Anemia neonatal grave secundaria a transfusion feto-materna: a proposito de un caso / Severe neonatal anemia due to fetomaternal hemorrhage: an ilustrative case

La transfusión feto-materna es el paso de eritrocitos fetales a la circulación materna. Cuando es masiva, tiene una incidencia aproximada del 0,2-0,9 %. Generalmente, se desconoce el agente desencadenante, pero, en ocasiones, se pueden identificar factores de riesgo. En el embarazo, suele ser asintomática; el síntoma más frecuente es la disminución de los movimientos fetales (el 26 %) en relación con la anemia grave. Se diagnostica mediante la detección de hemoglobina fetal en la sangre materna (test de Kleihauer o citometría de flujo). Se presenta a un recién nacido con anemia crónica secundaria a la transfusión fetomaterna, que, después del tratamiento con transfusión de concentrado de hematíes, tuvo como complicación síntomas de sobrecarga de volumen y empeoramiento clínico. Tras la realización de una exanguinotransfusión, evolucionó favorablemente, sin secuelas.

Fetomaternal transfusion (FMT) is defined by the transfer of fetal blood into the maternal circulation. The incidence of massive FMT is estimated to be approximately 0.2-0.9 % of births. Although a number of etiologies have been associated with FMT, most causes remain unidentified and the pregnancy is usually asymptomatic. The most frequent symptom is the decrease in fetal movements (26 %) in relation to severe anemia. Several diagnostic modalities for FMT are described (Kleihauer stain, flow cytometry). We describe a case of a newborn with chronic anemia secondary to FMT who, after treatment with transfusions of red blood cells, presented volume overload and clinical worsening as a complication. In this case, our patient needed exchange transfusion for definitive improvement without disability.

Safety of umbilical cord milking in very preterm neonates: a randomized controlled study

OBJECTIVE: To investigate the safety of umbilical cord milking on both the mother and neonate among very preterm deliveries of less than 33 weeks of gestation. METHODS: Pregnant women who were expected to deliver at between 24 0/7 and 32 6/7 weeks of gestation were randomized to either the umbilical cord milking or immediate cord clamping group. Maternal and neonatal data associated with delivery, in addition to neonatal morbidity and mortality data, were collected and analyzed. RESULTS: Of the 66 preterm deliveries included in the study, 34 were randomized into the milking and 32 into the clamping group. Differences between maternal pre- and post-partum hemoglobin levels were 1.35 g/dL in the milking and 1.58 g/dL in the clamping group (P=0.451). Neonatal Apgar scores at both 1 and 5 minutes, initial blood gas analysis results, body temperature at admission, need for early intubation, and maximum bilirubin levels were all similar between the 2 groups. However, neonatal hemoglobin levels at birth (15.79 vs. 14.69 g/dL; P<0.05) and at 24 hours of age (14.83 vs. 13.29 g/dL; P<0.05) were significantly higher in the milking group. Neonates in the clamping group required more blood transfusion (1.78 vs. 0.93; P=0.049), and a higher percentage of neonates in the clamping group required inotropic drugs (63% vs. 29%; P=0.007). The mortality rate was significantly lower in the milking group (6% vs. 28%; P=0.015). CONCLUSION: Umbilical cord milking can be a safe and beneficial procedure for both the mother and the neonate in deliveries of less than 33 weeks of gestation.

Massive Fetomaternal Hemorrhage Diagnosed with High-performance Liquid Chromatography / 임상소아혈액종양

Massive fetomaternal hemorrhage (FMH) is a major cause of unexplained fetal death and neonatal anemia. FMH can be diagnosed using the Kleihauer-Betke test or flow cytometry by identifying the presence of fetal red cells in the maternal blood. However, timely diagnosis is a challenge because many hospitals lack the equipment needed to perform such tests. The authors experienced a case of FMH diagnosed via high-performance liquid chromatography (HPLC) which is generally used in measuring glycated hemoglobin (HbA1c) in a patient with unexplained neonatal anemia. A girl aged 2 days was transferred to our hospital for showing pallor and a hemoglobin level of 5.0 g/dL. HPLC revealed 3% fetal hemoglobin (HbF) in the maternal blood. HPLC is a quick test for quantifying HbF that is readily available in many hospitals and could serve as a promising alternative for diagnosing FMH.

