Kleihauer-Betke Research Articles

Reduced fetal movement during pregnancy: Is the Kleihauer-Betke test really useful?

IntroductionReduced fetal movement (rFM) is a frequent cause of consultation during the pregnancy and can reveal feto-maternal hemorrhage (FMH) that is sometimes responsible of severe fetal anemia. Our primary objective was to evaluate the contribution of the KBT in case of rFM. Our secondary objective was to compare it with ultrasound examination including peak systolic velocity of the middle cerebral artery (MCA-PSV) to predict neonatal anemia. Materials and methodsWe conducted a retrospective study from January 2016 to December 2017 at Armand-Trousseau Hospital in Paris. We analyzed all patients consulting for rFM from 18 to 41 weeks of gestation. We compared the performance of KBT and MCA-PSV to predict neonatal anemia (Hemoglobin at birth under 13.5 g/dL) and severe neonatal anemia (Hb < 10 g/dL). ResultsAmong the 338 patients, 327 KBT (96.7%) were performed. KBT was found positive in three cases (0.9%). Only one neonate (0.3%) presented with severe anemia requiring a postnatal transfusion. MCA-PSV was performed in 166 cases (49.1%). KBT and MCA-PSV were significantly correlated with neonatal hemoglobin at birth. KBT was better than MCA-PSV to predict neonatal anemia, while MCA-PSV was better than KBT to predict moderate to severe anemia. The KBT and MCA-PSV Doppler had excellent sensitivity and predictive negative values (100%), but they had poor predictive positive values for severe neonatal anemia. ConclusionIn case of decreased fetal movement, we suggest performing fetal cerebral Doppler. MCA-PSV could suffice in first approach. KBT may be performed if there is suspicion of fetal anemia in order to confirm FMH.

Intrauterine transfusions for maternofetal red‐blood‐cell incompatibility in monochorionic diamniotic twin pregnancy

Maternal alloimmunization to fetal red-blood-cell (RBC) antigens may cause hemolytic disease in the fetus with severe anemia. Intrauterine transfusions (IUTs) in twin pregnancy represent 1.5% of all fetal transfusions for RBC alloimmunization1, 2. Here, we present a case of a monochorionic diamniotic twin pregnancy complicated by severe anti-D maternofetal incompatibility, monitored by fetal middle cerebral artery (MCA) peak systolic velocity (PSV) and treated successfully by repeat IUTs of a single cotwin. The patient was referred to our center at 24 weeks' gestation for suspected fetal anemia. Fetal middle cerebral artery (MCA) peak systolic velocity (PSV) reached 1.64 multiples of the median (MoM) in Twin A and 2.02 MoM in Twin B. Both fetuses presented with ascites. Twin A was transfused with 30 mL of packed RBC. Pretransfusion hemoglobin (Hb) was 3.0 g/dL, with a Kleihauer–Betke test (KBT) result of 100% in fetal blood3, 4. Post-transfusion Hb increased to 8.8 g/dL and KBT decreased to 18%. MCA-PSV decreased from 1.64 to 1.19 MoM in Twin A and from 2.02 to 1.64 MoM in Twin B. Thirty minutes later, as MCA-PSV remained above 1.5 MoM in Twin B, an IUT of 15 mL was administered to Twin B, which enabled Hb level in Twin B to increase from 8.1 to 11.4 g/dL, and KBT in fetal blood decreased from 17% to 10%. The direct antiglobulin test showed a result of 3+ (high intensity) and cord bilirubin was over 70 µmol/L. These findings were suggestive of ongoing hemolytic disease. For subsequent IUTs at 25 + 4, 27 + 3 and 30 + 3 weeks' gestation, only Twin A was transfused. This strategy allowed for the normalization of MCA-PSV in both fetuses (Figure 1, Table 1). Cesarean section was performed at 31 weeks' gestation for non-reassuring fetal-heart tracing. The first delivered male neonate had birth weight of 1330 g, arterial cord blood pH of 7.37, Hb of 11.3 g/dL and bilirubin of 90 µmol/L. The second neonate had birth weight of 1310 g, arterial cord blood pH of 7.43, Hb of 11.5 g/dL and bilirubin of 88 µmol/L. Placental colored dye injection showed several arterioarterial anastomoses. The twins had respiratory distress syndrome which was treated by non-invasive ventilatory support. Severe jaundice worsened despite intensive phototherapy and albumin infusion, requiring exchange transfusion in both neonates. Two transfusions at 15 and 45 days were also needed. The neonates were discharged at 66 days postpartum. In this case, during the first IUT, transplacental intertwin anastomoses were demonstrated by (1) MCA-PSV values in Twin B decreasing after IUT of Twin A, (2) KBT in fetal blood already being reduced in Twin B after IUT of Twin A but before IUT of Twin B, and (3) Hb in Twin B being similar to that observed in Twin A after IUT of Twin A but before IUT of Twin B. To our knowledge, this is the first reported case demonstrating the contribution of MCA-PSV to monitoring monochorionic twin pregnancy complicated by RBC alloimmunization, treated by repeat IUTs of a single cotwin. One case of a monochorionic twin pregnancy in which IUTs performed in turn in each cotwin has been reported, without using MCA-PSV monitoring2. In cases of fetal anemia caused by Rh alloimmunization in monochorionic twin gestations, it appears sufficient to transfuse only one of the fetuses at 2–3 week intervals.

