Impact of Physician Awareness on Diagnosis of Fetomaternal Hemorrhage

Abstract

Background: Fetomaternal hemorrhage (FMH) is a poorly understood condition in which the placenta allows transmission of fetal whole blood to the mother. FMH can cause fetal anemia resulting in critical illness, death or lifelong disability. Ascertainment of the incidence of FMH is limited by reliance on retrospective studies that are dependent on a diagnosis of FMH being made at the time of patient presentation. Objective: To determine whether the diagnosis of FMH is made more frequently after an educational intervention to increase physician awareness of the condition. Methods: This is a retrospective cohort study of all neonates born at our institution from 1988 through 2010. The medical records of all neonates diagnosed with anemia in the first 24 h of life were reviewed. The incidence of FMH as a documented etiology of anemia was compared between infants born before and after our educational intervention. Results: Of 124,738 births during the study period, 572 neonates with neonatal anemia were identified. A total of 23 cases of FMH demonstrated by positive Kleihauer-Betke testing occurred in our cohort. The incidence of diagnosed FMH prior to our intervention was 22 per 1,000 anemic neonates compared to 182 per 1,000 afterwards (p < 0.001), while the incidence of neonatal anemia remained unchanged (p = 0.377). Conclusions: FMH may be a significant cause of neonatal anemia. Diagnosis of FMH is highly dependent on physician awareness of the condition. Incorrect or absent diagnosis of the etiology of neonatal anemia has significant implications for our understanding of the epidemiology of FMH.

Diagnosis of Severe Fetomaternal Hemorrhage with Fetal Cerebral Doppler: Case Series and Systematic Review

“…The consequences of FMH encompass a wide spectrum of severity from neonatal anemia to intrauterine demise. Severe FMH is a life-threatening complication and has been estimated to cause up to 14% of fetal deaths [5,6] .Prenatal diagnosis of severe FMH is difficult. A decreased perception of fetal movements [7][8][9][10][11][12] and abnormal cardiotocography (CTG) [3,10] are usually present.…”

Demographic and Behavioral Predictors of Severe Fetomaternal Hemorrhage: A Case-Control Study

“…Cases were identified from a database of clinical information prospectively maintained for all patients admitted to the level I–IV newborn nurseries at our institution, as described previously. [4] Neonates with hematocrit one standard deviation below the mean for gestational age within the first 4 hours of life were considered to have congenital anemia. The medical records for these patients were reviewed to identify those with associated FMH.…”

“…Retrospective studies in large populations document an incidence of FMH diagnosis of 1–2/10,000 live births. [4, 5, 10] The true incidence of clinically significant FMH is likely much higher, however, as FMH testing is underutilized in clinical practice. [4, 5, 11] Currently, testing for FMH after live birth occurs when significant fetal or neonatal anemia or is recognized.…”

“…[4, 5, 10] The true incidence of clinically significant FMH is likely much higher, however, as FMH testing is underutilized in clinical practice. [4, 5, 11] Currently, testing for FMH after live birth occurs when significant fetal or neonatal anemia or is recognized. [1, 2, 12, 13] Symptomatic fetal or neonatal anemia -- as evidenced by decreased fetal movement, sinusoidal fetal heart tracing, fetal or neonatal distress, or neonatal pallor -- are late consequences of severe FMH.…”

Fetomaternal hemorrhage (FMH), an update: review of literature and an illustrative case

“…The incidence of clinically-significant cases is estimated as between 1 in 3000-10,000 women [1,10]. However, it is suspected that there is high number of cases that remains unreported, as in miscarriages, or intrauterine death of the fetus [27].…”