Massive Fetomaternal Hemorrhage Diagnosed with High-performance Liquid Chromatography / 임상소아혈액종양

Massive fetomaternal hemorrhage (FMH) is a major cause of unexplained fetal death and neonatal anemia. FMH can be diagnosed using the Kleihauer-Betke test or flow cytometry by identifying the presence of fetal red cells in the maternal blood. However, timely diagnosis is a challenge because many hospitals lack the equipment needed to perform such tests. The authors experienced a case of FMH diagnosed via high-performance liquid chromatography (HPLC) which is generally used in measuring glycated hemoglobin (HbA1c) in a patient with unexplained neonatal anemia. A girl aged 2 days was transferred to our hospital for showing pallor and a hemoglobin level of 5.0 g/dL. HPLC revealed 3% fetal hemoglobin (HbF) in the maternal blood. HPLC is a quick test for quantifying HbF that is readily available in many hospitals and could serve as a promising alternative for diagnosing FMH.

A Case of Neonatal Isoimmune Hemolytic Disease due to Anti-Mi(a) Antibody with Massive Fetomaternal Hemorrhage / 대한주산의학회잡지

Authors experienced a newborn treated with severe anemia transferred to our hospital due to pulselessness and apnea shortly after birth. Laboratory analysis of the blood on admission revealed hemoglobin 3.1 g/dL, reticulocyte 11.0%. Kleihauer-Betke test for fetal hemoglobin from maternal blood was seen Hgb F 7%, then we suggested almost 180 ml fetomaternal hemorrhage. But, anemia was not improved despite repeated packed RBC transfusion. So, we evaluated the other cause of intractable anemia. The results were as follows; the Coombs' test was positive. The antibody identification test using mother's serum revealed anti-Mia antibody. The patient improved with supportive treatment, but got hypoxic brain injury due to massive fetomaternal hemorrhage. At day 29, the infant was doing well and was discharged. We report a case of neonatal isoimmune hemolytic disease due to anti-Mia with massive fetomaternal hemorrhage with a brief review of the related literatures.

Early versus late external cephalic version

To find out whether initiating external cephalic version [ECV] earlier in pregnancy increase the rate of successful ECV procedures, and be more effective in decreasing the non cephalic presentations at birth and also cesarean section rate. This interventional study was conducted in Department of Obstetrics and Gynecology Mardan Medical Complex from first July 2010 to 31[st] Dec 2011.It included women with singleton breech fetus at a gestational age of 34 to 35 weeks. Patients were randomly divided into two groups, those having a first ECV procedure between 34[238 days] and 35 weeks of gestation were called early ECV group the second group included those who had first ECV at or after 37 weeks[259 days] and were called delayed ECV group. Percentages were calculated for qualitative variables like Gravida, complications etc, while mean and SD for quantitative variables like gestational age. Out of total 203 women who had breech presentation 123 were finally selected for the trial. Early ECV group included 63 patients while delayed group included 60 patients.. Fewer fetuses were in non cephalic presentation at birth in the early ECV group [41/63[65%] versus 29/60[49%] in the delayed ECV group, p = 0.04. There were no differences in rates of cesarean section [19/63[30%] versus 20/60 [33%],p=0.42] in the early ECV group versus the delayed ECV group. The rate of preterm birth was not different between groups, early ECV group [2/63[3%] versus 0/60[o], p=o.26] delayed ECV group. External cephalic version at 34 and 35 weeks increase the likelihood of cephalic presentation at birth but it does not decrease the rate of cesarean sections and may increase the rate of preterm birth in the early ECV group

Hemorragia fetomaterna masiva como causa de hidrops en gestación a término: reporte de caso y revisión de la literatura / Massive fetomaternal hemorrage cause hydrops in pregnancy at term: case report and literature revision