Fetomaternal Hemorrhage: Can We Use Hemoglobin Electrophoresis as a Diagnostic Tool?

Fetomaternal hemorrhage (FMH) is usually detected by either the Kleihauer-Betke (KB) test or by 2 cytometry, the latter of which represents the gold standard of FMH diagnosis today. But what do we do when neither method is available? We present two cases of suspected FMH due to their characteristic signs and symptoms that were ultimately confirmed by hemoglobin electrophoresis (HE).

Bach1 Inhibitors Reduce Stasis in Townes Sickle Cell Mouse Model

In sickle cell disease (SCD) excessive release of Hb and heme into the vasculature can activate innate immune toll-like receptor 4 (TLR4) signaling in the vasculature leading to inflammation and vaso-occlusion. Heme-mediated TLR4 signaling can be interrupted by inducing heme oxygenase 1 (HO-1) to degrade heme or ferritin heavy chain (FTH1) to sequester iron. Globin synthesis, HO-1 expression, heme/iron homeostasis, and antioxidant levels are regulated in part by antioxidant response genes, which is a set of hundreds of genes that possess antioxidant response elements (ARE) in their promoter regions. Bach1 complexes bind to ARE sites and dominantly repress Nrf2 transcriptional activity. This transcriptional repression can be inactivated by heme binding to Bach1. We have discovered small molecule BACH1 inhibitors that increase HO-1 and FTH1 mRNA in HepG2 cells. Additionally, they restore glutathione levels and inhibit VCAM-1 expression in human primary aortic endothelial cells upon hemin or TNFα challenge. To investigate if Bach1 inhibitors could have an effect on vaso-occlusion in vivo, microvascular stasis was examined in Townes-SS mice with implanted dorsal skin-fold chambers. Townes-SS mice were orally gavaged with vehicle or Bach1 inhibitors at different doses once daily for 8 days. Microvascular stasis was determined in 20-25 preselected flowing subcutaneous venules in response to intravenous infusion of hemin (3.2 μmol/kg). Stasis was significantly inhibited by Bach1 inhibitors in a dose responsive manner. After stasis measurement, blood was collected and the F-cells were stained using the Kleihauer-Betke Test. F-cell % was significantly increased by Bach1 inhibitor treatment at all doses tested. Disclosures Belcher: Mitobridge, an Astellas Company: Consultancy, Research Funding. Biddle:Mitobrige, an Astellas Company: Employment, Membership on an entity's Board of Directors or advisory committees, Patents &amp; Royalties. Stickens:Mitobridge, an Astellas Company: Employment, Membership on an entity's Board of Directors or advisory committees, Patents &amp; Royalties. Olson:Mitobridge, an Astellas Company: Employment. Bell:Mitobridge, an Astellas Company: Employment. Vercellotti:Mitobridge, an Astellas Company: Consultancy, Research Funding.

