Maternal hydrops syndrome: a review

Mirror syndrome: a systematic literature review

OBJECTIVE

This study aimed to review the diagnostic criteria for mirror syndrome and describe its clinical presentation.

DATA SOURCES

Databases from PubMed, Scopus, Cochrane Library, ClinicalTrials.gov, and CINAHL were inquired for case series containing ≥2 cases of mirror syndrome from inception to February 2022.

STUDY ELIGIBILITY CRITERIA

Studies were included if they reported ≥2 cases of mirror syndrome and included case reports, case series, cohort studies, and case-control studies.

STUDY APPRAISAL AND SYNTHESIS METHODS

The studies' quality and risk of bias were independently assessed. Data were tabulated using Microsoft Excel and summarized using narrative review and descriptive statistics. This systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement. All eligible references were assessed. Screening of records and data extraction were independently performed, and a third author resolved disagreements.

RESULTS

Of 13 citations, 12 studies (n=82) reported diagnostic criteria for mirror syndrome: maternal edema (11/12), fetal hydrops (9/12), placental edema (6/12), placentomegaly (5/12), and preeclampsia (2/12); 12 studies (n=82) described the clinical presentation of mirror syndrome as maternal edema (62.2%), hypoalbuminemia (54.9%), anemia (39.0%), and new-onset hypertension (39.0%); 4 studies (n=36) reported that hemodilution was present in all patients; 8 studies (n=36) reported the etiology of fetal hydrops, with the most common being structural cardiac malformations (19.4%), alpha thalassemia (19.4%), Rh isoimmunization (13.9%), and nonimmune hydrops fetalis (13.9%); and 6 studies (n=47) reported maternal complications, 89.4% of which were major: postpartum hemorrhage (44.7%), hemorrhage requiring blood transfusion (19.1%), intensive care unit admission (12.8%), heart failure (10.6%), pulmonary edema (8.5%), and renal dysfunction (8.5%). In 39 cases, the reported fetal outcomes were stillbirth (66.6%) and neonatal or infant death (25.6%). The overall survival rate among continued pregnancies was 7.7%.

CONCLUSION

The diagnostic criteria of mirror syndrome differed considerably among studies. Mirror syndrome clinical presentation overlapped with preeclampsia. Only 4 studies discussed hemodilution. Significant maternal morbidity and fetal mortality were associated with mirror syndrome. Further research is warranted to elucidate the pathogenesis of mirror syndrome to better guide clinicians in identifying and managing the condition.

Mirror syndrome in monochorionic diamniotic twins presenting as maternal hyponatremia: A case report

This is a case report of a 39-year-old patient, G5P1031, with monochorionic diamniotic twins at 30 weeks and 1 day of gestation, who developed mirror syndrome without twin-to-twin transfusion syndrome (TTTS) with a unique presentation of maternal and neonatal hyponatremia. Coinciding with severe hyponatremia were maternal symptoms of edema, nausea and vomiting, hypoalbuminemia, elevated uric acid, as well as fetal selective growth restriction, polyhydramnios, umbilical artery absent end diastolic flow and prolonged bradycardia of twin B. Given the poor status of twin B and the risks to twin A, the patient underwent emergent cesarean delivery. Hyponatremia in all three patients resolved in the following 48–72 h. Mirror syndrome is associated with significant maternal and fetal morbidity and mortality. In this case, severe hyponatremia posed additional risks. Therefore, electrolyte monitoring should be considered in both mother and neonate(s).

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Mirror syndrome is also known as Ballantyne syndrome, maternal hydrops, triple edema and pseudotoxemia.

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This is the first reported case of mirror syndrome presenting with maternal and neonatal hyponatremia.

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The pathogenesis of the disease has not been fully elucidated, and this disease is often confused with preeclampsia.

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The disease can be difficult to diagnose, and is associated with a substantial increase in fetal and maternal morbidity.

