Author's reply.

Sir,

We thank the authors for their comments on our article in this issue of the IJA.[1] Infective endocarditis prophylaxis was not administered in this patient, as it is no more recommended as per the latest AHA guidelines for prevention of infective endocarditis. The guidelines clearly state in the conclusion and we quote ‘Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure’.[2] Though Table 3 in the guidelines mentions uncorrected cyanotic heart disease as the highest risk of adverse outcome from endocarditis, absence of an established genitourinary infection made prophylaxis unnecessary.[2] We did use invasive arterial monitoring during the drainage of the vulval haematoma. Epidural analgesia for the drainage of haematoma was achieved with 10 mL of 0.125% bupivacaine and 50 mcg of fentanyl, which was given in small aliquots of 2-3 mL at a time. We do agree with the authors that phenylephrine is the vasopressor of choice, if hypotension results due to epidural analgesia, which was available and kept ready. Our patient did not require any vasopressor as epidural analgesia was achieved in a graded manner. Paradoxical air embolism[3] and fall in SVR, following oxytocin bolus[4] are valid concerns in patients with right to left shunts. Our institutional protocol mandates us to give oxytocin only as a slow infusion and never as bolus in all our patients. Giving all these details was not considered necessary, within the purview of the case report.