Transplacental haemorrhage in women having third trimester bleeding and perinatal outcome

doi:10.4236/ojog.2011.13028

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Open Journal of Obstetrics and Gynecology, 2011, 1, 149-152

doi:10.4236/ojog.2011.13028 Published Online September 2011 (http://www.SciRP.org/journal/ojog/ OJOG

Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJOG

Transplacental haemorrhage in women having third trimester

bleeding and perinatal outcome

Shakuntala Chhabra*, Preetindar Kaur, Chandan Tickoo, Prashant Zode

Obstetrics & Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India.

E-mail: *[email protected]

Received 12 April 2011; revised 10 June 2011; accepted 20 June 2011.

ABSTRACT

Objectives: Present prospective study was carried out

to know the frequency of transplacental fetomaternal

hemorrhage in pregnancies complicated by third

trimester vaginal bleeding and it’s correlation with

fetoneonatal outcome. Material methods: One hun-

dred, out of 170 Rh-positive primigravida/multigra-

vida with singleton pregnancy of more than 28 weeks

gestation, admitted with third trimester vaginal bleed-

ing with no other obstetric disorder, were the study

subjects and 100 controls were women with no bleed-

ing, admitted immediately after the study case with

same inclusion and exclusion criteria. Maternal peri-

pheral blood was collected at admission and at 2

hours of delivery and volume of FMH was calculated

by Kleihauer’s formula. Results: Statistically signifi-

cantly more perinatal deaths occurred in women with

FMH, 35% in study subjects compared to 2.7% am-

ongst controls. Conclusion: In the cases of third tri-

mester bleeding and fetomaternal hemorrhage,

chances of perinatal deaths are more.

Keywords: Third Trimester Bleeding; Foetomaternal

Haemorrha ge; Peri nat a l De at h; Feta l Haemoglobin ;

Perinatal Outcome

1. INTRODUCTION

Fetomaternal hemorrhage (FMH) is known to occur in

upto 70% of pregnancies but the amount of bleeding is

less than 0.1 ml in the majority [1-3], however on rare

occasions, it may be massive and fatal [4,5]. Massive

FMH may occur in 1:1000 deliveries. It is more com-

mon after traumatic diagnostic amniocentesis or external

cephalic version, also after placental abruption and trau-

ma. However in most of the cases, the cause is unex-

plained [6,7]. Pregnancies complicated by antepartum

hemorrhage (APH), like placental abruption (P Ab),

Placenta Previa (PP) and Unclassified Hemorrhage

(UCH) have been considered high risk for FMH [8,9].

Gordon and Bhoyroo [10] were the first to report mas-

sive FMH in APH and now some researchers recom-

mend looking for FMH in every case of APH [2,3,11,12].

A number of methods have been used to determine the

amount of FMH. The acid elution test described by Klei-

hauer Braun and Betke [13] has been the landmark, the

simplest for the detection of fetal cells. This test is based

on resistance by hemoglobin F from the cell to elution in

an acid medium. Many other tests, including alkaline

denaturation tests described by Apt and Downey [14]

known as APT Test and Ogita Test [15] have been tried

since then. The newer sophisticated and expensive me-

thods limit their use in low resource settings.

2. OBJECTIVES

The present prospective study was carried out to know

the frequency of Transplacental FMH (TPFMH) in preg-

nancies complicated by third trimester vaginal bleeding

and to study it’s correlation with the fetoneonatal out-

come.

3. MATERIAL AND METHODS

During the stud y period of 26 months, 170 cases of third

trimester vaginal bleeding were admitted. Inclusion cri-

teria for the study were Rh-positive primigravida/multi-

gravida with singleton pregnancy of more than 28 weeks

gestation with vaginal bleeding and no other obstetric

disorder. Controls were pregnant women with singleton

pregnancy of more than 28 weeks gestation who got

admitted immediately after the study case with same

inclusion and exclusion criteria except no bleeding, (not

even concealed bleeding), so these cases were of pain in

abdomen/labour pains without any disorder.

