Mirror Syndrome: A Systematic Review of Fetal Associated Conditions, Maternal Presentation and Perinatal Outcome

Introduction: Mirror syndrome, also referred to as Ballantyne’s syndrome, is normally defined as the development of maternal edema in association with fetal hydrops. The incidence of mirror syndrome is low and few cases have been published. We describe a case report in association with fetal Ebstein anomaly and provide a systematic review on the fetal associated conditions, maternal presentation and perinatal outcome reported for mirror syndrome. Data Sources: A PubMed database search was done until December 2008 (English, French or German) without any restriction of publication date or journal, using the following key words: Ballantyne syndrome, Mirror syndrome, Triple edema, Pseudotoxemia, Maternal hydrops syndrome, Pregnancy toxemia, Acute second trimester gestosis, and Early onset preeclampsia. Reported cases were considered eligible when fetal associated conditions, maternal symptoms and fetal outcome were clearly described. Results: Among 151 publications a total of 56 reported cases satisfying all inclusion criteria were identified. Mirror syndrome was associated with rhesus isoimmunization (29%), twin-twin transfusion syndrome (18%), Received: August 28, 2009 Accepted after revision: February 2, 2010 Published online: March 27, 2010 Dr. Thorsten Braun, MD Department of Obstetrics Charité Medical University Berlin, Campus Virchow-Klinikum Augustenburger Platz 1, DE–13353 Berlin (Germany) Tel. +49 30 450 664 309, Fax +49 30 450 564 901, E-Mail thorsten.braun @ charite.de © 2010 S. Karger AG, Basel 1015–3837/10/0274–0191$26.00/0 Accessible online at: www.karger.com/fdt Braun /Brauer /Fuchs /Czernik / Dudenhausen /Henrich /Sarioglu Fetal Diagn Ther 2010;27:191–203 192 than) 25 cases were reported [7, 8] . The pathogenesis and pathophysiology is unknown [8] . In the late 1970s the development of ultrasound and prenatal diagnosis allowed description of cases of mirror syndrome in association with non-immunological, structural causes, for example aneurysm of Galen’s vein [9] , sacrococcygeal teratoma [10] or placental chorioangioma [11] . Non-structural causes such as fetal arrhythmias [12] , human parvovirus infection [7, 13, 14] and Coxsackie virus [15] infection were reported as well ( table 1 ). Ebstein’s anomaly occurs in 0.5% of patients with congenital heart disease with a sonographic typical distal displacement of the septal and posterior leaflets of the tricuspid valve. In severe cases this malformation is associated with hydrops fetalis and a very poor fetal prognosis [6, 16, 17] .