[Ballantyne syndrome associated with fetal cardiac rhabdomyoma: a case report]

Le syndrome de Ballantyne ou syndrome en miroir qui a été décrit pour la première fois en 1892 est une pathologie maternelle désignant un syndrome d´anasarque fœtale compliqué d´œdèmes maternels plus ou moins généralisés accompagnés d´albuminurie et parfois d´une anémie. C´est une entité clinique rare. Le diagnostic repose sur une triade qui consiste dans la coexistence d´hydrops fœtal, œdème maternel généralisé et placentomégalie. Il peut être en relation avec l´hydrops fœtal de n´importe quelle cause. Son diagnostic doit être évoqué devant un syndrome œdémateux maternel associé à un état d´anasarque fœtale. Le pronostic fœtal réservé auquel peut s'associer une forte morbidité maternelle expliquent l'intérêt de poser un diagnostic précoce en identifiant son étiologie afin d'établir un traitement anténatal pouvant améliorer ainsi le pronostic materno-fœtal. Nous rapportons un cas unique, jamais décris dans la littérature, d´un syndrome de Ballantyne chez une patiente de 32 ans dont l´étiologie de l´hydrops fœtale était une tumeur cardiaque fœtale type rhabdomyome cardiaque.

New Trends in Fetal Anesthesia

Fetal anesthesia teams must understand the pathophysiology and rationale for the treatment of each disease process. Treatment can range from minimally invasive procedures to maternal laparotomy, hysterotomy, and major fetal surgery. Timing may be in early, mid-, or late gestation. Techniques continue to be refined, and the anesthetic plans must evolve to meet the needs of the procedures. Anesthetic plans range from moderate sedation to general anesthesia that includes monitoring of 2 patients simultaneously, fluid restriction, invasive blood pressure monitoring, vasopressor administration, and advanced medication choices to optimize fetal cardiac function.

Maternal Mirror Syndrome Masquerading as Congestive Heart Failure: A Case Report

Mirror syndrome is a rare pregnancy complication, life-threatening to mother and fetus. Increasing survival rates of congenital heart disease into reproductive age mean that complications like Mirror syndrome in this population may be more challenging to diagnose, given overlapping signs of edema in cases of heart failure exacerbation. We report a case of a pregnant woman with a history of unspecified congenital heart disease, presenting with swelling and distension, with diagnostic findings not consistent with preeclampsia. Her course was complicated by dyspnea, oliguria, and fetal hydrops. A cesarean delivery under neuraxial anesthesia was performed. We review the clinical manifestations of Mirror syndrome and discuss anesthetic and obstetric management considerations for this condition.

Mirror Syndrome in Monochorionic Twin Pregnancy with Acardiac Fetus

We report the case of a 20-year-old patient, primigravida, with twin monochorionic pregnancy, with a weight gain of 6 kg in one week and increased blood pressure. During the ultrasound diagnostic investigation, placental edema and hydrops were identified in both fetuses, which, in association with maternal anasarca and pressure control, constitute the triad for mirror syndrome, also known as triple edema. In addition to being hydropic, one of the twins was an acardiac fetus, which is a rare combination of events. Gestation was terminated at 22 weeks and five days because of high maternal risk. The patient progressed with clinical and laboratory improvement. Our study is relevant in that it documents an extremely rare case and discusses relevant aspects of the symptoms and diagnosis of mirror syndrome. It also systematically reviews the condition.

Treatment of congenital pulmonary airway malformation induced hydrops fetalis via percutaneous sclerotherapy

Large type II and III congenital pulmonary airway malformations (CPAMs) can cause pulmonary hypoplasia, non-immune hydrops fetalis and fetal demise. Fetal intervention is indicated if hydrops fetalis develops. In this report, we describe three cases of type II and III CPAMs complicated by hydrops and treated with percutaneous sclerotherapy by ethanolamine injection into the tumor. All 3 cases demonstrated reduction in size of the CPAM and resolution of the hydrops with subsequent delivery at term. We believe that fetal percutaneous sclerotherapy can be used as a minimally invasive palliative strategy to treat CPAM-induced hydrops fetalis. Further studies are needed to delineate the risks of this novel technique.

