Management and Follow-up of Massive Fetomaternal Hemorrhage Requiring High-Dose Rh Immune Globulin: A Case Report.

OBJECTIVES: Massive fetomaternal hemorrhage (FMH) is rare and reported to be the cause in approximately 3% of all fetal deaths. Maternal management of massive FMH includes prevention of Rh(D) alloimmunization in Rh(D)-negative mothers by administration of Rh(D) immune globulin (RhIG). METHODS: We describe a case of a 30-year-old O-negative, primigravida woman who presented at 38 weeks of gestation with decreased fetal movements. She underwent an emergency cesarean section and delivered an O-positive baby girl who died shortly after birth. RESULTS: The patient's FMH screen was positive, with a Kleihauer-Betke test demonstrating 10.7% fetal blood in maternal circulation. The calculated dose of 6,300 µg RhIG was given prior to discharge over 2 days using an intravenous (IV) preparation. Antibody screening a week after discharge showed anti-D and anti-C. The anti-C was attributed to acquired passive immunity from the large dose of RhIG. Anti-C reactivity waned and was negative at 6 months, but the anti-D pattern persisted at 9 months postdelivery. Negative antibody screens were noted at 12 and 14 months. CONCLUSIONS: This case highlights the immunohematology challenges of IV RhIG as well as the success in preventing alloimmunization with IV RhIG given the patient's complete resolution of anti-C and no anti-D formation, with a subsequent healthy pregnancy.

Misinterpretation of blood group and antibody screen leading to serious errors in RhD immunoglobulin administration: A report on first two years of data from Serious Transfusion Incident Reporting program.

The Serious Transfusion Incident Reporting program (STIR) commenced haemovigilance in relation to RhD immunoglobulin (Ig) administration in 2015. During two years of reporting, 21 reports relating to RhD Ig administration were received. Thirty-three percent (7/21) were related to omission of RhD Ig, putting women at risk of RhD alloimmunisation and adverse consequences in future pregnancies. A recent case reported to STIR highlights poor communication and misinterpretation of pathology results leading to significant morbidity from haemolysis in the fetus. STIR makes recommendations related to education of staff and communication between clinical and laboratory staff to improve the safety of patient care.

Intraplacental choriocarcinoma coexisting with fetomaternal hemorrhage: Case report, chemotherapy management, and literature review.

RATIONALE: Near-term intraplacental choriocarcinoma (IC) coexisting with massive fetomaternal hemorrhage (FMH) is rare, and its clinical course is poorly understood. Here, we report a new case from our hospital, with detailed discussion and literature review. PATIENT CONCERNS: A 21-year-old Chinese female at 35 weeks gestation was admitted to our hospital due to reduced fetal movement. Near-term IC coexisting with massive FMH was diagnosed after delivery. INTERVENTION: The mother and infant were followed 3 months after delivery. Beta-human chorionic gonadotropin (ß-HCG), pathological examination of the placenta, and computed tomography scans were performed for the mother and ß-HCG was performed for the infant. OUTCOMES: The mother's ß-HCG serum level increased from 31,280 IU/L (6 days postdelivery) to 192,070 IU/L (49 days postdelivery), and then steadily fell to 42,468 IU/L (3 months postdelivery) without chemotherapy. The mother died from metastasis and cerebral hemorrhage. The infant survived and his ß-HCG serum level fell to within the normal range without chemotherapy. LESSONS: FMH associated with near-term IC is a rare disease. Measurement of maternal ß-HCG may therefore represent a useful parameter when IC is a possible differential diagnosis. A pathological examination of the placenta should be performed in all cases of FMH to better identify cases of IC. Future research should aim to develop methods of identifying which patients with IC should receive chemotherapy, whether we should use single- or multiagent chemotherapies, and whether there is a positive correlation between chemotherapy regimen and ß-HCG serum levels.

Relevance of new recommendations on routine antenatal prevention of rhesus immunization: an appraisal based on a retrospective analysis of all cases observed in two French administrative areas of 3 million inhabitants.

OBJECTIVE: To assess the potential impact of new guidelines recommending routine antenatal prophylaxis at 28 weeks of pregnancy on incidence, consequences and cost of rhesus immunization. STUDY DESIGN: All rhesus immunizations of 224,500 ongoing pregnancies in two neighbouring administrative areas in France between 2000 and 2006 were enrolled in this retrospective study. To determine the aetiology of immunization and to specify when sensitization occurred, we searched sensitizing events between the last negative and the first positive red-cell antibody test results. Perinatal consequences and costing were also analyzed. RESULTS: From 138 rhesus negative women bearing anti-D antibodies, none had received routine prophylaxis at 28 weeks. 37% were primary immunizations and 63% were reactivating former immunization. 63% sensitizations occurred after unprovoked foetal-maternal haemorrhage, mostly after 28 weeks (54%). Twenty-five (18.1%) sensitizations resulted from inappropriate management of existing prophylaxis. Immigrants with previously acquired antibodies accounted for 10% of cases. There was no foetal demise and none born before 28 weeks among our 140 babies. Only 25% required intensive care, mostly those born to mothers reactivating immunization, with an overall good perinatal outcome. Systematic 28-week prophylaxis would have cost about euro 2.5 million to reduce overall cost of immunizations by euro 0.6 million. CONCLUSIONS: The incidence of rhesus immunization in our population was low at 0.41 per thousand. Routine antenatal prophylaxis could have avoided 54% of these immunizations but expected perinatal benefits are low, as newborns with the worst issue were born to mothers with unavoidable immunizations. Therefore the cost-effectiveness of this strategy is doubtful.