Objetivo: la hemorragia fetomaterna masiva es una complicación rara del embarazo, que puede causar anemia fetal severa y muerte fetal intrauterina. Se presenta un caso clínico con el objetivo de hacer una revisión de la fisiopatología del diagnóstico y del tratamiento Materiales y métodos: se presenta el caso clínico de una mujer en la semana 39 de embarazo, remitida al Hospital La Paz de Madrid, centro de referencia de atención materna y perinatal, por signos ecográficos de hidrops y de insuficiencia cardíaca derecha. El registro cardiotocográfico evidenció un patrón sinusoidal. La recién nacida presentó acidosis metabólica y anemia severa. El estudio anatomopatológico de la placenta fue sugestivo de anemia fetal crónica. El test de Kleihauer-Betke evidenció hemorragia fetomaterna de 90-100 ml. Se realizó una búsqueda bibliográfica en las bases de datos Medline vía Pubmed, EMBASE, LILACS y SciELO y la biblioteca Cochrane. Conclusión: el diagnóstico intrauterino es difícil, se debe sospechar cuando una mujer refiere reducción de movimientos fetales y cuando el registro cardiotocográfico muestra un patrón sinusoidal. En general, el estudio ecográfico es anodino, el Doppler de la arteria cerebral media puede ayudar en la identificación de los casos de anemia fetal, donde se evidencia un aumento del pico sistólico. Es importante la identificación precoz de los casos afectados para empezar un tratamiento sintomático de la anemia...

Objective: massive fetomaternal hemorrhage is a rarely occurring complication during pregnancy which can cause severe fetal anemia and intrauterine fetal death. A clinical case is presented here to review the pertinent pathophysiology, diagnosis and treatment. Materials and methods: the case of a 39 weeks pregnant woman admitted to La Paz Hospital in Madrid is reported; this hospital is the center for perinatal and maternal attention. The patient was referred due to sonographic signs of hydrops and right heart failure. Cardiotocographic records showed a sinusoidal pattern. The newborn presented metabolic acidosis and severe anemia. Pathologic examination of the placenta was suggestive of chronic fetal anemia. The Kleihauer-Betke test revealed a 90-100 ml fetomaternal hemorrhage. A literature search was made in Medline via Pubmed, EMBASE, LILACS and SciELO and the Cochrane Library. Conclusion: intrauterine diagnosis is difficult; massive fetomaternal hemorrhage should be suspected when a woman refers to reduced fetal movements and when the record shows a sinusoidal pattern in cardiotocography. Ultrasound is usually bland and Doppler of the middle cerebral artery may help in identifying cases of fetal anemia, revealing an increased systolic peak. Such cases must be identified early on to start symptomatic treatment of anemia...

Hemorragia fetomaterna masiva con patrón cardiotocográfico sinusoidal: presentación de un caso y revisión de la literatura / Massive fetomaternal hemorrhage with cardiotocographic sinusoidal rhythm: a case presentation and literature review

Introducción: la transfusión fetomaterna masiva (TFM) es una entidad con una elevada morbilidad y mortalidad fetal, suele cursar con una disminución en la percepción de los movimientos fetales por parte de la madre, y la presencia de un patrón cardiotocográfico sinusoidal fetal, asociado a la anemia fetal. No obstante, ambas situaciones tienen muy baja especificidad. Se presenta un caso clínico con el objetivo de revisar la exactitud del patrón sinusoidal en el diagnóstico de anemia fetal. Materiales y metodos: se presenta el caso de una gestante de 36 semanas que fue atendida en el Hospital Universitario La Paz (complejo hospitalario de tercer nivel que forma parte del conjunto de hospitales públicos en España), en la que tras presentarse un patrón cardiotocográfico no tranquilizador, se realizó una inducción del parto en el que las pruebas habituales de bienestar fetal resultaron insuficientes para el diagnóstico de sufrimiento fetal. Tras un parto eutócico se comprobó la presencia de una anemia neonatal grave, comprobándose la presencia de un gran volumen de sangre fetal en la sangre materna mediante el test de Kleihauer Betke. Se hace una revisión de los artículos publicados en los últimos 10 años en las base de datos Medline vía PubMed, en español e inglés.Conclusión: la monitorización fetal intraparto podría ser útil en el diagnóstico de la hemorragia fetomaterna masiva, aunque se deben hacer estudios más amplios para determinar la exactitud diagnóstica...

