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Miletić AI, Stipoljev F, Vičić A, Šerman A, Bekavac Vlatković I. Dilatative fetal cardiomyopathy followed by a mirror syndrome. Wien Med Wochenschr 2024:10.1007/s10354-024-01041-z. [PMID: 38836950 DOI: 10.1007/s10354-024-01041-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/10/2024] [Indexed: 06/06/2024]
Abstract
Mirror syndrome (Ballantyne syndrome) is a rare condition characterized by maternal edema, which often affects the lungs. It mirrors the image of fetal and placental edema; therefore, it is also called triple edema. We present the case of a 37-year-old secundigravida, referred to our clinic at 26 weeks of a pregnancy complicated by fetal dilatative restrictive cardiomyopathy and hydrops, placentomegaly, new-onset dyspnea, and maternal calf edema. Due to worsening mirror syndrome, preterm labor was induced. Labor was complicated, with soft tissue dystocia, stillbirth, and postpartum hemorrhage. The first pregnancy was also complicated by fetal right ventricular noncompaction dilatative cardiomyopathy. A eutrophic male child was born vaginally at term and died due to deterioration of the cardiac disease in the third year of life. Next-generation sequencing panel for pediatric cardiology was performed in the deceased child and parents. Two gene variants were recorded: MYOM1: c.770_771delCA (p.Thr257fs) and TPM1: c.814G>A (p.Glu272Lys). Both variants were classified as variants of uncertain significance. This case emphasizes the importance of antenatal counseling, the timing of labor induction, appropriate management of possible complications such as postpartum hemorrhage and soft tissue dystocia, and the interpretation of placental biomarkers in the context of mirror syndrome. Finally, it contributes to understanding the clinical significance of the MYOM1 and TPM1 gene variants.
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Affiliation(s)
- Antonio Ivan Miletić
- Department of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia.
| | - Feodora Stipoljev
- Department of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia
- Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Ana Vičić
- Department of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia
- University of Applied Health Sciences, Zagreb, Croatia
| | - Alan Šerman
- Department of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia
- Faculty of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ivanka Bekavac Vlatković
- Department of Obstetrics and Gynecology, Clinical Hospital "Sveti Duh", Zagreb, Croatia
- Faculty of Medicine, University of Zagreb, Zagreb, Croatia
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Motomura K, Morita H, Naruse K, Saito H, Matsumoto K. Implication of viruses in the etiology of preeclampsia. Am J Reprod Immunol 2024; 91:e13844. [PMID: 38627916 DOI: 10.1111/aji.13844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
Preeclampsia is one of the most common disorders that poses threat to both mothers and neonates and a major contributor to perinatal morbidity and mortality worldwide. Viral infection during pregnancy is not typically considered to cause preeclampsia; however, syndromic nature of preeclampsia etiology and the immunomodulatory effects of viral infections suggest that microbes could trigger a subset of preeclampsia. Notably, SARS-CoV-2 infection is associated with an increased risk of preeclampsia. Herein, we review the potential role of viral infections in this great obstetrical syndrome. According to in vitro and in vivo experimental studies, viral infections can cause preeclampsia by introducing poor placentation, syncytiotrophoblast stress, and/or maternal systemic inflammation, which are all known to play a critical role in the development of preeclampsia. Moreover, clinical and experimental investigations have suggested a link between several viruses and the onset of preeclampsia via multiple pathways. However, the results of experimental and clinical research are not always consistent. Therefore, future studies should investigate the causal link between viral infections and preeclampsia to elucidate the mechanism behind this relationship and the etiology of preeclampsia itself.
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Affiliation(s)
- Kenichiro Motomura
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Katsuhiko Naruse
- Department of Obstetrics and Gynecology, Dokkyo Medical University, Tochigi, Japan
| | - Hirohisa Saito
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
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Biswas S, Gomez J, Horgan R, Sibai BM, Saad A, Powel JE, Al-Kouatly HB. Mirror syndrome: a systematic literature review. Am J Obstet Gynecol MFM 2023; 5:101067. [PMID: 37385374 DOI: 10.1016/j.ajogmf.2023.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023]
Abstract
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.
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Affiliation(s)
- Sonia Biswas
- Department of Obstetrics and Gynecology, Monmouth Medical Center, Long Branch, NJ (Dr Biswas)
| | - Julie Gomez
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (Dr Gomez)
| | - Rebecca Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Horgan)
| | - Baha M Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Sibai)
| | - Antonio Saad
- Department of Obstetrics and Anesthesia, The University of Texas Medical Branch, Galveston, TX (Dr Saad)
| | - Jennifer E Powel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ (Dr Powel)
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (Dr Al-Kouatly).
