Fetomaternal haemorrhage in delivery by cesarean section

Czech version

Authors: M. Lubušký ^1,2; O. Šimetka ³; M. Studničková ¹; M. Procházka ¹; L. Feketevíziová ³; M. Ordeltová ⁴; K. Langová ⁵
Authors‘ workplace: Porodnicko-gynekologická klinika LF UP a FN Olomouc, přednosta prof. MUDr. R. Pilka, Ph. D. ¹; Ústav lékařské genetiky a fetální medicíny LF UP a FN Olomouc, přednosta prof. MUDr. J. Šantavý, CSc. ²; Porodnicko-gynekologická klinika FN Ostrava, přednosta MUDr. O. Šimetka, Ph. D. ³; Ústav imunologie LF UP a FN Olomouc, přednosta prof. MUDr. E. Weigl, CSc. ⁴; Ústav lékařské biofyziky LF UP Olomouc, přednostka prof. RNDr. H. Kolářová, CSc. ⁵
Published in: Ceska Gynekol 2012; 77(2): 156-162
Category: Original Article

Overview

Objective:
To determine the incidence and volume of fetomaternal haemorrhage (FMH) in normal vaginal delivery and in delivery by cesarean section. Determination of these parameters would enable optimalization of guidelines for RhD alloimmunization prophylaxis.

Design:
A prospective cohort study.

Setting:
Palacky University Hospital, Olomouc, Czech Republic; University Hospital, Ostrava, Czech Rebublic.

Methods:
A total of 4862 examinations were performed. The volume of fetal red blood cell (RBC) entering maternal circulation in normal vaginal delivery (control group, n = 3295) and in delivery by cesarean section (risk group, n = 1567) was assessed by flow cytometry. FMH = fetal RBC volume; fetal blood volume si double (expected fetal hematocrit is 50%).

Results:
The fetal RBC volume diagnosed in maternal circulation after delivery ranged from insignificant FMH < 0.1 ml to excessive FMH = 65.9 ml (median 0.7; mean 0.79; SD 1.38). High values of FMH > 1.7 ml were observed in 5.8% cases (280/4862), FMH > 2.0 ml in 3.2% (157/4862), FMH > 2.0 ml in 1.4% (69/4862) and excessive FMH > 5ml (IgG anti-D insufficient dose 100 μg) in 0.25% (15/4862). Delivery by cesarean section presented a higher risk of incidence of high values of FMH > 1.7 ml (OR 1.6; p 0.0002), FMH > 2.0 ml (OR 2.2; p <0.0001) and FMH > 2.5 ml (OR 2.2; p 0.002) when compared with normal vaginal delivery. It did not, however, present a statistically significant risk factor for the incidence of excessive FMH > 5ml.

Conclusion:
In normal vaginal delivery as well as in delivery by cesarean section, FMH less than 5 ml (10 ml of whole blood) occurs in the great majority of cases, and thus for the prevention of RhD alloimmunization, an IgG anti-D dose of 100 μg should be sufficient. Contrarily, only rarely does greater FMH occur and delivery by cesarean section does not present a risk factor.

Key words:
fetomaternal haemorrhage, cesarean section, RhD alloimmunization, anti-D immunoglobulin.

Sources

1. ACOG – American College of Obstetricians and Gynecologists. Prevention of RhD alloimmunization. ACOG practice bulletin no.4. Washington, DC, 1999.

2. Augustson, BM., Fong, EA., Grey, DE., et al. Postpartum anti-D: can we safely reduce the dose? Med J Aust, 2006, 184 (12), p. 611–613.

3. Crowther, C., Middleton, P. Anti-D administration after childbirth for preventing Rhesus alloimmunisation. The Cochrane Database of Systematic Reviews, 2010, 7 (updated May 2010).

4. Crowther, C., Middleton, P. Anti-D administration in pregnancy for preventing Rhesus alloimmunisation. The Cochrane Database of Systematic Reviews, 2009, 1 (updated Jauary 2009).

5. Dziegiel, MH., Nielsen, LK., Berkowicz, A. Detecting fetomaternal hemorrhage by flow cytometry. Curr Opin Hematol, 2006, 13 (6), p. 490–495.

6. Feldman, N., Skoll, A., Sibai, B. The incidence of significant fetomaternal haemorrhage in patients undergoing cesarean section. Am J Obstet Gynecol, 1990, 163 (3), p. 855–858.

