We thank Drs. Palmer and Frölich for their questions regarding our article recently published in Anesthesiology.1We would like to respond to their questions. Even though this was not a prospective trial but rather a prospective study, in the last paragraph of our introduction, we describe admission criteria for a cohort of women referred to our hospital in severe postpartum hemorrhage. Also defined in this paragraph are our outcome measures (incidence and outcome of myocardial ischemia and identification of independent risk factors for myocardial ischemia in this subpopulation). Furthermore, we extensively described in the Materials and Methods how these outcome measures were detected (electrocardiogram, cardiac troponin I). Cardiac complications were those described by Arlati et al. ,2which are likely related to myocardial ischemia.

As usual, univariate analysis was performed before multivariate analysis. The univariate step allowed a better understanding of the relations between variables and outcomes and allowed to select the variables to introduce in the multivariate model building process (screening process). Indeed, our conclusion was only based on the multivariate analysis. Using multivariate stepwise modeling, the α risk was fixed and appropriately maintained during the procedure. Accordingly, low systolic and diastolic blood pressures and increased heart rate can be considered true independent predictors of myocardial injury in studied patients. In addition, catecholamines were administered exclusively in patients with high cardiac troponin I, implying a strong link between catecholamine administration and myocardial ischemia. As regards the comment on the power, it is not relevant because, as stated in the Conclusion, our study did not rule out other factors that were not identified in our study. However, it is true that the small number of patients implied that we had a reasonable probability only for detecting parameters corresponding to large odds ratio, thus clinically important.

Finally, we would like to reflect on the high prevalence of myocardial ischemia in “poorly resuscitated” women. The mortality as described in the literature is relatively high in this cohort of women, close to 5% in Western countries.3To date, the study presented by our group1is the largest worldwide series of parturients admitted with severe postpartum hemorrhage with hemodynamic follow-up. We are one of the main reference centers for this pathology, catering to 10 million inhabitants in the Paris region in close collaboration with well-trained interventional radiologists and obstetricians. In a series of more than 400 such patients, the majority of which were transferred from other hospitals, mortality remains less than 2% (mostly amniotic embolisms), likely because we learned to focus, during transport and during early hospital stay, on restoring blood pressure, hemoglobin level, and heart rate while surgical treatment and/or embolization are performed, as rapidly as possible, to stop uterine bleeding and prevent myocardial ischemia.

* Hôpital Lariboisière, Paris, France. alexandre.mebazaa@lrb.ap-hop-paris.fr

Karpati CJ, Rossignol M, Pirot M, Cholley B, Vicaut E, Henry P, Kevorkian JP, Schurando P, Peynet J, Jacob D, Payen D, Mebazaa A: High incidence of myocardial ischemia during post-partum hemorrhage. Anesthesiology 2004; 100:30–6
Arlati S, Brenna S, Prencipe L, Marocchi A, Casella GP, Lanzani M, Gandini C: Myocardial necrosis in ICU patients with acute non-cardiac disease: A prospective study. Intensive Care Med 2000; 26:31–7
Panchal S, Arria AM, Harris AP: Intensive care utilization during hospital admission for delivery: Prevalence, risk factors, and outcomes in a statewide population. Anesthesiology 2000; 92:1537–44