Hundred women out of 170 cases of APH admitted

during study period and 100 controls without APH se-

lected randomly, (depending on the availability of the

investigator for collection of blood at the time of admis-

sion of study subject) were subjected to investigations

for FMH.

S. Chhabra et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 149-152

150

After informed consent Kleihauer-Betke [16] test was

performed on maternal peripheral blood at admission

and within 2 hours of delivery in the study subjects and

controls. Volume of FMH was calculated by using Klei-

hauer’s formula [17].

4. RESULTS

Of the 100 study subjects, 23 were of PP, 42 P Ab and 35

UCH. Overall 40 out of 100 study cases and 24 controls

had FMH at the time of admission [statistically signifi-

cantly more study cases (p value < 0.05) compared to

controls], also significantly more cases of P Ab [23

(54.7%)] compared to PP [8 (34.7%)], UCH [9 (25.7%)]

and controls (24%) (P value < 0.05) had FMH.

Fifty six study cases and 37 controls had FMH post

delivery, statistically significant difference (p value <

0.05). Post delivery, there was increase in cases with

FMH in study, from 40% to 56% and in controls from

24% to 37%, FMH was statistically significantly more

post delivery compared to pre-delivery both in study and

control cases (p value < 0.05).Of 23 cases of PP 15

(65.2%), of 42 P Ab 24 (57.1%) and of 35 cases of UCH

17 (48.5%) had FMH post delivery. FMH increased sta-

tistically significantly more post delivery in cases of PP

(65.2% VS 34.7%, p value < 0.05) and in UCH (48.5%

vs 25.7%, p value < 0.05). There was no significant in-

crease in cases with FMH post delivery in P Ab (57.1%

and 54.7%, p value > 0.05).

Of the 40 study subjects w ith FMH, 20 (50%) h ad less

than 0.25 ml, 11 (27.5%) had FMH between 0.25 ml - 1

ml and 9 (22.5%) had more than 1 ml FMH. Of the 24

con- trols with FMH, 21 (87.5%) had less than 0.25 ml

FMH and 3 (12.5%) had between 0.25 to 1 ml and none

more than 1 ml FMH (Pie Diagram 1).

Of the 40 (40%) study subjects with FMH at admis-

sion, 26 (65%) had live births, 14 (35%) stillbirths, two

(5%) neonatal deaths occurred, however all 24 controls

with FMH had live births. And of 60 study cases without

FMH, 49 (81.7%) had live births, 11 (18.3%) stillbirths

occurred significantly more (p value < 0.05) and amongst

76 controls with no FMH, 74 (97.6%) had live births, 2

(2.6%) stillbirths occurred.

Overall of the 100 study subjects, 56 (56%) had FMH

post delivery, 42 (75%) of them had live births and 14

(25%) stillbirths and 37 controls had FMH post delivery,

all had live births. Of the 44 study subjects with no FMH

post delivery, 34 (77.3%) had live births, 10 (22.7%)

stillbirths occurred and of 63 controls with no FMH post

delivery 61 (96.7%) had live births and 2 (3.3%) still-

births occurred (Bar Diagram 1).

Of study subjects with FMH at admission, 40% peri-

natal deaths (PD), occurred compared to 4.1% in con-

trols (statistically significant difference p value < 0.05),

Pie Diagram 1. FMH at admission.

Bar Diagram 1. Live birth and still birth.

25% in PP with FMH,43.4% in P Ab and 44.4% in UCH,

statistically significantly more in P Ab and UCH than PP

(p value < 0.05). With no FMH at admission, 26.6%

study cases and 5.2% controls had PD, [statistically

significant difference (p value < 0.05)], however PD

were 52.5% in cases of P Ab, 13.2% cases of PP and

15.3% UCH had statistically significantly more in P Ab

(p value < 0.05).

In study subjects with FMH < 0.25 ml at admission,

20% PD occurred and with >1 ml FMH 77.7% had PD

(p value < 0.05, statistically significant difference).

