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Dr.
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Introduction
Fetomaternal hemorrhage (FMH)
Loss of fetal blood cells to maternal circulation.
Moderate to severe FMH 0,3% of all life births.
Transference fetal blood maternal blood system
physiologis in pregnancy and at birth.
Diagnosis : severe blood loss + fetuses exhibiting
symptoms of decompensation.
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Data Sources
Pubmed library to search articles with keyword
Fetomaternal hemorrhage
Fetomaternal infusion and/or bleeding
Exclusive use of english literature.
Review of literature
FMH
Describe since 1950s fetal blood loss or
bleeding into the placenta.
Since introduction of prophylaxis and/or treatment of
Rhesus isoummunization detection rate of FMH .
Kleihauer-Betke stain commonly used in Rh(-)
women to calculate the dosage of RhIG that
has to be injected to prevent isoimmunization.
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Detection of FMH
Detect symptoms and signs of potential FMH early
appropriate action to prevent futher damage to
fetus and mother.
Wylie and DAlton in 2010, most common sign :
neonatal anemia, or absent fetal movement,
stillbirth, hydrops fetalis, pathological CTG
pattern, intrauterine growth restriction.
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Detection of FMH
Suspect FMH
Detection of fetal
cells in maternal
blood stream
Kleihauer-Betke
stain
Flow Cytometry
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Illustrative Case
, 31 yo, G2P1,
37 and 2/7
gestational
week
History : cesarean
section due to failure to
progress in labor 1 year
previously.
Localized itching
exanthema on
chest, neck, &
face.
Treated
accordingly
Diagnosis : PUPP
(Pruritic Urticarial
Papules & Plaques
of Pregnancy)
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Illustrative Case
Around estimated
due date
fetal
movement,
consistent
itching
exanthema, joint
pain, fatigue,
nausea
Illustrative Case
40 and 3/7
gestational weeks
with regular
contraction
Emergency
transfusion of 0 Rh(-),
immediately transfer
to perinatal center and
admitted to NICU.
CTG : temporarily a
sinusoidal pattern with
variable decelerations.
Maladaptation of
neonate with pH
7,13. fetal Hb 3,5.
Cesarean delivery
was undertaken
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Illustrative Case
Mother felt fine,
expected postoperative
pain & persistent itching
on the chest spreading
to face.
Diagnostic evaluation of
infectious disease
(CMV,Parvovirus B19,
EBV) negative.
Maternal alpha
fetoprotein highly
elevated
Kleihauer-Betke stain
revealed 25,3% fetal
cell in maternal blood
circulation massive
FMH
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Illustrative Case
Conservative
management, oral and
topical cortisone for
exanthema
Maternal laboratory
result improving,
improvement of
exanthema.
Illustrative Case
Mother presented again 39
days after delivery
complaining dry eyes,
aggravation of itching
exanthema on chest, fatigue,
thirstiness, Jaundice & brown
urine
Histopathological :
normal weighing placenta with
delayed maturation of
chorionic villi, sign circulatory
disorder. No indication of
malignancy or inflammation.
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Discussion
Final diagnosis was made 24h after delivery.
Neonates extremely low Hb treated immediately by
emergency transfusion, although the cause is
unknown.
The mothers course of the disease was more
complex.
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Discussion
, 31 yo, G2P1,
37 and 2/7
gestational
week
Localized itching
exanthema on
chest, neck, &
face.
Treated
accordingly
Diagnosis : PUPP
(Pruritic Urticarial
Papules & Plaques
of Pregnancy)
Rash caused by immune
reaction of fetal cells in the
maternal
25 blood stream.
Discussion
Adams et al : small population of cells can survive
within another genetically-distinct individual lead
autoimmune disease (primary biliary sclerosis,
Sjorgren syndrome) Microchimerism
Solano et al : maternal cells can also reside in
fetal/neonatal system.
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Discussion
Around estimated
due date
fetal
movement,
consistent
itching
exanthema, joint
pain, fatigue,
nausea
Indicative of a variety of
immune and autoimmune
disease
Discussion
no further diagnostics have
been performed prenatally.
Emergency transfusion
of 0 Rh(-), immediately
transfer to perinatal
center and admitted to
NICU.
Although the
underlying cause
was unknown
CTG : temporarily a
sinusoidal pattern with
variable decelerations.
Maladaptation of
neonate with pH 7,13.
fetal Hb 3,5.
Discussion
In cases suspect FMH during 2nd & early 3rd
trimester perform flow cytometry or HLPC to
assess fetal Hb and estimate the lost blood volume
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Discussion
Mother felt fine,
expected
postoperative pain &
persistent itching on
the chest spreading to
face.
Diagnostic evaluation
of infectious disease
(CMV,Parvovirus B19,
EBV) negative.
Maternal alpha
fetoprotein highly
elevated
Kleihauer-Betke stain
revealed 25,3% fetal
cell in maternal blood
circulation massive
FMH
Discussion
Conservative
management, oral and
topical cortisone for
exanthema
Maternal laboratory
result improving,
improvement of
exanthema.
Discussion
AFP : screening marker
for embryonal or fetal
abnormalities
up to 32 weeks of
gestation and drops.
Histopathological of
placenta : normal weighing
placenta with delayed
maturation of chorionic villi,
sign circulatory disorder. No
indication of malignancy or
inflammation.
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Conclusion
Severe FMH fetal distress
Rare, but serious pregnancy complication.
Preinatal death 31-50%
There is trafficking of fetal and maternal cells back
and forth between both blood streams.
Condition that Disrupt placental barrier associated
with FMH.
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Conclusion
Majority of FMH cases present with or absent
fetal movement.
CTG, Doppler velocity, measurement of fetal
cell in maternal blood.
Treatment : prolong pregnancy or deiver, by
experienced physicians and parents
FMH is rare, international register should be initiated
to collect data and do a long term follow up.
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