Postpartum hemorrhage (PPH) is a critical emergency in obstetrics and one of the leading causes of maternal mortality. Its diagnosis and treatment directly relate to maternal and infant safety and the quality of obstetric care. With the increasing proportion of high-risk pregnant women (such as those with preeclampsia, advanced age, and scarred uterus), the difficulty of clinical management has significantly increased. To address this, Obstetrics and Gynecology Network specially invites Professor Hua Xiaolin from the International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine to elaborate on the pathophysiological mechanisms, high-risk prevention, and combined medication strategies for postpartum hemorrhage in preeclamptic patients with underlying diseases. Drawing on practical experience, she provides core decision-making insights to offer precise references for obstetric healthcare professionals and enhance their ability to manage postpartum hemorrhage.

Obstetrics and Gynecology Network

The risk of postpartum hemorrhage in preeclamptic patients is significantly higher than in ordinary pregnant women. From a pathophysiological perspective, which factors play key roles? What preventive measures are taken prenatally and intrapartum for high-risk preeclamptic patients?

Professor Hua Xiaolin

International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

➱ The high risk of postpartum hemorrhage in preeclamptic patients is fundamentally determined by their pathophysiological mechanisms, mainly involving five key factors:

Abnormal placental implantation and blood vessels: Preeclamptic patients have shallow placental implantation and inadequate remodeling of uterine spiral arteries, leading to increased fragility of distal arteries. When separated from the placenta, blood pools are prone to form, directly increasing the risk of hemorrhage.

Decreased uterine contractility: Patients often have generalized edema, and the uterine myometrium also exhibits relative edema, which directly impairs uterine contraction. Meanwhile, medications for preeclampsia (such as antihypertensives, spasmolytics, and sedatives) can also inhibit uterine contraction to a certain extent. These dual factors elevate the risk of uterine atony-related hemorrhage.

Superimposed effect of high-risk populations: Preeclampsia is more common in obese and advanced-age individuals, who are already high-risk groups for postpartum hemorrhage. The combination of these two high-risk factors further amplifies the bleeding risk.

Coagulopathy decompensation: Patients have abnormalities in the coagulation system—on one hand, the number of coagulation factors increases but the level of anticoagulant factors decreases; on the other hand, complications such as placental abruption lead to excessive consumption of coagulation factors (especially a sharp drop in fibrinogen). Additionally, preeclampsia may involve the liver, causing liver function impairment and reducing coagulation factor synthesis. These multiple issues trigger coagulopathy-related hemorrhage.

Genetic factors: Genetic mutations in coagulation factors (such as Laden mutation) can also increase the likelihood of postpartum hemorrhage in preeclamptic patients to a certain extent.

➱ For high-risk preeclamptic patients, we formulate preventive measures in two stages: "prenatal" and "intrapartum":

Prenatal prevention: The primary task is to correct antenatal anemia to reserve tolerance for intrapartum bleeding. Secondly, reasonable calcium supplementation is needed to enhance uterine contractility. Meanwhile, prophylactic use of low-molecular-weight heparin (LMWH) is feasible—it does not increase the incidence of postpartum hemorrhage but instead reduces the bleeding risk.

Intrapartum prevention: Most patients with severe preeclampsia terminate pregnancy via cesarean section, which should be performed by senior physicians to ensure surgical safety. Intraoperatively, blood pressure must be strictly maintained stable to avoid excessive fluctuations, as blood pressure changes significantly increase bleeding risk. Furthermore, uterotonics should be administered early (not waiting for bleeding to occur). However, caution is required: if the patient has concurrent uterine fibroids (e.g., subserosal fibroids), uterotonics should be used cautiously to prevent a sharp rise in blood pressure. If bleeding signs appear, coagulation factors (such as platelets) should be transfused promptly to halt the progression of hemorrhage.

Obstetrics and Gynecology Network

For preeclamptic patients with comorbidities such as diabetes, obesity, or thyroid dysfunction, the risk of postpartum hemorrhage exhibits a "multifactorial superimposed" effect. In clinical practice, how to implement combined medication to achieve the therapeutic goal of "rapid hemostasis + long-term maintenance"? For potent uterotonics, how to rationally apply them in combined medication regimens to exert their advantages while avoiding potential risks?