Fetomaternal hemorrhage among pregnant women in Accra, Ghana.

To determine the occurrence of and risk factors for fetomaternal hemorrhage (FMH) among pregnant women at Korle Bu Teaching Hospital in Accra, Ghana. A prospective study of FMH among pregnant women without hemoglobinopathies in the second trimester attending prenatal care between October 2015 and May 2016 performed using the Kleihauer-Betke test. Volume of FMH was estimated; ABO and Rh blood groups of participants were determined. A data extraction form and structured questionnaire were used to collect demographic and clinical information, and data on risk factors. Of 151 participants, 32 (21.2%) had FMH. Almost 18% (n=27) had FMH at baseline (16-24weeks), 10% (10/100) at 28-32weeks, and 11.1% (11/99) at 34-37weeks of pregnancy. Volume of FMH was less than 30mL in 30 (19.9%) women, whereas it was greater than 30mL in 2 (1.3%) women. No identifiable patient-specific factors were associated with occurrence of FMH. FMH is common among pregnant women in Ghana and can occur as early as 16weeks, without identifiable risk factors. RhD negative women who may be pregnant with RhD positive fetuses should be screened early in pregnancy, not only at delivery, for occurrence of FMH.

Fetomaternal Bleeding and Neonatal Hematocrit following Cesarean Delivery: Routine versus Transplacental Transection

Objective To evaluate fetomaternal bleeding following routine cesarean delivery compared with cesarean delivery involving transplacental transection. Study Design A prospective cohort study evaluating cesarean delivery in which the placenta was transected (cases) versus controls (placenta not transected) from January 2016 to April 2018. A maternal Kleihauer–Betke's (KB) test and newborn hematocrit were performed shortly after delivery. Results The rate of a positive KB test was not significantly different between cases ( n = 31) and controls ( n = 61) (19 vs. 14%; odds ratio [OR]: 1.44; 95% confidence interval [CI]: 0.46–4.49; p = 0.74). Median neonatal hematocrits were not different. However, the rate of newborn hematocrits <40% at delivery was higher in cases compared with controls (23 vs. 3%; OR: 8.90; 95% CI: 1.72–45.90; p = 0.005). Conclusion A cesarean requiring transplacental transection to accomplish delivery does not significantly increase the rate of fetomaternal bleeding but is associated with a higher likelihood of newborn hematocrit <40% at delivery.

Use of Fetal Hemoglobin Quantitation for Rh-Positive Pregnant Females: A National Survey and Review of the Literature.

The Kleihauer-Betke (KB) test is validated for estimating the dose of Rh immune globulin needed for Rh-negative pregnant females. However, some clinicians are also ordering the test for Rh-positive women. The degree to which this practice occurs is unknown. To evaluate the number of laboratories that perform the KB test on Rh-positive pregnant women, and to establish current ordering practices for this indication. We added 9 supplemental questions regarding KB test use for fetomaternal hemorrhage to the 2016 College of American Pathologists proficiency test survey. We also reviewed the available literature regarding the diagnostic utility of the KB test for Rh-positive women. A total of 1578 surveys were evaluated and revealed that 52% (824) of respondents perform these tests for Rh-positive women, and more than 50% (440 of 819; 53.7%) of these laboratories report that the results for Rh-positive women are treated as important or very important. The KB test is commonly used for Rh-positive women, and the information obtained from the test is considered as urgent and important. However, the available literature in support of this practice is still nonconclusive.

