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Introduction: Fetomaternal haemorrhage (FMH) is a loss of fetal blood into the maternal circulation. Massive FMH represents a loss of more than 80 ml (occurs in 1 of 1000 deliveries) or more than 150 ml (occurs in 1:5000 deliveries). The symptoms of FMH are nonspecific, and the most common prenatal presentation is decreased or absent fetal movements. It may be a cause of fetal hydrops as well as intrauterine fetal death. After birth, FMH may be presented as severe neonatal anemia, asphyxia, hypovolemic shock and respiratory distress. Kleihauer-Betke test or acid elution test is golden standard for diagnosis of FMH. Objectives: To highlight FMH as a rare and potentially fatal cause of neonatal anemia. Methods: We presented case report of the newborn with severe anemia at birth and the single tertiary center perennial experience trough the retrospective case series study. Severe neonatal anemia was defined as hematocrit < 30 % or hemoglobin < 10 g/dl. Diagnosis of FMH was set by Kleihauer-Betke test. The clinical and presentation, laboratory tests, diagnostic and therapeutic approach was presented. Results: A term female infant from uneventful pregnancy was born by c-section because of incipient fetal asphyxia. Apgar scores were 4, 6 and 8 at the first, fifth and tenth minute, respectively. At birth, the newborn presented with pallor and signs of moderate asphyxia. Laboratory tests revealed severe anemia with hemoglobin level 5 g/dl. Kleihaurer-Betke test revealed the presence of fetal red cells in maternal circulation, equivalent to 287 mL blood loss. EEG showed. Hypotonia, hyporeflexia and depressed EEG activity was present in first few days of life. Patient was treated with multiple red blood cell transfusions. Outcome was favorable and infant was discharged home at 8th day of life. During the last seven years, eight infants with severe anemia caused by FMH were treated in our hospital. Majority of them were born at term (7/8) with average birth weight of 3188 ± 144 grams. Apgar scores ranged from 1 to 6 in the first minute, and from 0 to 8 in fifth minute. The commonest clinical manifestations were pallor, tachycardia, tachypnea, apnea, lethargy, respiratory and circulatory failure. One infant was presented with signs of fetal hydrops and other one with pulmonary hypertension. Average hemoglobin concentrations on admission were 5.1±2.9 g/dl (from 2.8 to 10 g/dl). Estimated volume of fetal blood loss ranged from 94 to 530 ml. Elevated level of fetal hemoglobin and alpha-fetoprotein in maternal blood additionally confirmed the diagnosis of FMH. All patients were treated with red blood cell transfusion. Outcome was favorable in 6 out of 8 newborns. Two patients died due to shock with adrenal hemorrhage and pulmonary hypertension. Conclusions. FMH is rare but potentially fatal cause of neonatal anemia. Because of nonspecific prenatal signs recognition of this condition is difficult. We hope that our report raise awareness about possible severity of FMH. [ABSTRACT FROM AUTHOR]

Amniocentesis is the most commonly performed invasive prenatal diagnostic procedure. The relative simplicity of the method has made amniocentesis available in a large number of centres. Amniocentesis may increase the risk of fetomaternal hemorrhage (FMH) due to needle transfixation of the maternal abdomen skin to the amniotic membrane and sometimes the placenta. There is an increase in FMH after performing amniocentesis, but there is no consensus regarding the best method to monitor the safety of these procedure. Flow cytometry immunophenotyping, using a monoclonal antibody against fetal hemoglobin, has become an interesting alternative to classical Kleihauer test to measuring FMH. Blood contamination of amniotic fluid (AF) during amniocentesis correlates directly with: needle thickness, physician experience, number of puncture points taken for sample acquisition, placental location. The puncture needle is recommended to have a thickness between 20-23 gauge (G).. Maternal cell contamination is prevented by discharging the first 2 ml of each sample. Another factor affecting safety of amniocentesis is the volume of procedures performed by the operator. High volume experience is reported to have decisive impact on rates of procedure-related adverse outcomes The impossibility of AF extraction at the first puncture requires its repetition, which increases the risk of AF contamination. From this point of view, it is extremely important to identify before the procedure the most voluminous AF bags, but also to choose a tract that avoids the transplacental passage. Placement of the placenta on the anterior wall increases the risk of AF contamination compared to the back or posterior wall location. Regarding the isoimunisation risc after amniocentesis, when a FMH occurs with less than 0.1 ml, isoimmunization at six months after delivery is 3%. Amniocentesis is safe to be carried out in fetal medicine when is followed by standard methods and conducted by trained professionals. [ABSTRACT FROM AUTHOR]