Hsieh, Wu-Shiun

Lee, Chien-Nan

Li, Yi-Ping

Lin, Shin-Yu

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Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 441e443Contents lists avaiTaiwanese Journal of Obstetrics & Gynecology
journal homepage: www.t jog-onl ine.comResearch LetterUnusual maternal hemoglobin elevation before delivery as a rare
presentation of massive fetomaternal hemorrhage
Yi-Ping Li a, Chien-Nan Lee a, Wu-Shiun Hsieh b, Shin-Yu Lin a, *
a Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
b Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwana r t i c l e i n f oArticle history:
Accepted 17 September 2014Table 1
Maternal laboratory data.
Variable First
admission
Second
admission
(5 d later)
Reference
range
Erythrocyte
count (/mm3)
4,850,000 5,170,000 3,780,000
e4,990,000
Hemoglobin (g/dL) 14.0 15.3 10.80e14.90Dear Editor,
We present a case of unusual maternal hemoglobin elevation
before delivery as a rare presentation of massive fetomaternal
hemorrhage (FMH). Ethical approval was obtained from National
Taiwan University Hospital, code: 201404050RINA.
A 36-year-old woman, gravida 3, para 1, ectopic 1, without other
systemic disease, was admitted to our hospital for the ﬁrst time at
37 and 4/7 completed gestational weeks. The blood group of both
the patient and her husband was O type and Rh positive. She un-
derwent regular prenatal examination, and neither any major fetal
anomaly nor any medical complications of the mother was found.
No relevant family history was noted. She was admitted due to
regular labor pain every 3e5 minutes. Uterine contractions every
3 minutes with 80e100% amplitude were detected by cardiotoco-
gram. Fetal heart beat tracing was Category I. Bishop score was 6/10
(cervix: posterior presentation, intermediate consistency, 60%
effacement, 2 cm dilatation, and Stage 0). However, uterine con-
tractions weakened and ceased 1 day after admission. Induction
with oxytocin (5 IU) in Ringer solution (500 mL) at a rate of 8 mL/
hour with titrationwas prescribed. Augmentation of labor failed, so
she was discharged 3 days later.
Five days after the ﬁrst discharge, decreased fetal movement
was noticed for 1 day. Fetal cardiotocogram showed nonreassuring
fetal tracing (baseline: 170 beats/minute, minimal variability, and
variable deceleration >50% contraction), so shewas admitted to our
hospital for continuous monitoring. Complete blood count test was
performed routinely in our hospital. Maternal hemoglobin level
was elevated from 14.0 g/dL to 15.3 g/dL, comparedwith that 5 days* Corresponding author. Number 8, Chung-Shan South Road, Taipei 100, Taiwan.
E-mail address: lin.shinyu@gmail.com (S.-Y. Lin).
http://dx.doi.org/10.1016/j.tjog.2016.04.024
1028-4559/Copyright © 2016, Taiwan Association of Obstetrics & Gynecology. Published b
(http://creativecommons.org/licenses/by-nc-nd/4.0/).ago. No fever, no chills, and no other transfusion reaction symptom
were noted. No trauma was found or no invasive procedure was
performed between these two admissions. Other laboratory tests
are shown in Table 1.
Fetal heartbeat deceleration to an undetectable level was noted
6 hours after admission, and emergent cesarean section was per-
formed. Onemature female baby weighing 3250 g was delivered by
vertex extraction at 38 and 2/7 completed gestational weeks. The
ﬁrst and ﬁfth Apgar scores were 0 to 0.
Neonatal resuscitation was performed immediately and return
of spontaneous circulation at the 50th minute. On examination, the
neonatewas very palewithout obvious external bleeder. A neonatal
hemoglobin level of 3.6 g/dL, an arterial cord pH of 7.07, and a base
deﬁcit of 23.7 mmol/L were reported. Other laboratory test results
are shown in Table 2. The KleihauereBetke test was performed and
it showed 159 fetal red blood cells in 2000 cells.
Massive FMH was diagnosed, and the neonate was admitted to
the neonatal intensive care unit. Component therapy was given
immediately. Brain magnetic resonance imaging showed extensive
intraventricular hemorrhage and diffuse cerebral ischemic changes
(Figure 1). Electroencephalogram reported low-amplitude and no
epileptic spikes. Severe hypoxic-ischemic encephalopathy was
diagnosed, and hypothermia therapy was given. After head-cooling
therapy and supportive care at the neonatal intensive care unit for
1month, the babywas dischargedwith stable vital signs and severeHematocrit (%) 39.8 43.6 35.60e45.40
Mean corpuscular volume
(mm3)
82.1 84.3 80e100
Platelet count (/mm3) 255,000 225,000 150,000e361,000
White-cell count (/mm3) 11,030 10,760 3540e9060
y Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license
Table 2
Neonatal laboratory data.
Variable Initially Reference range (age adjusted)
Erythrocyte count (/mm3) 950,000 4,100,000e5,740,000
Hemoglobin (g/dL) 3.6 12e20
Hematocrit (%) 11.4 36e60
Mean corpuscular volume (mm3) 120.0 91.3e120
Reticulocyte (%) 6.95 2e5.4
Reticulocyte number (/mm3) 196,700 22,400e82,900
Platelet count (/mm3) 148,000 144,000e450,000
White-cell count (/mm3) 52,740 4940e27,480
pH 7.074 7.35e7.45
pCO2 (mmHg) 22.4 35e45
pO2 (mmHg) 33.9 83e108
HCO3e (mmol/L) 6.6 21e28
Base excess (mmol/L) 23.7 2 to 3
Direct: Coombs test Negative Negative
Indirect: Coombs test Negative Negative
Figure 1. Brain MRI of the neonate. (A) Intraventricular hemorrhage within both frontal horns and occipital horns found at T2 phase (arrow). Hypoxic-ischemic injury to gray
matter results in (B) the characteristic T1 hyperintensity () and (C) variable T2 intensity. Injury to white matter results in the T1 hypointensity and T2 hyperintensity due to
ischemia-induced edema.
Y.-P. Li et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 441e443442neurological impairment. The maternal postpartum course was
smooth and she was discharged 5 days after cesarean section.
FMH refers to the entry of fetal blood into the maternal circu-
lation before or during delivery. Fetal blood likely enters the
maternal circulation during all pregnancies [1], and the volume lost
is typically small, usually <15mL [2]. An earlier summary of cases of
hemorrhage of >30 mL, as detected by the KleihauereBetke test,
reported a similarly high risk of perinatal morbidity and mortality
[2]. Massive FMH was deﬁned as more than 80 mL fetal blood loss
because neonatal anemia appeared at this level [3]. The incidence
of FMH was found to be 22e182 per 1000 anemic neonates [4].
Perinatal mortality due tomassive FMH occurs in about one in 1000
deliveries [5]. It was reported that nine in 18 neonates diagnosed
with massive FMH and a hemoglobin level of below 7.5 g/dL
exhibited poor outcomes, such as cerebral palsy, mental retarda-
tion, attention deﬁcit/hyperactivity disorder, and epilepsy [6].
Antenatal diagnosis requires a high index of suspicion, as the
presenting signs are often nonspeciﬁc [7]. In previous research, the
presenting signs and symptoms were described as follows:
neonatal anemia: 35.0%; decreased or absent fetal movement:
26.7%; stillbirth: 12.5%; hydrops fetalis: 7.5%; nonreassuring fetal
tracing: 6.7%; and other signs and symptoms: intrauterine growth
restriction, sinusoidal fetal tracing, fetal atrial ﬁbrillation, and
maternal transfusion reaction [8]. FMH could be presented by
chronic fetal anemia, acute fetal anemia, or both acute and chronic
clinical features [9].In our case, besides decreased fetal movement and neonatal
anemia, one unique sign of FMH was elevated maternal hemoglo-
bin level. Several formulas for estimating fetal blood loss volume
had been published [7]. Assuming an average maternal blood vol-
ume of 5000 mL, the estimated fetal blood volume lost ranges from
397 mL to 1520 mL, using different formulas [7]. In our case, a
signiﬁcant elevation of hemoglobin level from 14.0 g/dL to 15.3 g/dL
in 5 days came into notice for the suspicion of massive FMH.
Erythrocytosis during pregnancy is uncommon and may be
due to chronic hypoxia environment, cigarette smoking, poly-
cythemia vera, or neoplasm [10,11]. In this case, unusual maternal
hemoglobin elevation was a rare presentation of massive FMH. In
conclusion, in case of pregnant woman with unexplained eleva-
tion of maternal hemoglobin, examination of FMH may be
considered.Conﬂicts of interest
The authors have no conﬂicts of interest relevant to this article.Acknowledgments
We would like to thank the patient, staff of the National Taiwan
University Hospital, and all the reviewers for their assistance in this
project.
Y.-P. Li et al. / Taiwanese Journal of Obstetrics & Gynecology 55 (2016) 441e443 443References
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Unusual maternal hemoglobin elevation before delivery as a rare presentation of massive fetomaternal hemorrhage 

Yi-Ping Li

Chien-Nan Lee

Wu-Shiun Hsieh

Shin-Yu Lin

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Unusual maternal hemoglobin elevation before delivery as a rare presentation of massive fetomaternal hemorrhage

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Unusual maternal hemoglobin elevation before delivery as a rare presentation of massive fetomaternal hemorrhage

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