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Romero R, Jung E, Chaiworapongsa T, Erez O, Gudicha DW, Kim YM, Kim JS, Kim B, Kusanovic JP, Gotsch F, Taran AB, Yoon BH, Hassan SS, Hsu CD, Chaemsaithong P, Gomez-Lopez N, Yeo L, Kim CJ, Tarca AL. Toward a new taxonomy of obstetrical disease: improved performance of maternal blood biomarkers for the great obstetrical syndromes when classified according to placental pathology. Am J Obstet Gynecol 2022; 227:615.e1-615.e25. [PMID: 36180175 PMCID: PMC9525890 DOI: 10.1016/j.ajog.2022.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The major challenge for obstetrics is the prediction and prevention of the great obstetrical syndromes. We propose that defining obstetrical diseases by the combination of clinical presentation and disease mechanisms as inferred by placental pathology will aid in the discovery of biomarkers and add specificity to those already known. OBJECTIVE To describe the longitudinal profile of placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), and the PlGF/sFlt-1 ratio throughout gestation, and to determine whether the association between abnormal biomarker profiles and obstetrical syndromes is strengthened by information derived from placental examination, eg, the presence or absence of placental lesions of maternal vascular malperfusion. STUDY DESIGN This retrospective case cohort study was based on a parent cohort of 4006 pregnant women enrolled prospectively. The case cohort of 1499 pregnant women included 1000 randomly selected patients from the parent cohort and all additional patients with obstetrical syndromes from the parent cohort. Pregnant women were classified into six groups: 1) term delivery without pregnancy complications (n=540; control); 2) preterm labor and delivery (n=203); 3) preterm premature rupture of the membranes (n=112); 4) preeclampsia (n=230); 5) small-for-gestational-age neonate (n=334); and 6) other pregnancy complications (n=182). Maternal plasma concentrations of PlGF and sFlt-1 were determined by enzyme-linked immunosorbent assays in 7560 longitudinal samples. Placental pathologists, masked to clinical outcomes, diagnosed the presence or absence of placental lesions of maternal vascular malperfusion. Comparisons between mean biomarker concentrations in cases and controls were performed by utilizing longitudinal generalized additive models. Comparisons were made between controls and each obstetrical syndrome with and without subclassifying cases according to the presence or absence of placental lesions of maternal vascular malperfusion. RESULTS 1) When obstetrical syndromes are classified based on the presence or absence of placental lesions of maternal vascular malperfusion, significant differences in the mean plasma concentrations of PlGF, sFlt-1, and the PlGF/sFlt-1 ratio between cases and controls emerge earlier in gestation; 2) the strength of association between an abnormal PlGF/sFlt-1 ratio and the occurrence of obstetrical syndromes increases when placental lesions of maternal vascular malperfusion are present (adjusted odds ratio [aOR], 13.6 vs 6.7 for preeclampsia; aOR, 8.1 vs 4.4 for small-for-gestational-age neonates; aOR, 5.5 vs 2.1 for preterm premature rupture of the membranes; and aOR, 3.3 vs 2.1 for preterm labor (all P<0.05); and 3) the PlGF/sFlt-1 ratio at 28 to 32 weeks of gestation is abnormal in patients who subsequently delivered due to preterm labor with intact membranes and in those with preterm premature rupture of the membranes if both groups have placental lesions of maternal vascular malperfusion. Such association is not significant in patients with these obstetrical syndromes who do not have placental lesions. CONCLUSION Classification of obstetrical syndromes according to the presence or absence of placental lesions of maternal vascular malperfusion allows biomarkers to be informative earlier in gestation and enhances the strength of association between biomarkers and clinical outcomes. We propose that a new taxonomy of obstetrical disorders informed by placental pathology will facilitate the discovery and implementation of biomarkers as well as the prediction and prevention of such disorders.
