The role of fetal therapy in the management of mirror syndrome: a narrative review

Figures & data

Figure 1. PRISMA flow diagram for mirror syndrome search. Figure 1 illustrates the flow of study identification and selection. Initial search resulted in 660 manuscripts, which after removal of duplicates and those that did not include a fetal intervention or discuss maternal response, yielded 16 reports that were eligible for inclusion.

Table 1. Maternal mirror syndrome cases.

Publication	Fetal condition	GA at treatment	Intervention	Maternal symptoms	Additional maternal treatment	Time to resolution of hydrops (days)	Time to resolution of mirror syndrome (days)	Outcome	GA at delivery
Midgley	SVT	27.1	Flecainide	Hypertension, proteinuria, edema, oliguria	None	10	15	Livebirth, 3625g, resolved arrhythmia	41
Chang	Stage IV TTTS	23.6	Fetoscopic laser	Pulmonary edema, anemia, proteinuria	None	14	14	Livebirth	36
Livingston	Hydrops with urinary ascites	30.5	Shunt	Edema, hypertension, hypoxia, anemia	Oxygen, diuretics	21	21	Livebirth, 3230 g	34
Masakuzu	Stage IV TTTS	21.3	Fetoscopic laser	Edema, anemia	Oxygen, diuretics	10	10	Livebirth	37
Duthie	Parvovirus anemia	25.2	Fetal transfusion	Proteinuria, hypertension	None	7	11	Livebirth, 2490 g	37
Valsky	Blackfan-Diamond anemia	27	Fetal transfusion × 2	Hypertension, edema	None	14	14	Livebirth, 2350 g	34
Lobato	Rh disease	28.2	Fetal transfusion × 4	Hypertension, edema	Antihypertensive treatment	Not resolved	7	Livebirth, 2170 g	32
Nassr	Post-laser anemia	22.4	Fetal transfusion	Edema, transaminitis	None	1	5	Livebirth	27.1
Chimenea	Parvovirus anemia	27.4	Fetal transfusion	Edema, transaminitis	None	3	5	Livebirth	34
Chimenea	Hydrothorax	31.1	Shunt	Edema, anemia	Diuresis	3	5	Livebirth	35.2
Goa	Parvovirus anemia	22	Fetal transfusion × 2	Oliguria, anemia	None	35	32	Livebirth, 3100 g	38
Yoshimura	Stage IV TTTS	23	Fetoscopic laser	Pulmonary edema, edema, proteinuria	Intubation	3	1.5	Livebirth	36
Goeden	Parvovirus anemia	23.4	Transfusion	Edema, proteinuria, hypertension	None	7	10	Livebirth, 1932 g	36
Llurba	Hydrothorax	28.4	Shunt	Hypertension, edema	None	30	32	Livebirth	38.2
Desvignes	Parvovirus anemia	23.3	Transfusion	Hypertension, edema	Antihypertensive treatment	18	14	Livebirth, 3140 g	37.2
Munoz	SVT	24	Digoxin	Hypertension	None	Not resolved	Not resolved	Neonatal demise	30
Brandao	Stage IV TTTS	23.1	Fetoscopic laser	Edema, oliguria	Diuretics	5	4	Livebirth, 2085 g	34
Institution	Anemia	25	Transfusion	Edema	Oxygen	Not resolved	9	Livebirth	28
Institution	Fetomaternal hemorrhage	26	Transfusion	Edema, pulmonary edema	Oxygen	6	5	Livebirth	39
Institution	Stage IV TTTS	25	Fetoscopic laser	Pulmonary edema	Oxygen	5	7	Livebirth	35

Table 2. Maternal and fetal clinical characteristics.

	Number (frequency)/Median [IQR]
Fetal condition
Anemia Twin transfusion syndrome Arrhythmia Hydrothorax Ascites	10 (50%)
	5 (25%)
	2 (10%)
	2 (10%)
	1 (5%)
Maternal signs & symptoms
Edema Proteinuria Pulmonary edema Hypertension Anemia Elevated creatinine or transaminases	15 (75%)
	10 (50%)
	8 (40%)
	8 (40%)
	8 (40%)
	5 (25%)
Fetal therapy
Fetal blood transfusion Fetoscopic laser Shunt placement Antiarrhythmic medication	10 (50%)
	5 (25%)
	3 (15%)
	2 (10%)
Gestational age at diagnosis	24 + 5 [23 + 0 − 27 + 2]
Gestational age at fetal treatment	24 + 5 [23 + 2 − 27 + 3]
Resolution of hydrops	17 (85%)
Days to hydrops resolution	7.5 [3–15]
Resolution of mirror syndrome	19 (95%)
Days to mirror syndrome resolution	10 [5–15]
Supplemental maternal treatment
Diuretics Antihypertensives Supplemental oxygen Mechanical ventilation	3 (15%)
	2 (10%)
	2 (10%)
	1 (5%)
Delivery outcome
Treatment to delivery interval (weeks) Gestational age at delivery Delivery route Vaginal Cesarean delivery Neonatal death	10.6 [5–13.7]
	35 + 5 [34 + 0 − 37 + 1]
	6 (30%)
	14 (70%)1 (5%)

Data availability statement

The data that support the findings of this study are available from the corresponding author upon request.