Massive fetomaternal hemorrhage
- Kenneth J Moise Jr, MD
Kenneth J Moise Jr, MD
- Professor of Obstetrics, Gynecology and Reproductive Sciences
- Professor of Pediatric Surgery
- University of Texas School of Medicine at Houston
Bidirectional passage of minute numbers of cells across the placenta is a physiological event, even though the placenta is considered a barrier separating the maternal and fetal circulations [1,2]. Massive fetomaternal hemorrhage (FMH), however, can result in serious sequelae. This topic will review the clinical presentation, diagnosis, management, and prognosis of pregnancies complicated by massive FMH.
No universally accepted threshold defines the volume of fetal erythrocytes in the maternal circulation that constitutes a massive FMH; volumes of 10 to 150 mL have been proposed . To put this in context, fetoplacental blood volume is approximately 100 mL/kg fetal weight , ranging from 117 mL/kg at 18 weeks to 93 mL/kg at 31 weeks gestation .
A better approach for assessing the magnitude of FMH is to estimate the percentage of the fetal blood volume represented by the FMH. Looked at in this way, a FMH of 20 mL/kg, which represents 20 percent of the fetoplacental blood volume, is considered massive because it has been associated with significant fetal/neonatal morbidity or mortality. (See 'Prognosis' below.)
Experiments in sheep show that the rapidity of fetal blood loss is an additional major factor affecting morbidity and mortality [6,7]. Massive FMH is more likely to be fatal if blood loss occurs over minutes rather than hours, days, or weeks. Although a critical prognostic factor, the rate of fetomaternal bleeding in human pregnancies is generally impossible to assess clinically, unless the fetus is hydropic, which suggests chronic anemia.
FMH >20 to 30 mL at delivery is estimated to occur in approximately 1 in 200 to 300 deliveries [3,8,9]. FMH >80 mL and >150 mL is estimated to occur in 1 in 1000 deliveries and 1 in 5000 deliveries, respectively .
- Bianchi DW, Romero R. Biological implications of bi-directional fetomaternal cell traffic: a summary of a National Institute of Child Health and Human Development-sponsored conference. J Matern Fetal Neonatal Med 2003; 14:123.
- Lo YM, Lau TK, Chan LY, et al. Quantitative analysis of the bidirectional fetomaternal transfer of nucleated cells and plasma DNA. Clin Chem 2000; 46:1301.
- de Almeida V, Bowman JM. Massive fetomaternal hemorrhage: Manitoba experience. Obstet Gynecol 1994; 83:323.
- Leduc L, Moise KJ Jr, Carpenter RJ Jr, Cano LE. Fetoplacental blood volume estimation in pregnancies with Rh alloimmunization. Fetal Diagn Ther 1990; 5:138.
- Nicolaides KH, Clewell WH, Rodeck CH. Measurement of human fetoplacental blood volume in erythroblastosis fetalis. Am J Obstet Gynecol 1987; 157:50.
- Brace RA. Mechanisms of fetal blood volume restoration after slow fetal hemorrhage. Am J Physiol 1989; 256:R1040.
- Brace RA, Cheung CY. Fetal blood volume restoration following rapid fetal hemorrhage. Am J Physiol 1990; 259:H567.
- Sebring ES, Polesky HF. Fetomaternal hemorrhage: incidence, risk factors, time of occurrence, and clinical effects. Transfusion 1990; 30:344.
- Rubod C, Deruelle P, Le Goueff F, et al. Long-term prognosis for infants after massive fetomaternal hemorrhage. Obstet Gynecol 2007; 110:256.
- Christensen RD, Lambert DK, Baer VL, et al. Severe neonatal anemia from fetomaternal hemorrhage: report from a multihospital health-care system. J Perinatol 2013; 33:429.
- Adeniji AO, Mabayoje VO, Raji AA, et al. Feto - maternal haemorrhage in parturients: Incidence and its determinants. J Obstet Gynaecol 2008; 28:60.
- Salim R, Ben-Shlomo I, Nachum Z, et al. The incidence of large fetomaternal hemorrhage and the Kleihauer-Betke test. Obstet Gynecol 2005; 105:1039.
- Devi B, Jennison RF, Langley FA. Significance of placental pathology in transplacental haemorrhage. J Clin Pathol 1968; 21:322.
- Murphy KW, Venkatraman N, Stevens J. Limitations of ultrasound in the diagnosis of fetomaternal haemorrhage. BJOG 2000; 107:1317.
- Glasser L, West JH, Hagood RM. Incompatible fetomaternal transfusion with maternal intravascular lysis. Transfusion 1970; 10:322.
- Giacoia GP. Severe fetomaternal hemorrhage: a review. Obstet Gynecol Surv 1997; 52:372.
- Modanlou HD, Freeman RK, Ortiz O, et al. Sinusoidal fetal heart rate pattern and severe fetal anemia. Obstet Gynecol 1977; 49:537.
- Nicolaides KH, Sadovsky G, Visser GH. Heart rate patterns in normoxemic, hypoxemic, and anemic second-trimester fetuses. Am J Obstet Gynecol 1989; 160:1034.
