Large Fetomaternal Hemorrhage Research Articles

Investigation and management of stillbirth: a descriptive review of major guidelines.

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

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 <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.

Inaccurate Doses of Rh Immune Globulin After Rh-Incompatible Fetomaternal Hemorrhage: Survey of Laboratory Practice

Abstract Context.—Rh(D)-negative women with a large fetomaternal hemorrhage (FMH) from an Rh(D)-positive fetus are at risk for anti-D alloimmunization if they do not receive adequate Rh immune globulin (RhIG). Determination of the adequate RhIG dose for these women is a critical laboratory procedure for protecting their future Rh(D)-positive children. Objective.—To determine how often laboratories recommended an inaccurate dose of RhIG for excess FMH. Design.—Nearly 1600 laboratories using the College of American Pathologists' proficiency testing for fetal red blood cell detection were surveyed to determine (1) their calculation method and (2) the number of RhIG doses recommended for a survey specimen, based on their measured percentage of fetal red blood cells. We surveyed nearly 1450 laboratories for their accuracy in determining RhIG dose, using 2 common calculation methods we provided. Results.—The AABB Technical Manual method was used by 67% of responding laboratories. However, 20.7% of laboratories ...

Inaccurate Doses of Rh Immune Globulin After Rh-Incompatible Fetomaternal Hemorrhage: Survey of Laboratory Practice

Abstract Context.—Rh(D)-negative women with a large fetomaternal hemorrhage (FMH) from an Rh(D)-positive fetus are at risk for anti-D alloimmunization if they do not receive adequate Rh immune globulin (RhIG). Determination of the adequate RhIG dose for these women is a critical laboratory procedure for protecting their future Rh(D)-positive children. Objective.—To determine how often laboratories recommended an inaccurate dose of RhIG for excess FMH. Design.—Nearly 1600 laboratories using the College of American Pathologists' proficiency testing for fetal red blood cell detection were surveyed to determine (1) their calculation method and (2) the number of RhIG doses recommended for a survey specimen, based on their measured percentage of fetal red blood cells. We surveyed nearly 1450 laboratories for their accuracy in determining RhIG dose, using 2 common calculation methods we provided. Results.—The AABB Technical Manual method was used by 67% of responding laboratories. However, 20.7% of laboratories using this method would have recommended an inaccurate dose of RhIG—11.5% too much and 9.2% too little—for the level of FMH reported in the survey specimen. If all laboratories had used the common recommendation of 300 μg/30 mL of fetal blood present, 2% would have recommended RhIG doses too low for the volume of FMH they measured. In 3 of the 4 calculation exercises we provided, 20% to 30% of laboratories underestimated the necessary dose of RhIG. Conclusions.—Based on our surveys, some mothers with excess FMH may be receiving inaccurate doses of RhIG. Laboratories performing quantification of FMH should review their procedures and training for calculating RhIG dosage.

Large Fetomaternal Hemorrhage: Prenatal Predictive Factors for Perinatal Outcome

We sought to identify prenatal predictive factors for perinatal outcome and to estimate fetal hemoglobin (Hb) levels in large fetomaternal hemorrhages (transfused blood volume [TBV] > 20 mL) by performing a case-series study ( N = 32). Perinatal outcome was favorable (F group, N = 22) and poor (P group, N = 10: four fetal deaths, three postnatal deaths, three cases of severe anemia). Median TBV was 25 mL for the F group and 325 mL for the P group ( P < 0.0001) and median Hb concentration at birth was 15 g/dL for the F group and 5 g/dL for the P group ( P < 0.0001). Receiver operating characteristic analysis revealed that a Kleihauer-Betke test value above 2.5% was the best threshold for predicting adverse outcome, with sensitivity of 100% (95% confidence interval [CI] 76 to 100) and specificity of 96% (95% CI 77 to 100). In utero estimated Hb concentration best correlated with Hb level at birth when calculated using TBV corrected for fetoplacental weight ( P < 0.0001, R(2) = 0.874). The value obtained in the Kleihauer-Betke test was a prognostic factor, and TBV corrected for fetoplacental weight was the best biological marker for assessing fetal Hb level.

