1/20. The importance of simple microscopy.A case of severe neonatal anaemia, the cause of which was found to be severe fetomaternal haemorrhage is presented. The diagnosis was confirmed by simple microscopic examination of the maternal blood using the technique of acid elution, the Kleihauer-Betke test. In the differential diagnosis of anaemia of a newborn, the diagnosis of fetomaternal haemorrhage must be considered and the simple Kleihauer-Betke test should be performed on the maternal blood as soon as possible.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
2/20. Detection of massive transplacental haemorrhage by flow cytometry.flow cytometry has been shown to be a more accurate and sensitive method than the Kleihauer-Betke test for the measurement of feto-maternal haemorrhage in Rh(D) incompatibility. This report describes the successful use of flow cytometry to detect and monitor the management of a massive transplacental haemorrhage (105 ml) of fetal Rh(D) positive cells in a Rh(D) negative woman. The report highlights the accuracy and reproducibility of the test and the stability of a blood sample when transferred 596 kilometres to a central testing facility.- - - - - - - - - - ranking = 3keywords = haemorrhage (Clic here for more details about this article) |
3/20. Doppler sonography for predicting fetal anemia caused by massive fetomaternal hemorrhage.Fetomaternal hemorrhage (FMH) can cause severe anemia in the fetus. Untreated, this may cause hydrops or even fetal death. However, correct diagnosis of FMH followed by blood transfusion can prevent these life-threatening consequences. We describe two cases in which fetal anemia was suspected because of maternal reporting of decreased or absent fetal movements, the detection of a sinusoidal heart rate pattern and increased blood flow velocities of the middle cerebral artery and umbilical vein. Together with the Betke-Kleihauer test showing fetal cells in the maternal circulation, this led to the correct diagnosis of severe fetal anemia caused by FMH. A cesarean section was performed within a few hours. Both neonates were severely anemic and received immediate blood transfusions. They are currently alive and well.- - - - - - - - - - ranking = 0.0012824958073335keywords = cerebral (Clic here for more details about this article) |
4/20. autopsy findings in a series of five cases of fetomaternal haemorrhages.AIMS: Fetal blood cells enter the maternal circulation in up to 95% of pregnancies, but usually in minute volumes. Haemodynamically significant fetomaternal haemorrhage (FMH) is a much rarer event reported in approximately 1 in 2800 pregnancies. Most of the literature on this phenomenon emphasises the clinical aspects, and there is no comprehensive description of the autopsy findings. We present a series of five fatal FMH. The aim of this series is to highlight some of the autopsy findings that may prompt consideration of a diagnosis of FMH and lead to appropriate confirmatory testing and counselling of the affected couple. methods: The five cases were referred to the Children's Hospital at Westmead for full autopsy. A Kleihauer-Betke test was performed on the mother's blood within one week of delivery in each case. RESULTS: The infants ranged in age from 27 to 40 weeks gestation (mean 36.6 weeks) with a mean birth weight of 2793 g. The estimated volumes of fetal blood lost ranged from 443 to 104 mL (mean loss 243 mL). The estimated percentage of fetal blood volume loss was an average of 107% (i.e., greater than the entire blood volume of the fetus). No other causes of hydrops were identified. pallor was often noted, and in most cases the autopsies were markedly bloodless with large vessels collapsed. Where the brain:liver ratio could be applied, two fetuses showed a mild increase in ratio, while one infant showed moderate growth restriction with a ratio of 6.2:1 (normal ratio 2.8:1 on non-macerated fetuses over 28 weeks gestation). Placental abnormalities included thrombosis of the umbilical vein and intervillous 'haematomas' in two cases. The most striking microscopic feature was the presence of intravascular nucleated RBC within virtually all organs. Placental intervillous (i.e., within the maternal vascular compartment) nucleated red blood cells were also seen in all cases. CONCLUSIONS: The autopsy findings of FMH can be subtle and easily overlooked unless a high index of suspicion is maintained. The most reliable autopsy features are pallor, subcutaneous oedema or serous effusions, and intravascular nucleated red blood cells (RBC) in organs or more specifically in the placental intervillous space. In all cases of unexplained fetal death a Kleihauer-Betke test should be performed.- - - - - - - - - - ranking = 2.5keywords = haemorrhage (Clic here for more details about this article) |
