Shock management in acute fetomaternal hemorrhage

Acute severe fetomaternal hemorrhage (FMH) is a lifethreatening condition both for fetus and neonate. If promptly recognized, two important management steps can prevent demise or serious complications. A 37-week multigravida presented at the obstetrical unit of our hospital complaining of decreased fetal movements for 48 h. The fetal heart rate recording showed a repetitive sinusoidal heart rate pattern typical for severe anemia. An emergency Caesarean section was planned and O negative blood for the neonate was immediately ordered. The Apgar scores of a male infant, birth weight 3200 g, were 8 after 1 and 5 min, respectively. The neonate was extremely pale. Approximately 10 min after birth, he started grunting and developed a tachypneu of 60/min for which supplemental oxygen was given and infant flow at 5 cm H2O positive endexpiratory pressure. His pulse was 140/min and blood pressure was 50/12 mmHg. After obtaining intravascular access, he received a fluid bolus of 10 ml/kg, followed by a transfusion of 15 ml/kg O negative blood in 20 min. Thereafter, his respiratory and circulatory status significantly improved. The hemoglobin level increased from 3.1 mmol/l pretransfusion to 6.6 mmol/l. Afterward, the Kleihauer-Betke test, the most common method for the detection of fetal red blood cells in the maternal circulation, was 5.7% and indicative for an estimate fetomaternal transfusion of 285 ml (blood). On the second day, he showed signs of temporary liver (ASAT 508 U/L, ALAT 432 U/L, LD 4814 U/L) and renal failure (creatinine, 168 mmol/l), which spontaneously normalized over time. A cranial ultrasound revealed signs of flaring on the third day, but this was not detectable on the 10th day. The first important management step after the diagnosis of acute FMH is suspected or made is clear and direct communication between the obstetrician and pediatrician to emphasize that hypovolemic shock may be present for the