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

Massive fetomaternal hemorrhage is a rare condition occurring during pregnancy and severe fetal anemia, hydrops and death may occur. Case: We report a case of massive fetomaternal hemorrhage due to serial amnioreduction in a pregnancy complicated by stage IV twin-to-twin transfusion syndrome. Fetomaternal hemorrhage occurred at 23 + 4 weeks of gestation as a consequence of the second amnioreduction, which determined a chronic blood loss in the placental puncture site. Moreover the middle cerebral artery peak systolic velocity vales of both twins began to increase after the amnioreduction indicating severe anemia in the recipient twin and mild anemia in the donor twin after the fourth amnireduction. The Kleihauer-Betke stain showed 5% fetal cells in maternal circulation, indicating a fetomaternal hemorrhage of 120 ml. Emergent cesarean section has been performed at 25 + 5 weeks of gestation because of placental abruptio and hemoglobin levels confirmed severe and mild anemia in the recipient and donor twin, respectively. We conclude that Doppler assessment of the middle cerebral artery peak systolic velocity should diagnose fetal anemia due to fetomaternal hemorrhage in a non-invasive fashion and time the need of invasive procedure