Congenital disorders of glycosylation type Ia as a cause of mirror syndrome

Mirror syndrome (that is fetal hydrops with subsequent edema in the pregnant woman) is a rare condition. Early diagnosis is warranted, as maternal and fetal morbidity and mortality is increased if not diagnosed and treated properly. In most cases, the underlying cause remains unclear. We report a woman who has had two pregnancies complicated by mirror syndrome. Congenital disorder of glycosylation type Ia (CDG-Ia) was identified as the underlying fetal disease in both cases.

[Reversal of Ballantyne's syndrome by selective fetal termination in a twin pregnancy]

OBJECTIVES

We describe Ballantyne's syndrome, a severe clinical materno-fetal entity, a pre-eclampsia-like disease.

MATERIALS AND METHODS

We report the case of a woman with twin pregnancy presenting a Ballantyne's syndrome. Ultrasound examination at 22 weeks of gestation (wg), found heart abnormalities for one of the fetus. The ultrasonographic supervision revealed a fetal hydrops and at 28 wg a generalized maternal edema picture occurred. At this time, a Ballantyne's syndrome was suspected.

RESULTS

A selective fetal termination of the affected twin was performed leading to a complete reversal of clinical and biochemical maternal picture, allowing the continuance of the pregnancy until 32 wg.

CONCLUSION

Our article illustrates that when the diagnosis of Ballantyne's syndrome is quickly suspected and a treatable cause can be found, it allows sometimes a prenatal management and improves the materno-fetal prognosis.

Mirror Syndrome

BACKGROUND

Mirror syndrome is a rare entity characterized by maternal disease mimicking fetal hydrops. In mirror syndrome, there is maternal hypertension, edema, and often proteinuria in association with fetal hydrops. The causal link between mirror syndrome and hydrops fetalis remains elusive.

CASE

This is a case report of a pregnant woman who developed mirror syndrome associated with fetal hydrops. A fetal pelvic mass resulted in bladder outlet obstruction, subsequent bladder rupture, and massive urinary ascites. The resultant massive ascites caused thoracic and cardiac compression and subsequent hydrops fetalis. Placement of a peritoneal-amniotic shunt resolved the fetal hydrops and maternal mirror syndrome.

CONCLUSION

In utero treatment of hydropic fetus can result in the cure of maternal mirror syndrome.

Selective Fetocide Reversed Mirror Syndrome in a Dichorionic Triplet Pregnancy with Severe Twin-Twin Transfusion Syndrome: A Case Report

We report a patient with a dichorionic triplet pregnancy complicated by Quintero stage IV twin-twin transfusion syndrome, presenting with hypertension and severe edema at 19 weeks of gestation. Sonography revealed one set of female twins with poly-/oligohydramnios sequence, the recipient twin showing hydropic changes, and another male fetus with normal amniotic fluid content. The maternal laboratory data revealed that, in addition to mild anemia (hemoglobin 10.2 g/dl, hematocrit 32%), there was a high lactate dehydrogenase level of up to 1,042 U/l. Due to the placenta of the uninvolved male fetus hampering the insertion of a fetoscope into the recipient sac and because the distance of the two cords of the 2 female fetuses was as short as 2.5 cm, laser coagulation of the communicating vessels on the placenta of the female twins with twin-twin transfusion syndrome would have posed great difficulty. After discussing other treatment options, including serial amniocentesis, selective termination of the hydropic fetus, or reducing the triplet pregnancy to a singleton pregnancy, the parents decided to perform selective fetocide. Hypertension and severe edema of the mother resolved after selective termination of the hydropic fetus, and so did the lactate dehydrogenase level that dropped from 1,042 to 90 U/l. Unfortunately the donor twin died in utero 2 days after selective termination, and the whole pregnancy was lost at the gestational age of 21 weeks. Nevertheless, we have demonstrated an example of reversal of maternal symptoms and signs after termination of the hydropic fetus in twin-twin transfusion syndrome complicated by mirror syndrome.

