To determine the incidence, size, and outcome of spontaneous massive fetomaternal transplacental hemorrhage in Manitoba.
The Kleihauer maternal-fetal screening records at the Rh Laboratory were reviewed for the period October 1970 to December 1992. Rh Laboratory correspondence for the 7-year period ending December 31, 1992, was reviewed to determine those instances of fetomaternal transplacental hemorrhage for which there was knowledge regarding fetal and neonatal outcome.
Twenty-seven of 30,944 Rh-negative women undergoing routine Kleihauer screening at delivery had fetomaternal transplacental hemorrhages of at least 80 mL of fetal blood (incidence one in 1146 pregnancies); in 11 of the 27, the hemorrhages were 150 mL of blood or more (one in 2813 pregnancies). In non-routinely screened, selected maternal blood samples, sent because of unexplained fetal distress, fetal death, or neonatal anemia, 36 had evidence of fetomaternal transplacental hemorrhage of at least 80 mL of blood, 28 of which were in the 7-year period ending December 31, 1992 (one in 3893 pregnancies). Of these 28, 25 had hemorrhages of at least 150 mL of blood (one in 4360 pregnancies). Ascertainment of fetomaternal transplacental hemorrhage of 150 mL or more in women referred because of fetal or neonatal problems was 2813/4360 x 100 = 64.5%. Twenty-six cases in the final 7-year period had information regarding perinatal outcome. The incidence of adverse outcomes following massive fetomaternal transplacental hemorrhage was 46% (12 of 26). There were ten perinatal deaths, one infant death at 6 months, and one infant with spastic quadriplegia.
Massive fetomaternal transplacental hemorrhage is uncommon but not rare, and subsequent adverse outcomes are common. A high index of suspicion with prompt investigation and appropriate management may improve the perinatal outcome following massive fetomaternal transplacental hemorrhage.
The Winnipeg Rh Laboratory has reviewed its experiences with maternal CW alloimmunization. From September 24, 1956, to March 31, 1992, 12 women with significant CW alloimmunization underwent 18 pregnancies. In 3 (4 pregnancies) the antibody, despite its strength, was 'naturally occurring' (i.e. there was no known exposure to CW-positive red cells). The remaining 9 women (14 pregnancies) had CW-positive husbands. Two had CW-negative babies and a third infant, probably CW negative, was stillborn and macerated at 43 weeks gestation. Eleven babies were CW positive and had hemolytic disease of the newborn (HDN), with antiglobulin-positive red cells. Five did not require treatment; 2 needed phototherapy only, and 4 (born between 1956 and 1963) required exchange transfusions. No anti-CW screening was carried out until 1977; thereafter it was sporadic, 11 of 51 screening red cells being CW positive in the 39-month period ending March 31st, 1992. From November 1, 1977, to March 31, 1992, 24 women (30 pregnancies, 31 conceptuses) with insignificant anti-CW alloantibodies were identified. Extrapolating these figures to the entire period from September 24, 1956, to March 31, 1992, we estimate that at least 430 women (at least 573 pregnancies) were CW alloimmunized, most of the antibodies being 'naturally occurring'. Only 2% of the conceptuses were CW positive and affected; none were severely affected. Anti-CW is relatively common, occurring in about 1 pregnant Manitoban woman in 1,100. On very rare occasions (11 times in Manitoba in 36 years and 5 months) anti-CW HDN occurs which, although not severe, may end in kernicterus with brain damage or neonatal death unless it is detected promptly and treated appropriately.
Great advances have been made in the management of Rh erythroblastosis fetalis in the past two decades. Perinatal mortality has been reduced from 16.4% to 3.2%. However, perinatal mortality can only be reduced to zero if Rh erythroblastosis can be eradicated by prevention of Rh isoimmunization. Although prevention of Rh immunization by Rh immune globulin prophylaxis is now a reality, it does not appear that Rh immunization will be completely prevented with a single postdelivery injection. Antenatal treatment plus screening by the Kleihauer technique for massive transplacental hemorrhage may be necessary before complete suppression can be achieved. Low protein Rh immune globulin, and ultimately column-produced, very low protein, highly purified Rh immune globulin for intravenous use may prove to be the safest, most economical, and effective material for Rh prevention and total eradication of Rh erythroblastosis fetalis.
For two decades the perinatal mortality caused by erythroblastosis has been decreasing in Manitoba. The improved management of Rh-immunized pregnancies has lowered the death rate among affected infants from 10.8% to 3.4%, while the prevention of Rh immunization has reduced its incidence from 9.1 to 2.2 per 1000 total births. In its first 6 years and 8 months Manitoba's antenatal prophylaxis program, in which immunoglobulin is administered to Rh-negative women at 28 weeks' gestation, reduced the incidence of Rh immunization during pregnancy by 93%. In combination with post-abortion and postpartum prophylaxis the antenatal treatment has provided a protection rate of 98.6% among primigravidas at risk. Further improvements are expected.
Cites: Can Med Assoc J. 1977 Feb 5;116(3):282-4402178
Cites: Can Med Assoc J. 1980 Dec 6;123(11):1121-76161687