الفهرس 
Fetomaternal Hemorrhage (FMH)Only 14 pages are availabe for public view
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Abstract
F
etomaternal hemorrhage is considered to be a grave complication which may occur during pregnancy (Sebring et al., 1990).
Fetal and maternal circulations normally are supposed not to be in direct contact (Bernstein et al., 1992).
In normal pregnancy this abnormal contact between the fetal and maternal circulations may occur so late during delivery. Up to 1 ml of blood may pass. But in an abnormal pregnancy, fetomaternal haemorrhage is defined as the haemorrhage of 30 ml or more, of whole blood from a fetus into the maternal circulation. As less than 30 ml is considered benign and passes without any remarkable side effects (Sebring et al., 1990).
The problem in fetomaternal hemorrhage appears when fetal blood escapes into the maternal circulation in a considerable amount 30 ml or more. That shall compromise the fetal condition leading to many morbidities and mortalities. The result varies from minimal degree of fetal anaemia up to severe degree of fetal anemia. And lethal hydrops fetalis may follow that, leading to fetal cerebral edema, kernicterus, fluid collection in all body spaces, severe pallor and failed circulation (due to the escaping red cells) and eventually ending in death of the fetus (Zizka et al., 2001).
Quantification of fetomaternal haemorrhage is done when severe FMH is suspected, and accordingly dose of Ante D can be adjusted if Rh –ve mother gives birth to Rh +ve baby. Additional dose of 10 lg of antiD should be given for every additional 0.5 mL of fetal RBCs in maternal circulation (White et al., 2009).
Methods for quantification of FMH:
Kleihauer–Betke test is the gold standard test for quantification of FMH (Maciuleviciene et al., 2008).
The controversy appears in that Kleihaeur -Betke test is a test which requires a specific laboratory setting and a highly performing haematology specialist so it is not that easy to be conducted and to give reliable results and is also liable for inter and intra-observer variations as it is subjected to the human error (in the microscopic manual method) (Agarwal et al., 2011).
Also the time between sampling and testing, if prolonged, this may lead to clotting of the sample and consequently false interpretation (in both of the microscopic manual and the microscopic automated methods) (Lachman et al., 1977).
Moreover, over estimation for the number of fetal erythrocytes may occur by KBT, as Freese and Titel (1963) reported 10–55% women with fetal erythrocytes in their blood in the first trimester as a result of the increased amount of HbF in maternal circulation. Another reason could be the staining of adult reticulocytes as described by Clayton et al., (1963) where all the 50 (100%) of antepartum and postpartum women and 60% of controls (males and non-pregnant females) were positive for fetal erythrocytes.
Alpha- fetoprotein(AFP) is found in both fetal serum and also amniotic fluid. This protein is produced early in gestation by the fetal yolk sac and then later in the liver and gastrointestinal tract. The true function of AFP is unknown (Johnson et al., 2012).
Since maternal serum level of Alpha-Fetoprotein is found by evidence to be raised in cases of severe fetal anaemia (Bartha et al., 2003).
Also based on assumption that damaged trophoblasts would allow both AFP and fetal cells to escape into maternal circulation.
Therefore changes in level of maternal serum Alfa-Feto protein can be used for detection of significant FMH.
The advantage of measuring AFP over KBT during FMH would include that AFP is dispersed within maternal circulation within 15 minutes,there is no agglutination or aggregation effect of fetal RBCS, Also AFP is stable in case of fetomaternal ABO incompatibility and is not invalidated by clotting of the blood sample (Bartha et al., 2006).
So estimation of maternal serum level of Alpha-Fetoprotein may act as a new method for detection of occurrence of FMH in cases of women at risk of fetal anaemia (Bartha et al., 2006).
The aim of this studty is to test the diagnostic accuracy of change in MSAFP as an easy, available change and non-operator dependant alternative to Kleiheuar-Betke test for detection of significant FMH.
There were three prospective studies; (Kaberi et al., 2004) which compared amount of FMH after 1st trimester abortion using change in MSAFP and KBT, (Shuji et al., 2005) compared amount of FMH after full term vaginal delivery using both tests and (Katiyar et al., 2007) which compared amount of FMH detected after CVS by both tests.
The three tests showed that change in maternal serum alfa-fetoprotein is of almost same sensitivity and specificity however the concordance between the two tests is poor, also the amount of fetomaternal haemorrhage detected by the two tests is different.
The study included any normal pregnant female of more than 37 weeks of gestation admitted at Ain shams university hospital for elective caesarean delivery at the period from june to august 2015.
Patients excluded for medical disorders as Diabetes hypertension or liver disease, risk for severe intrapartum or postpartum haemorrhage, presence of congenital fetal malformations,intrauterine fetal death, multiple gestation or abnormal placentation.
The study population included 49 pregnant women after taking informed consent of being part of the study project.
For each subject two blood samples were drawn on two occasions, one (before delivery) for predelivery value of maternal AFP and ABO,RH blood group and one (2 hours after delivery),samples for AFP were collected in a plain tube,centrifuged and the serum obtained was kept at temperature -20 c while samples for KBT were collected in EDTA containing tubes and kept at a temperature -20 c till both tests were sent to the clinical pathology department for analysis within a period not more than 2 hours.
Cord blood samples were drawn from each subject for fetal ABO and RH group.
The results of our study showed that changes in MSAFP is less sensitive than KBT for detection FMH after elective caesarean delivery with low risk for severe FMH,
However, it could be a convenient alternative in cases of fetomaternal ABO incompatibility which may yield false –ve results by KBT and in cases with suspected severe FMH during first trimester where it may yield false +ve results by KBT.
Conclusion:
Our study showed that change in MSAFP can be used as an easy available and cheap alternative test for detection of significant FMH especially in cases of maternal and fetal ABO incompatibility which could yield false negative results by KBT and during first trimester as it could yield false positive results by KBT, however further studies should work on accurate cut-off value for change in MSAFP for diagnosis of significant FMH.
The use of percent change in MSAFP from pre-delivery value gives stastically more significant results than use of postnatal value or absolute increase in level of MSAFP.