We thank Holck et al.  for their interest in our publication and comments regarding our flow diagram guiding the management of amniotic fluid embolism.1The format of our case scenario was intended to be an overview of the presentation and management of amniotic fluid embolism, and the purpose of the flow chart was to serve as a very general educational guide toward management options. It was not meant to be a completely exhaustive algorithm of clinical analysis and treatment course.

However, we appreciate the authors suggesting the possibility of using fibrinogen concentrate as a newer alternative blood product therapy. We acknowledge that there may be a benefit of rapid low-volume bolus administration when compared with the delay encountered to thaw fresh frozen plasma or cryoprecipitate. However, use of fibrinogen concentrate also relies on its availability. Neither our community-based obstetric unit nor our level I trauma university hospital has fibrinogen concentrate readily available, and we suspect the same may be true of many institutions. It is also important to recognize that the dose and timing of administration of alternative blood products remains controversial.2,3As was discussed both in our case scenario and emphasized by Holck et al. , the use of factor VII should only be considered in cases of hemorrhage refractory to other therapies due to the risk of embolic consequences. Caution should also likely be exercised for fibrinogen concentrate because larger prospective studies are needed to determine its clinical efficacy and safety.3 

Holck et al.  are correct in stating that there is probably no flow chart that would direct every possible available therapy in managing the coagulopathy and the hemodynamic presentation of cases of amniotic fluid embolism. We would like to reemphasize the importance of having a transfusion protocol for massive obstetric hemorrhage, regardless of etiology. A multidisciplinary approach with specific guidelines outlining rapid, early, and aggressive intervention and resuscitation is likely to optimize maternal outcomes.4,5 

Dean LS, Rogers RP 3rd, Harley RA, Hood DD: Case scenario: Amniotic fluid embolism. ANESTHESIOLOGY 2012; 116:186–92
Bell SF, Rayment R, Collins PW, Collis RE: The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth 2010; 19:218–23
Sørensen B, Tang M, Larsen OH, Laursen PN, Fenger-Eriksen C, Rea CJ: The role of fibrinogen: A new paradigm in the treatment of coagulopathic bleeding. Thromb Res 2011; 128 Suppl 1:S13–6
Skupski DW, Lowenwirt IP, Weinbaum FI, Brodsky D, Danek M, Eglinton GS: Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006; 107:977–83
Lyndon A, Lagrew D, Shields L, et al. (Eds). Improving health care response to obstetric hemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Care Quality Care Collaborative, 2010