Prospective quantification of fetomaternal hemorrhage with dilation and evacuation procedures

ObjectiveTo describe fetomaternal hemorrhage (FMH) during second-trimester dilation and evacuation (D&E) to evaluate if Rhesus-immune globulin (RhIG) 100 mcg (used in the United Kingdom) and 300 mcg (used in the United States) provide adequate prophylaxis. Study designWe conducted an exploratory prospective descriptive study of women undergoing D&E between 15 weeks 0 days and 23 weeks 6 days of gestation. Enrolled participants had Kleihauer–Betke testing on specimens obtained before and after D&E. We assessed the main outcome measures of FMH in mL suggesting need for more than 100 mcg and 300 mcg RhIG (FMH of 10 mL and 30 mL fetal whole blood, respectively) and association of postprocedure FMH with demographic characteristics and procedure-related variables. ResultsThe 300 participants had a mean gestational age of 19 weeks 6 days±2 weeks 2 days. The median preprocedure FMH was 0 mL (range 0–50 mL) with 2 (0.67%) women exceeding 10 mL (19 mL and 50 mL). The median postprocedure FMH was 1 mL (range 0–60 mL). Almost all participants had postprocedure FMH <10 mL (n=295, 98.3%) and <30 mL (n=298, 99.3%). All participants under 18 weeks had FMH <10 mL. We found no demographic or procedure-related factors to be predictive of FMH quantity. ConclusionsFMH occurring with routine second-trimester D&E procedures is minimal. Adequate prophylaxis with RhIG 100 mcg and 300 mcg occurred in >98% of women and in all cases <18 weeks of gestation. This study is the first step to potentially reducing the dose and costs of RhIG administration with D&E. ImplicationsThis study is a first step in quantifying fetomaternal hemorrhage with routine dilation and evacuation procedures; larger trials are needed, especially to understand why some women have recognizable hemorrhage preprocedure. If dosing requirements are too high with current guidelines, lower doses will result in resource and cost savings.

Evaluation of Flow Cytometry and Kleihauer Techniques for Quantification of Fetomaternal Hemorrhage: A Prospective Cohort Study in Southwestern Iran

Background: Quantification of fetal red blood cells (RBCs) in maternal blood is of great importance to calculate appropriate dose of post-deliver anti D immunoglobulin in a rhesus D (RhD)-negative woman. Objective: The aim of this study is to evaluate a direct immunofluorescence flow cytometry technique in artificial and clinical samples and compared it to the Kleihauer-Betke test (KBT). Methods: This study was a prospective cohort design. Blood samples from 26 pregnant women who gave birth to RhD positive babies were tested using direct immunofluorescence flow cytometry and KBT techniques to determine the amount of FMH in the maternal circulation. The zone of D-positive cells was identified employing artificial samples including 0.3%, 0.6%, 1%, 1.5%, 2%, 5%, 10%, and 50% of D-positive fetal cells in D-negative maternal cells. Results: Analysis of 26 clinical samples for FMH showed consistent quantification with the flow cytometry and Kleihauer techniques. Although a good correlation was found between the KBT and flow cytometry results, in artificial samples containing more than 2% of fetal RhD positive cells, the flow cytometry results were closer to theoretical percentages. In a patient with FMH &gt;4 mL, the FMH and consequently the required vial of Ig were overestimated using KBT. Conclusion: Most of the FMH calculated could have been neutralized by doses less than 625 IU, whereas the routine dose in Iran is more than double that amount (1500 IU). This achievement demonstrates that adjusting between the RhD immune globulin (RhDIg) dose and FMH size is inevitable.

A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial.

Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking. To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use. Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded. A total of 26 UK obstetric units. Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated. Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed. Primary - donor blood transfusion. Secondary - units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer-Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes - costs of resources and service provision taking the UK NHS perspective. We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at £8110 per donor blood transfusion avoided. The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective. Research into risk of alloimmunisation among women exposed to cell salvage is needed. Current Controlled Trials ISRCTN66118656. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 2. See the NIHR Journals Library website for further project information.

Risk factors for fetomaternal bleeding after laser therapy for twin-twin transfusion syndrome.

