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Spinal Anesthetic for a Parturient with Mirror Syndrome
Abstract Number: F3C-6
Abstract Type: Case Report/Case Series
Case: 21 yo G2P1001 at 27w3d presented with HTN, painful contractions, and leaking fluid. Fetus had a diagnosis of hydrops fetalis by ultrasound showing total body edema with cystic hygroma engulfing entire head and neck and bilateral pleural effusions with significant pulmonary hypoplasia. Patient was SOB with speech on 2L NC and actively vomiting. She had diffuse crackles and leg edema. Cervical exam was 8cm/80%/-3. The OB team was concerned for Mirror syndrome and determined vaginal delivery would be fatal to fetus given disease process. EXIT and ECMO were not possible due to hydrops of unknown etiology and significant pulmonary hypoplasia. Patient strongly wished to deliver and hold a live infant, though understood the poor prognosis. Given persistent deep variable decelerations in FHT and “impending fetal death” per OBs, emergent cesarean was performed under spinal. Prior to case, stat labs resulted: Platelets 280K/uL, Hgb 6.4g/d. The live-born neonate was grossly edematous with large neck mass. Though an ETT was placed, neonatology could not ventilate the baby, who had lost her pulse. Care was withdrawn after discussion with parents. Mother remained hemodynamically stable, but was given 2 units uncrossmatched PRBCs and furosemide as cesarean proceeded. She was discharged on POD4 in stable condition.
Discussion: Mirror syndrome describes a rarely reported condition in which maternal edema develops in the setting of fetal hydrops. Pathogenesis of Mirror syndrome is unclear. It is associated with Rh iso-immunization, twin-twin transfusion syndrome, viral infections, fetal malformations, and fetal or placental tumors. Pre-eclampsia is often the first suspected diagnosis, as symptoms and lab abnormalities are similar. Maternal edema is present in greater than 80% of reported cases, HTN in 57-78%, and proteinuria in 20-56%. Severe pulmonary edema occurs in greater than 20% of parturients. Symptoms resolve about 7 days after delivery. (1,2)
General anesthesia is reserved for patients in which neuraxial is relatively contraindicated, due to airway edema and pulmonary involvement (3). GA risks for our patient included active vomiting, pulmonary edema, oxygen requirement and known anemia with no crossmatch available. Given the mother’s wishes, impending fetal death, and normal platelets, spinal was performed as we felt risks of GA outweighed risks of spinal.
Intrauterine death occurs in more than half of the fetuses. With this high mortality rate, it is critical to balance the needs and wishes of the mother with the needs of the fetus. Maternal edema will begin to resolve after delivery. Early diagnosis of fetal abnormalities can help prepare multidisciplinary teams to care for these patients and make delivery plans before more serious characteristics such as pulmonary edema develop (1).
1. Fetal Diagn Ther 2010;27:191–203
2. Int J Clin Exp Med. 2015; 8(9): 16132–16136
3. Int J Obstet Anesth 2014;23(4):386-9