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A cautionary note about Monsel’s solution

Published:August 17, 2015DOI:https://doi.org/10.1016/j.ajog.2015.08.026
      To the Editors:
      I read with interest the Expert Review by Miller et al entitled, “Use of Monsel’s solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents.”
      • Miller D.T.
      • Roque D.M.
      • Santin A.D.
      Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents.
      Although the authors cautioned against exposure of the peritoneal cavity to Monsel’s solution, I do not feel that they adequately represented the danger. Their reference number 30 (Shuhaiber J et al
      • Shuhaiber J.H.
      • Lipnick S.
      • Teresi M.
      • Molinari M.
      • Ryoo J.
      • Cintron J.
      More on Monsel’s solution….
      ) is a case report of vaginal packing after cervical cone biopsy with pads soaked with Monsel’s solution. In that report, Monsel’s solution actually caused a full-thickness necrosis of the uterus and extensive damage in the peritoneal cavity that ultimately resulted in the patient’s death from multiorgan failure. Monsel’s solution, as described by the authors, is an excellent agent for causing hemostasis. However, it can defuse through the cell layers of bowel over several days and ultimately can produce full-thickness bowel necrosis. A small amount of Monsel’s solution can be cleared by the polymorphonuclear response it elicits; however, if large amounts are present, it may overwhelm the system.
      • Shuhaiber J.H.
      • Lipnick S.
      • Teresi M.
      • Molinari M.
      • Ryoo J.
      • Cintron J.
      More on Monsel’s solution….
      Given this risk, Monsel’s solution should be applied very cautiously in minimal amounts. If the amount applied to the placental site is in excess of the amount that can be cleared by the polymorphonuclear response, it may result in necrosis and uterine perforation. I agree with the authors that the solution should never be allowed to leak into the perineal cavity. In their reference number 30,
      • Shuhaiber J.H.
      • Lipnick S.
      • Teresi M.
      • Molinari M.
      • Ryoo J.
      • Cintron J.
      More on Monsel’s solution….
      the patient died of exposure to the Monsel’s solution, in spite of extensive peritoneal irrigations. All applications of Monsel’s solution should be done with great care in this setting, and the patient should be monitored carefully for signs of uterine perforation.

      References

        • Miller D.T.
        • Roque D.M.
        • Santin A.D.
        Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents.
        Am J Obstet Gynecol. 2015; 212: 725-735
        • Shuhaiber J.H.
        • Lipnick S.
        • Teresi M.
        • Molinari M.
        • Ryoo J.
        • Cintron J.
        More on Monsel’s solution….
        Surgery. 2005; 137: 263-264

      Linked Article

      • Use of Monsel solution to treat obstetrical hemorrhage: a review and comparison to other topical hemostatic agents
        American Journal of Obstetrics & GynecologyVol. 212Issue 6
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          Peripartum hemorrhage accounts for 8% of maternal deaths in the United States, and nearly 27% worldwide. A growing need exists for tactics to spare morbidity given a rise of abnormal placentation that contributes to excessive blood loss at the time of delivery. Approaches such as compression sutures, balloon tamponade, and pelvic artery embolization are not without side effects and potential implications for future fertility. The use of topical hemostatic agents has become widespread in gynecologic and obstetric surgery despite a paucity of distinct studies in the field, and may allow providers to increasingly avoid cesarean hysterectomy.
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        American Journal of Obstetrics & GynecologyVol. 213Issue 6
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          The authors concur that the peritoneal cavity must not be exposed to Monsel solution, and that the consequences of spillage may be catastrophic. The authors disagree, however, with Dr Witter's interpretation that Monsel solution “caused a full-thickness necrosis of the uterus” in the case report of Shuhaiber et al.1 It seems more likely that the physician who performed the cone biopsy (who also unknowingly damaged the bilateral uterine arteries leading to the patient's exsanguination with a hemoglobin of 4 g/dL within 60 minutes of departing the operating room) may also have created an unintentional posterior colpotomy/defect in the posterior aspect of the uterus through which the Monsel solution leaked into the peritoneal cavity.
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