Fetomaternal haemorrhage – can we improve the outcome?

Abstract

A 30-year-old primigravida presented to the delivery suite at 36 weeks gestation with a three-hour history of decreased fetal movements. Her antenatal history was unremarkable. CTG showed a sinusoidal pattern with a baseline of 135 bpm but absent decelerations. An ultrasound scan showed the growth and amniotic fluid parameters to be within normal limits. Umbilical artery Doppler studies were normal but fetal movements were observed to be absent during the examination. As there was a suspicion of fetomaternal haemorrhage, a Kleihauer test was requested and was noted to be strongly positive. The CTG trace continued to be abnormal with development of decelerations ( Figure 1).A decision for emergency caesarean section was made. A live, pale infant weighing 3500 g was delivered with Apgar scores of 7 at 1 minute and 8 at 5 minutes. The child was immediately intubated and ventilated. The haemoglobin of the infant at birth was 3.4 g/dL, necessitating transfusion, and the pH of the umbilical arterial blood was 6.9. No reticulocyte count was carried out, although the mean corpuscular volume was raised at 110.8 fL. The histological examination of the placenta was normal. Subsequent problems encountered included pneumothorax requiring a chest drain, and pulmonary hypertension.The child was subsequently transferred to a tertiary centre for oscillation ventilation and nitric oxide. The subsequent course remained stormy, the infant enduring a cardiac arrest, pulmonary haemorrhage, sepsis and requiring repeat transfusions. The infant had grade I intraventricular haemorrhage, requiring phenobarbitone, but is now doing well.The mother was Rhesus (D) positive, and so did not require anti-D gamma globulin.

Prenatal ultrasonography and Doppler sonography for the clinical investigation of isolated ventricular septal defects in a late second-trimester population

“…The biparietal diameter (BPD) was measured on a transverse axial section of the fetal head, which included the midline falx and the thalami, symmetrically positioned on either side of the falx from the outer edge of the nearer parietal bone to the inner edge of the more distant parietal bone, and the septum pellucidum was visualized at one-third of the frontal–occipital distance [24]. …”

“…This plane was at the level of the liver and stomach bubble including the ductus venosus within the point of bifurcation of the main portal vein into its right and left branches in the anterior third of the fetal abdomen in the axial plane 90° to the fetal spine and posterior to the aorta. Measured from skin to skin, the transverse and anterior–posterior diameters were first measured as the long or short axis of an onscreen ellipse, and the circumference was obtained using elliptical calipers superimposed on the four points [24]. The single measurement plane of six limb bones (humerus, ulna, radius, femur, tibia, and fibula) was on the longest section of each structure.…”

Antenatal exercise in overweight and obese women and its effects on offspring and maternal health: design and rationale of the IMPROVE (Improving Maternal and Progeny Obesity Via Exercise) randomised controlled trial

“…Standard growth measurements including biparietal diameter (BPD), head circumference (HC), humerus diaphyseal length (HDL), abdominal circumference (AC), and femur diaphyseal length (FL) are performed according to the protocols published by the Australasian Society for Ultrasound in Medicine [31]. At each examination, all measurements are obtained three times from three separately generated ultrasound images, and then averaged.…”

Case Report of Massive Fetomaternal Hemorrhage and a Guideline for Acute Neonatal Management

“…16 The well-documented finding of fetal sinusoidal heart rate pattern is attributed to fetal anemia ( Fig 1). [17][18][19][20] A sinusoidal heart rate pattern shows no reactivity, fixed or flat short-term variability, and oscillation of the sinusoidal waveform above and below baseline. The rate is 120 to 160 beats/minute.…”