Introduction: massive fetomaternal transfusion (MFT) is an entity having high fetal morbidity and mortality; it usually involves the mother’s reduced perception of fetal movements and the presence of a cardiotocographic fetal sinusoidal rhythm, associated with fetal anemia. However, both situations have very low specificity. A clinical case is presented here to arouse interest in reviewing the precision of the sinusoidal rhythm when diagnosing fetal anemia. Materials and methods: the case of a 36-weeks pregnant mother is presented; she attended La Paz teaching hospital (a third-level hospital forming part of the Spanish public hospital system). After presenting a non-reassuring cardiotocographic heart rate pattern, birth was induced in which the usual fetal wellbeing tests proved insufficient for diagnosing fetal suffering. The presence of serious neonatal anemia was shown following a eutocic delivery, the Kleihauer-Betke test proving the presence of a large volume of fetal blood in the mother’s blood. Articles published in both Spanish and English during the last 10 years in the Medline database were reviewed via PubMed. Conclusion: intradelivery fetal monitoring could be useful in diagnosing massive fetal-maternal hemorrhage, even though broader studies should be carried out for determining diagnostic precision...

Atualizações na profilaxia da isoimunização Rh / Updates in the prophylaxis of the Rh isoimmunization

O conhecimento da isoimunização Rh e das bases moleculares do gene RHD e de suas variantes cresceu muito nos últimos anos. Esse crescimento permitiu a introdução de ferramentas realmente úteis no acompanhamento a gestantes isoimunizadas ou em risco de desenvolver a doença hemolítica perinatal (DHPN). A introdução da imunoprofilaxia RhD, por volta dos anos 1960, propiciou uma significativa redução na incidência de aloimunização materna por anti-D. Essa redução torna-se ainda mais significante quando há a associação da profilaxia pós-natal à antenatal, entretanto, seu uso ainda não é amplamente difundido no Brasil e sua eficiência está diretamente relacionada à dose correta, que vai depender da idade gestacional e da quantidade de hemorragia feto-materna (HFM). Sabe-se ainda que a imunoglobulina anti-D policlonal, por ser de origem humana, não é isenta de riscos à gestante ou ao concepto. Dada essa limitação, anticorpos monoclonais têm sido produzidos e avaliados a fim de substituir o anti-D policlonal. Todavia, até o momento, o sucesso dessa nova tecnologia tem sido apenas parcial. Como uma importante alternativa, entretanto, tem sido estudada a habilidade de indução de tolerância à proteína RhD, em ratos transgênicos, a partir de peptídios sintéticos

The knowledge of the Rh isoimmunization and the molecular bases of RHD gene and its variants has grown in recent years. This growth allowed the introduction of useful tools in monitoring pregnant women with alloimmunization or at risk of developing hemolytic disease of the newborn (HDN). The introduction of RhD immunoprophylaxis, in the 1960 years, provided a significant reduction in the incidence of maternal alloimmunization by anti-D. This reduction becomes even more significant when associated with antenatal prophylaxis, however, its use is not yet widespread in Brazil and its efficiency is directly related to the correct dose that will depends on the gestational age and the fetomaternal hemorrhage (FMH) quantity. It is also known that anti-D polyclonal, to be of human origin, is not without risk to the mother or the fetus. Given this limitation, monoclonal antibodies have been produced and evaluated in order to replace the polyclonal anti-D. Nevertheless, so far the success of this new technology has been only partial. As an important alternative, however, the ability to induce tolerance to the RhD protein in transgenic mice from synthetic peptides has been studied

Two cases of massive fetomaternal hemorrhage treated by exchange transfusion / 대한주산의학회잡지

Massive fetomaternal hemorrhage is major cause of neonatal anemia. And neonatal anemia is fatal disease of high mortality rate. Massive fetomaternal hemorrhage is defined as hemorrhage of fetal blood above 150 mL in the maternal circulation. Massive fetomaternal hemorrhage is infrequent but represents a fatal cause of perinatal death. To identify fetal blood in the maternal circulation, Kleihauer-Betke test or flow cytometry has been usually used. But recently HPLC (high performance liquid chromatography) is used in the detection and quantification of fetomaternal transfusion. In fetomaternal transfusion, anemic newborn must be treated when circulatory failure is present. Circulatory failure often necessitates blood transfusion. We report two cases of severe anemia due to massive fetomaternal hemorrhage in full term baby. Each case was diagnosed by high performance lipuid chromatography and treated with exchange transfusion in order to avoid fluid overload and subsequent heart failure.

