Fetomaternal hemorrhage (FMH) refers to the entry of fetal blood into the maternal bloodstream before or during delivery. FMH of more than 30 mL occurs with the frequency of about 1/300. Fetal outcomes may be compromised by still births, hydrops fetalis, cardiac complications, and increased rates of postpartum infant death. In most cases, the cause is not identified. Clinical manifestations of FMH depend on the volume of blood lost and the rate that it occurred. We report a case of chronic massive FMH in a newborn of an immigrant mother with a favorable outcome. Medical visits and tests during pregnancy, including ultrasound scans, were not performed. The baby was hemodynamically stable after birth, manifesting only pallor. The complete blood count revealed severe hypochromic anemia (hemoglobin 3,8 g/dl, hematocrit 14,4%) and reticulocytosis (reticulocyte 25,2%). There was no ABO blood type incompatibility and the result of direct Coomb's test was negative. The Kleihauer-Betke test revealed 5 % of fetal erythrocytes in the maternal bloodstream equivalent to 180 mL. The fact that FMH can occur without prior risk factors, and the diagnosis is often postnatal, underscores the importance of heightened of medical suspicion particularly in infants born to immigrants where there is often the lack of prenatal visits. Riassuntol' emorragia Feto materna (eFM) riguarda l'entrata del sangue fetale nel sangue materno prima o durante il parto. l' eFM superiore a 30 ml si verifica con la frequenza di circa 1/300. il neonato affetto puo' essere compromesso in vario modo: nato morto, idrope fetale, complicanze cardiache e aumento del tasso di mortalità infantile dopo il parto. nella maggior parte dei casi, la causa non è identificata. le manifestazioni cliniche della eFM dipendono dal volume di sangue perso e dal tempo in cui avviene lo scambio. riportiamo un caso di eFM cronica massiva in un nato da madre madre immigrata con un esito favorevole. le visite mediche e i test durante la gravidanza, tra cui l'ecografia, non sono stati effettuati. Alla nascita il bambino era emodinamicamente stabile manifestando solo pallore. l'esame emocromocitometrico eseguito ha mostrato una grave anemia ipocromica (emoglobina 3,8 g / dl, ematocrito 14,4%) e reticolocitosi (reticolociti 25,2%). non c'era incompatibilità ABo tra madre e neonato e il test diretto Coombs era negativo. il Kleihauer Betke-test ha rivelato il 5% degli eritrociti fetali nel sangue materno corrispondente a 180 ml. il fatto che l' eFM possa verificarsi in assenza di fattori di rischio, e che la diagnosi sia spesso post-natale, sottolinea l'importanza di aumentare il sospetto diagnostico in particolare nei bambini nati da madri immigrate che spesso non si sottopongono alle visite prenatali.

BackgroundInter-observer delineation variation has been detailed for many years in almost every tumor location. Inadequate delineation can impair the chance of cure and/or increase toxicity. The aim of our original work was to prospectively improve the homogeneity of delineation among all of the senior radiation oncologists in the Nord-Pas de Calais region, irrespective of the conditions of practice.MethodsAll 11 centers were involved. The first studied cancer was prostate cancer. Three clinical cases were studied: a low-risk prostate cancer case (case 1), a high-risk prostate cancer case (pelvic nodes, case 2) and a case of post-operative biochemical elevated PSA (case 3). All of the involved physicians delineated characteristically the clinical target volume (CTV) and organs at risk. The volumes were compared using validated indexes: the volume ratio (VR), common and additional volumes (CV and AV), volume overlap (VO) and Dice similarity coefficient (DSC). A second delineation of the same three cases was performed after discussion of the slice results and the choice of shared guidelines to evaluate homogenization. A comparative analysis of the indexes before and after discussion was conducted using the Wilcoxon test for paired samples. A p-value less than 0.05 was considered to indicate statistical significance.ResultsThe indexes were not improved in case 1, for which the inter-observer agreement was considered good after the first comparison (DSC = 0.83±0.06). In case 2, the second comparison showed homogenization of the CTV delineation with a significant improvement in CV (81.4±11.7 vs. 88.6±10.26, respectively, p = 0.048), VO (0.41±0.09 vs. 0.47±0.07, respectively; p = 0.009) and DSC (0.58±0.09 vs. 0.63±0.07, respectively; p = 0.0098). In case 3, VR and AV were significantly improved: VR: 1.71(±0.6) vs. 1.34(±0.46), respectively, p = 0.0034; AV: 46.58(±14.50) vs. 38.08(±15.10), respectively, p = 0.0024. DSC was not improved, but it was already superior to 0.6 in the first comparison.ConclusionOur prospective work showed that a collaborative discussion about clinical cases and the choice of shared guidelines within an established framework improved the homogeneity of CTV delineation among the senior radiation oncologists in our region.

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