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Anesthetic Management of Mirror Syndrome
Abstract Number: S5C-9
Abstract Type: Case Report/Case Series
Background: Mirror syndrome is a rare disorder which can lead to maternal and fetal mortality. It is characterized by fetal hydrops and maternal edema with possible preeclamptic features(1). There is little data describing the anesthetic care of these patients(2,3). We present a case of mirror syndrome where the mother’s course was complicated by EKG changes and acute kidney injury (AKI).
Case Presentation: The patient is a 30 year old G5P1031 at 32 weeks with history of discoid lupus (SLE) on plaquenil and a prior cesarean section (CS) transferred to our institution with fetal tachycardia to 230 bpm. Pediatric cardiology was consulted and recommended starting digoxin and flecanide. The patient’s renal function deteriorated with her creatinine peaking at 3.23 mg/dL, her edema worsened, and she developed ST depressions, T wave inversion, a 1st degree AV block, and EKG signs of left ventricular strain (LVS). Fetal heart rate decreased with digoxin therapy but progressed to heart block with dropped beats every 4-7 beats. Maternal digoxin level was monitored with peak level of 2.4 ng/ml. Fetal echocardiogram showed increasing hydrops. The patient underwent 2 liter amnioreduction on day of admission (DOA) 2 for suspected abdominal compartment syndrome with symptomatic improvement but no decrease in creatinine. Urology and interventional radiology were consulted for possible interventions but felt none were indicated. The worsening maternal status led to the decision for CS on DOA 3. A neuraxial technique was selected as the primary anesthetic since her coagulation was normal and to avoid general anesthesia in the setting of a potentially difficult airway and to improve LVS. A combined spinal/epidural was performed and intrathecal hyperbaric bupivacaine, fentanyl, and morphine were given. The fetus was delivered and intubated with extubation on day 7. The mother tolerated the procedure without complication, and subsequently had resolution of AKI and EKG changes.
Discussion: Mirror syndrome is a rare disorder which necessitates balancing the worsening health of the mother with the risks of delivering a premature hydropic fetus. There is currently little evidence to guide anesthesia providers in the care of these patients(2,3). Our patient’s care was further complicated by uncertainty in the etiology of her EKG changes in the setting of AKI. Neuraxial technique was felt to be most appropriate for this patient given her clinical picture.
1.Braun T, Brauer M, Fuchs I, et al. Mirror Syndrome: A Systematic Review of Fetal Associated Conditions, Maternal Presentation and Perinatal Outcome. Fetal Diagn Ther. 2010;27:191-203.
2.Xu Z, Huan Y, Zhang Y, Liu Z. Anesthetic management of a parturient with mirror syndrome: a case report. International Journal of Clinical and Experimental Medicine. 2015;8(8):14161-5.
3.Tayler E, DeSimone C. Anesthetic Management of Maternal Mirror Syndrome. International Journal of Obstetric Anesthesia. 2014;23(4):386