5/20. Idiopathic chronic fetomaternal haemorrhage resulting in hydrops--a case report.INTRODUCTION: We report a case of idiopathic chronic fetomaternal haemorrhage (FMH) that developed in the late trimester. CLINICAL PRESENTATION: The patient presented with decreased fetal movement at 38 weeks gestation. Antenatal follow-up was uneventful with normal serial ultrasound performed at 22 and 35 weeks. Prior to delivery, the cardiotocography (CTG) was abnormal with decreased baseline variability and late deceleration. Emergency lower segment caesarean section was performed. Upon delivery, a hydropic neonate with a haemoglobin level of 3.9 g/dL was noted. The Kleihauer-Betke test was positive, confirming FMH. OUTCOME: The neonate later developed intraventricular haemorrhage (IVH) and spastic cerebral palsy on follow-up. DISCUSSION: It is possible for FMH to occur late at the third trimester leading to detrimental effect. The fact that FMH can occur without antecedent risk factors underscores the importance of further research, and a high index of suspicion.- - - - - - - - - - ranking = 3.0012824958073keywords = haemorrhage, cerebral (Clic here for more details about this article) |
6/20. Massive feto-maternal haemorrhage with good perinatal outcome following failed external cephalic version.OBJECTIVE: To reinforce the risk of feto-maternal haemorrhage associated with external cephalic version for breech presentation. METHOD: A single case report with a literature review. RESULTS: Our case report was associated with the largest feto-maternal haemorrhage following external cephalic version reported so far. The perinatal outcome in this case was favourable despite a significant amount of fetal haemorrhage. The literature review did include cases with unfavourable outcomes. No reliable method of monitoring fetuses with feto-maternal haemorrhage has been reported, although middle cerebral artery Doppler studies appear to show promise. CONCLUSION: External cephalic version is useful in the management of breech presentations at term, but it is not without risks and clinicians need to be aware of this.- - - - - - - - - - ranking = 4.0012824958073keywords = haemorrhage, cerebral (Clic here for more details about this article) |
7/20. Treatment options in fetomaternal hemorrhage: four case studies.BACKGROUND: Significant fetomaternal hemorrhage (FMH) is an uncommon event that places the fetus at risk of severe morbidity and mortality. Symptoms and signs at presentation are subtle and, if promptly recognized, appropriate management may permit the fetus to escape serious injury. CASES: Four cases of significant FMH were diagnosed in the high-risk obstetrical unit at Mount Sinai Hospital, Toronto, during 2003. Three of the women complained of reduced fetal movements and were investigated initially with a non-stress test, a Kleihauer-Betke test, and ultrasound, including Doppler of the middle cerebral artery. These women all required emergency Caesarean section for non-reassuring fetal status. One fetus was treated by intravascular transfusion. Another identified case was transfused postnatally. One asymptomatic case was identified after spontaneous vaginal birth and also treated by neonatal transfusion. Neurological outcomes were good in all four cases. CONCLUSIONS: Reduced fetal movements may be the only complaint of FMH. Increased awareness is required to ensure a diagnosis is made. When a non-stress test for reduced fetal movement is non-reactive, a Kleihauer-Betke test should be ordered, as well as detailed ultrasonography, including fetal Doppler studies. The perinatal prognosis for FMH may improve by facilitating the appropriate use of fetal blood transfusion or delivery by Caesarean section.- - - - - - - - - - ranking = 0.0012824958073335keywords = cerebral (Clic here for more details about this article) |
