Acute and chronic fetal anemia as a result of fetomaternal hemorrhage

Abstract

Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate's initial hemoglobin was 4.0 g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed.

Figure 1

Fetal echocardiography demonstrating right atrial and ventricular enlargement.

Figure 2

Note the antegrade Doppler flow present in the left ventricular outflow tract.

Figure 3

Note the torrential retrograde flow and aliasing seen in the distal aortic arch.

Figure 4

Increased brain vascularity seen on 2D and 3D ultrasound.

Figure 5

Increased middle cerebral artery end-diastolic velocities suggestive of brain sparing.