ARTICLES
NEONATAL
ANEMIA
DUE TO
FETAL
HEMORRHAGE
INTO
THE
MATERNAL
CIRCULATION
By H H. Gunson, MB., Ch.B.
Departments of Pathology, The Hospital for Sick Children and the University of Toronto; and
The Research Institute of The Hospital for Sick Children, Toronto, Canada
(Submitted August 29, accepted November 26, 1956.)
ADDRESS: The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada.
3
O
CCULT fetal hemorrhage in utero, asdistinct from a massive fetal hemor-rhage immediately prior to birth leading to a newborn infant in shock, may be clinically suspected in infants who show pallor as-sociated with a low concentration of hemo-globin during the first day of life. This anemia is not progressive and the infants do not develop early jaundice, which dif-ferentiates it from hemolytic disease of the newborn.
The suggestion that occult hemorrhage from the fetal side of the placenta could be a cause of anemia in the newborn infant was first made by Wiener.1 This entity was also listed by Wickster and Christian as a
possible cause of posthemorrhagic anemia
in newly born infants. Proof of this concept was not obtained until Chown3 demon-strated erythrocytes of the infant in the mother’s blood in the investigation of a case of neonatal anemia.
The present report concerns an infant who presented with anemia from the time
of birth. The infant’s blood groups differed from his mother’s both in the ABO and Rh systems and the fetal erythrocytes were demonstrated in the maternal circulation by differential agglutination. The survival of these cells in the mother’s blood was fol-lowed during the first S months of the post-partum period. After the infant’s
Rh-positive cells disappeared from the mother’s
circulation, anti-Rh antibodies were de-monstrated.
CASE REPORT
The infant was born after an uneventful
pregnancy and labor. There was no excessive
bleeding during parturition. He cried lustily
after birth but appeared pale. He was not
jaundiced but because of anemia, he was ad-mitted to The Hospital for Sick Children as a possible case of hemolytic disease of the new-born. At 4 hours of age the concentration of hemoglobin in capillary blood was 9.5 gm/100
ml. Smears made from the infant’s peripheral blood showed 12 nucleated erythrocytes per 100 leukocytes, and reticulocytes numbered
8.5%. His blood group was 0 Rh positive
(subtype cDE/cde). The direct Coombs’ test on his cells was negative.
The infant’s mother was 25 years old and this was her first pregnancy. There was no
his-tory of a blood transfusion. Her blood group was A1 Rh negative (subtype cde/cde). Anti-bodies were not detected in her serum at 32 weeks gestation or on the first day post partum.
The sample of blood taken from the mother on the first day post partum revealed numerous small agglutinates after incubating the
erythro-cytes with anti-D and anti-E sera, but a
corn-pletely negative reaction with anti-C serum. These agglutinates correspond to the D and E antigens possessed by the child. Conversely,
the addition of anti-A serum to the mother’s
erythrocytes left many more unagglutinated cells than were seen with similar suspensions
of five random group A bloods. By gently
cen-trifuging the erythrocyte suspension after add-ing anti-A serum the unagglutinated cells were separated. These cells gave strong positive re-actions with anti-D and anti-E sera but not with anti-C. They did not react with anti-A or anti-B sera. These reactions indicated that
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4 PEDIATRICS-JULY 1957
had the D and E antigens identical with the Rh-positive antigens of the child. The presence
of fetal cells in the maternal circulation was
proven, therefore, beyond any reasonable doubt.
Treatment consisted of a simple transfusion of group 0 Rh positive blood. Examination at 3 months of age showed that there had been no progressive anemia.
SPECIAL STUDIES
The gradual disappearance of the infant’s cells in the maternal circulation was fol-lowed by means of the quantitative dif-ferential agglutination test of Ashby4 at regular intervals during the post-partum period. The method used was a modification of the technique described
by
Dacie.5Method f or Differential Agglutination Test
Oxalated samples of venous blood were taken from the mother on seven occasions dur-ing the post-partum period and the tests were carried out within 2 hours. In order to mini-mize errors in technique, five separate dilutions
were prepared and the tests on all specimens
carried out in parallel.