Desproporción fetopélvica: diagnóstico ecosonográfico / Feto-pelvic disproportion: ultrasound diagnosis

Determinar si la ecosonografía es útil en el diagnóstico de la desproporción fetopélvica. Estudio transversal/correlacional de 81 gestantes con embarazos simples iguales o mayores a 37 semanas, que no se encontraban en trabajo de parto. Se midió el conjugado obstétrico, el diámetro biparietal y la circunferencia cefálica fetal mediante ecosonografía y se establecieron los índices de estos últimos con el conjugado obstétrico ecosonográfico: Unidad de Ultrasonido. Maternidad "Concepción Palacios". Caracas. El valor medio del conjugado obstétrico fue 115,58 mm. La sensibilidad del mismo para predecir desproporción fetopélvica fue 46 por ciento y especificidad de 86 por ciento. El índice diámetro biparietal/conjugado obstétrico tuvo una sensibilidad y especificidad de 46 y 89 por ciento respectivamente. El conjugado obstétrico y el índice diámetro biparietal/conjugado obstétrico tienen baja sensibilidad para el diagnóstico de desproporción fetopélvica

Avaliação da hemorragia feto-materna em puérperas com indicação para ministração de imunoglobulina anti-D / Evaluation of fetomaternal hemorrhage in postpartum patients with indication for administration of anti-D immunoglobulin

Avaliamos a ocorrência da hemorragia feto-materna entre 343 puérperas que receberiam profilaxia da aloimunização Rh com emprego de imunoglobulina anti-D. Realizamos o teste de roseta para triagem dos casos que necessitariam determinação quantitativa do volume de sangue fetal transferido para circulação materna, que foi então apurado pelo teste de Kleihauer-Betke (K-B). O teste de roseta apresentou resultado positivo em 22 casos (6,4 por cento). Em cinco dessas amostras o teste de K-B não apontou hemorragia feto-materna (falso positivo do teste de roseta de 1,45 por cento) e noutra a leitura do teste não foi conclusiva. Tivemos oito casos com volume apurado de hemorragia feto-materna < 10ml (2,3 por cento), seis com hemorragia feto-materna entre 10 e 30ml (1,7 por cento) e duas puérperas apresentaram transferência sangüínea feto-materna maior que 30ml (0,58 por cento), necessitando suplementação além da dose padrão de anti-D. O teste de roseta dispensou 93,6 por cento das pacientes da avaliação adicional da hemorragia feto-materna por método quantitativo.

Feto-maternal hemorrhage after cordocentesis at Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To evaluate the incidence and volume of feto-maternal hemorrhage following cordocentesis. STUDY DESIGN: Descriptive study. MATERIAL AND METHOD: One hundred and sixteen asymptomatic non-anemic pregnant women with an indication for cordocentesis at 18-22 weeks of gestation between January and June 2004 were recruited. Maternal blood samples were obtained immediately before and 30 minutes after cordocentesis. Fetal cells in the maternal blood were counted using Kleihauer Betke test. About 25,000 maternal cells per slide were scanned by the same examiner. Feto-maternal hemorrhage was considered significant if the fetal bleeding was more than 0.25 ml. RESULTS: There was a significant increase in fetal blood volume in maternal circulation after cordocentesis (Paired Students t test, p < 0.001). A significant hemorrhage (> 0.25 ml) occurred in 63 from 116 women (54. 7%). Only one had marked hemorrhage of more than 5.0 ml and none had massive hemorrhage (> 15 ml). CONCLUSION: Cordocentesis at 18-22 weeks of gestation can be associated with feto-maternal hemorrhage in more than half of the cases but nearly all cases had only minimal hemorrhage and none had massive hemorrhage.

Evaluation of fetomaternal hemorrhage after post - abortion therapeutic curettage

