1 The Journal of Maternal-Fetal and Neonatal Medicine, 2012; Early Online: 1–3 © 2012 Informa UK, Ltd. ISSN 1476-7058 print/ISSN 1476-4954 online DOI: 10.3109/14767058.2012.722734 Aim: Mirror syndrome is a triad consisting of fetal hydrops, maternal edema and placentomegaly. Its pathogenesis is unclear and it is frequently mistaken for preeclampsia, even though distinguishing features can be identified. It is associ- ated with an increase in fetal mortality and maternal morbility. Methods: We report an uncommon case of mirror syndrome, which appeared late in pregnancy (38 weeks) in a young nulliparous and characterized by sudden and massive vulvar edema, with placentomegaly and hydramnios but without fetal hydrops. Results: Our report is an interesting example of an unusual form of Mirror syndrome for several reasons. First of all, the gestational age in which the disorder appeared differs remarkably from the data of literature; in our case, clinical signs and symptoms appeared only at 37 weeks. Another difference consists in the lack of hypertension that represents the second most common symptom associated and explains the difficulty to differentiate this syndrome from preeclampsia. Conclusions: Although mirror syndrome is associated with an increase in perinatal mortality, in the case we reported the late onset of the disorder associated with the medical treatment and the timely decision to perform a caesarean section allowed the birth of a healthy baby. Keywords: Ballantyne’s syndrome, hydrops, mirror syndrome, placentomegaly, vulvar edema Introduction John W. Ballantyne in 1892 irst described a syndrome character- ized by the combination of maternal edema, fetal hydrops and placentomegaly due to rhesus alloimmunization [1]. his rare disease is also known as “Mirror Syndrome” owing to the pres- ence of maternal edema that “mirrors” the fetal and placental conditions. Mirror syndrome can be associated with both immu- nological and nonimmunological causes of fetal hydrops such as twin–twin transfusion syndrome, structural fetal malformations, viral infections, fetal arrythmias and placental or fetal tumors. he pathogenesis is poorly understood and this syndrome is oten related to preeclampsia because of clinical signs common to both disorders. Like preeclampsia, it is characterized by adverse peri- natal outcome with poor fetal prognosis and increased maternal morbidity [2]. As it is uncommon and frequently underdiagnosed, its inci- dence is not clear and few cases have been reported in literature [3]. We describe a case report of massive vulvar edema in an 18-year-old primigravida at 38 gestational weeks associated with placentomegaly and hydramnios. Case report An 18-year-old woman, gravida 1, para 0, group B rhesus-positive, was referred at 37 weeks of gestation to our Department because of a massive vulvar edema (Figure 1). On admission, physical examination revealed a fairly good general state, normal blood pressure (120/80 mmHg), weight of 54 Kg, height of 156 cm and body temperature of 36.4°C. Abdominal examination evidenced a gravid uterine fundus equivalent to gestational age, a fetus in cephalic presentation and a normal fetal heart rate. On physical examination, the pregnant woman had moderate edema of the ankles and legs while external genitalia were swollen without vaginal discharge and digital vaginal examination was diicult due to tenderness. A Foley catheter was inserted to relieve urinary retention. Maternal laboratory tests revealed mild anemia (hemoglobin 11.6 g %, hematocrit 35%), hypoalbuminaemia (2.76 g/dL) and mild proteinuria (1+ on urinalysis 350 mg/24 h). Renal (creatinine 0.7 mg/dL, uric acid 5.3 mg/dL) and hepatic function (alanine transaminase 15 U/L, aspartate transaminase 8 U/L, γ-glutamyl transpeptidase 5 U/L) were normal. Other maternal signs and symptoms such as oliguria, headache, visual disturbances and low platelets were absent. he woman and her husband were not consanguineous and were apparently healthy and there was no family history of congenital malformations. he conception of the pregnancy was spontaneous and its course was regular with a weight gain comprised in the normal range (12 kg). he pregnant woman was on no medication and she gave no history of trauma or contact exposure. here was no history of drug or alcohol use and no recent infections. TORCH serology was negative and the patient had not undergone irst-trimester maternal serum screening for Down syndrome. Obstetric ultrasound showed a male fetus with biometry equivalent to the gestational age with regular development of all the examined organs. No signs of hydrops or localized edema were evidenced in fetal district while an increased amniotic luid (AFI 27) and placentomegaly were evidenced Figure 2. In consideration of vulvar massive edema, proteinuria and placentomegaly at US examination, the diagnosis of mirror syndrome was made, albumin was administered and the use of SHORT REPORT An unusual form of mirror syndrome: a case report Annamaria Giacobbe, Roberta Grasso, Maria Lieta Interdonato, Antonio Simone Laganà, Giacobbe Valentina, Onofrio Triolo & Alfredo Mancuso Department of Gynecological, Obstetrical Sciences and Reproductive Medicine, University Hospital, Messina, Italy Correspondence: Alfredo Mancuso, Department of Gynecological, Obstetrical Sciences and Reproductive Medicine, University Hospital, Policlinico “G. Martino,” Dip. Scienze Ginecologiche, Via Consolare Valeria 1, 98125 Messina, Italy. Tel: 00390902212965. Fax: 00390902212201. E-mail: amancuso@unime.it; annamaria_8119@yahoo.it J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Miss Lindsay Duncan on 09/25/12 For personal use only.