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.” 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 ) 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. 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, 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.