In Reply:—
“Those who stare at the past have their backs turned to the future.”—Anonymous
I thank Drs. Waters and Ford for an additional opportunity to share the legacy of Gerard Ostheimer and highlight the purpose of the “What’s New in Obstetric Anesthesia” lecture given in his honor at Annual Meeting of the Society for Obstetric Anesthesia and Perinatology. The lecture and accompanying articles in Anesthesiology1and the International Journal of Obstetric Anesthesia 2serve as a review of published literature from the preceding calendar year relevant to clinical care and research in the obstetric patient. Although the Anesthesiology article provides a more focused look at a few subtopics, the overall premise is to feature new and novel concepts, techniques, and advances in understanding.
Recombinant factor VIIa, interventional radiology embolization, and Sengstaken-Blakemore esophageal balloon catheters in the management of obstetric hemorrhage are modalities that can be described as both new and novel; more importantly, each represents a potentially lifesaving intervention for which there is growing literature support. Of note, although Drs. Waters and Ford are advocates for the controversial use of cell salvage in the obstetric setting,3,4I am not aware of any published reports where cell salvage has been able to successfully reverse clinical disseminated intravascular coagulation, as has been reported with recombinant factor VIIa,5–7or stop postpartum hemorrhaging from specific uterine vessels, as witnessed with interventional radiology procedures,8,9and from diffuse intrauterine vessels, as observed with Sengstaken-Blakemore esophageal balloon catheters.10,11Within the past 6 months, I have personally witnessed the successful reversal of disseminated intravascular coagulation with recombinant factor VIIa in two hemorrhaging obstetric patients and the avoidance of three gravid hysterectomies through the involvement of interventional radiology.
Drs. Waters and Ford misinterpret the level of support given to erythropoietin and darbepoetin, a hyperglycosylated analog, in obstetric patients. Indeed, the limited understanding of erythropoietin has been properly framed in the original article, and further investigations will be needed. Clearly, the induction of erythrocyte production through endogenous or exogenous erythropoietin during pregnancy is a complex riddle that will require robust analyses into the influences of iron, serum ferritin, transferrin, and hormones such as estradiol.12
It is interesting that all of the modalities cited above are finding increased validation in clinical practice. Although further investigations are necessary, even with cell-saver technologies, the introduction of new concepts and modalities for investigators and clinicians is vital to the practice of anesthesia. The value of many “old” modalities in the control of obstetric hemorrhage should be acknowledged; however, the most appropriate and specific interventions may not currently be known, and for these situations, an acceptance of what is “new and novel” may be the difference between life and death.
Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts. ltsen@zeus.bwh.harvard.edu