Whole blood (0.1 ml) was diluted to 1 :50 in
0.9% solution of sodium chloride. To 0.2 ml of
this suspension, an equal volume of a potent anti-A serum was added. A control of 0.2 ml of cell suspension and 0.2 ml of physiologic saline was also made. The test and control tubes were corked and allowed to stand at room
temperature for 2 hours. After centrifuging
at 1500 rev/mm for 1 minute, the tubes were
shaken to break up the button of cells at the bottom of the tube. Within 30 seconds, when the large agglutinates had sunk to the bottom of the tube, all of the supernatant erythrocyte suspension was withdrawn and centrifuged. The cells were resuspended by tilting the tube 50 times through an angle of approximately 45#{176}.An erythrocyte counting chamber was then filled with the resulting suspension. The average number of unagglutinated cells in the five dilutions was then expressed as a per-centage of the average counts of the saline control specimens. It was found that by this method about 0.5% of group A cells remained unagglutmnated by the anti-A serum.
Fic. 1. Estimate of infant’s cells in maternal circulation by differential erythrocyte counts. In estimating the number of infant’s cells in the maternal circulation, the
Results
Figure 1 shows the rate of disappearance of the unagglutinated cells during the
post-partum period expressed as a percentage of
the total erythrocyte count of the mother. This gave a measure of the fetal cells pres-ent in the maternal circulation. On the tenth day post partum there were 37% unagglu-tinated cells in the mother’s blood. The number of these cells gradually decreased during the succeeding weeks and reached a level of 0.5% after 80 days, which level was then maintained.
At 80
days post partum, Rh antibodieswere demonstrated in the mother’s serum for the first time. On this occasion anti-D was present (titer 1:8 (albumin)). A further sample of the serum tested approximately S weeks later revealed the presence of anti-E in addition to the anti-D.
DISCUSSION
It
is reasonable to conclude that the anemia in this infant was caused by fetal bleeding into the maternal circulation. The anemia was well established at 4 hours of age and the slightly increased number of reticulocytes and nucleated erythrocytes in the child’s peripheral blood proves that ac-tive erythropoiesis was occurring.Using fetal erythrocytes tagged with radioactive chromium and transfusing them into normal adult volunteers,
Hollings-worth6 found that the half life of these cells
was approximately two-thirds of the autog-enous survival time of adult cells. In the case reported here the fetal erythrocyte survived approximately 80 days. If we take 120 days for the survival of adult cells determined by Ashby counts,7 it is likely that 80 days may be the full survival time for fetal cells in an adult circulation. The fetal hemorrhage into the maternal circula-tion probably occurred, therefore, close to the birth of the child,
Anemia in newborn infants subsequent to hemorrhage from the placenta may occur not infrequently. At the Hospital for
Sick
Children, 20 cases have been noted duringthe past few years in which a presumptive diagnosis of this syndrome has been made, care having been taken to rule out other causes of neonatal anemia.8 Hitherto, only the reports of have described proven cases of fetal hemorrhage into the maternal circulation; one into the general circulation of the mother, and the second primarily into the placenta itself with fetal blood in the intervillous sinuses adjacent to the area of hemorrhage.
In addition to the case reported in detail
in this paper, the author has had the
op-portunity of investigating six other infants with strong clinical evidence of loss of fetal blood in utero. Two of these infants and their mothers had identical ABO, MN, and Rh blood groups. In four cases major blood group differences were demonstrated
be-tween the infant and mother and differential
agglutination tests were carried out. Fetal
erythrocytes were not detected in the
mother’s blood in three of these cases, where two of the mothers were group 0 with group A babies, and one was group A Rh negative with a group A Rh positive infant. In the final case where the mother was group B, M, Rh positive and her infant group 0, MN, Rh positive, fetal cells were demonstrated in the maternal circulation on the first day post partum. Unfortunately, this family lived a considerable distance from Toronto and quantitative determina-tions of fetal cells in the maternal circula-tion could not be made.
