnancy to prevent thrombosis, but the drugs are not fully metabolized during emergency termination of pregnancy, which increases the risk of postpartum hemorrhage.
Dual effects of hormone therapy: High-dose hormones can prevent immune disease attacks, but may lead to increased blood pressure, abnormal blood glucose, and increased infection risk, requiring a balance between efficacy and side effects.
Contradiction in the choice of anesthesia method: For patients using anticoagulant drugs undergoing cesarean section, epidural anesthesia may increase the risk of epidural hematoma, so general anesthesia should be chosen, but general anesthesia further increases the probability of postpartum hemorrhage.
Summary
Postpartum hemorrhage is the leading cause of maternal death. Currently, the proportion of high-risk pregnant women is increasing, making a single treatment method difficult 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 in the promotion of postpartum hemorrhage treatment. It is necessary to strengthen the identification and management of high-risk pregnant women; in terms of medication, it is necessary to distinguish between preventive and therapeutic drugs, and adjust medication regimens for special populations. Meanwhile, the principles for managing hemorrhage in scarred uterus, difficulties in early identification of postpartum hemorrhage, and medication strategies and coagulation function management during amniotic fluid embolism are also mentioned, providing references for obstetric medical staff in clinical practice, helping to improve the level of postpartum hemorrhage treatment and ensure maternal and infant safety.
Expert Introduction
Professor Zhang Lijuan
✿ Professor, Chief Physician, Doctoral Supervisor, Visiting Scholar at Yale University, Young Famous Doctor of "Xingliao Talent Program" in Liaoning Province. Director of the 6th Obstetric Ward, Shengjing Hospital of China Medical University.
✿ Academic Positions: Member of the Youth Group of the Perinatal Medicine Branch of the Chinese Medical Association; Deputy Chairman of the Perinatal Medicine Branch of the Liaoning Medical Association; Chairman of the Youth Committee of the Northeast Obstetrics and Maternal-Fetal Medicine Branch of the Liaoning Society of Life Sciences; Director of the Liaoning Immunology Society; Standing Committee Member of the Pregnancy Immunology Branch of the Liaoning Immunology Society, etc.
✿ Scientific Research: Principal investigator of two National Natural Science Foundation projects and two provincial projects related to preterm birth; participant in multiple national, provincial, and municipal projects; published more than 20 SCI papers and multiple core journal articles as the first author or corresponding author. Invited reviewer of "Chinese Journal of Perinatal Medicine" and first-instance expert of the National Natural Science Foundation of China. Main research directions: prediction, prevention, and treatment of preterm birth and late miscarriage, as well as research on the pathogenesis of labor.
✿ Professional Expertise: Prevention and treatment of preterm birth, cervical insufficiency, recurrent spontaneous abortion, repeated implantation failure, hypertensive disorders of pregnancy, etc.; proficient in cervical cerclage, various complex cesarean sections, critical maternal rescue, and management of dystocia in vaginal delivery.
Editor-in-Charge: Lily