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Affiliation(s)
- Roberto Romero
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI.
| | - Eunjung Jung
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Offer Erez
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Faculty of Health Sciences, Division of Obstetrics and Gynecology, Maternity Department "D," Soroka University Medical Center, School of Medicine, Ben-Gurion University of the Negev, Beersheba, Israel; Department of Obstetrics and Gynecology, HaEmek Medical Center, Afula, Israel
| | - Dereje W Gudicha
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Yeon Mee Kim
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Pathology, Wayne State University School of Medicine, Detroit, MI; Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Sun Kim
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Pathology, Wayne State University School of Medicine, Detroit, MI; Department of Pathology, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Bomi Kim
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Pathology, Wayne State University School of Medicine, Detroit, MI; Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Juan Pedro Kusanovic
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; División de Obstetricia y Ginecología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Centro de Investigación e Innovación en Medicina Materno-Fetal, Unidad de Alto Riesgo Obstétrico, Hospital Sotero Del Rio, Santiago, Chile
| | - Francesca Gotsch
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Andreea B Taran
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Bo Hyun Yoon
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sonia S Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Office of Women's Health, Integrative Biosciences Center, Wayne State University, Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Physiology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, University of Arizona, College of Medicine - Tucson, Tucson, AZ
| | - Piya Chaemsaithong
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Faculty of Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Biochemistry, Microbiology, and Immunology, Wayne State University School of Medicine, Detroit, MI
| | - Lami Yeo
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Chong Jai Kim
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Pathology, Wayne State University School of Medicine, Detroit, MI; Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Adi L Tarca
- Perinatology Research Branch, Divisions of Obstetrics and Maternal-Fetal Medicine and Intramural Research, US Department of Health and Human Services, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
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Hussain FN, Parikh B, Shenoy MS, Al-Ibraheemi Z, Lewis D. Mirror syndrome in monochorionic diamniotic twins presenting as maternal hyponatremia: A case report. Case Rep Womens Health 2022; 34:e00401. [PMID: 35242600 PMCID: PMC8861140 DOI: 10.1016/j.crwh.2022.e00401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022] Open
Abstract
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). Mirror syndrome is also known as Ballantyne syndrome, maternal hydrops, triple edema and pseudotoxemia. This is the first reported case of mirror syndrome presenting with maternal and neonatal hyponatremia. The pathogenesis of the disease has not been fully elucidated, and this disease is often confused with preeclampsia. The disease can be difficult to diagnose, and is associated with a substantial increase in fetal and maternal morbidity.
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Affiliation(s)
- Farrah Naz Hussain
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, 1000 10 Ave, New York, NY 10019, United States of America
- Corresponding author.
| | - Bijal Parikh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, 1000 10 Ave, New York, NY 10019, United States of America
| | - Mangalore S. Shenoy
- Division of Nephrology, Department of Medicine, Mount Sinai West, Icahn School of Medicine at Mount Sinai, 1000 10 Ave, New York, NY 10019, United States of America
| | - Zainab Al-Ibraheemi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai West, Icahn School of Medicine at Mount Sinai, 1000 10 Ave, New York, NY 10019, United States of America
| | - Dawnette Lewis
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, 3rd floor Levitt Bldg, Manhasset, NY 11030, United States of America
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Redman CW, Staff AC, Roberts JM. Syncytiotrophoblast stress in preeclampsia: the convergence point for multiple pathways. Am J Obstet Gynecol 2022; 226:S907-S927. [PMID: 33546842 DOI: 10.1016/j.ajog.2020.09.047] [Citation(s) in RCA: 119] [Impact Index Per Article: 59.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/14/2020] [Accepted: 09/19/2020] [Indexed: 12/29/2022]
Abstract
Preeclampsia evolves in 2 stages: a placental problem that generates signals to the mother to cause a range of responses that comprise the second stage (preeclampsia syndrome). The first stage of early-onset preeclampsia is poor placentation, which we here call malplacentation. The spiral arteries are incompletely remodeled, leading to later placental malperfusion, relatively early in the second half of pregnancy. The long duration of the first stage (several months) is unsurprisingly associated with fetal growth restriction. The first stage of late-onset preeclampsia, approximately 80% of total cases, is shorter (several weeks) and part of a process that is common to all pregnancies. Placental function declines as it outgrows uterine capacity, with increasing chorionic villous packing, compression of the intervillous space, and fetal hypoxia, and causes late-onset clinical presentations such as "unexplained" stillbirths, late-onset fetal growth restriction, or preeclampsia. The second stages of early- and late-onset preeclampsia share syncytiotrophoblast stress as the most relevant feature that causes the maternal syndrome. Syncytiotrophoblast stress signals in the maternal circulation are probably the most specific biomarkers for preeclampsia. In addition, soluble fms-like tyrosine kinase-1 (mainly produced by syncytiotrophoblast) is the best-known biomarker and is routinely used in clinical practice in many locations. How the stress signals change over time in normal pregnancies indicates that syncytiotrophoblast stress begins on average at 30 to 32 weeks' gestation and progresses to term. At term, syncytiotrophoblast shows increasing markers of stress, including apoptosis, pyroptosis, autophagy, syncytial knots, and necrosis. We label this phenotype the "twilight placenta" and argue that it accounts for the clinical problems of postmature pregnancies. Senescence as a stress response differs in multinuclear syncytiotrophoblast from that of mononuclear cells. Syncytiotrophoblast irreversibly acquires part of the senescence phenotype (cell cycle arrest) when it is formed by cell fusion. The 2 pathways converge on the common pathologic endpoint, syncytiotrophoblast stress, and contribute to preeclampsia subtypes. We highlight that the well-known heterogeneity of the preeclampsia syndrome arises from different pathways to this common endpoint, influenced by maternal genetics, epigenetics, lifestyle, and environmental factors with different fetal and maternal responses to the ensuing insults. This complexity mandates a reassessment of our approach to predicting and preventing preeclampsia, and we summarize research priorities to maximize what we can learn about these important issues.
