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 ::  Abstract
 ::  Introduction
 ::  Material And Methods
 ::  Results
 ::  Discussion
 ::  Acknowledgements
 ::  References
 ::  Article Tables

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Year : 1979  |  Volume : 25  |  Issue : 2  |  Page : 75-80

Transplacental haemorrhage and maternal iso-immunization

Blood Group Reference Centre (I.C.M.R.), Seth G.S. Medical College, Parel, Bombay-400 012, India

Correspondence Address:
Daxa M Mehta
Blood Group Reference Centre (I.C.M.R.), Seth G.S. Medical College, Parel, Bombay-400 012
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Source of Support: None, Conflict of Interest: None

PMID: 115996

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 :: Abstract 

Foetomaternal haemorrhage is one of the important factors influencing maternal iso-immunization. In the present report at­tempt is made to study various aspects of foetomaternal haemor­rhage. While the overall incidence of foetal cell leak was observed in 21.43%, the incidence in the complicated deliveries ranged from. 27.94 to 85.72%. Incidence was not influenced by parity, however ABO compatible deliveries showed slight increase in the incidence (22.56%) as compared to ABO incompatible (18.75%) deliveries. ABO incompatible foetal cells were eliminated within 24 hours after delivery. Incidence of foetal cell leak was 8.28% in medical termination of pregnancy. Anth-Rh was produced in two out of nine women having foetal cell leak.

How to cite this article:
Mehta DM, Gupte SC, Bhatia H M. Transplacental haemorrhage and maternal iso-immunization. J Postgrad Med 1979;25:75-80

How to cite this URL:
Mehta DM, Gupte SC, Bhatia H M. Transplacental haemorrhage and maternal iso-immunization. J Postgrad Med [serial online] 1979 [cited 2023 Jun 3];25:75-80. Available from:

 :: Introduction Top

Mechanismm of Rh (D) immunization by transfer of foetal cells, was postulated by Levine et. al. (1941). [7] However the direct evidence for the transfer was pre­sented by Javer and Reiss in 1952 [5] Vari­ous techniques have been used to study foetal cell leak into maternal circula­tion. [2],[6],[9],[10],[11] Using either of these tech­niques, several foetal cell leak studies have been done during pregnancy and after delivery [3],[11],[12] In the present re­port various aspects of foetomaternal haemorrhage are presented.

 :: Material And Methods Top

Patients studied were drawn from the antenatal clinics and labour ward of the Cama and Albless Maternity Hospital, Bombay. Cases of medical termination of pregnancy were obtained from Nowrosjee Wadia Maternity Hospital.

Blood samples were collected in oxalat­ed and plain bulbs. Among the cases with full term delivery, the first sample was collected within two hours of delivery and the subsequent samples were collect­ed after six to twelve and twenty to twenty four hours after delivery.

All the details like age, past obstetric history, type of the delivery were obtain­ed from the labour ward records. Attempt was also made to contact all the Rh (D) negative patients, 3 and 6 months after the delivery, for the detection of Rh (D) antibodies.

All serological methods used were the standard tube techniques outlined by Bhatia, [1] using locally prepared diagno­stic reagents. Maternal blood samples were examined for ABO and Rh (D) groups, presence of Rh antibodies and detection and quantitation of foetal cells. Investigations on new born infants in­cluded ABO and Rh (D) groups and direct Coomb's test.

Detection of foetal cells:

One drop of blood was mixed with two drops of normal saline and one drop of this was taken on a clean slide and made into thin smear. Blood smears, thus pre­pared were fixed by keeping in 80% alcohol for 5 minutes and then rinsed with water and air dried. Slides were stained by Nierhaus and Betke (1968) [9] acid elution technique, using following reagents.

Solution A:- 0.75 gms haematoxylin

+100 ml of 95% alcohol.

Solution B: - 2.4 gms. Ferric Chloride

+ 2 ml of 25% HCI +

100 ml distilled water

(pH 1.5).

Counter stain: 0.1% erythrocin in dis­tilled water.

Five parts of solution A were mixed with one part of solution B. This mixture was used for six weeks with filtration every 4-5 days.