- Laube DW, Schauberger CW. Fetomaternal bleeding as a cause for "unexplained" fetal death. Obstet Gynecol 1982; 60:649.
- ACOG Practice Bulletin No. 102: management of stillbirth. Obstet Gynecol 2009; 113:748. Reaffirmed February 2017.
- Stillbirth Collaborative Research Network Writing Group. Causes of death among stillbirths. JAMA 2011; 306:2459.
- Watanabe N, Jwa SC, Ozawa N, Sago H. Sinusoidal heart rate patterns as a manifestation of massive fetomaternal hemorrhage in a monochorionic-diamniotic twin pregnancy: a case report. Fetal Diagn Ther 2010; 27:168.
- Sueters M, Arabin B, Oepkes D. Doppler sonography for predicting fetal anemia caused by massive fetomaternal hemorrhage. Ultrasound Obstet Gynecol 2003; 22:186.
- Stroustrup A, Plafkin C, Savitz DA. Impact of physician awareness on diagnosis of fetomaternal hemorrhage. Neonatology 2014; 105:250.
- Wylie BJ, D'Alton ME. Fetomaternal hemorrhage. Obstet Gynecol 2010; 115:1039.
- Dhanraj D, Lambers D. The incidences of positive Kleihauer-Betke test in low-risk pregnancies and maternal trauma patients. Am J Obstet Gynecol 2004; 190:1461.
- Muench MV, Baschat AA, Reddy UM, et al. Kleihauer-betke testing is important in all cases of maternal trauma. J Trauma 2004; 57:1094.
- Chames MC, Pearlman MD. Trauma during pregnancy: outcomes and clinical management. Clin Obstet Gynecol 2008; 51:398.
- Goodwin TM, Breen MT. Pregnancy outcome and fetomaternal hemorrhage after noncatastrophic trauma. Am J Obstet Gynecol 1990; 162:665.
- Pearlman MD, Tintinallli JE, Lorenz RP. A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol 1990; 162:1502.
- Pepperell RJ, Rubinstein E, MacIsaac IA. Motor-car accidents during pregnancy. Med J Aust 1977; 1:203.
- Brecher ME. Technical Manual of the American Association of Blood Banks. American Association of Blood Banks, Bethesda, Maryland 2005.
- KLEIHAUER E, BRAUN H, BETKE K. [Demonstration of fetal hemoglobin in erythrocytes of a blood smear]. Klin Wochenschr 1957; 35:637.
- Sandler SG, Gottschall JL. Postpartum Rh immunoprophylaxis. Obstet Gynecol 2012; 120:1428.
- Dziegiel MH, Nielsen LK, Berkowicz A. Detecting fetomaternal hemorrhage by flow cytometry. Curr Opin Hematol 2006; 13:490.
- Bromilow IM, Duguid JK. Measurement of feto-maternal haemorrhage: a comparative study of three Kleihauer techniques and tow flow cytometry methods. Clin Lab Haematol 1997; 19:137.
- 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.
- Stefanovic V, Paavonen J, Halmesmäki E, et al. Two intrauterine rescue transfusions in treatment of severe fetomaternal hemorrhage in the early third trimester. Clin Case Rep 2013; 1:59.
- Votino C, Mirlesse V, Gourand L, et al. Successful treatment of a severe second trimester fetomaternal hemorrhage by repeated fetal intravascular transfusions. Fetal Diagn Ther 2008; 24:503.
- Friszer S, Cortey A, Pierre F, Carbonne B. Using middle cerebral artery peak systolic velocity to time in utero transfusions in fetomaternal hemorrhage. Obstet Gynecol 2010; 115:1036.
- Mari G, Zimmermann R, Moise KJ Jr, Deter RL. Correlation between middle cerebral artery peak systolic velocity and fetal hemoglobin after 2 previous intrauterine transfusions. Am J Obstet Gynecol 2005; 193:1117.
- Sifakis S, Koukoura O, Konstantinidou AE, et al. Sonographic findings in severe fetomaternal transfusion. Arch Gynecol Obstet 2010; 281:241.
- Catalano PM, Capeless EL. Fetomaternal bleeding as a cause of recurrent fetal morbidity and mortality. Obstet Gynecol 1990; 76:972.
- Maass B, Würfel B, Fusch C. Recurrent fetomaternal transfusion in two consecutive pregnancies. Prenat Diagn 2001; 21:791.
- RISK FACTORS
- SPONTANEOUS VERSUS TRAUMATIC FMH
- CLINICAL PRESENTATION
- WHEN TO TEST FOR FMH
- Fetal demise or stillbirth
- Sinusoidal fetal heart rate or hydrops fetalis
- Neonatal anemia
- POSSIBLE INDICATIONS FOR TESTING FOR FMH
- Decreased fetal movement
- Maternal abdominal trauma
- LABORATORY EVALUATION
- Flow cytometry
- MANAGEMENT OF SPONTANEOUS FMH
- Massive hemorrhage/moderate to severe anemia
- Small hemorrhage/no or mild anemia
- Anti-D immune globulin
- SUMMARY AND RECOMMENDATIONS