At a recent meeting of the Society for Pediatric Research, O’Connor et al.bo de-scribed elevation of the concentration of fetal hemoglobin in the maternal circulation in a high proportion of cases of anemic newborn infants. This method, carefully standardized, may well prove to be a great help in the diagnosis.
There is no doubt that fetal hemorrhage
in utero is a real clinical entity and may
6 PEDIATRICS-JULY 1957
in only two out of five cases. The blood groups of the mother and infant must have certain differences before the differential agglutination test can be used to detect fetal cells in the mother’s blood. But given this difference and with careful technique one would expect a relatively small propor-tion of fetal erythrocytes could be demon-strated, since in the case reported 0.5 to
1.0% of unagglutinated cells were readily
estimated. Perhaps therefore, the failure to make an absolute diagnosis was due to some extent to the hemorrhage remaining local-ized near the placental site and not enter-ing the general circulation of the mother. Another possibility is that fetal cells may be destroyed as they enter the maternal circulation which one might expect with group 0 mothers who have group A or B babies, as the mother’s serum normally contains anti-A and anti-B agglutinins.
An interesting sequela to the fetal bleed-ing in the case reported was antibody for-mation in the mother to both the D and E antigens of the child. This supports the theory that fetal hemorrhage into the mother’s circulation may be one mechanism of Rh iso-immunization as a result of preg-nancy. In the majority of cases in which the mother develops antibodies, the quantity of fetal blood entering the maternal circulation
is probably small and causes no significant anemia in the child.
SUMMARY
A case of anemia caused by loss of fetal blood into the maternal circulation is re-ported. The diagnosis was established by detection of fetal erythrocytes in the ma-ternal circulation by differential agglutina-tion. Ashby counts on the mother’s blood, showed that the fetal cells persisted in the maternal circulation for approximately 80 days, following which the mother developed Rh antibodies. Fetal hemorrhage from the placenta probably not infrequently causes anemia in the newborn period. In many cases, however, conclusive proof of such a diagnosis is not made.
REFERENCES
1. Wiener, A. S. : Diagnosis and treatment of anemia of newborn caused by occult placental hemorrhage. Am.
J.
Obst. &Gynec., 56:717, 1948.
2. Wickster, C. Z., and Christian,
J.
R. : Post-hemorrhagic shock in the newborn pre-mature. Ped. Clin. North America, 1: 555, 1954.3, Chown, B. : Anaemia from bleeding of the fetus into the mother’s circulation. Lancet, 1:1213, 1954.
4. Ashby, W. : Study of transfused blood; periodicity in eliminative activity shown
by the organism.
J.
Exper. Med., 34: 127, 1921.5. Dacie,
J.
V : The Haemolytic Anaemias, Congenital and Acquired. London, Churchill, 1955, chap. 1.6. Hollingsworth,
J.
W. : Lifespan of fetal erythrocytes.J.
Lab. & Clin. Med., 45: 469, 1955.7. Mollison, P. : Blood Transfusion in Clinical
Medicine, Oxford, Blackwell;
Spring-field, Thomas, 1951, p. 104.
8. Laski, B. : Personal communication,
9. Chown, B.: The fetus can bleed; three
dinicopathological pictures. Am.
J,
Obst. & Gynec., 70: 1298, 1955.10, O’Connor, W.
J.,
Shields, C., Schuyler, K., and Sussman, K. : The occurrence of anemia of the newborn in association with the appearance of fetal hemoglobin in maternal circulation (Abstract). Am.J-
Dis. Child., 93:10, 1957.SUMMARIO
IN INTERLINGUA
Anemia de Neonatos, Resultante de Hemorrhagia Fetal a in le