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

© 2005 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

The Incidence of Large Fetomaternal Hemorrhage and the Kleihauer-Betke Test

To assess the frequency of large fetomaternal hemorrhage and to estimate its incidence in cesarean compared with vaginal deliveries. In this prospective cohort study, the study group was composed of 313 women who underwent cesarean delivery. Control subjects were 253 women who delivered vaginally and were matched for age, parity, ethnic origin, and gestational age. Ninety-six pregnant women at term, but before delivery (prelabor group), were also included to determine whether delivery itself is the cause of fetomaternal hemorrhage. Fetomaternal hemorrhage was measured by using the Kleihauer-Betke test. Twenty women (6.4%) in the study group and 17 (6.7%) in the control group had a large fetomaternal hemorrhage (Kleihauer-Betke test > 0.4%). Five women (5.2%) in the prelabor group had a large fetomaternal hemorrhage. The differences were not significant. A large fetomaternal hemorrhage occurred in 14 of 146 (9.6%) women who underwent emergency cesarean, compared with 6 of 167 (3.5%) who delivered by elective cesarean (P = .04). In deliveries complicated by oligohydramnios, cord around the neck, or low birth weight, a higher rate of large fetomaternal hemorrhage was seen. Our results indicate a rate of large fetomaternal hemorrhage that is substantially higher than previously reported, with no difference between vaginal and cesarean deliveries. This may reflect inaccuracies with the current method used to estimate the degree of fetomaternal hemorrhage.

Massive antenatal fetomaternal hemorrhage: evidence for long‐term survival of fetal red blood cells

Massive fetomaternal hemorrhage (FMH) can lead to life-threatening anemia. Quantification based on flow cytometry with anti-hemoglobin F (HbF) is applicable in all cases but underestimation of large fetal bleeds has been reported. A large FMH from an ABO-compatible fetus allows an estimation of the life span of fetal red blood cells (RBCs) in the maternal circulation. The mother went to the obstetrician twice antepartum owing to symptoms assumed to be preeclampsia; that, however, was not found. She later delivered by cesarean section owing to diminished fetal movements. No fetal weight gain was observed during the last 2 weeks of pregnancy. Fetal RBCs were quantified by flow cytometry with anti-HbF, anti-Fy(a), anti-s, and anti-Jk(b) on a regular basis. The infant had anemia at delivery and an FMH was determined to be 314 +/- 17 mL (+/- SD) of whole blood. It is assumed that the two antenatal visits were associated with the FMH. Postpartum follow-up showed that fetal RBCs in the maternal circulation were detectable with anti-HbF up to 119 days. Quantification by flow cytometry based on anti-HbF was in agreement with quantification based on anti-Fy(a), anti-s, and anti-Jk(b), although they were less sensitive. ABO-compatible fetal RBCs from an FMH had a life span in the maternal circulation close to that of adult RBCs.

Increased Systolic Peak Velocity in Fetal Middle Cerebral Artery Blood Flow Shown by Doppler Sonography in Acute Fetomaternal Hemorrhage

Doppler measurement of peak systolic velocity of fetal middle cerebral artery (MCA) blood flow provides a noninvasive method to assess the degree of anemia in fetuses with chronic anemia secondary to Rh alloimmunization or parvovirus infection. 1 - 8 There are 2 prior case reports of increased MCA peak systolic velocity in acute fetal anemia. 9 , 1 0 This report adds to that literature and stresses the importance of checking the MCA peak systolic velocity when acute fetal anemia is of concern to appropriately care for the anemic neonate at birth. In this case of a large fetomaternal hemorrhage, neonatal transfusion was set up at the time of the cesarean delivery because of the information gleaned from the MCA Doppler study.

