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.
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
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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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