Large Fetomaternal Hemorrhage: Prenatal Predictive Factors for Perinatal Outcome

 

 Buy Article Permissions and Reprints

ABSTRACT

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.

REFERENCES

• 1 de Almeida V, Bowman J M. Massive fetomaternal hemorrhage: Manitoba experience.  Obstet Gynecol. 1994;  83 323-328
  PubMedGoogle Scholar
• 2 Purwosunu Y, Sekizawa A, Farina A et al.. Enrichment of NRBC in maternal blood: a more feasible method for noninvasive prenatal diagnosis.  Prenat Diagn. 2006;  26 545-547
  CrossrefPubMedGoogle Scholar
• 3 Marions L, Thomassen P. Six cases of massive feto-maternal bleeding causing intra-uterine fetal death.  Acta Obstet Gynecol Scand. 1991;  70 85-88
  CrossrefPubMedGoogle Scholar
• 4 Boulos J, Andrini P, Haddad J, Villar C F. Fetomaternal hemorrhage: a series of 9 cases.  Arch Pediatr. 1998;  5 1206-1210
  CrossrefPubMedGoogle Scholar
• 5 Renaer M, Van de Putte I, Vermylen C. Massive feto-maternal hemorrhage as a cause of perinatal mortality and morbidity.  Eur J Obstet Gynecol Reprod Biol. 1976;  6 125-140
  CrossrefPubMedGoogle Scholar
• 6 Giacoia G P. Severe fetomaternal hemorrhage: a review.  Obstet Gynecol Surv. 1997;  52 372-380
  CrossrefPubMedGoogle Scholar
• 7 Kecskes Z. Large fetomaternal hemorrhage: clinical presentation and outcome.  J Matern Fetal Neonatal Med. 2003;  13 128-132
  CrossrefPubMedGoogle Scholar
• 8 Rubod C, Deruelle P, Le Goueff F, Tunez V, Fournier M, Subtil D. Long-term prognosis for infants after massive fetomaternal hemorrhage.  Obstet Gynecol. 2007;  110 256-260
  CrossrefPubMedGoogle Scholar
• 9 Kleihauer E. Beihefte zum.  Arch Kinderheilkd. 1966;  53 234-235
  PubMedGoogle Scholar
• 10 Thomson A M, Billewicz W Z, Hytten F E. The weight of the placenta in relation to birthweight.  J Obstet Gynaecol Br Commonw. 1969;  76 865-872
  PubMedGoogle Scholar
• 11 Leduc L, Moise Jr K J, Carpenter Jr R J, Cano L E. Fetoplacental blood volume estimation in pregnancies with Rh alloimmunization.  Fetal Diagn Ther. 1990;  5 138-146
  PubMedGoogle Scholar
• 12 Nicolaides K H, Clewell W H, Rodeck C H. Measurement of human fetoplacental blood volume in erythroblastosis fetalis.  Am J Obstet Gynecol. 1987;  157 50-53
  PubMedGoogle Scholar
• 13 Fuhrmann W, Altland K, Kohler A et al.. Feto-maternal transfusion after chorionic villus sampling. Evaluation by maternal serum alphafetoprotein measurement.  Hum Genet. 1988;  78 83-85
  PubMedGoogle Scholar
• 14 Kohlenberg C F, Ellwood D A. Fetomaternal haemorrhage treated with intravascular transfusion: a late complication of amniocentesis?.  Br J Obstet Gynaecol. 1994;  101 912-913
  PubMedGoogle Scholar
• 15 Tabor A, Bang J, Norgaard-Pedersen B. Feto-maternal haemorrhage associated with genetic amniocentesis: results of a randomized trial.  Br J Obstet Gynaecol. 1987;  94 528-534
  CrossrefPubMedGoogle Scholar
• 16 Lau T K, Lo K W, Chan L Y, Leung T Y, Lo Y M. Cell-free fetal deoxyribonucleic acid in maternal circulation as a marker of fetal-maternal hemorrhage in patients undergoing external cephalic version near term.  Am J Obstet Gynecol. 2000;  183 712-716