In study cases with po st d elivery FMH, 35 .7% h ad PD

S. Chhabra et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 149-152 151

compared to 2.7% in controls, statistically significant

difference (p value < 0.05). With post delivery FMH, PD

occurred in 20% cases of PP, 54.1% of P Ab and 23.5%

of UCH cases {statistically significant difference (p

value < 0.05) between P Ab, PP and UCH}. Of the total

study subjects with no FMH, post delivery, 27.2% and in

controls 6.3% had PD [statistically significant difference

(p value < 0.05)]. With no FMH at admission in 38.8%

cases of P Ab, PD occurred compared to 12.5% cases of

PP and 22.2% cases of UCH, statistically significant

difference (p value < 0.05) between P Ab and other two

conditions.

5. DISCUSSION

FMH has been reported to occur in 25% - 50% of all

pregnancies [18,19] however higher incidence (60% -

70%) has been reported in pregnancies complicated by

bleeding in third trimester [1,4,12,20-22].

Theoretically placental separation may lead to in-

creased chances of fetal blood going into maternal cir-

culation. But there have been conflicting reports about

the presence of FMH in cases of third trimester bleeding.

The clinical manifestations an d prognosis with FMH de-

pend on the hemorrhage and the rapidity with which he-

morrhage occurs. If the hemorrhage is small, prolonged

or repeated the fetus gets an opportunity to develop he-

modynamic compensation with increased hemopoietic

activity (increased reticulocytes and erythroblasts in the

peripheral smear). The diagnosis is often postnatal and

these infants may manifest only pallor at birth. However

rapid blood loss could lead to intrauterine hypoxia and

death or severe anemia and hypoxia at birth. A decrease

in the fetal movements associated with abnormal car-

diotocographic findings, such as a sinusoidal pattern of

the fetal heart rate, may be a warning sign of a massive

FMH, especially in a low risk pregnancy [7].

Management of massive hemorrhage requires imme-

diate delivery by caeserian section, if the gestational age

is suitable, alternatively for very premature fetuses serial

fetal intravascular transfu sions could be used if facilities

and experienced personnel are available.

In the present prospective pilot study, one hundred

women with third trimester bleeding and one hundred

controls were investigated for FMH. At admission, FMH

was found in 40% study subjects and 24% controls, sig-

nificantly more in P Ab (54.7%) compared to PP (34%),

UCH (25.7%) and controls (24%). No evidence of in-

crease in FMH in third trimester vaginal bleeding, has

been reported by Frazer and Raper [23], Zipursky [24],

Sebring and Polesky [11],high between 20% and 43.4%

by Kizza and Rogo [25], Stettler [26] and Boyle [12],

much higher (75.8%) reported by Minchin and Bhoyroo

[27] and a low incidence of 8.1% has also been reported

by Holcomb [28], who carried out KB test in 205 wo-

men who had various problems including vaginal bl-

eeding in 49 (33%).

Substantial increase in frequency of passage of fetal

erythrocytes immediately after delivery has been re-

ported [19]. In the present study, post delivery FMH was

56% in the study subjects and 37% in controls, increase

in FMH in study subjects from 40 to 56% an d fro m 24 to

37% in controls did not affect the neonatal outcome.

Choavartana [4] has reported FMH in 76% post delivery

cases similar to the present study. In cases of separation

of placenta, chances of hemorrhage seem to be more

during the time of delivery.

Of study cases with FMH at admission, statistically

significantly more PD occurred compared to controls.

Further, PD in P Ab and UCH cases with FMH at admis-

sion as well as post delivery were statistically signifi-

cantly more than PP (p value < 0.05). Amongst study

subjects with post delivery FMH, 35% PD occurred

compared to 2.7% amongst controls. Higher PD in pre-

gnancies complicated by FMH in third trimester bleed-

ing has been reported by other researchers [5,11,29,30]

also.

6. CONCLUSIONS

Present study revealed that there are more chances as

well as there is more volume of FMH in cases of APH,

more so in P Ab, some others also report the same

[5,21,22]. In study cases with FMH < 0.25 ml at admis-

sion, 20% had PD and with FMH > 1 ml, 77.7% had PD

(p value < 0.05). Present study has limitations but does

reveal the necessity of more studies to have the appro-

priate strategies of management of cases of APH to en-

sure an optimal perinatal outcome.

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