Fetomaternal haemorrhage treated with intravascular transfusion: a late complication of amniocentesis?

The Recurrence Risk of Fetomaternal Hemorrhage

Massive fetomaternal hemorrhage (FMH) can cause devastating pregnancy outcomes. Perinatal prognosis may be improved by intrauterine transfusion, but the appropriate management for these pregnancies remains unclear. To determine the recurrence risk of FMH after intrauterine transfusion, we performed a systematic review of all case reports/series of patients with proven FMH treated with intrauterine transfusion and who had subsequent follow-up of at least 72 h until delivery. This revealed 13 cases, with 1 additional case from our institution. Ten patients (71.4%) had a second episode of FMH requiring a second intrauterine transfusion. Five patients (35.7%) required at least 3 intrauterine transfusions. The time interval between intrauterine transfusions was progressively reduced. The gestational age at the onset of signs/symptoms was 26.6 ± 2.1 weeks, and gestational age at delivery was 34.2 ± 4.2 weeks. Two cases of fetal demise (14.3%) and no neonatal deaths were recorded. Limited postnatal follow-up on 8 neonates was normal. The mean neonatal hemoglobin and transfusion rates were 13.2 ± 5.7 g/dL and 33.3%, respectively. Close fetal monitoring, likely daily, is necessary to recognize FMH recurrence. Several transfusions may be necessary once FMH is diagnosed if pregnancy is allowed to continue > 72 h.

Successful in utero Treatment of Chronic and Massive Fetomaternal Hemorrhage with Fetal Hydrops

BACKGROUND

Massive fetomaternal hemorrhage is an uncommon cause of chronic fetal anemia. Without treatment, hydrops fetalis can occur and progress toward death. In some cases, an early diagnosis can improve the management.

CASE

A patient was found to have a fetus with non-immune hydrops related to massive and early fetomaternal hemorrhage successfully treated with serial fetal intravascular transfusion. After the treatment, ultrasonographic signs of hydrops disappeared and the pregnancy resulted in a good fetal outcome. There was no need for neonatal transfusion. Neurological examination at 1 month post-natal was normal.

CONCLUSION

When massive fetomaternal hemorrhage is diagnosed early in the pregnancy, serial fetal intravascular transfusion may be an alternative to immediate delivery.

Macrotransfusion fœto-maternelle spontanée révélée par une diminution de la perception des mouvements actifs fœtaux

Massive fetomaternal hemorrhage is rare. Without risk factors, early diagnosis is difficult to establish. The clinical and paraclinical manifestations are not specific and depend on fetal compensatory reactions; the Kleihauer test will confirm the diagnosis. Two cases of massive fetomaternal hemorrhage preceded by decreased fetal movements are presented here. An emergency delivery by cesarean section saved one child. Despite a favorable clinical and laboratory evaluation, one fetal death could not be avoided. Early diagnosis and specialised management are essential to improve prognosis. These observations indicate that it is mandatory to carry out a Kleihauer test whenever a decrease of fetal movements is observed.

[Fetomaternal hemorrhage: a series of 9 cases]

AIM

This study was designed to stress the importance of early diagnosis of fetomaternal hemorrhage (FMH) in attempt to prevent the subsequent adverse outcome on the fetus and the newborn.

PATIENTS AND METHODS

Nine newborns were admitted because of neonatal anemia to our neonatal unit from October 1989 through September 1995. The diagnosis of FMH was made by the sigma diagnostic fetal hemoglobin that is the Kleihauer test in our hematologic laboratory. Other causes of neonatal anemia have been ruled out.

RESULTS

Seven out of the nine cases have expressed early signs of fetal distress in term of abnormal fetal monitoring and/or thick meconium associated with decreased fetal movements. At birth, a wide clinical spectrum depending on the amount of the hemorrhage was seen, ranging from mild anemia with no symptoms (four cases), hypovolemic shock (one case), respiratory distress syndrome (two cases) and maladjustment to extra-uterine life (one case). There was one death at 48 hours after birth; one infant survived with severe encephalopathy.

CONCLUSION

These results indicate that it is mandatory to carry out a Kleihauer test whenever a high suspicious index of FMH is faced or an unexplained neonatal anemia is found.

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.