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Fetal Diagn Ther 2010;27:191–203

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

Braun T.a · Brauer M.a · Fuchs I.a · Czernik C.b · Dudenhausen J.W.a · Henrich W.a · Sarioglu N.c
Departments of aObstetrics, bNeonatology, and cPathology, Charité Campus Virchow, Berlin, Germany
email Corresponding Author

 goto top of outline Key Words

  • Ebstein’s anomaly
  • Mirror syndrome
  • Ballantyne syndrome
  • Hydrops fetalis
  • Anemia
  • Maternal edema

 goto top of outline Abstract

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%), viral infection (16%) and fetal malformations, fetal or placental tumors (37.5%). Gestational age at diagnosis ranged from 22.5 to 27.8 weeks of gestation. Maternal key signs were edema (80–100%), hypertension (57–78%) and proteinuria (20–56%). The overall rate of intrauterine death was 56%. Severe maternal complications including pulmonary edema occurred in 21.4%. Maternal symptoms disappeared 4.8–13.5 days after delivery. Discussion: Mirror syndrome is associated with a substantial increase in fetal mortality and maternal morbidity.

Copyright © 2010 S. Karger AG, Basel

 goto top of outline References
  1. Dunn PM: Dr John Ballantyne (1861–1923): perinatologist extraordinary of Edinburgh. Arch Dis Child 1993;68:66–67.
  2. Ballantyne JW: The disease and deformities of the fetus. Edinburgh, Oliver & Boyd, 1892.
  3. Reiss HE: Historical insights: John William Ballantyne 1861–1923. Hum Reprod Update 1999;5:386–389.
  4. Kaiser IH: Ballantyne and triple edema. Am J Obstet Gynecol 1971;110:115–120.
  5. Van Selm M, Kanhai HH, Gravenhorst JB: Maternal hydrops syndrome: a review. Obstet Gynecol Surv 1991;46:785–788.
  6. Carbillon L, Oury JF, Guerin JM, Azancot A, Blot P: Clinical biological features of Ballantyne syndrome and the role of placental hydrops. Obstet Gynecol Surv 1997;52:310–314.
  7. Goeden AM, Worthington D: Spontaneous resolution of mirror syndrome. Obstet Gynecol 2005;106:1183–1186.
  8. Kumar B, Nazaretian SP, Ryan AJ, Simpson I: Mirror syndrome: a rare entity. Pathology 2007;39:373–375.
  9. Ordorica SA, Marks F, Frieden FJ, Hoskins IA, Young BK: Aneurysm of the vein of Galen: a new cause for Ballantyne syndrome. Am J Obstet Gynecol 1990;162:1166–1167.
  10. Finamore PS, Kontopoulos E, Price M, Giannina G, Smulian JC: Mirror syndrome associated with sacrococcygeal teratoma: a case report. J Reprod Med 2007;52:225–227.
  11. Dorman SL, Cardwell MS: Ballantyne syndrome caused by a large placental chorioangioma. Am J Obstet Gynecol 1995;173:1632–1633.
  12. Midgley DY, Harding K: The mirror syndrome. Eur J Obstet Gynecol Reprod Biol 2000;88:201–202.
  13. Brochot C, Collinet P, Provost N, Subtil D: Mirror syndrome due to parvovirus B19 hydrops complicated by severe maternal pulmonary effusion. Prenat Diagn 2006;26:179–180.
  14. Ville Y, de Gayffier A, Brivet F, Leruez M, Marchal P, Morinet F, Troalen F, Fernandez H, Frydman R: Fetal-maternal hydrops syndrome in human parvovirus infection. Fetal Diagn Ther 1995;10:204–206.
  15. Ambrosini G, Nanhorngue K, Pascoli I, Cester M, Cosmi E: Mirror syndrome due to Coxsackie B virus associated to maternal peripartum cardiomyopathy. J Perinat Med 2008;36:453–454.
  16. Chaoui R, Bollmann R, Hoffmann H, Zienert A, Bartho S: Ebstein anomaly as a rare cause of a non[-]immunological fetal hydrops: prenatal diagnosis using Doppler echocardiography (in German). Klin Pädiatr 1990;202:173–175.
  17. Hornberger LK, Sahn DJ, Kleinman CS, Copel JA, Reed KL: Tricuspid valve disease with significant tricuspid insufficiency in the fetus: diagnosis and outcome. J Am Coll Cardiol 1991;17:167–173.