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The etiology of preeclampsia. Am J Obstet Gynecol 2022; 226:S844-S866. [PMID: 35177222 PMCID: PMC8988238 DOI: 10.1016/j.ajog.2021.11.1356] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023]
Abstract
Preeclampsia is one of the "great obstetrical syndromes" in which multiple and sometimes overlapping pathologic processes activate a common pathway consisting of endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. This article reviews the potential etiologies of preeclampsia. The role of uteroplacental ischemia is well-established on the basis of a solid body of clinical and experimental evidence. A causal role for microorganisms has gained recognition through the realization that periodontal disease and maternal gut dysbiosis are linked to atherosclerosis, thus possibly to a subset of patients with preeclampsia. The recent reports indicating that SARS-CoV-2 infection might be causally linked to preeclampsia are reviewed along with the potential mechanisms involved. Particular etiologic factors, such as the breakdown of maternal-fetal immune tolerance (thought to account for the excess of preeclampsia in primipaternity and egg donation), may operate, in part, through uteroplacental ischemia, whereas other factors such as placental aging may operate largely through syncytiotrophoblast stress. This article also examines the association between gestational diabetes mellitus and maternal obesity with preeclampsia. The role of autoimmunity, fetal diseases, and endocrine disorders is discussed. A greater understanding of the etiologic factors of preeclampsia is essential to improve treatment and prevention.
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Imbalances in circulating angiogenic factors in the pathophysiology of preeclampsia and related disorders. Am J Obstet Gynecol 2022; 226:S1019-S1034. [PMID: 33096092 PMCID: PMC8884164 DOI: 10.1016/j.ajog.2020.10.022] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/26/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022]
Abstract
Preeclampsia is a devastating medical complication of pregnancy that can lead to significant maternal and fetal morbidity and mortality. It is currently believed that there is abnormal placentation in as early as the first trimester in women destined to develop preeclampsia. Although the etiology of the abnormal placentation is being debated, numerous epidemiologic and experimental studies suggest that imbalances in circulating angiogenic factors released from the placenta are responsible for the maternal signs and symptoms of preeclampsia. In particular, circulating levels of soluble fms-like tyrosine kinase 1, an antiangiogenic factor, are markedly increased in women with preeclampsia, whereas free levels of its ligand, placental, growth factor are markedly diminished. Alterations in these angiogenic factors precede the onset of clinical signs of preeclampsia and correlate with disease severity. Recently, the availability of automated assays for the measurement of angiogenic biomarkers in the plasma, serum, and urine has helped investigators worldwide to demonstrate a key role for these factors in the clinical diagnosis and prediction of preeclampsia. Numerous studies have reported that circulating angiogenic biomarkers have a very high negative predictive value to rule out clinical disease among women with suspected preeclampsia. These blood-based biomarkers have provided a valuable tool to clinicians to accelerate the time to clinical diagnosis and minimize maternal adverse outcomes in women with preeclampsia. Angiogenic biomarkers have also been useful to elucidate the pathogenesis of related disorders of abnormal placentation such as intrauterine growth restriction, intrauterine fetal death, twin-to-twin transfusion syndrome, and fetal hydrops. In summary, the discovery and characterization of angiogenic proteins of placental origin have provided clinicians a noninvasive blood-based tool to monitor placental function and health and for early detection of disorders of placentation. Uncovering the mechanisms of altered angiogenic factors in preeclampsia and related disorders of placentation may provide insights into novel preventive and therapeutic options.