Fetal intervention for mass lesions and hydrops improves outcome: a 15-year experience

PURPOSE

The natural history of certain prenatally diagnosed masses is well known. Large thoracic mass lesions can evolve one of 2 ways, either to regress and cause minimal morbidity, or to progress and enlarge, often resulting in hydropic changes in the fetus. This nonimmune hydrops carries a dismal prognosis, with nearly all fetuses expiring before or shortly after birth. However, hydrops associated with fetal mass lesions can be halted and even reversed with fetal intervention and treatment of the underlying defect. We examined our patients with fetal mass lesions to evaluate survival after intervention.

METHODS

Institutional approval was obtained by the Committee on Human Research. A retrospective review was performed of 294 fetuses evaluated over 15 years with large mass lesions. All patients were evaluated for evidence of fetal hydrops using ultrasound criteria. Patients were divided according to type of intervention. Primary outcome measure was 30-day survival after birth.

RESULTS

(1) Patients without fetal hydrops did not undergo fetal intervention and survived to 30 days after birth (167/172, 97%). (2) Patients with fetal mass lesions that developed hydrops fared poorly with no intervention (1/33 survival, 3%), whereas fetuses undergoing prenatal intervention fared much better (15/30 open, 50%; 3/10 percutaneous, 30%). (3) Four patients with hydropic congenital cystic adenomatoid malformation (n = 3) or pulmonary sequestration (n = 1) received steroids in preparation for surgery but underwent no intervention, and the patients survived the neonatal period.

CONCLUSION

Fetuses with prenatal diagnoses of masses not associated with hydrops have excellent prognosis with survival higher than 95%. Nonimmune hydrops associated with prenatal diagnosis of a fetal mass is a devastating complication with less than 5% survival. Open resection of a mass causing hydrops resulted in 50% survival, with reversal of hydrops in a group with near-uniform fatality. Further investigation is warranted regarding the use of minimally invasive prenatal therapies including steroid administration for hydropic fetuses.

Maternal mirror syndrome after in utero aortic valve dilation. A case report

Fetal hydrops of various etiologies can be associated with maternal mirror syndrome. The exact pathophysiology of this rare disorder remains unclear, yet it can result in significant maternal and fetal morbidity. The recent advances in prenatal diagnosis and therapeutic interventions have focused on altering the course of pathologies associated with an expected poor prognosis. Severe fetal aortic valve stenosis with its potential for hypoplastic left heart fit this category. We report a case of maternal mirror syndrome in a parturient following intrauterine therapy for severe fetal aortic stenosis and hydrops. Despite a technically successful intervention, the mother required emergency cesarean section. We review the few reports of mirror syndrome as well as the current approaches to fetal aortic stenosis. This case reinforces the need for in depth risk analysis prior to fetal interventions. It also emphasizes the advantage of earlier detection and therapy with fetal aortic stenosis since fetal hydrops carries a somber prognosis.

[Mirror pre-eclampsia: Ballantyne's syndrome. Two cases]

We report two cases of Ballantyne's syndrome which was first described in association with foeto-placental hydrops caused by rhesus isoimmunization. Our two cases occurred in association with materno-fetal parvovirus infection. Although the pathogenic mechanism remains to be fully elucidated, fluid retention and hyperplacentation are the main features. Together with these two case reports, a literature review confirmed the diverse nonimmunological etiologies associated with Ballantyne's syndrome. Clinicians should be aware of this particular presentation of hydrops fetalis resulting from a mechanism different from hypotrophic placentation because specific etiological treatment can avoid unnecessary pregnancy termination. Pre-conception counselling is also different.

Spontaneous Rupture of Fetal Sacrococcygeal Teratoma

With recent advances in technology, fetal sacrococcygeal teratoma is being diagnosed increasingly during the early prenatal period by ultrasound examination. In addition, early detection of tumor related complications such as polyhydramnios, congestive heart failure, hydrops, hemorrhage, urinary tract or bowel obstruction can be followed closely in utero. Active prenatal management can improve fetal perinatal outcome by allowing planned delivery for neonatal surgery [Chisholm, C.A. et al.: Am J Perinatol 1999;16:47-50] or in some cases, fetal intervention. Additionally, families can be counseled appropriately regarding the range of outcomes. We report a case of fetal sacrococcygeal teratoma Type I diagnosed at 20 weeks with a prominent vessel supplying the tumor mass. At 23 weeks, there was a sudden appearance of an additional lobular mass, consistent with intrauterine spontaneous ruptured of a sacrococcygeal teratoma mass.