  18. Hsieh YY, Lee CC, Chang CC, Tsai HD, Yeh LS, Tsai CH: Successful prenatal digoxin therapy for Ebstein’s anomaly with hydrops fetalis. A case report. J Reprod Med 1998;43:710–712.
  19. Rana S, Venkatesha S, DePaepe M, Chien EK, Paglia M, Karumanchi SA: Cytomegalovirus-induced mirror syndrome associated with elevated levels of circulating antiangiogenic factors. Obstet Gynecol 2007;109:549–552.
  20. Stepan H, Faber R: Cytomegalovirus-induced mirror syndrome associated with elevated levels of angiogenic factors. Obstet Gynecol 2007;109:1205–1206.
  21. Redman CW: Hypertension in pregnancy: a case discussion. Kidney Int 1987;32:151–160.
  22. Livingston JC, Malik KM, Crombleholme TM, Lim FY, Sibai BM: Mirror syndrome: a novel approach to therapy with fetal peritoneal-amniotic shunt. Obstet Gynecol 2007;110:540–543.
  23. Heyborne KD, Chism DM: Reversal of Ballantyne syndrome by selective second-trimester fetal termination. A case report. J Reprod Med 2000;45:360–362.
  24. Heyborne KD, Porreco RP: Selective fetocide reverses preeclampsia in discordant twins. Am J Obstet Gynecol 2004;191:477–480.
  25. Frohn-Mulder IM, Stewart PA, Witsenburg M, Den Hollander NS, Wladimiroff JW, Hess J: The efficacy of flecainide versus digoxin in the management of fetal supraventricular tachycardia. Prenat Diagn 1995;15:1297–1302.
  26. Simpson JM, Sharland GK: Fetal tachycardias: management and outcome of 127 consecutive cases. Heart 1998;79:576–581.
  27. Leung WC, Lam HS, Tang MH, Lao TT: Biochemical hypothyroidism – a new finding in mirror syndrome? Eur J Obstet Gynecol Reprod Biol 2006;125:269–271.
  28. Cohen A: Maternal syndrome in Rh iso-immunization: report of a case. J Obstet Gynaecol Br Emp 1960;67:325–327.
  29. De Silva K, Fonseka MN: Rhesus iso-immunization with a complex maternal syndrome. A case report of a patient with hydrops foetalis, pregnancy, toxaemia, large placenta and bilateral theca-lutein cysts with torsion of one ovary. Ceylon Med J 1971;16:178–181.
  30. Hirsch MR, Mark MS: Pseudotoxemia and erythroblastosis. Report of a case. Obstet Gynecol 1964;24:47–48.
  31. John AH, Duncan AS: The maternal syndrome associated with hydrops foetalis. J Obstet Gynaecol Br Commonw 1964;71:61–65.
  32. Keane B: Maternal syndrome associated with hydrops fetalis: case report. NZ Med J 1978;88:56–57.
  33. Lobato G, Nakamura-Pereira M: Reversion of the Ballantyne syndrome despite fetal hydrops persistence. Fetal Diagn Ther 2008;24:474–477.
  34. Mahmood TA: A reappraisal of the maternal syndrome associated with hydrops fetalis. Eur J Obstet Gynecol Reprod Biol 1987;25:159–163.
  35. Nicolay KS, Gainey HL: Pseudotoxemic state associated with severe Rh isoimmunization. Am J Obstet Gynecol 1964;89:41–45.
  36. O’Driscoll DT: A fluid retention syndrome associated with severe iso-immunization to the rhesus factor. J Obstet Gynaecol Br Emp 1956;63:372–374.
  37. Rustamov O: PO02.85: mirror syndrome: a case report. Ultrasound Obstet Gynecol 2006;28:543.

    External Resources

  38. Pirhonen JP, Hartgill TW: Spontaneous reversal of mirror syndrome in a twin pregnancy after a single fetal death. Eur J Obstet Gynecol Reprod Biol 2004;116:106–107.
  39. Hayashi S, Sago H, Hayashi R, Nakagawa S, Kitagawa M, Miyasaka K, Chiba T, Natori M: Manifestation of mirror syndrome after fetoscopic laser photocoagulation in severe twin-twin transfusion syndrome. Fetal Diagn Ther 2006;21:51–54.
  40. Matsubara S, Ohmaru T, Ohkuchi A, Arai F, Kuwata T, Usui R, Takahashi K, Izumi A, Watanabe T, Suzuki M: Mirror syndrome associated with hydropic acardius in triplet pregnancy. Fetal Diagn Ther 2008;24:429–433.
  41. Olivella A, Martinez JM, Lopez M, Del Rio M, Bennasar M, Peurto B, Coll O, Gratacos E: PO5.07: Two cases of mirror syndrome in TTTS with and without fetoscopic treatment. Ultrasound Obstet Gynecol 2006; 28:561.