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Mimura K, Tomimatsu T, Endo M, Kimura T. Atypical preeclampsia without underlying disease and elevated sFlt-1/PlGF ratio. J Obstet Gynaecol Res 2021; 48:471-476. [PMID: 34852396 DOI: 10.1111/jog.15117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/29/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
Atypical preeclampsia before 20 weeks of gestation without an underlying disease is very rare; however, the soluble Fms-like tyrosine kinase 1/placental growth factor (sFlt-1/PlGF) ratios remain unknown. Four pregnant women with no underlying disease, except for a history of childhood IgA vasculitis, developed preeclampsia at 13, 14, 17, and 18 weeks of gestation with sFlt-1/PlGF ratios of 1589, 1183, 500, and 1460 pg/mL, respectively. Their pregnancies were terminated, and they delivered within 2 weeks. All previously abnormal clinical findings normalized within 3 months. The sFlt-1/PlGF ratios were elevated in the four patients with atypical preeclampsia without underlying disease before 20 weeks of gestation. A high sFlt-1/PlGF ratio may be indicative of preeclampsia when no underlying disease is present in pregnancies of less than 20 weeks of gestation.
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Affiliation(s)
- Kazuya Mimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takuji Tomimatsu
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Japan
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Mogharbel H, Hunt J, D’Souza R, Hobson SR. Clinical presentation and maternal-fetal outcomes of mirror syndrome: A case series of 10 affected pregnancies. Obstet Med 2021; 15:190-194. [PMID: 36262819 PMCID: PMC9574449 DOI: 10.1177/1753495x211058043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background Mirror Syndrome, also known as Ballantyne syndrome, is a rare condition with
fewer than 120 cases described in the literature. A simultaneous edematous
state of the mother, fetus and placenta is pathognomonic, with the maternal
condition frequently presenting with signs and symptoms similar to that of
preeclampsia. Objective Our aim was to add to the international body of literature through
identification of all cases of Mirror Syndrome at two Canadian tertiary
obstetric centres and characterize the maternal presentation, laboratory
findings, and perinatal outcomes. Methodology We performed a retrospective chart review of all cases of fetal hydrops from
two tertiary centres in Winnipeg (Manitoba, Canada) between 2000 and 2019.
There were 276 cases of fetal hydrops during this period, of which 10 cases
satisfied the diagnostic criteria for Mirror Syndrome where maternal and
perinatal outcomes were analysed. Results The median gestational age at diagnosis with Mirror Syndrome was 23 weeks and
3 days of gestation and at birth was 25 weeks and 0 days of gestation. The
majority of women were multiparous (80%) and had elevated maternal body mass
index (median 33 kg/m2). The most common maternal clinical
findings included weight gain (100%) and hypertension (90%). The most common
laboratory findings included low hematocrit (100%), hypoalbuminemia (80%),
anemia (70%) and hyperuricemia (70%). Structural anomalies were observed in
50% of cases, over half of the fetuses were stillborn (66.7%) and one
quarter of pregnancies resulted in neonatal deaths (25%). The median time
until maternal improvement of Mirror Syndrome was 2 days postpartum. Conclusion Mirror Syndrome affected 3.6% of all cases of fetal hydrops in our cohort,
and showed associations with multiparity, elevated BMI, hemodilution,
hypoalbuminemia, anemia and hyperuricemia. Delivery is frequently required
for fetal and/or maternal indications and symptoms usually improved rapidly
after delivery.
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Affiliation(s)
- Hussain Mogharbel
- Division of Maternal-Fetal medicine, Department of Obstetrics and gynecology, University of Toronto, Toronto, ON, Canada
- Division of Maternal-Fetal medicine, Department of Obstetrics and gynecology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Obstetrics and gynecology, King Abdulaziz university, Jeddah, KSA
| | - Jennifer Hunt
- Division of Maternal-Fetal medicine, Department of Obstetrics and gynecology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rohan D’Souza
- Division of Maternal-Fetal medicine, Department of Obstetrics and gynecology, University of Toronto, Toronto, ON, Canada
| | - Sebastian R Hobson
- Division of Maternal-Fetal medicine, Department of Obstetrics and gynecology, University of Toronto, Toronto, ON, Canada
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Velásquez-Penagos JA, Flórez-Ríos AM, Muñoz-Ortiz E, Gándara-Ricardo JA, Flórez-Muñoz JP, Holguín-González E. Mirror syndrome with noncompaction cardiomyopathy in the mother and fetus. Case report. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2021; 72:298-306. [PMID: 34851572 PMCID: PMC8614231 DOI: 10.18597/rcog.3659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022]
Abstract
Objective To report the case of a pregnant woman with mirror syndrome associated with non-compaction cardiomyopathy in the mother and the fetus, in which antenatal medical treatment provided to the mother resulted in a favorable perinatal maternal outcome. Case presentation A 16-year old primigravida with 33 weeks of gestation referred from a Level I institution to a private Level IV center in Medellín, Colombia, because of a finding of fetal hydrops on obstetric ultrasound. During hospitalization, the patient showed clinical and ultrasonographic signs of heart failure (dyspnea, edema and hypoxemia), with the diagnosis of hydrops fetalis (mirror syndrome) also confirmed. Diuretic treatment with furosemide was initiated in the mother, with subsequent improvement of the maternal condition as well as of the fetal edema. During the subacute postpartum period in the hospital, the presence of non-compaction cardiomyopathy was confirmed on cardiac nuclear magnetic resonance imaging in both the mother and the newborn. After discharge in adequated condition, they were included in the cardiovascular follow-up program for heart failure and congenital heart disease, respectively. Conclusion A case of mirror syndrome associated with maternal and fetal non-compaction cardiomyopathy is presented. There is a limited number of reports on mirror syndrome due to cardiac anomalies (maternal and fetal), with weak treatment descriptions, pointing to the need for research in this area. It would be important to consider the diagnosis of non-compaction cardiomyopathy in fetuses with hydrops unrelated to isoimmunization or cardiac dysfunction, and approach these cases from a multi-disciplinary perspective.