Manifestation of Mirror Syndrome after Fetoscopic Laser Photocoagulation in Severe Twin-Twin Transfusion Syndrome

Mirror syndrome is a preeclampsia-like disease first described in a case of severe hydrops fetalis caused by rhesus isoimmunization, later reported in some cases of nonimmunological fetal hydrops. Twin-twin transfusion syndrome (TTTS) is a severe complication associated with monochorionic pregnancies, in particular, severe TTTS with one hydropic fetus leading to a poor prognosis. We report here a case of mirror syndrome that occurred after selective fetoscopic laser photocoagulation in severe TTTS at 24 weeks' gestation.

Ballantyne Syndrome: A Case Report

Ballantyne syndrome (also called mirror syndrome or triple edema) describes the unusual association of fetal and placental hydrops with maternal preeclampsia. This is a case report illustrating a 37-year-old patient who was referred to our clinics at 28 weeks of gestation (wg) because of fetal hydrothorax. On examination, the woman did not show signs of preeclampsia. The fetal ultrasound examination revealed bulky hydrothorax, generalized subcutaneous edema, placental edema, and polyhydramnios. It was not possible to find the cause of the fetal hydrops. At 29 weeks and 4 days of gestation, the fetal hydrothorax was removed by two pleuro-amniotic shunts, but at the moment of our intervention anasarca was already present. In the following 3 days, despite observing bed rest, the mother developed edema of hands and face, while blood pressure remained normal. At 30 wg the patient underwent cesarean section because fetal movements ceased and the fetal heart rate monitoring showed loss of variability and decelerations. Before dying, the neonate lived for 20 days in a state of deep hypotension.

Spontaneous Resolution of Mirror Syndrome

BACKGROUND

Mirror syndrome, a rare condition characterized by maternal anasarca in a pregnancy complicated by fetal hydrops, may have a devastating fetal outcome and significant maternal morbidity.

CASE

We report a case of mirror syndrome caused by parvovirus B19 infection, which resolved spontaneously with good fetal and maternal outcome.

CONCLUSION

The pathogenesis of mirror syndrome is not understood. The trigger for mirror syndrome may be derived from a compromised fetus or placenta.

Spontaneous reversal of mirror syndrome in a twin pregnancy after a single fetal death

The case report illustrates that pre-eclampsia like symptoms can arise as a consequence of pathological changes in a single feto-placental unit of a twin pregnancy and may resolve spontaneously when the cause is removed.

Inferior vena cava thrombosis presenting as non-immune hydrops in the fetus of a woman with diabetes

We present a rare case of non-immune hydrops fetalis (NIHF) caused by a thrombus in the inferior vena cava in a neonate with low levels of anti-thrombin III. The diagnosis of (NIHF) was made in utero in a 43-year-old woman with poorly controlled gestational diabetes who subsequently developed pre-eclampsia. Cesarean section was performed due to fetal compromise and worsening pre-eclampsia. The thrombus resolved after neonatal treatment with heparin.

