The diagnostic conundrum of maternal mirror syndrome progressing to pre-eclampsia – A case report

Abstract

Mirror syndrome, also called Ballantyne syndrome, is a rare condition in pregnancy, defined by the presence of the clinical triad of fetal hydrops, placentomegaly and maternal oedema. Any aetiology of fetal hydrops, including rhesus iso-immunization, congenital infection, twin-to-twin transfusion, structural anomalies and fetal malignancies, can lead to the syndrome. The pathogenesis, although not well established, mimics trophoblastic damage and maternal vascular endothelial dysfunction, as is also seen in pre-eclampsia, and, hence, the two conditions may have a similar clinical presentation. They may even co-exist, where a patient with maternal mirror syndrome develops features of pre-eclampsia. A timely, accurate diagnosis and prompt interventions are needed to prevent fetal mortality and maternal morbidity.

Is Fetal Hydrops in Turner Syndrome a Risk Factor for the Development of Maternal Mirror Syndrome?

“…Espinoza et al proposed that hypoxia of the villous trophoblast leads to increased release of antiangiogenic factors [ 2 ]. This seems to play an important role in the pathogenesis of Mirror syndrome [ 2 , 3 , 5 , 10 ].…”

“…Documented fetal cardiac activity beyond 16 weeks of gestation. This is the earliest gestational age at which Mirror syndrome has been reported [ 5 , 7 ].…”

“…Mirror syndrome was first described by John William Ballantyne in 1892 as a combination of fetal and placental hydrops as well as maternal edema and preeclampsia-like symptoms (triple edema) [ 1 , 2 , 3 ]. Mirror syndrome is a rare condition that is associated with immune and non-immune fetal hydrops [ 4 , 5 ]. The incidence is 1 in 3000 pregnancies, but it may be underestimated due to its similarity with preeclampsia [ 6 ].…”

“…The incidence is 1 in 3000 pregnancies, but it may be underestimated due to its similarity with preeclampsia [ 6 ]. Mirror syndrome has been described as early as 16 weeks of pregnancy [ 5 , 7 ]. Some authors proposed that placental-derived antiangiogenic factors are involved in the pathogenesis of Mirror syndrome [ 2 , 8 , 9 , 10 , 11 ].…”

Fetal brain, head, and neck tumors: Prenatal imaging and management

“…Fetal complications include hydrocephalus, intracranial hemorrhage, and rapidly increasing head size, which in extreme cases can result in severe obstetric complications such as spontaneous rupture of the fetal head during delivery, uterine rupture, or severe dystocia resulting from cephalopelvic disproportion 23,25,26 . Tumors with increased vascularity may lead to fetal high output heart failure and nonimmune fetal hydrops; these conditions pose an increased risk for the development of maternal mirror (Ballantyne) syndrome that can result in significant risk to the mother including intensive care admission and potential death, particularly in cases of delayed diagnosis 24,55,56 . The prognosis for prenatally diagnosed intracranial tumors is generally poor, especially for teratomas, with a significantly increased risk for in utero demise and a low survival rate of under 10% for neonates depending on the time of diagnosis and on the size of the teratoma 57,58 .…”