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Teles Abrao Trad A, Czeresnia R, Elrefaei A, Ibirogba ER, Narang K, Ruano R. What do we know about the diagnosis and management of mirror syndrome? J Matern Fetal Neonatal Med 2021; 35:4022-4027. [PMID: 33722118 DOI: 10.1080/14767058.2020.1844656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Mirror syndrome is a rare disease associated with high fetal mortality of up to 67.2%. It is thought to be underdiagnosed and is often associated with preeclampsia. Mirror syndrome is characterized by "triple edema": generalized maternal, placental, and fetal edema. OBJECTIVE This comprehensive review aims to thoroughly summarize the existing data and provide a broad update on the topic to help accurate diagnosis and encourage further research. METHODS A comprehensive search of several databases (Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) was conducted. RESULTS The last systematic review of mirror syndrome cases was conducted in 2016 and included 113 patients. Much is still unknown about the pathophysiology of the disease and it remains underdiagnosed. CONCLUSIONS AND RELEVANCE Mirror syndrome is likely more prevalent than current data suggests for it is often misdiagnosed as pre-eclampsia. The differential of Mirror syndrome should be considered in anomalous presentations of pre-eclampsia as intervention may save the fetus and improve maternal symptoms. It is important to further the study on the pathophysiology of the disease to better understand, diagnose and potentially treat it, to avoid its high morbidity and mortality.
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Affiliation(s)
- Ayssa Teles Abrao Trad
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ricardo Czeresnia
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Amro Elrefaei
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eniola R Ibirogba
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Kavita Narang
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Rodrigo Ruano
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Bartnik P, Kacperczyk-Bartnik J, Malinowska-Polubiec A, Romejko-Wolniewicz E. Mirror Syndrome with Severe Postpartum Presentation following Stillbirth and Shoulder Dystocia. Fetal Pediatr Pathol 2020; 39:441-445. [PMID: 31559885 DOI: 10.1080/15513815.2019.1658246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Mirror syndrome (MS) is a pregnancy-related condition characterized by fetal, placental and maternal edema. Methods: We report a case of MS with severe postpartum presentation following stillbirth, shoulder dystocia, McRoberts maneuver, anterior shoulder disimpaction and manual posterior shoulder delivery together with serum soluble fms-like tyrosine kinase 1 (sFlt-1)/placental growth factor (PlGF) ratio results. Results: A 33-year-old patient G3P0A2 at 34 weeks gestation was referred with fetal Ebstein anomaly and fetal hydrops. At 36 weeks of gestation, examination revealed fetal demise with placental hydrops. Delivery of a stillborn child was complicated by shoulder dystocia. Twelve hours postpartum patient developed massive edema and acute kidney injury. Five days postpartum serum creatinine level (CrL) peaked and the sFlt-1/PlGF ratio was elevated. Twelve days after delivery CrL normalized and edema resolved. Conclusions: Shoulder dystocia may increase the severity of postpartum MS. The sFlt-1/PlGF ratio may be useful for MS management.
