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Severe neonatal anemia from fetomaternal hemorrhage: report from a multihospital health-care system

Abstract

Objective:

The incidence of fetomaternal hemorrhage that is severe enough to cause neonatal anemia is not known. Owing to its relative rarity, much of the literature describing this condition is in the form of case reports and small case series. We performed a large, muiticentered, sequential, case series to determine the incidence, antecedents and outcomes.

Study Design:

From the multicentered databases of Intermountain Healthcare, we obtained records of all neonates with hematocrit (Hct) <30% or hemoglobin (Hgb) <10 g dl−1 on the day of birth, who had Kleihauer–Betke staining or flow cytometric evidence of fetomaternal hemorrhage.

Result:

Among 219 853 live births, 24 had anemia with evidence of fetomaternal hemorrhage (incidence estimate, 1 per 9160 live births). The initial Hgb ranged from 1.4 to 10.2 g dl−1 (Hct 29.8%). The initial Hgb was <7 g dl−1 in 18 (67%), <5 g dl−1 in 12 (50%) and was <3 g dl−1 in 7 (29%). All 7 mothers in whom neonatal Hgb was <3 g dl−1 had reported absent fetal movement, as did 13 of 18 mothers when the initial Hgb was <7 g dl−1. Outcomes were poorer in those with the lowest initial Hgb; in the two lowest, one died on day 1, and the other developed a grade 4 intraventricular hemorrhage (IVH). The adverse outcomes of death, IVH, periventricular leukomalacia, bronchopulmonary dysplasia or hypoxic-ischemic encephalopathy were common; occurring in 71% (17 of the 24), including all with an initial Hgb <5 g dl−1 and all born at 35 weeks of gestation.

Conclusion:

Fetomaternal hemorrhage is a rare but sometimes devastating condition. Those with fetomaternal hemorrhage and an initial Hgb of <5 g dl−1 are expected to need resuscitation at birth, to receive emergent transfusion support and to be at risk for death and major morbidities. Antenatal suspicion of this diagnosis should occur when absent fetal movement is reported. Improvements in rapid diagnosis are needed to prepare first responders and transfusion services.

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References

  1. Bianchi DW . Robert E. Gross Lecture. Fetomaternal cell trafficking: a story that begins with prenatal diagnosis and may end with stem cell therapy. J Pediatr Surg 2007; 42: 12–18.

    Article  PubMed  Google Scholar 

  2. Wylie BJ, D'Alton ME . Fetomaternal hemorrhage. Obstet Gynecol 2010; 115: 1039–1051.

    Article  PubMed  Google Scholar 

  3. Sebring ES, Polesky HF . Fetomaternal hemorrhage: incidence, risk factors, time of occurrence, and clinical effects. Transfusion 1990; 30: 344–357.

    Article  CAS  PubMed  Google Scholar 

  4. Pollack W, Ascari WQ, Kochesky RJ, O’Connor RR, Ho Ty, Tripodi D . Studies on Rh prophylaxis. Relationship between dose of anti-Rh and size of antigenic stimulus. Transfusion 1971; 11: 333–339.

    Article  CAS  PubMed  Google Scholar 

  5. 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.

    Article  PubMed  Google Scholar 

  6. De Almeida V, Bowman JM . Massive fetomaternal hemorrhage: Manitoba experience. Obstet Gynecol 1994; 83: 323–328.

    CAS  PubMed  Google Scholar 

  7. Silver RM, Varner MW, Reddy U, Goldenberg R, Pinar H, Conway D et al. Work-up of stillbirth: a review of the evidence. Am J Obstet Gynecol 2007; 196: 433–444.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ahmed M, Abdullatif M . Fetomaternal transfusion as a cause of severe fetal anemia causing early neonatal death: a case report. Oman Med J 2011; 26: 444–446.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Siemer J, Wendler A, Schild RL, Grab D . Massive fetomaternal hemorrhage and severe anemia in the newborn - two case reports. Ultraschall Med 2010; 31: 192–194.

    Article  CAS  PubMed  Google Scholar 

  10. De Luca D, Pietrini D, Piastra M, Tiberi E, Romiti A, Bernardini T et al. Successful resuscitation of unexpected neonatal hemorrhagic shock due to massive feto-maternal hemorrhage. Paediatr Anaesth 2008; 18: 1004–1006.

