Non‐invasive diagnosis by Doppler ultrasonography of fetal anemia due to massive fetomaternal hemorrhage in a case of twin–twin transfusion syndrome treated with serial amnioreduction (2005)

Massive fetomaternal hemorrhage (FMH) is a rare but serious condition during pregnancy that can cause severe fetal anemia, hydrops and even death1-3. We report a case of a twin pregnancy referred at 22 + 3 weeks of gestation complicated by Stage IV4 twin–twin transfusion syndrome (TTTS). Amnioreduction was performed using a sterile 18-gauge needle and 1800 mL of clear amniotic fluid were drained from the amniotic cavity of the recipient twin obtaining a maximum vertical pocket (MVP) of 5 cm. The patient was assessed twice weekly and amnioreduction was performed when the MVP exceeded 8 cm. At all ultrasound examinations, fetal growth and Doppler velocimetry, including the middle cerebral artery peak systolic velocity (MCA-PSV), were assessed. MCA-PSV values were assessed in both twins as previously described5-8 and the values were plotted against the reference ranges established by Mari et al.5. (MCA-PSV of > 1.50 multiples of the median (MoM) was indicative of moderate or severe anemia.) The recipient twin was hydropic and exhibited reversed flow in the umbilical artery and ductus venosus; however, the MCA-PSV values were normal for both twins. Amnioreduction was repeated at 23 + 4, 25 + 0 and 25 + 5 weeks of gestation and 1500, 1650 and 1750 mL of amniotic fluid were drained, respectively. During the second procedure, needle insertion caused placental blood loss and at the end of the procedure the amniotic fluid drained was bloody, as it was during the third and fourth amnioreduction procedures. MCA-PSV values increased following the second amnioreduction, indicating the development of severe and mild anemia in the recipient and donor twins, respectively (Figure 1). Soon after the fourth amnioreduction, the Kleihauer-Betke stain test showed 5% fetal cells in the maternal circulation indicating a FMH of 120 mL. Three hours after the fourth amnioreduction, placental abruption was suspected because of vaginal bleeding and uterine contractions. An emergency Cesarean section was performed and upon opening the uterus the amniotic fluid was dark and bloody and blood clots were evident. Neonatal blood sampling was performed soon after delivery and the hemoglobin levels of the recipient and donor twins were 5.4 and 8.1 g/dL, confirming severe and mild anemia, respectively. The recipient twin was pale and hydropic and died after 72 h because of cardiac failure, while the donor twin did not require neonatal blood transfusion and was doing well 16 months after delivery. Middle cerebral artery peak systolic velocity (MCA-PSV) values of the recipient (▵, ▴ ) and donor (○, ●) twins. ▵, ○, values during the ultrasound sessions; ▴, ●, values after amnioreduction. The solid line represents the median. The dotted line indicates 1.5 multiples of the median (MoM). Doppler assessment of the MCA-PSV has been exhaustively studied in the non-invasive diagnosis of fetal anemia in maternal red cell alloimmunization and in non-immune hydrops fetalis5-7. Moreover, Doppler investigation of the MCA-PSV is a useful tool to predict fetal anemia due to FMH9, which may be treated by fetal blood transfusion10. In the present case, fetal blood transfusion was taken into consideration to treat fetal anemia but Cesarean section was performed because of placental abruption. E. Cosmi*, P. Litta*, A. Andrisani*, L. Di Lenardo*, G. M. Fadda*, G. Ambrosini*, * Prenatal Diagnosis Fetal Therapy Unit, Department of Gynecological Science Reproductive Medicine, University of Padua, Via Giustiniani 3, 35100 Padua, Italy