Integration of Fetal Middle Cerebral Arterial (MCA) Ultrasonography in Acute Fetal-Maternal Hemorrhage

case reports in obstetrics and gynecology
18 Nov, 2019 ,

Jessian L. Munoz et al present a case of maternal-fetal hemorrhage characterized by intermittently reassuring fetal testing. Additional testing performed with ultrasound, including middle cerebral artery (MCA) doppler waveforms, confirmed fetal hemorrhage followed by emergent cesarean section. This report highlights the acute usage of MCA dopplers in obstetric decision making. The Newborn required transfusion but otherwise recovered well. MCA may be a useful tool for fetal assessment in Labor and Delivery units.

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Patient is a 32-year-old G1P0 at 33 weeks and 1 day gestation that was admitted to the hospital for further evaluation of decreased fetal movement for the two days. Pregnancy was uncomplicated prior to this admission. The patient was started on continuous fetal monitoring along with intravenous fluids. The patient was found to have alternating category II and III tracing. Given the prematurity of the fetus, Maternal-Fetal Medicine was emergently consulted. Bedside ultrasound was performed for amniotic fluid index, biophysical profile, placental appearance and MCA Doppler. Middle cerebral artery peak systolic velocity was 96 cm/s (1.88MoM).

This data was suggestive of fetal anemia most probably secondary to spontaneous feto-maternal hemorrhage. Due to nonreassuring fetal status along with intermittent category-three tracing, the decision was then made to proceed with emergent primary low transverse cesarean section. She then underwent a low transverse cesarean section and delivered a 4 pound, 6 ounce infant female with a one-minute Apgar score of four and a five-minute Apgar score of seven. Umbilical blood gas pH was 6.98. At time of surgery, placenta was noted to be pale in appearance. Placental pathology revealed a 368 g, appropriate for gestational age placenta with increased circulating nucleated red blood cells and focal chronic villitis.

Perioperatively, female infant was also noted to be pale appearing; hemoglobin at that time was 2 g/dL. Infant required transfusion of 2 units of packed red blood cells. Kleihauer betke staining revealed 318 mL's of Fetal blood present in maternal circulation. Infant progressed normally throughout admission. Infant is currently 3 years old with no deficits.