Selective fetocide reversed mirror syndrome in a dichorionic triplet pregnancy with severe twin-twin transfusion syndrome: A case report

We report a patient with a dichorionic triplet pregnancy complicated by Quintero stage IV twin-twin transfusion syndrome, presenting with hypertension and severe edema at 19 weeks of gestation. Sonography revealed one set of female twins with poly-/oligohydramnios sequence, the recipient twin showing hydropic changes, and another male fetus with normal amniotic fluid content. The maternal laboratory data revealed that, in addition to mild anemia (hemoglobin 10.2 g/dl, hematocrit 32%), there was a high lactate dehydrogenase level of up to 1,042 U/l. Due to the placenta of the uninvolved male fetus hampering the insertion of a fetoscope into the recipient sac and because the distance of the two cords of the 2 female fetuses was as short as 2.5 cm, laser coagulation of the communicating vessels on the placenta of the female twins with twin-twin transfusion syndrome would have posed great difficulty. After discussing other treatment options, including serial amniocentesis, selective termination of the hydropic fetus, or reducing the triplet pregnancy to a singleton pregnancy, the parents decided to perform selective fetocide. Hypertension and severe edema of the mother resolved after selective termination of the hydropic fetus, and so did the lactate dehydrogenase level that dropped from 1,042 to 90 U/l. Unfortunately the donor twin died in utero 2 days after selective termination, and the whole pregnancy was lost at the gestational age of 21 weeks. Nevertheless, we have demonstrated an example of reversal of maternal symptoms and signs after termination of the hydropic fetus in twin-twin transfusion syndrome complicated by mirror syndrome.