7. Fung Kee Fung, K., Eason, E., Crane, J., et al. Maternal-Fetal Medicine Committee, Genetics Committee. Prevention of Rh alloimmunization. J Obstet Gynaecol Can, 2003, 25 (9), p. 765–773.

8. International Forum: Engelfriet CP, Reesink HW, Judd WJ, Ulander VM, Kuosmanen M, Koskinen S, Rouger P, Morelati F, Tantalo V, Fujii T, de Haas M, van der Schoot CE, Overbeeke M, Koelewijn J, Bonsel G, Vrijkotte T, Zupańska B, Martin-Vega C, Parra Lopez R, de Silva M, Contreras M, Panzer S, Ulm B, Mayr WR. Current status of immunoprophylaxis with anti-D immunoglobulin. Vox Sang, 2003, 85 (4), p. 328–337.

9 Lubusky, M. Prevention of RhD alloimmunization in RhD negative women. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 2010, 154 (1), p. 3–8.

10. Lubusky, M., Prochazka, M., Simetka, O., Holuskova, I. Guideline for prevention of RhD alloimmunization in RhD negative women. Ces Gynek, 2010, 75 (4), p. 323–324.

11. Lubusky, M., Simetka, O., Studnickova, M., Ordeltova M. Fetomaternal hemorrhage in normal vaginal delivery and in delivery by cesarean section. Transfusion, 2012, doi: 10.1111/j.1537–2995.2011.03536.x.

12. Moise, KJ. Jr. Prevention of Rh (D) alloimmunization. The UpToDate Database of Systematic Reviews 2011 (updated January 2011). Available from: www.uptodate.com

13. Moise, KJ. Jr. Management of rhesus alloimunization in pregnancy. Obstet Gynecol, 2002, 100 (3), p. 600–611.

14. Ness, PM., Baldwin, ML., Niebyl, JR. Clinical high-risk designation does not predict excess fetal-maternal haemorrhage. Am J Obstet Gynecol, 1987, 156 (1), p. 154–158.

15. Perslev, A., Jorgensen, FS., Nielsen, LK., et al. Fetomaternal hemorrhage in women undergoing elective cesarea section. Acta Obstet Gynecol Scand, in press.

16. RANZCOG – Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Guidelines for the use of RH D Immunoglobulin (Anti-D) in obstetrics in Australia 2007. Available from: www.ranzcog.edu.au/publications/statements/C-obs6.pdf

17. RCOG – Royal College of Obstetrics and Gynaecology. United Kingdom. Green Top Guidelines (Green-top 22). Anti-D Immunoglobulin for Rh Prophylaxis 2002. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/use-anti-d-immunoglobulin-rh-prophylaxis-green-top-22

18. Scientific Subcommittee of the Australian and New Zealand Society of Blood Transfusion. Guidelines for laboratory assessment of fetomaternal haemorrhage. 1st ed. Sydney: ANZSBT, 2002, p. 3–12.

19. Sebring, E., Polesky, H. Fetomaternal hemorrhage: incidence, risk factors, time of occurence and clinical effects. Transfusion, 1990, 30 (4), p. 344–357.

20. Stedman, CM., Baudin, JC., White, CA., Cooper, ES. Use of the erythrocyte rosette test to screen for excessive fetomaternal hemorrhage in Rh negative women. Am J Obstet Gynecol, 1986, 154 (6), p. 1363–1369.

21. Studnickova, M., Lubusky, M., Ordeltova, M., Prochazka, M. Possibility to identify fetomaternal haemorrgahe. Ces Gynek, 2010, 75 (5), p. 443–446.

22. Urbaniak, S. The clinical application of anti-D prophylaxis. In: Hadley A, Soothill P. Alloimmune disorders of pregnancy: anaemia, thrombocytopenia and neutropenia in the fetus and newborn. Cambridge, UK: Cambridge University Press; 2002. p. 97–120.

23. Uriel, M., Subira, D., Plaza, J., et al. Identification of feto-maternal haemorrhage around labour using flow cytometry immunophenotyping. Eur J Obstet Gynecol Reprod Biol, 2010, 151 (1), p. 20–25.

24. Wylie, BJ., D’Alton, ME. Fetomaternal hemorrhage. Obstet Gynecol, 2010, 115 (5), p. 1039–1051.