Treatment options in fetomaternal hemorrhage: four case studies

Significant fetomaternal hemorrhage (FMH) is an uncommon event that places the fetus at risk of severe morbidity and mortality. Symptoms and signs at presentation are subtle and, if promptly recognized, appropriate management may permit the fetus to escape serious injury.

Four cases of significant FMH were diagnosed in the high-risk obstetrical unit at Mount Sinai Hospital, Toronto, during 2003. Three of the women complained of reduced fetal movements and were investigated initially with a non-stress test, a Kleihauer-Betke test, and ultrasound, including Doppler of the middle cerebral artery. These women all required emergency Caesarean section for non-reassuring fetal status. One fetus was treated by intravascular transfusion. Another identified case was transfused postnatally. One asymptomatic case was identified after spontaneous vaginal birth and also treated by neonatal transfusion. Neurological outcomes were good in all four cases.

Reduced fetal movements may be the only complaint of FMH. Increased awareness is required to ensure a diagnosis is made. When a non-stress test for reduced fetal movement is non-reactive, a Kleihauer-Betke test should be ordered, as well as detailed ultrasonography, including fetal Doppler studies. The perinatal prognosis for FMH may improve by facilitating the appropriate use of fetal blood transfusion or delivery by Caesarean section.