Systematic Kleihauer-Betke Test after External Cephalic Version for Breech Presentation: Is It Useful?

Johanna Lemaitre,Guillaume Ducarme,Lucie Planche

doi:10.3390/jcm9072053

Abstract

The incidence of fetomaternal hemorrhage (FMH) after external cephalic version (ECV) has been poorly reported. In this study, we evaluated the frequency of FMH, diagnosed by positive Kleihauer–Betke test (KBT), after ECV attempt and then evaluate the relevance of its routine use after procedure. A total of 282 women with a term breech presentation and who had ECV attempt were recruited from January 2014 and December 2018. After ECV attempt, women were systematically screened for FMH using KBT. Data on ECV attempt, KBT results, perinatal and neonatal outcomes were collected and compared between women with positive (cases) and negative KBT (controls) after ECV. The success rate of ECV was 22.0% (62/282). Eight women (2.9%) experienced transient fetal heart rate (FHR) abnormalities after ECV. In five (1.8%) women, KBT was positive after ECV. Obstetrical management was modified for two of these five women due to continuous positivity of KBT at day 1 and day 7 controls after ECV attempt. A cesarean section was planned 7 days earlier due to persistent high FMH on day 7 (6 mL fetal blood) in one woman and the labor was induced for persistent high FMH on day 7 (20 mL fetal blood) for another woman. No newborns have signs of fetal anemia at birth and there was no significant difference in neonatal status between two groups. FMH after ECV attempt are rare, and no negative fetal or neonatal outcomes were observed when KBT was positive, even strongly (>5 mL fetal blood). It appears that systematic KBT after attempted ECV is probably not useful.

Highlights

13,035 births took place in our tertiary public hospital, 544 women presented a fetus in breech presentation at term (4.1%), 12 women (2.2%) presented absolute contraindications to external cephalic version (ECV) attempt, and 250 women (45.9%) refused ECV attempt after oral and written information
Our study found a low rate of fetomaternal hemorrhage (FMH) (1.8%) after attempted ECV, and no negative fetal and neonatal outcome was observed with a positive, even strongly (>5 mL fetal blood) Kleihauer–Betke test (KBT) after attempted ECV
The neonatal outcomes were good in our study without significant difference, according to the presentation at delivery and to the results of KBT after ECV attempt, even though we only reported the outcomes of 5 women with a low-positive KBT after ECV attempt

Summary

Introduction

The French College of Obstetricians and Gynecologists (CNGOF) has recommended ECV attempt for breech presentation at term (>36 weeks) [2]. A routine Kleihauer–Betke test (KBT) is performed after each ECV attempt in France, whatever the Rhesus-D status of the women. It consists of a microscopic count of fetal red cells on a maternal blood smear by the biologist, and is, correlated to the volume of FMH [4]. In a large prospective observational Canadian study that included 1311 women who had attempted ECV for a breech presentation at term, the authors concluded that there was no need for KBT after uncomplicated ECV attempt because they observed 2.4% women with a positive KBT after ECV, but only 0.08% of these women had an estimated significant volume of FMH (>30 mL) [5]

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