CLINICOPATHOLOGIC

CONFERENCE
Tejada, Michael Leonelle A.
Block 10
01 History of present Illness

02 Physical Examination and Diagnostics

03 Impression and Differnetials

04 Final Diagnosis and Pathophysiology

05 Management
 History of Present Illness
Case Protocol

A baby is born at 41 weeks gestation to a

32 year old woman.
The mother had received oral iron therapy
due to first trimester anemia
Her Hgb level was 11.8 g/dL in the 3rd
trimester.
Her blood group is A+.
Screening revealed no evidence of
infection
 History of Present Illness
Case Protocol

At 20 weeksTriple screen and UTZ gave normal

results .
Unremarkable Familial, Personal and Social
history
Demonstrated late and variable decelerations
and a sinusoidal rhythm
The infant was delivered by CS.
The placenta appeared with no retroplacental
clot.
Maternal blood loss was estimated to be 300 ml.
 Physical examination
and Diagnostics
Cord ABG showed
pH 7.12, PCO2 55 PO2 25 HCO3 17 and BE -10.
The baby has poor respiratory efforts , requiring brief bag and mask ventilation.
Apgar scores are at 6,6 at 1,5,minutes respectively.
He weighs 3.1 kg
extremely pale but has no bruises or cephalhematoma.
He is mildly tachypneic for 6 hours but has clear lungs.
O2 sat is 100% at room air. Pulses are palpable in all extremities.
His HR is 150, BP 75/35 mm Hg with no gradients between arms and legs.
A grade 2 systolic ejection murmur is audible at the LSB.
 Physical examination
and Diagnostics
WBC 23,000/cu.mm.
Hct 0.17
Hgb 4.8 g/dL
PLt 168,000/cu mm
Blood Type A+
Direct Coombs test:negative
Reticulocyte count 17%
PBS shows normal cell morphology.
G6PD level normal.
UTZ of the head heart and abdomen reveals normal anatomy.
CXR reveals fluid in the middle fissure.
Salient Features
Maternal and Birth History
First trimester anemia - oral iron therapy
Third Trimester - Hgb : 11.8 g/dL
MBT: A+
No evidence of infection, Normal Triple screen and
UTZ at 20 weeks AOG
(+) Late and Variable decelerations
Delivered via CS
Cord ABG : pH 7.12, PCO2 55 PO2 25 HCO3 17
and BE -10
Born extremely pale
Apgar score: 6,6,7 and 8 at 1,5,10 and 1
Salient Features
Diagnostics
WBC 23,000/cu.mm. (NV: 9,000 - 30,000)
Hct 0.17 (NV: 0.33 - 0.64)
Hgb 4.8 g/dL (NV: 13.7 - 20.1 g/dL)
PLT 68,000/cu mm (NV: 150 - 450)
Blood Type A+ Direct Coombs test negative
Reticulocyte count 17% (NV: 2.5% - 6.5%)
PBS shows normal cell morphology.
G6PD level normal.
UTZ of the head heart and abdomen reveals
normal anatomy.
CXR reveals fluid in the middle fissure.
 Differential Diagnosis
ANEMIA

HEMOLYTIC HEMORRHAGIC

Born extremely Pale

Mildy tachypneic for 6 hours
Hct 0.17 (NV: 0.33 - 0.64)
Hgb 4.8 g/dL (NV: 13.7 - 20.1 g/dL)
Reticulocyte count 17% (NV: 2.5% - 6.5%)

Negative Coombs test

Normal Peripheral
blood smear
No jaundice
No hepatomegaly
Final Diagnosis

Chronic anemia
secondary to
Fetomaternal
Hemorrhage
 Fetomaternal Hemorrhage
FMH is defined as fetal blood transfer into the maternal
circulation without any history of trauma and without clinical or
histopathological evidence of placental abruption.

The pathogenesis of Abnormal fetal heart rate,

massive spontaneous
FMH is not fully
understood.
and decreased fetal
Clinical signs are movement can be signs of
massive but non-lethal or
nonspecific and chronic intermittent acute
bleeding
unpredictable
In the case presented, the suspicion of FMH had to be
confirmed by the presence of fetal cells in the maternal
bloodstream.
Kleihauer–Betke The test result quantifies the percentage of
fetal cells observed under a microscope.

Flow cytometry is a test based on the fetal cell count (Hb F)

linked to monoclonal antibodies, measured by fluorescence
intensity.
Management of massive FMH depends mainly on gestational
age at diagnosis

The availability of cordocentesis, which allows fetal blood

sampling to diagnose fetal anemia.
Correction of the hypovolemia and metabolic acidosis was
started.
To perform neonatal blood transfusion.
If necessary, and the capacity of the neonatal intensive care
unit (NICU).
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