Fetomaternal haemorrhage - a cause for stillbirths, neonatal mortality and neonatal morbidity

Posted: 26/11/2024

What is fetomaternal haemorrhage and what issues can arise because of it?

Fetomaternal haemorrhage (FMH) is caused by the passage of fetal blood into the maternal circulation, and can be responsible for stillbirths, neonatal mortality and neonatal morbidity. 

It is notable that severe FMH can lead to fetal anaemia (when the circulating red blood cells and haemoglobin in a fetus fall below normal levels); cardiovascular failure; fetal hydrops (where fluid accumulates in at least two fetal compartments); and subsequently to intrauterine death, but this is a rare condition.

Women may have small amounts of fetal blood in their circulation following pregnancy and delivery, but when the levels are high, problems can result and the only hope for improved outcome is prompt recognition and intervention.

Signs, symptoms, and how FMH is diagnosed  

Symptoms of FMH may include the mother feeling faint or weak, suffering lower abdominal pain, and other symptoms of anaemia.

In terms of signs that can be ascertained from monitoring the fetus, fetal movements may be reduced or absent, there may be a non-reassuring or sinusoidal pattern on the cardiotocograph (CTG) trace (where the monitoring shows a sinus-shaped signal for longer than 30 minutes without short-term variability), and there may be fetal growth restriction and/or fetal hydrops evident from ultrasound scanning.

Fetal anaemia can be detected by Doppler peak systolic velocity measurement of the middle cerebral artery and by using the Kleihauer, Braun and Betke stain test. 

Long-term impact of FMH on the fetus when a diagnosis has not been made promptly

We have acted for children who have suffered neurological conditions such as cerebral palsy because of the delayed diagnosis of FMH and appropriate intervention. This may be because of a failure to look at the presenting picture of maternal and fetal signs in a holistic way.

In one case, a pregnant mother presented at term with severe abdominal pain and possible reduced fetal movements. There were CTG abnormalities that were not picked up, namely evidence of a sinusoidal pattern and an absence of accelerations. These CTG findings suggested fetal anaemia, but a diagnosis was not made, and neither was escalation for review by a senior obstetrician.

As the sinusoidal pattern on the CTG was not recognised, the urgency of the situation was not appreciated, and the mother was not told. A decision to proceed to a category 1 caesarean section, with delivery within 30 minutes, was not made, as should have been the case. 

After a significant delay, delivery took place and the baby was born in poor condition, being pale, floppy, not breathing and requiring resuscitation. Ultimately, they were intubated, diagnosed with hypoxic ischaemic encephalopathy (HIE), and underwent therapeutic cooling. Blood transfusions were required. An MRI scan evidenced widespread brain damage due to chronic partial hypoxia because of FMH. The child now has global developmental delay and cerebral palsy affecting their mobility and cognition. 

It can be seen that, whilst rare, severe FMH can have devastating consequences, and it is therefore vital that the condition is recognised promptly and intervention, such as urgent delivery, is effected.

If you have concerns about receiving a delayed or incorrect diagnosis, or have suffered injury as a result of medical treatment, please contact our team of specialists by email or on 0800 328 9545. Initial advice is offered free of charge and without obligation.

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