Hemolytic diseases in fetus and newborn were known for years; the principle of these pathologies is defined Basically entrance of fetal blood cells to maternal circulation results in these ranges of diseases. Risk factor determination, early diagnosis of F.M H and adequate dosage of Anti - D Ig administration will be attempted to prevent subsequent adverse outcome on fetus and newborn. The quantification of fetal cells in the maternal circulation post - curettage miscarriage remains an important goal to prevent active immunization in mother. In this cross sectional study, during six months, from April 2004, one hundred patients post - abortion therapeutic curettage enrolled, in Ghaem Hospital, Mashhad University. Maternal age, gestational age, maternal blood group and Rh, gravidity, severity of maternal hemorrhage, HcT, BP and duration of vaginal bleeding were recorded. The KB test was done in all patients amount of FIMIH and Rh IgG dosage in positive KB patients were calculated. Data were analyzed with SPSS [Ver. 10] software. The KB test was positive in 35% of the patient. Gestational age, maternal H.ct, pain and severity of hemorrhage had significant relation to K.B test positive. F.M.H was 0.1-5 cc in 17 patients and in 18 it was less. Lower gestational age in abortion time decreases FMH risk the usual Rh - IgG dosage [50 micro gr] sounded to be adequate for Rh Immunization after post - abortion therapeutic curettage

The Association of Fetal Heart Rate Pattern following Cordocentesis with Pregnancy outcome / 대한산부인과학회잡지

OBJECTIVE: The cordocentesis is regarded as an useful procedure for the prenatal evaluation of fetal disease, but it's complications are fetal loss, umbilical cord bleeding, umbilical cord hematoma, fetal bradycardia, fetomaternal hemorrhage, abruptio placentae, and chorioamnionitis due to it's invasiveness. The fetal bradycardia following cordocentesis is transient and self-limited in most cases, and the prevalence rate of fetal bradycardia following cordocentesis was reported to be between 1.5 and 13 per cent. The purpose of this study was to evaluate the association of fetal heart rate pattern following cordocentesis with adverse pregnancy outcome. METHODS: We investigated retrospectively the fetal heart rate following cordocentesis, the Apgar score of neonate, the birth weight of neonate, gestational age at delivery, preterm delivery, intrauterine growth retardation, stillbirth, and chromosome analysis in 64 codocenteses between 1 February 2000 and 28 February 2001. Normal fetal heart rate was defined as 100 up to 170 bpm, fetal bradycardia as less than 100 bpm lasting one more minute, and fetal tachycardia as more than 170 bpm lasting one more minute. RESULTS: 1. Fetal heart rate pattern following the cordocentesis was normal in 53 cases (82.8%), bradycardia in 6 cases (9.4%) and tachycardia in 5 cases (7.8%). 2. The pregnancy outcome was well-being fetus at birth in 51 cases, terminated pregnancy in 5 cases, intrauterine growth restricted fetus in 5 cases, preterm birth in 1 case and intrauterine death in 2 cases. 3. Mean Apgar-1minute/-5minute scores in neonates were 8.4 +/- 0.2/9.3 +/- 0.2 in the normal fetal heart rate group, 6.8 +/- 1.7/7.6 +/- 1.9 in fetal bradycardia group and 8.4 +/- 0.2/9.4 +/- 0.2 in fetal tachycardia group, that showed no statistically significant difference between groups. 4. The gestational weeks at birth/birth weight were 38.9 +/- 0.4 weeks/3193 +/- 90 g in normal fetal heart rate group, 36.8 +/- 3.2 weeks/2733 +/- 340 g in bradycardia group and 40.0 +/- 0.2/3465 +/- 21 g in tachycardia group, that showed no statistically significant difference between groups. 5. The number of puncture at the same time of cordocentesis was one in 45 cases, two in 15 cases and three in 4 cases. 6. There was no difference in fetal heart rate pattern following cordocentesis between 60 cases of normal and 4 cases of abnormal cardiovascular findings sonographycally. 7. The karyotyping was normal in 60 cases and abnormal in 4 cases, each of which was 46,XY,inv(9),46,X,i(Xq)/45,X,47,XY,+mar, and 46,XX,t(7;15)(q10;q10) respectively. CONCLUSION: Fetal bradycardia or tachycardia following cordocentesis was not associated with adverse pregnancy outcomes.

Acute massive feto-maternal hemorrhange: a challenge to the neonatologist

Acute Feto-Maternl hemorrhage [FMH] is an unexpected medical emergency. The diagnosis should be considered in all cases of unexplained fetal deaths, fetal distress, in severe asphyxia, in non-immune hydrops fetalis, neonatal shock, severely pale baby, and in non-hemolytic anemia presenting in the newborn period. Prognosis remains poor with mortality around 50%. Anticipation, ideal aggressive management of the newborn and successful outcome in such cases remains even today a real challenge for the neonatologist