# I. Introduction he entrance of small quantity of fetal red cells into the maternal circulation during or before delivery is commonplace in all pregnancies. However, a blood loss of more than half of fetal blood volume is rare and can potentially lead to severe neonatal anemia and death up to 0.04% of all births (1,2) . Usually the cause is idiopathic and happens in low-risk late pregnancies (3,4) . Fetomaternal hemorrhage can take place early in pregnancy because of disorders of the placental circulation. About half of mothers have detectable fetal red cells in their circulation of a very small amount (5) . Volumes in the range of 10-150 ml can be associated with FMH (6,7) . Amount exceeding 150 ml happens in a very small number of pregnancies and the severity of FMH can be assessed by the quantity of fetal cells in the maternal circulation (8) . Known incipitating factors of fetomaternal hemorrhage include placental abruption, vasa previa, amniocentesis, chorionic villous sampling, external cephalic version, choriocarcinoma (8) . In addition, Rhesus alloimmunization has been identified as a possible cause of fetomaternal hemorrhage (9) . In that case, Rhesus + fetal cells sensitize Rhesus -maternal cells resulting in alloantibody production. This in turn can lead to hemolytic disease of the newborn (HDN) (10) . The rates of such complications are very low due to Rhesus screening and immunoprophylaxis. However in up to 82% of cases of fetomaternal hemorrhage no causative agent can be identified (11) . There are specialised tests that can confirm the presence of fetomaternal bleeding. The rosette screen can detect small quantities of fetal blood in the maternal circulation and the Kleihauer-Betke test remains the method of choice that can confirm the diagnosis and quantify the amount of fetal cells (12,13,14) . Moreover flowcytometry can also assist in the detection of fetal cells but has no increased sensitivity in comparison to KB (15) . In early pregnancy a sensitive marker supporting FMH is increased alfa fetoprotein (AFP). Later on, the diagnosis of FMH can be supported by both increased AFP and a positive Kleihauer-Betke test (16) . The clinical picture can vary greatly. Fetomaternal hemorrhage can manifest as decreased fetal movements without an association with abdominal injury, pain or bleeding (17) . Abnormal CTG tracings can be discovered accidentally with decreased variability, variable or late decelerations (18,19) . Ultrasound findings include intraventricular hemorrhage, pleural and pericardial effusion and ascites (20,21) (Fig. 1 # , 2 & 3). The child can suffer from severe respiratory depression and hepatomegaly or subcutaneous edema as a consequence of congestive heart failure (22,23,24) . Additionally, possible complications include neurological sequelae, for example spastic cerebral palsy and stillbirth (25,26) . The laboratory results at delivery may include increased reticulocyte number suggestive of chronic blood loss, deranged coagulation and liver enzymes and hematuria (27) (Table 1). The management of fetomaternal hemorrhage can also be complicated. In early pregnancy intrauterine transfusion may be attempted to correct the anemia but in cases of continuous bleeding, repeat transfusions or delivery may be indicated (28) . Although massive fetomaternal hemorrhage is a rare condition, it is possibly under diagnosed because of the lack of clinical suspicion (10) . With fetomaternal hemorrhage being an etiology of serious fetal morbidity and mortality, further research is essential for avoiding significant complications. 1![Fig. 1: MRI, Sagittal view showing Intraventricular Hemorrhage](image-2.png "Fig. 1 :") 23![Fig. 2: US showing Pleural Effusion Fig. 3: US showing Ascites](image-3.png "Fig. 2 : 3 :") 1Year 20181 * Massive fetomaternal hemorrhage preceded by decreased fetal movement and a nonreactive fetal heart rate pattern TSKosasa IEbesugawa RTNakayama RWHale Obstet Gynecol 1 4 1993. Kosasa Oct: 82 Pt 2. Suppl * Jr Identification of acute transplacental hemorrhage in a low-risk patient as a result of daily counting of fetal movements RHHeise VanWinter JTOgburn PL Mayo Clin Proc 9 1993. Sep * Massive fetomaternal hemorrhage: Manitoba experience VDe Almeida JMBowman Obstet Gynecol 83 3 1994. Mar * Occult fetomaternal haemorrhage as a cause of fetal mortality and morbidity JRFliegner FortuneD W BarrieJ Aust N Z J Obstet Gynaecol 2 1987. May: 27 * Newsletter of Wisconsin Still birth service program RMPauli N. 3 1993 1 Fetomaternal hemorrhage and still birth * Long-term prognosis for infants after massive fetomaternal hemorrhage CRubod PDeruelle LeGoueff FTunez VFournier MSubtil D Obstet Gynecol 2 2007. Aug: 110 Pt 1 * Fetomaternal hemorrhage: incidence, risk factors, time of occurrence, and clinical effects ESSebring HFPolesky Transfusion 4 1990. May: 30 * Fetomaternal Transfusion as a Cause of Severe Fetal Anemia Causing Early Neonatal Death: A Case Report MAhmed MAbdullatif Oman Med J 6 2011 Nov: 26 * Detection of fetomaternal hemorrhage YAKim RSMakar Am J Hematol 87 4 2012 Apr * WylieB JD'alton MEHemorrhage Obstet Gynecol 115 2010 * Severe fetomaternal hemorrhage: a review GPGiacoia Obstet Gynecol Surv 6 1997. Jun: 52 * Evaluation of methods for detection and quantitation of fetal cells and their effect on RhIg G usage HFPolesky ESSebring Am J Clin Pathol 4 1981 Suppl * Use of the erythrocyte rosette test to screen for excessive fetomaternal hemorrhage in Rh-negative women CMStedman JCBaudin CAWhite ESCooper Am J Obstet Gynecol 154 1986 * Detecting fetomaternal hemorrhage: A comparison of five methods KMBayliss BDKueck JohnsonS TFueger JT Transfusion 31 1991 * Detection of fetomaternal hemorrhage following chorionic villus sampling by Kleihauer Betke test and rise in maternal serum alpha feto protein RKatiyar AKriplani NAgarwal NBhatla MKabra Prenat Diagn 2 2007. Feb: 27 * Evaluating fetomaternal hemorrhage by alpha fetoprotein and Kleihauer following therapeutic abortions. Department of Pathology, The Royal Women's Hospital, Melbourne, Australia Department of Anaesthetics, The Royal Women's Hospital DLHay IHoracek JPaull 18 May 1981. July 1981. 10 April 2004 Melbourne, Australia Received * Fetomaternal bleeding as a cause for "unexplained" fetal death DWLaube CWSchauberger Obstet Gynecol 5 1982. Nov * Idiopathic chronic fetomaternalhaemorrhage resulting in hydrops -a case report MSLau TanJ V TanT Ann Acad Med 5 2003 Sep: 32 * A Case Report of Decreased Fetal Movement during Fetomaternal Hemorrhage JCPlace LRPlano J Obstet Gynecol Neonatal Nurs 6 2015 Nov-Dec: 44 * Fetal cerebral accident due to massive fetomaternal hemorrhage. A case report CLionnet GBody FGold CPaillet MCVaillant CAlle J Gynecol Obstet Biol Reprod 5 1995 * Ultrasound diagnosis of abruptio placentae with fetomaternal hemorrhage MSDardwell Am J Obstet Gynecol 2 1987 Aug: 157 * Management of severe neonatal anemia due to fetomaternal transfusion GNaulaers SBarten CVanhole Am J Perinatol 16 4 1999 * Hematologic disorders and nonimmune hydrops fetalis MOArcasoy PGGallagher Semin Perinatol 6 1995 Dec: 19 * Fetomaternal blood transfusion as a cause of severe obstetrical HPusch HRosegger