Introduction. Fetomaternal hemorrhage represents a transfer of fetal blood to the maternal circulation. Although many etiologies have been described, most causes of fetomaternal hemorrhage remain unidentified. The differentiation between acute and chronic fetomaternal hemorrhage may be accomplished antenatally and may influence perinatal management. Case. A 36-year-old gravida 6 para 3 presented at 37 and 5/7 completed gestational weeks with ultrasound findings suggestive of chronic fetal anemia such as right ventricular enlargement, diminished cerebral vascular resistance, and elevated middle cerebral artery end-diastolic velocity. On the other hand, signs of acute fetal decompensation such as deterioration of the fetal heart tracing, diminished biophysical score, decreased cord pH, and increased cord base deficit were noted. Following delivery, the neonate’s initial hemoglobin was 4.0？g/dL and the maternal KB ratio was 0.015 indicative of a significant fetomaternal hemorrhage. Discussion. One should consider FMH as part of the differential diagnosis for fetal or immediate neonatal anemia. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. It is our hope that this case will assist practitioners in differentiating acute FMH that may require emergent delivery from chronic FMH which may be able to be expectantly managed. 1. Introduction Fetomaternal hemorrhage (FMH) refers to the passage of fetal blood into the maternal circulation before or during delivery. The incidence of FMH is between 1/300 and 1/1500 pregnancies and has been reported to account for approximately 0.04 percent of stillbirths [1]. Although a number of etiologies have been associated with FMH, most causes remain unidentified [2]. Although the differentiation between acute and chronic FMH may be clinically problematic, its distinction can significantly influence perinatal management. We describe a unique case of FMH that demonstrated both acute and chronic clinical features. 2. Case A 36-year-old gravida 6 para 3 at 37 and 5/7 completed gestational weeks was referred to our perinatal diagnostic center for fetal right atrial enlargement. Fetal echocardiography confirmed a dilated right atrium and ventricle (Figure 1). Although antegrade flow was present in the left ventricular outflow tract (Figure 2) and proximal aortic arch, this was followed by torrential retrograde flow in the distal aortic arch (Figure 3). Color Doppler interrogation of the fetal brain showed markedly increased vascularity within the fetal brain at the level of the circle of
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