Fetomaternal Bleed, New York
Clinical Information Discusses physiology, pathophysiology, and general clinical aspects, as they relate to a laboratory test
In hemolytic disease of the newborn, fetal red cells become coated with IgG alloantibody of maternal origin, directed against an antigen on the fetal cells that is of paternal origin and absent on maternal cells. The IgG-coated cells undergo accelerated destruction, both before and after birth. The clinical severity of the disease can vary from intrauterine death to hematological abnormalities detected only if blood from an apparently healthy infant is subject to serologic testing.
Pregnancy causes immunization when fetal red cells possessing a paternal antigen foreign to the mother enter the maternal circulation, an event described as fetomaternal hemorrhage (FMH). FMH occurs in up to 75% of pregnancies, usually during the third trimester and immediately after delivery. Delivery is the most common immunizing event, but fetal red cells can also enter the mother's circulation after amniocentesis, spontaneous or induced abortion, chorionic villus sampling, cordocentesis, or rupture of an ectopic pregnancy, as well as blunt trauma to the abdomen.(2)
Rh immune globulin (RhIG, anti-D antibody) is given to Rh-negative mothers who are pregnant with an Rh-positive fetus. Anti-D antibody binds to fetal D-positive red cells, preventing development of the maternal immune response. RhIG can be given either before or after delivery. The volume of FMH determines the dose of RhIG to be administered.
Determining the volume of fetal-to-maternal hemorrhage for the purposes of recommending an increased dose of the Rh immune globulin
Greater than 15 mL of fetal RBCs (30 mL of fetal whole blood) is consistent with significant fetomaternal hemorrhage (FMH).
A recommended dose of Rh immune globulin (RhIG) will be reported for all Rh-negative maternal specimens. No dose recommendations will be made for Rh-positive maternal specimens. One 300 mcg dose of RhIG protects against a FMH of 30 mL of D-positive fetal whole blood or 15 mL of D-positive fetal red blood cells. Recommended standard of practice is to administer RhIG within 72 hours of the fetomaternal bleed for optimal protective effects. The effectiveness of RhIG decreases beyond 72 hours post-exposure but may still be clinically warranted. This assay has been validated out to 5 days post collection.
Mothers who are weak D express decreased amounts or only a portion of the D antigen that constitutes the Rh status of red blood cells. Local standards of care vary as to whether these mothers should receive a dose of RhIG. If the mother is determined to be weak D, a RhIG dose will be reported but the ordering physician should consult local experts to determine if RhIG is given as the local standard of care.
Cautions Discusses conditions that may cause diagnostic confusion, including improper specimen collection and handling, inappropriate test selection, and interfering substances
Clinical conditions exist that may result in an increased level of fetal hemoglobin-containing red cells, including hereditary persistence of fetal hemoglobin (HPFH) and thalassemia. Such red cells (also referred to as F cells) are detected by this assay. Results must be interpreted with caution in these situations.
This assay does not sensitively test for weak D and should not be used to make this determination for purposes other than Rh immune globulin.
This test is not used to detect the hereditary persistence of fetal hemoglobin (see HPFH/8270 Hemoglobin F, Red Cell Distribution, Blood).
Reference Values Describes reference intervals and additional information for interpretation of test results. May include intervals based on age and sex when appropriate. Intervals are Mayo-derived, unless otherwise designated. If an interpretive report is provided, the reference value field will state this.
< or =0.75 mL of fetal RBCs in normal adults
Clinical References Provides recommendations for further in-depth reading of a clinical nature
1. Iyer R, Mcelhinney B, Heasley N, et al: False positive Kleihauer tests and unnecessary administration of anti-D immunoglobulin. Clin Lab Haematol 2003;25:405-408
2. Technical Manual. Sixteenth edition. Edited by J Roback, MR Combs, B Grossman, C Hillyer. Bethesda, MD, AABB Press, 2008, pp 625-637, pp 888