    External Resources

  42. Chang YL, Chao AS, Hsu JJ, Chang SD, Soong YK: Selective fetocide reversed mirror syndrome in a dichorionic triplet pregnancy with severe twin-twin transfusion syndrome: a case report. Fetal Diagn Ther 2007;22:428–430.
  43. Matsubara M, Nakata M, Murata S, Miwa I, Sumie M, Sugino N: Resolution of mirror syndrome after successful fetoscopic laser photocoagulation of communicating placental vessels in severe twin-twin transfusion syndrome. Prenat Diagn 2008;28:1167–1168.
  44. Quagliarello JR, Passalaqua AM, Greco MA, Zinberg S, Young BK: Ballantyne’s triple edema syndrome: prenatal diagnosis with ultrasound and maternal renal biopsy findings. Am J Obstet Gynecol 1978;132:580–581.
  45. Duthie SJ, Walkinshaw SA: Parvovirus associated fetal hydrops: reversal of pregnancy-induced proteinuric hypertension by in utero fetal transfusion. Br J Obstet Gynaecol 1995;102:1011–1013.
  46. Proust S, Philippe HJ, Paumier A, Joubert M, Boog G, Winer N: Mirror preeclampsia: Ballantyne’s syndrome. Two cases (in French). J Gynecol Obstet Biol Reprod (Paris) 2006;35:270–274.
  47. Mizrahi-Arnaud A, Wilkins Haug L, Marshall A, Silva V: Maternal mirror syndrome after in utero aortic valve dilation. A case report. Fetal Diagn Ther 2006;21:439–443.
  48. Wurm D, Loffler G, Lindinger A, Gortner L: Congenital disorders of glycosylation type Ia as a cause of mirror syndrome. J Perinatol 2007;27:802–804.
  49. Paternoster DM, Manganelli F, Minucci D, Nanhorngue KN, Memmo A, Bertoldini M, Nicolini U: Ballantyne syndrome: a case report. Fetal Diagn Ther 2006;21:92–95.
  50. Valsky DV, Daum H, Yagel S: Reversal of mirror syndrome after prenatal treatment of Diamond-Blackfan anemia. Prenat Diagn 2007;27:1161–1164.
  51. Allen AT, Dress AF, Moore WF: Mirror syndrome resulting from metastatic congenital neuroblastoma. Int J Gynecol Pathol 2007;26:310–312.
  52. Gherman RB, Incerpi MH, Wing DA, Goodwin TM: Ballantyne syndrome: is placental ischemia the etiology? J Matern Fetal Med 1998;7:227–229.
  53. Galimberti A, Jain S: Placental chorioangioma as a cause of maternal hydrops syndrome. J Obstet Gynaecol 2000;20:91.
  54. Deurloo K, Devlieger R, Oepkes D: Maternal hydrops syndrome following successful treatment of fetal hydrops by shunting of bilateral hydrothorax. Prenat Diagn 2003;23:944–945.
  55. Ibele A, Flake A, Shaaban A: Survival of a profoundly hydropic fetus with a sacrococcygeal teratoma delivered at 27 weeks of gestation for maternal mirror syndrome. J Pediatr Surg 2008;43:e17–e20.
  56. Nakamura K, Itoh H, Sagawa N, Kakui K, Nakayama T, Yamada S, Fujii S: A case of peripartum cardiomyopathy with a transient increase of plasma interleukin-6 concentration occurred following mirror syndrome. J Perinat Med 2002;30:426–428.
  57. Vidaeff AC, Pschirrer ER, Mastrobattista JM, Gilstrap LC 3rd, Ramin SM: Mirror syndrome. A case report. J Reprod Med 2002;47:770–774.
  58. Vidaeff AC, Ross PJ, Livingston CK, Parks DH: Gigantomastia complicating mirror syndrome in pregnancy. Obstet Gynecol 2003;101:1139–1142.

 goto top of outline Author Contacts

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

 goto top of outline Article Information

Received: August 28, 2009
Accepted after revision: February 2, 2010
Published online: March 27, 2010
Number of Print Pages : 13
Number of Figures : 2, Number of Tables : 3, Number of References : 58

 goto top of outline Publication Details

Fetal Diagnosis and Therapy (Clinical Advances and Basic Research)

Vol. 27, No. 4, Year 2010 (Cover Date: July 2010)

Journal Editor: Gratacós E. (Barcelona)
ISSN: 1015-3837 (Print), eISSN: 1421-9964 (Online)

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