To quantify and assess potential risk factors for transplacental passage of fetal red blood cells (RBCs) into the maternal circulation (fetomaternal bleeding, FMB) after laser surgery for twin-twin transfusion syndrome (TTTS). A retrospective study of Rhesus-D negative patients that underwent laser surgery for TTTS. Patients with and without postoperative detectable fetal RBCs on Kleihauer-Betke (KB) testing were compared to determine risk factors for FMB. Patients were further sub-classified into those with a FMB<20% and ≥20% of estimated fetoplacental blood volume. Of 60 studied patients, 26/60 (43%) had a positive postoperative KB test. The median fetal:adult RBC ratio was 0.00125, estimated to be a FMB volume of 6.25mL. There were 17/26 (65%) of patients with FMB<20% and 9/26 (35%) patients with ≥20% of the fetoplacental blood volume. Stage III-Recipient and III-Recipient/Donor patients were more likely to have a positive KB test (14/21 [66.7%] vs 12/39 [30.8%], OR=4.50 [1.27-16.54], P=0.0162). No other risk factors for FMB were apparent. Fetomaternal bleed appears to be a common finding after laser surgery for TTTS. TTTS Stage, particularly stage III-Recipient and III-Recipient/Donor, appears to be a risk factor for FMB.

Prophylaxie anti-D dans l’incompatibilité fœto-maternelle érythrocytaire en Tunisie

Generalization of postnatal prophylaxis using anti-D immunoglobulins decreased the incidence of erythrocyte fetal-maternal incompatibility (EFMI) in the Rhesus system. Few recent studies have investigated the situation of anti-D prophylaxis in Tunisia and its effects on maternal and neonatal health. The aim of this study was therefore to analyze the situation of anti-D prophylaxis in Tunisia to detect defects and propose solutions. We conducted a retrospective descriptive study of IFME cases in the rhesus system in the Department of Medicine and Neonatal Resuscitation of the Tunis Maternity and Neonatology Center (CMNT) during an 8-year period from 1January 2006to 31December 2015. We collected 51cases of IFME. The prevalence of IFME was 3.4per 10000live births; 41% of the patients were transferred in utero and they were from the northwest of the country (17%). The rate of women with a history of at least one spontaneous miscarriage (SCF) was 45%. In 42% of the cases, pregnancies were monitored at local clinics. The search for irregular agglutinins (RAI) was performed in 86% of the women studied. RAI was positive in 97% of the cases. Anti-D prophylaxis was correctly performed in only 27% of the cases. The systematic prophylaxis of the third trimester and a systematic Kleihauer test must be combined with postpartum prophylaxis to better identify dysfunctions and improve the application of the recommendations.

Traumatisme et grossesse : le test de Kleihauer est-il vraiment utile ?

ObjectiveTo evaluate the pertinence of Kleihauer-Betke (KB) test, in case of abdominal trauma during pregnancy in forecast of fetal outcomes, according to trauma severity. MethodsA single-center retrospective study conducted between January 2014 and April 2016 in a maternity type III and a trauma center, which included the pregnant women admitted for abdominal trauma. The trauma's severity was assessed using the guidelines of the Society of Obstetricians and Gynaecologists of Canada. The impact of a positive KB test, defined as>0.1%, was analyzed. Adverse outcome was defined as one or more of the following complications: intrauterine fetal death, placental abruption, pre-term birth<37 weeks of gestation, and fetal or neonatal anemia. ResultsDuring the study period, 265 pregnancies involved into an abdominal trauma were included: 69% with a minor trauma and 31% with a severe trauma. Of all patients, 5.6% presented a positive KB test, among then 15.4% had an adverse outcome. There was no significant difference in the rate of adverse outcomes in the positive KB group and the KB negative group either in the overall population (P=0.16), in the minor trauma population (P=1) or in the major trauma population (P=0.14). The predictive positive values were respectively in the global population, in the minor trauma group and in the severe trauma group 15.4%, 0% and 25%. ConclusionsThe KB test does not seem to be useful in case of trauma during pregnancy to define adverse outcome.