Fetal surgery for sacrococcygeal teratoma

A great deal has been learned regarding the natural history and pathophysiology of fetal SCT. The logic behind fetal intervention for SCT and hydrops appears to be correct, and open and minimal access techniques of fetal intervention have been shown to be feasible. The development of fetal intervention for SCT has mirrored those developed for other diseases such as congenital diaphragmatic hernia. In a recent presentation, Harrison, the original pioneer in fetal surgery, outlined trends in fetal intervention. The first trend is that of moving from open, invasive techniques to minimally invasive techniques. In the case of SCT surgeons are moving from open resection to RFA and possibly to fetoscopic resection. The second trend outlined by Harrison is a movement away from total in utero repair of a defect that recapitulates postnatal treatment and toward manipulation of fetal pathophysiology to reverse life-threatening events. In SCT surgeons employ RFA to ablate causative blood vessels to reverse fetal hydrops with the knowledge that these fetuses will require postnatal resection of the tumor. In contrast to resection, RFA requires less time and significantly less maternal morbidity than open resection. Further study is required to determine the role of minimal access techniques in SCT. Future directions for treatment of fetal SCT with hydrops might include fetoscopic resection or high-intensity ultrasound ablation.

A case of peripartum cardiomyopathy with a transient increase of plasma interleukin-6 concentration occurred following mirror syndrome

Peripartum cardiomyopathy (PPCM) is an unusual heart failure of unknown etiology that occurs during pregnancy or postpartum. Mirror syndrome is a characteristic of maternal edema subsequent to fetal and/or placental edema. We report a case of PPCM with a transient increase of interleukin-6 concentration occurring in the postpartum period of mirror syndrome.

Prenatal diagnosis of sacrococcygeal teratomas by two- and three-dimensional ultrasound

We suspected two fetuses of having sacrococcygeal teratomas following initial two-dimensional ultrasound scanning at 18 and 22 weeks' gestation. The fetuses were then scanned with three-dimensional multiplanar surface and three-dimensional orthogonal planar ultrasound to establish a definitive diagnosis. Although we made a presumptive diagnosis in both cases after initial two-dimensional scanning, with three-dimensional ultrasound we were better able to define the degree of involvement of the sacrum and other pelvic structures of prognostic importance.

The Mirror syndrome

This is a case report illustrating a patient who developed pre-eclampsia with non-immunological hydrops fetalis associated with fetal tachycardia. It illustrates how successful treatment of a fetal disorder can lead to resolution of the maternal disorder.

Prenatal diagnosis and management of nonimmune hydrops fetalis

We examined the incidence, aetiological factors and outcome in 40 cases of nonimmune hydrops fetalis (NIH) and suggest a rational approach to management. The incidence of NIH was 1 in 830 deliveries during the last 10-year period. In spite of extensive antenatal and postnatal investigation no cause could be established in 14 (35%) cases. A probable aetiological factor was found in 65% of cases. These included viral infection (7), cardiovascular (6), twin-to-twin transfusion (3), chromosomal abnormality (3), other malformation syndromes (4), renal dysplasia (1), laryngeal atresia (1) and severe fetomaternal haemorrhage (1). Five of the 40 fetuses survived, 2 treated antenatally for tachyarrhythmia, 2 had spontaneous resolution and the fifth fetus had repeated intrauterine transfusions because of human parvovirus B19-induced anaemia. After diagnosis of nonimmune hydrops fetalis, early referral to a tertiary centre is to be encouraged for investigation and provision of intensive perinatal care. Investigation allows parents to be counselled appropriately that the mortality is no longer 100% and a steadily growing number may be amenable to some form of fetal therapy.

Clinical biological features of Ballantyne syndrome and the role of placental hydrops

Ballantyne syndrome was first described in association with severe hydrops fetalis caused by rhesus isoimmunization, and lately, in association with diverse etiologies of nonimmunological severe fetal hydrops. This report is a case of typical Ballantyne syndrome in association with lethal hydrops fetalis caused by Ebstein's anomaly. It is likely that any severe fetal hydrops with massive placental hydrops may produce Ballantyne syndrome. Hemodilution could be the main biological feature, differentiating Ballantyne syndrome from usual preeclamptic syndromes. Pathophysiological hypotheses are discussed.

Ballantyne syndrome caused by a large placental chorioangioma

Ballantyne syndrome has been found in association with a number of antenatal complications. This first reported case of Ballantyne syndrome with a large placental chorioangioma was successfully alleviated by delivery of the fetus, placenta, and tumor. A common denominator among the Ballantyne syndrome and its associated pathologic features has not been elucidated.