Fixed slides were kept in the mixture for exactly 20 seconds, rinsed in distilled water and counter stained for 2-3 minutes, in 0.1% erythrocin, washed with water and air dried. Foetal cells were recog­nised under microscope by their well defined distinct red colour, while the adult cells were light coloured ghost cells. Each slide was examined for 100,000 adult cells and the number of foetal cells encountered were counted. Amount of foetal blood in the maternal circulation was calculated on the follow­ing basis as obtained by the experimental artificial mixture of adult and cord cells.

 :: Results Top

300 Pregnant women were studied for the presence of foetal cells. Foetal cell leak was observed in 12 cases (4%). No foetal cells were detected in 129 women examined during I or II trimester, while 12 out of 171 women (7.01%) during third trimester showed the foetal cell leak.

[Table 1] gives the incidence of foetal cell leak among the women, at delivery in relation to their parity. Incidence of foetomaternal haemorrhage was 21.4 per cent among all the women. Incidence was slightly higher (26.82%) among pri­miparous women than in other parities (17.65 to 19.9%) though the difference was not statistically significant.

Findings in [Table 2] suggests that the incidence of foetal cell leak was higher in complicated deliveries than in normal deliveries. Highest incidence of 85.7 per cent was observed in twins deliveries.

While the overall incidence of foetal cell leak was 21.3%, it was 20.73% in ABO compatible and 18.75 per cent in ABO incompatible deliveries [Table 3]. [Table 3] also gives the follow up studies of those women during 24 hours. Find­ings suggest that though the incidence of foetal cell leak is 20.3% among ABO com­patible and 18.75 per cent among incom­patible, when the samples were collected within 2 hours after delivery the inci­dence of foetal cell leak at 12 and 24 hours was 20.73 and 13.42 in ABO compatible and 5.1 and 1.7% among ABO incompa­tible deliveries.

Incidence and amount of foetal haemor­rhage among Rh positive and Rh nega­tive women was not significantly diffe­rent. The data showed that 49 out of 222 Rh (D) negative (22.0%) and 98 out of 466 Rh positive (21.00%) women had foetal cell leak. Amount of foetal bleed was also similar among Rh positive and Rh negative mothers. In 60% of the cases having foetal leak, the amount of foetal cell leak was less than 0.15 ml. 22% had a leak up to 1.0 ml., 6% had upto 2.5 ml and only one case had more than 5 ml.

Thirty three cases of Rh (D) negative women were available for follow up to detect Rh antibodies. Among these 33 women, 9 had foetal cell leak. Anti-Rh was detected in 2 out of 9 Rh (D) nega­tive women having foetal cell leak. In both these cases the amount of foetal leak was 0.5 and 1.0 ml. respectively, while the remaining 7 cases had foetal cell leak less than 0.5 ml.

Foetomaternal haemorrhage in medical termination of pregnancy

193 cases of medical termination were studied for foetal cell leak. Findings given in [Table 4] indicate that. 8.29 percent of the medical terminations had foetal cell leak. Incidence was higher (14.06%) in those where intra-amniotic hypertonic saline injections were given for terminating the pregnancy. In all the sixteen cases the amount of foetal cell leak was less than 0.1 ml.

 :: Discussion Top

Haemolytic disease of the newborn due to Rh (D) immunization is more com­mon in Western countries than in India, since the incidence of Rh (D) negatives is 15% in Caucasians. In India the incidence of Rh (D) HDN has been reported as 1:30 Rh (D) negative women or 1:600 randam pregnancies. [8] One of the factors stimulating Rh immunization is foeto­-maternal haemorrhage which may occur either during pregnancy or at the time of delivery. Woodrow and Finn [11] report­ed an incidence of 12.6% during preg­nancy with increasing incidence from the first to the third trimester. In the pre­sent study the foetal cells were not detec­ted in women during the first and second trimester. Present data, like those of other investigators [4],[12] gives significantly higher incidence of foetomaternal haemorrhage in complicated deliveries in comparison to normal deliveries. Inci­dence was particularly high (85.7%) in twins delivery. Such significantly high incidence among women with complicat­ed deliveries may suggest this as one of the factors influencing Rh (D) immuniza­tion. Among the MTP patients, intra­amniotic saline procedure involved more risk of foetal cell leak (14.06%). The role of ABO compatibility is also reflect­ed in the present data since the foetal cell leak was very much similar among ABO compatible and incompatible deli­veries. ABO incompatible foetal cells were eliminated within 24 hours. These finding support the observation of higher risk of Rh immunization in Rh negative women with ABO compatible pregnan­cies.

