Counting fetal erythrocytes as a diagnostic aid in perinatal death and morbidity

Risk factors for fetal-to-maternal transfusion in Rh D-negative women--results of a prospective study on 942 pregnant women

AIMS

To investigate the incidence of severe fetal-to-maternal transfusion after delivery and to identify risk factors.

MATERIAL AND METHODS

In a prospective study at the Department of Obstetrics, Charité, Campus Virchow-Klinikum, Berlin, Germany, we analyzed the incidence of severe fetal-to-maternal transfusion (>10 ml) and fetal-to-maternal hemorrhage (>25 ml) in Rh D-negative pregnant women after delivery of Rh D-positive infants. 942 women were included in the study and Kleihauer-Betke tests were performed. The results were compared to perinatal data.

RESULTS

Fetal-to-maternal hemorrhage occurred in 13 cases out of 942 (incidence of 1.3%) and severe fetal-to-maternal transfusion in 61 cases (6.5%). In all of the cases with fetal-to-maternal hemorrhage, mothers were compatible with their infants in ABO-system. The incidence of fetal-to-maternal transfusion and its severe form was significantly higher in twin pregnancies (7/21 cases and 5/21 cases respectively, 33.3% and 23.8%) than in singleton pregnancies (22.5%, and 5.9%, P<0.001). All other factors, such as maternal age, parity, ethnicity, mode of delivery, presentation, duration of first and second stage of labor, CTG, or Apgar score were not associated with an increased risk of severe fetal-to-maternal transfusion.

CONCLUSIONS

Twin pregnancy is the only independent risk factor for severe fetal-to-maternal transfusion. ABO-incompatibility between mother and infant seems to be protective against Rh D-alloimmunization.

[Massive fetomaternal transfusion after induction of labor by oxytocin]

Severe fetomaternal transfusions are seldom, but may lead to neonatal morbidity or death.

CASE REPORT

We report a case of lethal fetomaternal transfusion in which a failure to induce labour, at term, can be suspected.

COMMENTS

We emphasize the need of a close monitoring of the fetal well-being in cases of failed induced labour at term.

Severe fetomaternal hemorrhage: a review

The etiology, clinical presentation, obstetrical antecedents, and outcome of pregnancies complicated by large fetomaternal hemorrhage (FMH) were reviewed by doing a MEDLINE search from 1966 to the present and manual search before 1966. One hundred thirty-four infants with FMH > 50 dl were reported in the literature. The primary variables: birth weight, gestational age, presence of sinusoidal fetal heart rate pattern, decrease or absent fetal body movements (FBM) estimated the amount of fetomaternal bleeding and the pretransfusion hemoglobin. Other variables included the condition of the infants at birth, erythroblasts, and reticulocyte blood counts at birth, as well as the year of publication. Thirty-five of the 134 cases were preterm. Twenty infants born to mothers reporting decreased or absent FBM survived. FBM was absent in 17 cases for a period ranging between 24 hours and 7 days. In this group, six infants survived, five were stillborn, and five died in the neonatal period. A sinusoidal heart rate (SHR) pattern was reported in 21 cases. A SHR pattern was associated with decreased FBM in 13 cases (39.3 percent). Fifteen cases with sinusoidal fetal heart rate pattern survived (71.4 percent). Both decreased or absent FBM and SHR patterns were reported more often in 1990 or later than before 1990 (P < .0017 and P < .008, respectively). The cause of FMH was not known in 82 percent of the cases. The most common presenting symptoms of FMH were anemia at birth (35.2 percent), decreased or absent FBM (26.8 percent), and unexpected stillbirths (12.5 percent). Seventeen intrauterine transfusions were performed in nine cases (eight survived). A negative correlation was found between pretransfusion hemoglobin and FMH (r = -0.35; P = .0019). No significant difference was found between the cases with FMH of > 200 ml or < 200 ml. Thus, decreased or absent FBM, SHR pattern, or hydrops fetalis are late signs of FMH. Other means of early detection are needed. The role of intrauterine transfusion (IUT) needs to be better defined. The inadequate outcome data indicate the need to follow infants born with large FMH into childhood to document the effect on the central nervous system.

Comparison of predelivery versus postdelivery Kleihauer-Betke stains in cases of fetal death

A prospective study was undertaken to determine whether the delivery process could introduce a significant amount of fetal cells into the maternal circulation in patients with a fetal death. Sixty-six cases of fetal death were studied over a 39-month period. All patients had both predelivery and postdelivery Kleihauer-Betke stains performed. Of these, three (4.6%) had a massive fetomaternal hemorrhage. None of the postdelivery stains showed evidence of a significant fetomaternal hemorrhage unless results of the antepartum stain had also been positive. We conclude that the delivery process itself does not simulate a massive fetomaternal hemorrhage in cases of fetal death.

Fetomaternal macrotransfusion in the Yorkshire region. 2. Perinatal outcome

The perinatal outcome associated with fetomaternal macrotransfusion (FMMT), defined as fetomaternal haemorrhage greater than or equal to 10 ml, was investigated in a study group of 179 cases of FMMT and compared with the outcome in 322 controls selected from the same population. Perinatal mortality and morbidity occurred more frequently in the case group (P less than 0.01). The mean Apgar score at 1 min and the cord haemoglobin level differed significantly between the case and control groups (P less than 0.01) and showed a significant inverse correlation with the estimated volumes of FMMT (P less than 0.0001). There was no significant difference in birthweight between the case and control groups. The mean estimated volumes of FMMT associated with perinatal mortality and with low cord haemoglobin (less than or equal to 9.0 g/dl) were significantly higher than the mean volume in the case group as a whole, which suggests the possibility of adapting these observations to a screening procedure.

Massive feto-maternal hemorrhage as a cause of perinatal mortality and morbidity

11 cases of massive feto-maternal hemorrhage (FMH) detected at the Leuven Blood Transfusion Center are described. Based on these case reports, a review is given of the various theoretical and practical problems related to this complication, e.g. the relative frequency of perinatal mortality and morbidity due to massive FMH, the causes and pathogenesis, the symptoms and diagnosis, the clinical varieties, and the pathophysiology as seen in the fetus and newborn. Finally, the indications for looking for large FMHs are described, and the therapeutic implications when this complication is discovered.