    Article  PubMed  Google Scholar 

  11. Markham LA, Charsha DS, Perelmuter B . Case report of massive fetomaternal hemorrhage and a guideline for acute neonatal management. Adv Neonatal Care 2006; 6: 197–205.

    Article  PubMed  Google Scholar 

  12. Tseng LL, Didone AM, Cheng CS . Severe anemia in a newborn due to massive fetomaternal hemorrhage: report of one case. Acta Paediatr Taiwan 2005; 46: 305–307.

    PubMed  Google Scholar 

  13. Pourbabak S, Rund CR, Crookston KP . Three cases of massive fetomaternal hemorrhage presenting without clinical suspicion. Arch Pathol Lab Med 2004; 128: 463–465.

    PubMed  Google Scholar 

  14. Thomas A, Mathew M, Unciano Moral E, Vaclavinkova V . Acute massive fetomaternal hemorrhage: case reports and review of the literature. Acta Obstet Gynecol Scand 2003; 82: 479–480.

    Article  PubMed  Google Scholar 

  15. Lafferty JD, Raby A, Crawford L, Linkins LA, Richardson H, Crowther M . Fetal-maternal hemorrhage detection in Ontario. Am J Clin Pathol 2003; 119: 72–77.

    Article  PubMed  Google Scholar 

  16. Vermont Oxford Network Database. Manuel of Operations. Vermont Oxford Network Database, Vermont Oxford: Burlington, VT Release 10.0 pp 77, 78 2007.

  17. Christensen RD, Henry E, Andres RL, Bennett ST . Reference ranges for blood concentrations of nucleated red blood cells in neonates. Neonatology 2011; 99: 289–294.

    Article  PubMed  Google Scholar 

  18. Christensen RD, Ohls RK . Anemias unique to the newborn In: Greer JP, Foerster J, Rodgers GM, Paraskevas F, Glader G, Arber DA, Means RT Jr., (eds) Wintrobe’s Clinical Hematology 12th edn Wolters Kluwer/Lippincott, Williams & Wilkins: Philadelphia, 2009 pp 1247–1261.

    Google Scholar 

  19. Christensen RD, Jopling J, Henry E, Wiedmeier SE . The erythrocyte indices of neonates, defined using data from over 12,000 patients in a multihospital health care system. J Perinatol 2008; 28: 24–28.

    Article  CAS  PubMed  Google Scholar 

  20. Jopling J, Henry E, Wiedmeier SE, Christensen RD . Reference ranges for hematocrit and blood hemoglobin concentration during the neonatal period: data from a multihospital health care system. Pediatrics 2009; 123: e333–e337.

    PubMed  Google Scholar 

  21. Brace RA . Mechanisms of fetal blood volume restoration after slow fetal hemorrhage. Am J Physiol 1989; 256: R1040–R1043.

    CAS  PubMed  Google Scholar 

  22. Poissonnier MH, Brossard Y, Demedeiros N, Vassileva J, Parnet F, Larsen M et al. Two hundred intrauterine exchange transfusions in severe blood incompatibilities. Am J Obstet Gynecol 1989; 161: 709–713.

    Article  CAS  PubMed  Google Scholar 

  23. Gacoia GP . Severe fetomaternal hemorrhage: a review. Obstet Gynecol Surv 1997; 52: 372–380.

    Article  Google Scholar 

  24. ACOG Practice Bulletin Number 9. Antepartum fetal surveillance. October 1999.

  25. Fong EA, Davies JI, Grey DE, Reid PJ, Erber WN . Detection of massive transplacental haemorrhage by flow cytometry. Clin Lab Haematol 2000; 22: 325–327.

    Article  CAS  PubMed  Google Scholar 

  26. Akanli LF, Cohen-Addad NE, Malabanan NV, Margono F, Krilov MA . Massive fetomaternal hemorrhage. Am J Perinatol 1997; 14: 271–273.

    Article  CAS  PubMed  Google Scholar 

Download references

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Correspondence to R D Christensen.

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Christensen, R., Lambert, D., Baer, V. et al. Severe neonatal anemia from fetomaternal hemorrhage: report from a multihospital health-care system. J Perinatol 33, 429–434 (2013). https://doi.org/10.1038/jp.2012.142

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