Placental findings in feto-maternal hemorrhage in livebirth and stillbirth

Feto-maternal hemorrhage (FMH) is not an uncommon event during pregnancy with important clinical implications for both maternal and fetal outcomes. The diagnosis is often made using Kleihauer-Betke (KB) test. As FMH occurs transplacentally, examination of the placenta may contribute to the diagnosis of FMH. This retrospective case-control study aims to examine the placental features associated FMH in patients with known positive KB test results. When compared with KB negative placentas (n=88), KB positive placentas (n=49) had significantly higher incidence of pallor (6/49 vs 0/88, p=0.0017), IVT (11/49 vs. 5/88, p=0.0032) and nRBCs (12/49 vs. 4/88, p=0.0008). Autopsy cases with fetal or neonatal death due to FMH, (n=13) compared to a cohort of 162 placentas associated with other, non-FMH causes of death also had significantly higher frequency of pallor (5/13 vs 0/162, p<0.0001), IVT (6/13 vs 24/162, p=0.011) and nRBCs (11/13 vs 67/162, p=0.003). Pallor and nRBC were also associated with higher volume of FMH. Placental parenchymal pallor, intervillous thrombi and presence of nRBCs are significantly associated with documented FMH in both normal pregnancies and pregnancies associated with fetal or neonatal death. The presence of these findings, especially in combination, may suggest the need for maternal KB testing to rule out FMH and neonatal monitoring and/or intervention.

English

BACKGROUND Entry of foetal erythrocytes into maternal circulation before or during delivery is referred as Foetomaternal Haemorrhage (FMH). An Rh-D negative women when exposed to the cells of an Rh-D positive foetus, produces anti-D antibodies that causes complications like foetal anaemia, hydrops foetalis and neonatal jaundice. The Kleihauer-Betke test is a quantitative test, which uses the concept of differential resistance to acid by foetal and adult haemoglobin. As the potential risk factors can be determined by placental morphology and provide information on pregnancy outcome, they may provide information on incidence and amount of FMH also.The objective of this study is to determine the relationship between placental parameters (weight and diameter) and the incidence as well as severity of Foetomaternal Haemorrhage (FMH). The secondary aim was to correlate FMH with maternal factors and neonatal anaemia.MATERIALS AND METHODS A total of 333 women who delivered in the hospital after 28 weeks of gestation were enrolled for the study. Maternal blood (2 mL) was collected in EDTA bottle after the delivery of the baby. Samples were sent to Blood Bank. FMH was quantified by Kleihauer-Betke’s test. The foetomaternal haemorrhage is calculated as: Number of foetal cells per high power field/Number of maternal cells per high power field x 2400.1 FMH > 2 mL was considered positive for FMH as per BSCH (British Committee for Standards in Haematology) guidelines.2 Placental parameters like weight (after trimming cord at 5 mm from the insertion point and clearing membranes, clots) and diameter were measured. A cut-off of 500 gms for placental weight and 22 cm for placental diameter was taken.3,4,5 Actual birth weight and neonatal Haemoglobin (Hb) was noted.BSCH = British Committee for Standards in Haematology.RESULTS Out of 333 subjects 48 (14.4%) were positive for FMH (Group 1) and 285 (85.6%) were negative for FMH (Group 2). The mean placental weight (508.54 ± 80.34 gm) and the mean placental diameter (19.92 ± 3.99 cm) were significantly more in patients having positive FMH when compared to those with negative FMH. (P value = 0.0005 for placental weight and p = 0.005 for placental diameter). When placental weight was ≥ 500 gm more subjects were significantly positive for FMH (25.6%) compared to when that was less than 500 gm (7%) (P value = 0.00). When the placental weight was between 600 and 699 gm, the odds of having FMH was 13.43 times more. When the placental diameter was ≥ 22 cm, the incidence of positive FMH was significantly more (33.9%) compared to when that was 2 mL both mean placental weight (508.54 ± 80.34 gm) and diameter (19.92 ± 4.00 cm) were significantly higher when compared to lesser FMH. (P value 0.00 for both weight and diameter). Incidence of positive FMH was significantly more in maternal risk factors such as GDM, preeclampsia, placenta previa. The odd of having positive FMH was 16.45 times more in the presence of placenta previa. There was a mild negative correlation coefficient existed between the neonatal haemoglobin and amount of FMH, which was statistically significant (p value = 0.000). That means although neonatal anaemia was not found in the babies in our study, there was a trend of having lower haemoglobin with higher FMH.CONCLUSION With the findings of present study, it was concluded that bigger the placenta in terms of weight and diameter more is the foetomaternal haemorrhage. Foetomaternal haemorrhage is associated with maternal complications such as multifoetal gestation, GDM, preeclampsia and a diagnostic test for FMH should be considered in such cases to detect neonatal anaemia at the earliest possible and to decide on adequate dose of anti-D to clear the foetal cells from maternal circulation.