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Affiliation(s)
- Pawel Bartnik
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Ewa Romejko-Wolniewicz
- 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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Tomimatsu T, Mimura K, Matsuzaki S, Endo M, Kumasawa K, Kimura T. Preeclampsia: Maternal Systemic Vascular Disorder Caused by Generalized Endothelial Dysfunction Due to Placental Antiangiogenic Factors. Int J Mol Sci 2019; 20:E4246. [PMID: 31480243 PMCID: PMC6747625 DOI: 10.3390/ijms20174246] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/20/2019] [Accepted: 08/28/2019] [Indexed: 12/13/2022] Open
Abstract
Preeclampsia, a systemic vascular disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation, is the leading cause of maternal and perinatal morbidity and mortality. Maternal endothelial dysfunction caused by placental factors has long been accepted with respect to the pathophysiology of preeclampsia. Over the past decade, increased production of placental antiangiogenic factors has been identified as a placental factor leading to maternal endothelial dysfunction and systemic vascular dysfunction. This review summarizes the recent advances in understanding the molecular mechanisms of endothelial dysfunction caused by placental antiangiogenic factors, and the novel clinical strategies based on these discoveries.
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Affiliation(s)
- Takuji Tomimatsu
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan.
| | - Kazuya Mimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Tokyo University Graduate School of Medicine, Tokyo 113-0033, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
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Staff AC. The two-stage placental model of preeclampsia: An update. J Reprod Immunol 2019; 134-135:1-10. [PMID: 31301487 DOI: 10.1016/j.jri.2019.07.004] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/07/2019] [Accepted: 07/05/2019] [Indexed: 12/17/2022]
Abstract
Early-onset preeclampsia has been linked to poor placentation and fetal growth restriction, whereas late-onset preeclampsia was suggested to result from maternal factors. We have proposed an alternative model, suggesting that both early- and late-onset preeclampsia result from placental syncytiotrophoblast stress. This stress represents a common endpoint of several Stage 1 processes, promoting the clinical stage 2 of preeclampsia (new-onset hypertension and proteinuria or other signs of end-organ dysfunction), but the causes and timing of placental malperfusion differ. We have suggested that late-onset preeclampsia, without evidence of poor spiral artery remodelling, may be secondary to intraplacental (intervillous) malperfusion due to mechanical restrictions. As the growing placenta reaches its size limit, malperfusion and hypoxia occurs. This latter pathway reflects what is observed in postmature or multiple pregnancies. Our revised two-stage model accommodates most risk factors for preeclampsia including primiparity, chronic pre-pregnancy disease (e.g. obesity, diabetic-, chronic hypertensive-, and some autoimmune diseases), and pregnancy risk factors (e.g. multiple or molar pregnancies, gestational diabetes or hypertension, and low circulating Placental Growth Factor). These factors may increase the risk of progressing to the second stage of preeclampsia (both early- and late-onset) by affecting one of or both pathways leading to Stage 1, as well as potentially accelerating the steps towards Stage 2, including priming the maternal cardiovascular susceptibility to inflammatory factors shed by the placenta. This paper reviews previous preeclampsia findings and concepts, which fit with the revised two-stage model, and argues that "maternal" preeclampsia does not exist, as all preeclampsia requires a placenta.
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Affiliation(s)
- Anne Cathrine Staff
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
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16
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Hobson SR, Wallace EM, Chan YF, Edwards AG, Teoh MWT, Khaw APL. Mirroring preeclampsia: the molecular basis of Ballantyne syndrome. J Matern Fetal Neonatal Med 2019; 33:768-773. [PMID: 30614331 DOI: 10.1080/14767058.2018.1500550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: The purpose of this article was to further elucidate the pathophysiology of Mirror (Ballantyne) syndrome within the context of known biomarkers for preeclampsia.Methods: This novel insight from clinical practice involved a case of post-twin-to-twin transfusion syndrome-laser hydrops in an ex-donor twin, corroborated by histopathologic placental territory edema and maternal sequelae of Mirror syndrome. We serially measured the levels of activin A, follistatin, endothelin-1 (ET-1), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), soluble fms-like tyrosine kinase 1 (sFlt), and von Willebrand factor (vWF) in the maternal serum from disease evolution through to recovery.Results: The paired finding of hydropic ex-donor twin and placenta, supports the theory of placental injury as the source of potential molecular mediators, leading to local placental edema, associated fetal hydrops and the maternal preeclamptic picture. Notably, we elucidated a temporal spectrum of maternal serum mediators (soluble Flt-1, endothelin-1, 8-isoprostane, activin-A, ICAM-1, and vWF) involved in the pathogenesis of Mirror syndrome.Conclusion: Better understanding of the pathogenesis of Mirror syndrome has important implications for clinical management.