Professor Hua Xiaolin

When preeclampsia is complicated by diabetes, obesity, or thyroid dysfunction, the patient’s physical foundation is more fragile, leading to increased bleeding risk and management difficulty. Clinically, we adhere to the principle of "prevention first + combined intervention," with specific measures as follows:

1. Combined Medication Strategy for "Rapid Hemostasis + Long-Term Maintenance"

The core is "uterotonic combination + simultaneous basic disease management": First, use short-acting uterotonics (such as oxytocin) to rapidly initiate uterine contraction and achieve immediate hemostasis. Then, combine with long-acting uterotonics to maintain uterine contraction and prevent recurrent bleeding. Meanwhile, basic issues must be managed synchronously—for example, stabilizing blood glucose (to avoid hyperglycemia affecting coagulation and wound healing), monitoring thyroid function (thyroid abnormalities may exacerbate uterine atony), rationally using LMWH to prevent thrombosis (preeclamptic patients are prone to hypercoagulability postpartum, with coexisting thrombosis and bleeding risks), and appropriately administering antibiotics to prevent infection, thereby reducing the interference of complications on hemostasis.

2. Principles for Rational Application of Potent Uterotonics

Strictly adhere to the "prevention-first" medication timing: Potent uterotonics should not be administered until bleeding reaches a certain threshold. Instead, for high-risk patients with multiple superimposed factors, they should be used early after delivery (or during cesarean section) to proactively prevent bleeding.

Clarify medication indications and dosage: The dosage of potent uterotonics (such as carbetocin) should be adjusted based on the patient’s blood pressure, heart rate, and uterine contraction status. Especially for preeclamptic patients with hypertension, excessive dosage should be avoided to prevent a sharp rise in blood pressure. If the patient has underlying cardiovascular diseases, administration should be under close monitoring.

Combine with surgical intervention to enhance efficacy: If uterotonics are ineffective, surgical methods (such as uterine artery ligation, B-Lynch suture) should be promptly combined to minimize intraoperative bleeding. Postoperatively, close observation of bleeding is crucial, with systematic screening for the "4 Ts" (Tone: uterine atony; Tissue: retained placenta/membranes; Trauma: genital tract laceration; Thrombin: coagulopathy). Timely targeted treatment is required—for example, urgent curettage for retained placenta, prompt suture for genital tract laceration, and supplementation of coagulation factors for coagulopathy. Through the combined regimen of "medication + surgery + targeted treatment," the goal of hemostasis is achieved while reducing risks.

Summary

Postpartum hemorrhage is the leading cause of maternal death. With the increasing number of high-risk pregnant women (e.g., preeclampsia, advanced age, scarred uterus), single-modal treatment can no longer meet clinical needs. Professor Hua Xiaolin elaborates on the key mechanisms of postpartum hemorrhage in preeclamptic patients, provides prenatal and intrapartum preventive measures, and outlines combined medication strategies for patients with underlying diseases. This offers valuable references for obstetric healthcare professionals and helps improve the level of hemorrhage management.

Expert Profile

Professor Hua Xiaolin

MD, Chief Physician, Doctoral Supervisor

Director of Perinatal Medicine, International Peace Maternity and Child Health Hospital Affiliated to Shanghai Jiao Tong University School of Medicine

✿ Standing Committee Member, Obstetric and Gynecological Health Medicine Association of China International Exchange and Promotion Association for Medical and Health Care

✿ Standing Committee Member, Obstetrics and Gynecology Professional Committee of Chinese Research Hospital Association

✿ Committee Member and Secretary, Obstetrics and Gynecology Branch of Shanghai Medical Association; Director, Obstetrics Group

✿ Expert, Medical Malpractice Appraisal Expert Database of Shanghai Medical Association

✿ Committee Member, Sexual Education Branch of Chinese Sexological Association

✿ Director, Shanghai Sexual Education Association

✿ Standing Committee Member, Anti-Aging Branch of National Health Industry Enterprise Management Association

✿ Advanced Worker in Shanghai Health System (2021)

✿ Outstanding Academic Leader of Shanghai Municipal Health Commission (2022)

✿ Research Focus: Hypertensive disorders of pregnancy and pregnancy complicated with cardiovascular diseases

✿ Principal Investigator of multiple research projects, including 3 National Natural Science Foundation projects. First/corresponding author of 48 papers (38 SCI-indexed), with a total impact factor exceeding 150. Holder of 2 invention patents

Editor-in-Charge:Lily