  CrossrefPubMedGoogle Scholar
• 17 Pelikan D M, Mesker W E, Scherjon S A, Kanhai H H, Tanke H J. Improvement of the Kleihauer-Betke test by automated detection of fetal erythrocytes in maternal blood.  Cytometry B Clin Cytom. 2003;  54 1-9
  PubMedGoogle Scholar
• 18 Kennedy G A, Shaw R, Just S et al.. Quantification of feto-maternal haemorrhage (FMH) by flow cytometry: anti-fetal haemoglobin labelling potentially underestimates massive FMH in comparison to labelling with anti-D.  Transfus Med. 2003;  13 25-33
  CrossrefPubMedGoogle Scholar
• 19 Meyers R L, Paulick R P, Rudolph C D, Rudolph A M. Cardiovascular responses to acute, severe haemorrhage in fetal sheep.  J Dev Physiol. 1991;  15 189-197
  PubMedGoogle Scholar
• 20 Salim R, Ben-Shlomo I, Nachum Z, Mader R, Shalev E. The incidence of large fetomaternal hemorrhage and the Kleihauer-Betke test.  Obstet Gynecol. 2005;  105 1039-1044
  PubMedGoogle Scholar
• 21 Sebring E S, Polesky H F. Fetomaternal hemorrhage: incidence, risk factors, time of occurrence, and clinical effects.  Transfusion. 1990;  30 344-357
  CrossrefPubMedGoogle Scholar
• 22 Murphy K W, Venkatraman N, Stevens J. Limitations of ultrasound in the diagnosis of fetomaternal haemorrhage.  BJOG. 2000;  107 1317-1319
  CrossrefPubMedGoogle Scholar
• 23 Eichbaum M, Gast A S, Sohn C. Doppler sonography of the fetal middle cerebral artery in the management of massive fetomaternal hemorrhage.  Fetal Diagn Ther. 2006;  21 334-338
  CrossrefPubMedGoogle Scholar
• 24 Sueters M, Arabin B, Oepkes D. Doppler sonography for predicting fetal anemia caused by massive fetomaternal hemorrhage.  Ultrasound Obstet Gynecol. 2003;  22 186-189
  CrossrefPubMedGoogle Scholar
• 25 Baschat A A, Harman C R, Alger L S, Weiner C P. Fetal coronary and cerebral blood flow in acute fetomaternal hemorrhage.  Ultrasound Obstet Gynecol. 1998;  12 128-131
  PubMedGoogle Scholar
• 26 Rubod C, Houfflin V, Belot F et al.. Successful in utero treatment of chronic and massive fetomaternal hemorrhage with fetal hydrops.  Fetal Diagn Ther. 2006;  21 410-413
  CrossrefPubMedGoogle Scholar
• 27 Malcus P, Bjorklund L J, Lilja M, Teleman P, Laurini R. Massive feto-maternal hemorrhage: diagnosis by cardiotocography, Doppler ultrasonography and ST waveform analysis of fetal electrocardiography.  Fetal Diagn Ther. 2006;  21 8-12
  CrossrefPubMedGoogle Scholar
• 28 Maass B, Wurfel B, Fusch C. Recurrent fetomaternal transfusion in two consecutive pregnancies.  Prenat Diagn. 2001;  21 791-793
  CrossrefPubMedGoogle Scholar
• 29 Catalano P M, Capeless E L. Fetomaternal bleeding as a cause of recurrent fetal morbidity and mortality.  Obstet Gynecol. 1990;  76 972-973
  CrossrefPubMedGoogle Scholar

Cyril HuissoudM.D. M.Sc. 

Hospices civils de Lyon, Department of Obstetrics and Gynecology, Hôpital de la Croix Rousse

93 Grande rue de la Croix- Rousse, 69004 Lyon, France

Email: cyril.huissoud@chu-lyon.fr