Quantitative fetomaternal hemorrhage assessment with the use of five laboratory tests.

In various countries, standard doses of anti-D IgG used for postpartum immunoprophylaxis of hemolytic disease of fetus and newborn (HDFN) vary from 100 μg to 300 μg. There are also different regulations concerning FMH assessment, and opinions about applicable tests are inconclusive. Three flow cytometry tests (FCTs) with anti-D, anti-HbF, anti-HbF+CA antibodies, and two modifications of microscopic Kleihauer-Betke test (KBT) were used. In all artificial mixtures with known concentrations, FCTs and KBT with counting 10 000 RBCs had similar satisfying sensitivity and specificity. KBT with counting 2000 RBCs had to be disqualified because of significant discrepancies between expected and measured values of FMH. The test procedure with anti-D was easier and shorter than the remaining tests, but it can be only used for FMH assessment in RhD-negative mothers with RhD-positive newborns. In one clinical sample, it was impossible to distinguish fetal RBCs from maternal F cells in KBT and FC with anti-HbF but other tests were useful. In the four tests, correlation between expected and obtained results was appropriate (CCC ̴1). Each test had some advantage and limitation in any clinical situation. Therefore, it is best to have opportunity to perform two or three assays in the laboratory.

A pilot prospective study of fetomaternal hemorrhage identified by anemia in asymptomatic neonates.

BackgroundFetomaternal hemorrhage (FMH) is a poorly understood condition in which fetal erythrocytes transfer to the maternal circulation via a faulty placental barrier. Little is known about the true incidence, epidemiology, or pathophysiology of FMH in the general pregnant population as existing studies are based on retrospective cohorts and manifest diagnosis and selection bias.ObjectiveTo evaluate the practicability of a prospective study of fetomaternal hemorrhage in the general population based on antepartum maternal blood testing and neonatal anemia.Study DesignProspective cohort study.ResultNineteen pregnant women were enrolled prior to the term delivery of twenty well infants. Five neonates were unexpectedly anemic on first postnatal testing. Antenatal maternal blood samples associated with 2 of 5 anemic newborns had positive Kleihauer-Betke testing while no newborn with a normal postnatal blood count had an associated abnormal Kleihauer-Betke test.ConclusionClinically significant FMH may be more common than previously thought. Prospective epidemiological study of FMH is feasible.

Assessment of Fetomaternal Hemorrhage in Rhesus D-negative Postpartum Women by Kleihauer—Betke Test

ABSTRACT Objectives The aim of this article is to assess fetomaternal hemorrhage (FMH) and determine its volume and also to study the relation of the amount of FMH to various factors. Materials and methods This was a prospective study carried out at Ahmedabad Civil Hospital from October 2012 to March 2013. A total of 75 blood samples were collected from RhDnegative mothers during the postnatal period. Sixteen samples were excluded because the fetus blood group was either Rh negative or unknown. The acid elution or Kleihauer—Betke quantitative test was used to measure the amount of FMH. The data were analyzed using Epi Info version 7. Results With Kleihauer—Betke/acid elution test (KBT), 45.76% of women had fetal whole blood in their blood circulation during a postnatal period varying from 1.2 to 9.6 mL. The test was negative (i.e., no fetal cells were identified) in 54.24% of women. The majority of women had hemorrhage less than 4 mL. None of them had a large FMH. Conclusion Most of the FMH calculated was &lt;10 mL, which could have been neutralized by lower doses of anti-D immunoglobulin, which have incurred lower costs than the 300-μg dosage. Thus, developing optimized testing and accessing dosing protocols is needed in health care facilities. In the present study, we found no significant relation between the amount of FMH and parity or type of delivery. How to cite this article Kapadia SN, Bansal KR, Parmar K, Panot H, Bandi F. Assessment of Fetomaternal Hemorrhage in Rhesus D-negative Postpartum Women by Kleihauer—Betke Test. J South Asian Feder Obst Gynae 2016;8(3):181-184.