Inaccurate doses of R immune globulin after rh-incompatible fetomaternal hemorrhage: survey of laboratory practice.

CONTEXT: Rh(D)-negative women with a large fetomaternal hemorrhage (FMH) from an Rh(D)-positive fetus are at risk for anti-D alloimmunization if they do not receive adequate Rh immune globulin (RhIG). Determination of the adequate RhIG dose for these women is a critical laboratory procedure for protecting their future Rh(D)-positive children. OBJECTIVE: To determine how often laboratories recommended an inaccurate dose of RhIG for excess FMH. DESIGN: Nearly 1600 laboratories using the College of American Pathologists' proficiency testing for fetal red blood cell detection were surveyed to determine (1) their calculation method and (2) the number of RhIG doses recommended for a survey specimen, based on their measured percentage of fetal red blood cells. We surveyed nearly 1450 laboratories for their accuracy in determining RhIG dose, using 2 common calculation methods we provided. RESULTS: The AABB Technical Manual method was used by 67% of responding laboratories. However, 20.7% of laboratories using this method would have recommended an inaccurate dose of RhIG--11.5% too much and 9.2% too little--for the level of FMH reported in the survey specimen. If all laboratories had used the common recommendation of 300 microg/30 mL of fetal blood present, 2% would have recommended RhIG doses too low for the volume of FMH they measured. In 3 of the 4 calculation exercises we provided, 20% to 30% of laboratories underestimated the necessary dose of RhIG. CONCLUSIONS: Based on our surveys, some mothers with excess FMH may be receiving inaccurate doses of RhIG. Laboratories performing quantification of FMH should review their procedures and training for calculating RhIG dosage.

Monitoring the clearance of fetal RhD-positive red cells in FMH following RhD immunoglobulin administration.

Anti-RhD immunoglobulin was administered to RhD-negative women based on estimates of fetal bleed size obtained using a direct immunofluorescence flow cytometric technique employing a FITC-conjugated monoclonal human anti-D (BRAD 3). The effectiveness of the dose administered was assessed by (i) measuring the fraction of RhD-positive fetal cells in the maternal circulation at d0, and between d2 and d10 post RhD Ig administration, (ii) quantifying the amount of anti-D detectable in maternal plasma following RhD Ig injection in the perinatal period and (iii) assessing maternal serum for the presence of immune anti-D in follow-up samples taken 3 months to 3 years after delivery. Fifty-four women were assessed, 29 having fetal bleeds in excess of 4 mL. Follow-up samples were received from 20/29 mothers after RhD Ig administration; 43-99% and 69-99% of fetal cells had been cleared by d2/3 and d5/6, respectively, in 14/20 mothers, whereas less than 50% had been cleared in the remaining mothers. Long-term follow-up samples were obtained from eight of the 29 mothers (four with bleeds >/=20 mL, two with bleeds >95 mL): none had detectable anti-D in the serum 4 months to 3 years after delivery despite the persistence of up to 36% fetal RhD-positive cells in the maternal circulation six days after delivery.

Fetal-maternal bleed in the second trimester of pregnancy. A report of two cases.

Two cases of nontraumatic fetal-maternal bleeding occurred in the second trimester. Both presented with mild, lower quadrant tenderness similar to round ligament pain, illustrating the potential for a misdiagnosis.

Minimizing the risk of amniocentesis for prenatal diagnosis.

Although the risk of amniocentesis in the second trimester of pregnancy is small, untoward sequelae can be further reduced. One hundred twenty amniocenteses were attempted during a two-year period. In eight instances, the patient had to return for a second tap because of bacterial contamination, inadequate number of fetal cells, or inability to obtain amniotic fluid. These eight patients all underwent repated amniocentesis and successful karyotyping. There were no major complications and one minor complication. Two spontaneous abortions were not apparently related to the procedure. In both these cases, fluid could not be obtained because one patient had a blighted ovum with a small sac and the other had large uterine fibromyomas.

[Feto-maternal microtranfusion after amniocentesis in the 2nd trimenon (author's transl)]. / Fetomaternaler Erythrozytenübertritt nach Amniozentese im zweiten Trimenon

120 healthy patients 16 to 34 years of age were studied. All patients were admitted to the clinic for legal abortion and were admitted to the clinic for legal abortion and were between 16 and 20 weeks pregnant. Amniocentesis were performed for intraamniotic application of prostaglandins. The incidence of microtransfusion of fetal red blood cells in these patients were studied. Blood samples were taken before and one hour after amniocentesis. 104 patients (86.7 p.c.) did not show any fetal erythrocytes in the peripheral blood neither before nore after amniocentesis. In ten patients (8.4 p.c.) less than 0.055 ml transfused fetal blood were determined as well before as after the puncture of the amniotic sac without any increasing tendency. In six patients (4.9 p.c.) signs of an induced fetal-maternal-microtransfusion could be proved. All six patients had no fetal cells in the circulation before treatment. Four of these had a microtransfusion of less than 0.05 ml, two patients between 0.05 and 0.10 ml. The localisation of the placenta by ultrasonic technic as an absolutely demand before amniocentesis is strongly recommended, especially in cases of prenatal diagnostic purpose.