Quantification of fetomaternal hemorrhage: a comparative study of the manual and automated microscopic Kleihauer-Betke tests and flow cytometry in clinical samples

ObjectiveThe purpose of this study was to evaluate the quantification of fetomaternal hemorrhage by the manual and automated microscopic analysis of Kleihauer-Betke stained slides and by flow cytometry. Study designBlood smears were stained and evaluated manually according to the Kleihauer-Betke test. The same slides were used for automated microscopy. In addition, blood flow cytometry was performed by anti–hemaglobin F immunostaining. ResultsFetomaternal hemorrhage >0.1% was detected in 4 patients by manual and automated Kleihauer-Betke test and by blood flow cytometry. Fetomaternal hemorrhage was absent according to all 3 methods in 13 patients; fetomaternal hemorrhage<0.1% was detected in 27 patients by either manual or automated Kleihauer-Betke test or both. Moderate agreement was observed between the manual and automated Kleihauer-Betke test (weighted κ, 0.56; 95% CI, 0.33–0.78). Agreement between the manual Kleihauer-Betke test and blood flow cytometry was fair (weighted κ, 0.40; 95% CI, 0.15–0.66). ConclusionAutomated microscopic detection of fetal blood cells in clinical samples provides accurate quantification that is comparable to the manual Kleihauer-Betke test in both small and large fetomaternal hemorrhage. Blood flow cytometry is capable only of quantifying fetomaternal hemorrhage of >0.1%.

Do obstetricians underestimate feto-maternal transfusion in patients delivered vaginally?

To assess the frequency of large feto-maternal hemorrhage (FMH) during cesarean sections compared to vaginal deliveries and to verify if current practice leads to undertreatment of FMH among low-risk women.

Large Fetomaternal Hemorrhage Clinical Presentation and Outcome

Fetomaternal hemorrhage, the passage of fetal red blood cells into the maternal circulation, occurs in up to 75% of pregnancies, but its volume is nearly always less than 1 mL. This retrospective analysis, covering the years 1987-2000, included 16 infants who were treated during this time for fetomaternal hemorrhage of 20 mL or more. These infants were among more than 65,000 born during the period under review. Seven infants (44%) were born before 37 weeks gestation. Five of the 16 affected infants (31%) had adverse outcomes; 3 died and 2 had periventricular leukomalacia. Nine infants received packed red cell transfusions and 4 underwent double-volume exchange transfusions. Both procedures were used in 2 cases and 1 infant died before treatment could be instituted. Only 2 of the 16 infants did not require transfusion. Five infants were delivered vaginally or by planned cesarean section. In 6 other infants, fetal movements were reduced or absent, prompting emergency cesarean section. Fetal decelerations were noted in 2 cases. Infants for whom there was antenatal concern did as well as the others, and these groups had similar amounts of fetomaternal hemorrhage. Seven infants had hydrops fetalis, respiratory distress, or bradycardia when born, and 5 of them had an adverse outcome. Pallor by itself did not predict a negative outcome. Again, the amount of fetomaternal hemorrhage did not correlate with the outcome. The only factors significantly associated with adverse outcomes were the postnatal presentation and an initial hemoglobin below 4 g/dL. Adverse outcomes are not uncommon in newborn infants with fetomaternal hemorrhage of 20 mL or more. The initial hemoglobin level was a better predictor than the volume of bleeding in this series.

Large fetomaternal hemorrhage: clinical presentation and outcome

Large fetomaternal hemorrhage: clinical presentation and outcome

Large fetomaternal hemorrhage: clinical presentation and outcome

Aim: To evaluate the incidence and outcome of all neonates with demonstrated fetomaternal hemorrhages ≥20 ml and to assess possible predictors of large fetomaternal hemorrhage and outcome.Methods:Retrospective data analysis 1987-2000. Clinical data included antenatal events, method of delivery, condition at birth, hematology results, treatment and outcome.Results: Sixteen infants wereidentified and treated for fetomaternal hemorrhage. Adverse outcome occurred in five infants (31%). Outcome was predicted by postnatal presentation and initial hemoglobin.Conclusion: Adverseoutcome amongst neonates with large fetomaternal hemorrhage is high. Outcome is better predicted by initial hemoglobin than volume of hemorrhage as per the Kleihauer test.

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.