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Affiliation(s)
- Sebastian Rupert Hobson
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.,Women'S Health Program, Monash Health, Melbourne, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia
| | - Euan Morrison Wallace
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia
| | - Yuen Fu Chan
- Department of Anatomical Pathology, Monash Health, Melbourne, Australia
| | - Andrew Grant Edwards
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.,Women'S Health Program, Monash Health, Melbourne, Australia
| | - Mark Wui Tee Teoh
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.,Women'S Health Program, Monash Health, Melbourne, Australia
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Katoh Y, Seyama T, Mimura N, Furuya H, Nakayama T, Iriyama T, Nagamatsu T, Osuga Y, Fujii T. Elevation of maternal serum sFlt-1 in pregnancy with mirror syndrome caused by fetal cardiac failure. Oxf Med Case Reports 2018; 2018:omx112. [PMID: 29942527 PMCID: PMC6007303 DOI: 10.1093/omcr/omx112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/08/2017] [Accepted: 12/24/2017] [Indexed: 11/14/2022] Open
Abstract
Mirror syndrome (MS) is characterized by the combination of maternal generalized edema, fetal hydrops and placental hypertrophy. A shift of the serum placenta-derived angiogenic factor like sFlt-1 in MS is similar to that in pre-eclampsia (PE). We experienced a MS case caused by cardiac myopathy in the fetus with normal cardiac structure. A 27-year-old primiparous woman at 28 weeks of gestation had systemic edema without hypertension and proteinuria. Her symptoms rapidly disappeared after delivery. Compared with previously reported MS cases with maternal hypertension or proteinuria, the serum sFlt-1 level was lower in our case. Severity of maternal symptoms in MS might be paralleled with the serum sFlt-1 level. Additionally, serum hCG level in MS is much higher than that in PE. Maternal edema rather than hypertension and proteinuria can be more remarkable in MS compared with PE. It can be potentially explained by increased serum hCG level.
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Affiliation(s)
- Yoshihisa Katoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuko Mimura
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hitomi Furuya
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshio Nakayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Allarakia S, Khayat HA, Karami MM, Aldakhil AM, Kashi AM, Algain AH, Khan MA, Alghifees LS, Alsulami RE. Characteristics and management of mirror syndrome: a systematic review (1956-2016). J Perinat Med 2017; 45:1013-1021. [PMID: 28315852 DOI: 10.1515/jpm-2016-0422] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/17/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To describe the clinical features of mirror syndrome and to correlate the effects of different treatments with the fetal outcomes. DATA SOURCES Online search up to May 2016 was conducted in the PubMed, Embase (Ovid platform) and clinicalTrials.gov without restrictions of language, date or journal. Only papers providing both fetal and maternal presentations and outcomes were included. RESULTS The study included 74 papers (n=111), with an additional two patients diagnosed at our center (n=113). The mean gestational age at diagnosis was 27 weeks±30 days (16-39 weeks). Whether early or late gestational age at diagnosis, and whether mother and fetus show symptoms simultaneously or on different dates, has insignificant impact on fetal outcome (P=0.06 and P=0.46, respectively). Edema (84%) followed by hypertension (60.1%) were the leading maternal findings. Fetal hydrops (94.7%) and placental edema (62.8%) were the commonest sonographic features. Procedures correcting fetal hydrops/anemia in utero as well as labor induction were the only treatment options correlated with improved fetal survival (χ2 analysis, P=0.01 and Fisher's exact test, P=0.02; respectively). The overall rate of fetal/neonatal mortality was 67.26%. CONCLUSION The gestational age at diagnosis and sequence of presentation have insignificant impact on fetal outcome. Improved fetal survival was associated with procedural interventions that correct fetal hydrops as well as labor induction.
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Burwick RM, Pilliod RA, Dukhovny SE, Caughey AB. Fetal hydrops and the risk of severe preeclampsia. J Matern Fetal Neonatal Med 2017; 32:961-965. [DOI: 10.1080/14767058.2017.1396312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Richard M. Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, OHSU, Portland, OR, USA
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20
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Imitators of preeclampsia: A review. Pregnancy Hypertens 2016; 6:1-9. [DOI: 10.1016/j.preghy.2016.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 02/05/2016] [Accepted: 02/11/2016] [Indexed: 12/16/2022]
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Norton ME, Chauhan SP, Dashe JS, Dashe JS. Society for maternal-fetal medicine (SMFM) clinical guideline #7: nonimmune hydrops fetalis. Am J Obstet Gynecol 2015; 212:127-39. [PMID: 25557883 DOI: 10.1016/j.ajog.2014.12.018] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/12/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis. METHODS A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.
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Affiliation(s)
| | | | | | - Jodi S Dashe
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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