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Abstract

We thank Dr Palacios Jaraquemada for his interest in our report. We would like to clarify several misinterpretations. First, we agree that typical muscle hematoma can easily be diagnosed by ultrasound when there is relevant trauma history and the presence of identifiable fluid-fluid levels.1van Holsbeeck MT Introcaso JH Sonography of muscle.in: 2nd ed. Musculoskeletal ultrasound. Mosby, St. Louis2001: 23-76Google Scholar However, as in our patient, acute active bleeding may lead to increased echogenicity of the abdominal wall muscles, which may be indistinguishable from thickened fibroadipose septa of the swollen muscles in the immediate postcesarean period. Second, postpartum hemorrhage (PPH) is a clinical diagnosis based on pertinent delivery history and massive uterine bleeding but not pelvic angiography. Occasionally, uterine hemorrhage cannot be demonstrated on angiography because it may be intermittent as a result of vascular spasm or its rate may be too low during taking angiographic films. For life-saving purposes, embolization of uterine arteries or hypogastric arteries should be immediately performed in such critical conditions as in our patient, regardless of whether the bleeding source is visible on angiography. In our patient, the decision was correct because her vaginal bleeding stopped immediately after embolization of bilateral uterine and hypogastric arteries, although the hypotension was not fully corrected. We agree that aortography should be the initial diagnostic approach. Indeed, we performed aortography at the beginning of the angiographic examination, on which bleeding from the inferior epigastric artery was suspicious and, thus, subsequent selective angiography was needed for confirmation. Third, Dr Palacios Jaraquemada has cited a case report of delayed PPH resulting from collateral supply from the epigastric artery after hypogastric artery2Sproule MW Bendomir AM Grant KA Reid AW Embolisation of massive bleeding following hysterectomy, despite internal iliac ligation.Br J Obstet Gynaecol. 1994; 101: 908-909Crossref PubMed Scopus (25) Google Scholar and has misinterpreted as this kind of anastomosis being the vaginal bleeding source in our patient. In fact, inferior epigastric artery bleeding of our patients did not contribute to vaginal bleeding; instead, it contributed to the concurrent abdominal wall hemorrhage related to inadvertent arterial injury during cesarean delivery. Fourth, our Fig 1 (left) demonstrates substantial difference in opacification of the right internal iliac artery and the right external iliac artery: good in the former but very poor in the latter. It is because the angiography catheter was placed in the right external iliac artery, hindering arterial inflow and causing a delay in opacification. Actually, the right external iliac artery was patent and was well demonstrated in the later phase of the aortoiliac arteriograms. Fifth, administration of methylergonovine, vaginal packing, fluid replenishment, and blood transfusion is the standard procedure in conservative management of PPH.3Norris TC Management of postpartum hemorrhage.Am Fam Physician. 1997; 55: 635-640PubMed Google Scholar Contraindications to methylergonovine include severe hypertension, preeclampsia, eclampsia, hypersensitivity, and recent myocardial infarction, but none of them was noted in this patient.3Norris TC Management of postpartum hemorrhage.Am Fam Physician. 1997; 55: 635-640PubMed Google Scholar