8/20. The issue of anti-D: an integrated seamless approach from recognition of need to bedside administration.BACKGROUND: The appropriate and timely administration of Anti-D immunoglobulin to Rhesus (D) negative women who have delivered Rhesus (D) positive babies is a vital part of obstetric care. Anti-D has an especially high profile in ireland because of the tragic inadvertent transmission of hepatitis c to Irish women in past decades. AUDIT: We have reviewed our policy and procedures pertaining to the administration of Anti-D for sensitising events during pregnancy and postnatally, in the Mid-Western health Board in 1999/2000. As a result, major changes were made in the storage, issue, recording and administration of Anti-D. New procedures in the transfusion laboratory and in the maternity hospital have been accepted by scientists and midwives and supported by haematology and obstetric medical staff. The pharmacy and haematology laboratory no longer have a role in this programme. IMPLEMENTATION OF MULTI-DISCIPLINARY CHANGE MANAGEMENT: As a result of these changes, the storage, issuing and tracking of Anti-D has become the responsibility of the hospital blood bank. Measurement offoeto-maternal haemorrhage (FMH) is now the responsibility of bio medical scientists in blood bank, utilising both flow cytometry (increasingly recognised as the gold standard method) and the Kleihauer method (Kleihauer-Betke).The programme has moved from a doctor-administered IV Anti-D Ig, to a midwife-administered IM preparation. Prescription remains the responsibility of the doctor.These changes are facilitated by the protocol guided issue of the appropriate dose of Anti-D Ig by bio medical scientists to midwives. The issue of the Anti-D Ig occurs simultaneously with issue of results of mother and baby's serology testing and estimation of volume of FMH.These major changes have been guided by audit and needs assessment and require close liaison between medical, nursing and laboratory scientific staff in haematology, transfusion and obstetrics. CRITICAL INCIDENT AUDIT-CASE REPORT: Before new procedures became official policy, a critical incident audit allowed us to pilot our protocol and to revise it using draft new procedures. In this critical incident we describe successful management of a patient with a large foeto-maternal haemorrhage. This incident supported the need for the procedural enhancements already underway. This critical incident re-emphasised the need for the planned systems improvements to be introduced quickly.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
9/20. Massive feto-maternal hemorrhage: diagnosis by cardiotocography, Doppler ultrasonography and ST waveform analysis of fetal electrocardiography.A 34-year-old healthy gravida 2 para 1 presented after an uncomplicated pregnancy at term with a 2-day history of diminished fetal movements. Fetal anemia was suspected by fetal heart rate monitoring and Doppler estimation of the fetal peak blood flow velocity of the middle cerebral artery. We were also fortunate to register pathological ST waveform changes of the fetal ECG indicating fetal hypoxia. The diagnosis of a massive feto-maternal hemorrhage was confirmed by an extremely high fraction of erythrocytes containing fetal hemoglobin in maternal blood and, after delivery, by placental histology.- - - - - - - - - - ranking = 0.0012824958073335keywords = cerebral (Clic here for more details about this article) |
10/20. Doppler sonography of the fetal middle cerebral artery in the management of massive fetomaternal hemorrhage.Massive fetomaternal hemorrhage (FMH) is a rare complication in pregnancy that may cause hydrops or can even be life-threatening for the fetus. We report on the case of a 19-year-old gravida I, para 0, who presented to our clinic at 32 weeks of gestation due to decreased fetal movements. The initial fetal heart rate tracing at admission showed a sinusoidal pattern without decelerations. The ultrasound examination performed immediately described a normally developed fetus with normal amounts of amniotic fluid and without abnormities of the placental structure. Doppler sonography of the fetal middle cerebral artery gave rise to the strong suspicion of fetal anemia, so that a cordocentesis was prepared for potential intrauterine blood transfusion. Meanwhile, the rate of fetal hemoglobin (HbF) cells in the maternal blood was found to be markedly increased with 66 per thousand. Correspondingly, cardiotocographic findings worsened with repeated decelerations, thus an immediate cesarean section was performed based on the suspected diagnosis of an acute FMH. A fetus weighing 1,860 g was delivered, who had severe anemia with hemoglobin level of 4.0 g/dl. After a direct blood transfusion, HbF levels normalized rapidly, the fetus stabilized, and a normal recovery has thus far been reported. The presented case demonstrates the successful and straightforward diagnosis, as well as the management of a case of severe FMH and illustrates the special value of Doppler sonography in this context.- - - - - - - - - - ranking = 0.0064124790366674keywords = cerebral (Clic here for more details about this article) |
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