The present data does not give any cor­relation of foetal cell leak with parity. Zipursky et al [12] observed that primary sensitisation requires 0.5 ml. or more blood and sensitisation may take place after a booster dose of 0.1 to 0.2 ml. of blood. In the present study, out of 9 Rh (D) negative women showing foetal cell leak two had foetal cell leak of 0.5 and 1 ml respectively after delivery. Both of these women developed Rh antibodies during their subsequent pregnancy sug­gesting primary response due to delivery. Remaining seven cases who did not deve­lop anti-Rh had foetal cell leak less than 0.5 ml.

 :: Acknowledgements Top

Authors are thankful to the Superin­tendent of Cama and Albless Hospital, Bombay and Dean of the Nowrosjee Wadia Maternity Hospital for the faci­lities provided.

 :: References Top

1.Bhatia, H. M.: "Techniques in Blood Group Serology". I. C . M . R. Technical report series No. 13, 1972.  Back to cited text no. 1    
2.Chown, B.: Anaemia from bleeding of fetus into the mother's circulation. Lancet, 1: 1213-1215, 1.954.  Back to cited text no. 2    
3.Cohen, F., Gustafson, D. C. and Evans, M. M.: Mechanism of isoimmunisation. I The transplacental passage of foetal ery­throcytes in homospecific pregnancies. Blood, 23: 621-646, 1964.  Back to cited text no. 3    
4.Deshpande V. L. and Sharma, K. D.: Incidence of transplacental haemorrhage in . post-partum and its relationship to use of obstetric procedures. J. Obst. Gynec. India, 25: 186-192, 1975.  Back to cited text no. 4    
5.Javert, C. T. and Reiss, C.: The origin and significance of the macroscopic inter­villous coagulation haematomas (red in­fants) of the human placenta. Surg. Gynec. and Obstet. 94: 257-269, 1952­  Back to cited text no. 5    
6.Kleihauer, E., Hildegard, B. and Bente, K.: Demonstration von fetalem Hemoglo­bin in den Erythrocyten eines Blutaus­trichs Klin. Wschr., 35: 637-638, 1957. As quoted by Oski, F. M. and Naiman, J. L. In, "Haematologic problems in the new­born." W. B. Saunders Company. 1966, p. 49.  Back to cited text no. 6    
7.Levine, P., Burnham, L.. Katzin, E. M., and Vogel, P.: The role of iso-immuniza­tion in the pathogenesis of erythroblasto­sis foetalis. Amer. J. Obst. and Gynec., 42:: 925-937, 1941.  Back to cited text no. 7    
8.Mehta, D. M., Gupte, S. C. and Bhatia, H. M. Analysis of maternal Rh immuni­zation in relation to parity, foetal loss and family size. Ind. J. Med. Sci., 64: 938­945, 1976.  Back to cited text no. 8    
9.Nierhaus, K., and Betke, K.: Eine verein­fachte modifikation der sauren Elution fur die cytologische Darstellung von fetalem Hamaglobin. Klin. Wochenscr., 46: 47, 1968. Quoted by Dacie, J. V. and Lewis, S. M. In, "Practical Haematology". 5 th edition, Churchill, Livingstone, Edin­burgh and London, 1975, p. 144.  Back to cited text no. 9    
10.Wiener, A. S.: Diagnosis and treatment of anemia of the newborn caused by occult placental haemorrhage. Amer. .7 . Obstet, and Gynec., 56: 717-722, 1948.  Back to cited text no. 10    
11.Woodrow, J. C. and Finn, R.: Trans placental haemorrhage. Brit. J. Haematol., 12: 297-309, 1966.  Back to cited text no. 11    
12.Zipursky, A., Pollack, Janet, Chown, B. and Israels, L. G. Transplacental foetal haemorrhage after placental injury during delivery or amniocentesis. Lancet, II: 493­496, 1963  Back to cited text no. 12    


  [Table 1], [Table 2], [Table 3], [Table 4]


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