Cellular mimicry in kleihauer–betke assay

The Kleihauer–Betke (KB) test is a time-consuming test with a lot of variables which affect the calculation of the extent of fetomaternal hemorrhage (FMH). There have been several formulae proposed by various authors to calculate FMH using KB test. In this article, we propose a simple mathematical alteration to accommodate the correction for some of the factors that lead to falsely high estimation of FMH.

Anti-D administration in pregnancy for preventing Rhesus alloimmunisation.

During pregnancy, a Rhesus negative (Rh-negative) woman may develop antibodies when her fetus is Rhesus positive (Rh-positive). These antibodies may harm Rh-positive babies. To assess the effects of antenatal anti-D immunoglobulin on the incidence of Rhesus D alloimmunisation when given to Rh-negative women without anti-D antibodies. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. Randomised trials in Rh-negative women without anti-D antibodies given anti-D after 28 weeks of pregnancy, compared with no treatment, placebo or a different regimen of anti-D. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We included two trials involving over 4500 women, comparing anti-D prophylaxis with no anti-D during pregnancy in this review. Overall, the trials were judged to be at moderate to high risk of bias. The quality of the evidence for pre-specified outcomes was also assessed using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.In regards to primary review outcomes, there did not appear to be a clear difference in the risks of immunisation when women who received anti-D at 28 and 34 weeks' gestation were compared with women who were not given antenatal anti-D: risk ratio (RR) for incidence of Rhesus D alloimmunisation during pregnancy was 0.42 (95% confidence interval (CI) 0.15 to 1.17, two trials, 3902 women; GRADE: low quality evidence); at birth of a Rh-positive infant the RR was 0.42 (95% CI 0.15 to 1.17, two trials, 2297 women); and within 12 months after birth of a Rh-positive infant the average RR was 0.39 (95% CI 0.10 to 1.62, two trials, 2048 women; Tau²: 0.47; I²: 39%; GRADE: low quality evidence). Neither of the trials reported on incidence of Rhesus D alloimmunisation in subsequent pregnancies.Considering secondary outcomes, in one trial, women receiving anti-D during pregnancy were shown to be less likely to register a positive Kleihauer test (which detects fetal cells in maternal blood) in pregnancy (at 32 to 25 weeks) (RR 0.60, 95% CI 0.41 to 0.88; 1884 women; GRADE: low quality evidence) and at the birth of a Rh-positive infant (RR 0.60, 95% CI 0.46 to 0.79; 1189 women; GRADE: low quality evidence). No clear differences were seen for neonatal jaundice (RR 0.26, 95% CI 0.03 to 2.30; 1882 infants; GRADE: very low quality evidence). Neither of the trials reported on adverse effects associated with anti-D treatment. Existing studies do not provide conclusive evidence that the use of anti-D during pregnancy benefits either mother or baby in terms of incidence of Rhesus D alloimmunisation during the pregnancy or postpartum, or the incidence of neonatal morbidity (jaundice) (low to very low quality evidence). However women receiving anti-D may be less likely to register a positive Kleihauer test in pregnancy and at the birth of a Rh-positive infant (low quality evidence). Fewer women who receive anti-D during pregnancy may have Rhesus D antibodies in a subsequent pregnancy, with benefits for the baby, however this needs to be tested in studies of robust design.