We would like to thank Butwick for his interest in our Case Scenario.1He raises several issues that we were not able to address in depth as the Case Scenario format does not allow for an in-depth review of all aspects of the field. To address each point in turn, we agree that an epidural is indicated when the surgery is likely to outlast the duration of a spinal block. Since this is almost always the case when abnormal placentation is expected, if neuraxial analgesia is used, an epidural with or without an intrathecal dose is advisable. The article was written about a case done with regional anesthesia, but of course hemodynamic instability is a contraindication to regional anesthesia, and in this case general anesthesia is preferred.

Blood loss at cesarean hysterectomy is variable, and we agree that one should always be prepared for extensive transfusion. In spite of the reference cited by Butwick, the average blood loss at planned cesarean hysterectomy for placenta accreta is in the range of 5 units in other published series and in our experience.2,3We meant to differentiate this from placenta percreta, which is more likely to require massive transfusion and, depending on the evidence for placental invasion, might cause the practitioner to favor general anesthesia from the start of the procedure.

Newer protocols for massive transfusion with higher ratios of plasma have emerged from the trauma literature. However, as we stated in our manuscript, “Additional clinical trials are needed to establish the cost-benefit and risk-benefit profiles for procoagulant drugs and to establish standards for treatment of massive bleeding in pregnancy.”1The use of more plasma in obstetrical hemorrhage seems reasonable in massive obstetrical hemorrhage, as fibrinogen levels are often found to be low and may be associated with continued oozing even when surgical bleeding is controlled. On the other hand, pregnancy is associated with enhanced procoagulant risk, making the hematologic situation more complex. The use of thromboelastography and rotational thromboelastometry may have been advocated for management of transfusion, but outcome data supporting their use in cardiothoracic surgery has been difficult to come by4and is not available for surgery in pregnancy. Finally, it should be remembered that a single unit of plasma is preserved with more EDTA than one unit of packed erythrocytes. As such, hypocalcemia may occur more rapidly with newer transfusion protocols than traditional protocols. Large clinical trials of transfusion practices in pregnancy are important but will be difficult to conduct because bleeding is often unexpected and occurs after hours. Careful retrospective analysis of outcomes after change to a new protocol may be helpful while we wait for more definitive guidance.

Reitman E, Devine PC, Laifer-Narin SL, Flood P: Perioperative management of a multigravida at 34-week gestation diagnosed with abnormal placentation. ANESTHESIOLOGY 2011; 115:852–7
Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ: Anesthetic management for obstetric hysterectomy: A multi-institutional study. ANESTHESIOLOGY 1989; 70:607–10
Wright JD, Pri-Paz S, Herzog TJ, Shah M, Bonanno C, Lewin SN, Simpson LL, Gaddipati S, Sun X, D'Alton ME, Devine P: Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol 2011; 205:38.e1–6
Wikkelsoe AJ, Afshari A, Wetterslev J, Brok J, Moeller AM: Monitoring patients at risk of massive transfusion with Thrombelastography or Thromboelastometry: A systematic review. Acta Anaesthesiol Scand 2011; 55:1174–89