Maternal-fetal complications of non-immune fetal hydrops - mirror syndrome and hypereactio luteinalis with ovarian torsion - A case report

Sep 29, 2026

Mirror syndrome, previously referred to as Ballantyne’s syndrome, is a rare obstetric disorder marked by maternal edema alongside fetal and placental hydrops. The report describes a 35-year-old multiparous woman who developed mirror syndrome secondary to fetal supraventricular tachycardia complicated by hydrops and intrauterine fetal demise. Her pregnancy was further complicated by hypereactio luteinalis with ovarian torsion requiring surgical detorsion, emphasizing management challenges and a rare HL association.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

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Introduction

Case Presentation

Discussion

Case Reports in Women’s Health 49 (2026) e00775 Contents lists available at ScienceDirect Case Reports in Women's Health journal [homepage:](homepage: www.elsevier.com/locate/crwh)[ www.elsevier.com/locate/crwh](homepage: www.elsevier.com/locate/crwh) | Maternal-fetal complications of non-immune fetal hydrops – mirror syndrome and hypereactio luteinalis with ovarian torsion: A case report
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Helena C. Bartels, Greg Ryan, Edgar Jaeggi, Homero Flores-Mendoza
Department of Obstetrics and Gynecology, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada | | | --- | --- | | A R T I C L E I N F O
Keywords:
Mirror syndrome Fetal hydrops Hypereactio luteinalis Preeclampsia | A B S T R A C T | | | Mirror syndrome, previously referred to as Ballantyne’s syndrome, is a rare obstetric disorder characterized by maternal edema in association with fetal hydrops and placental edema. This report concerns the case of a 35-year-old multiparous woman who developed mirror syndrome secondary to fetal supraventricular tachycardia complicated by hydrops and intrauterine fetal demise. Her pregnancy was further complicated by hypereactio luteinalis with ovarian torsion requiring surgical detorsion. The case highlights the challenges of managing maternal and fetal hydrps, and its rare association with hypereactio luteinalis. | 1. Introduction Mirror syndrome, first described by Ballantyne in 1892, is characterized by the triad of maternal oedema, placental oedema, and fetal hydrops [1]. However, the diagnostic criteria used to define mirror syndrome varies widely between studies, with a recent systematic review highlighting the lack of consensus and significant heterogeneity in the literature [2]. The pathogenesis of mirror syndrome remains incompletely understood; however, it is reported to involve placental injury with trophoblastic damage, resulting in widespread maternal endothelial dysfunction as a result of release of placental-derived antiangiogenic factors such as sFLT-1 and inflammatory cytokines [3,4]. Asa result of excessive sFLT-1 secretion, vascular endothelial growth factor and placental growth factor (PLGF) are suppressed in mirror syndrome, leading to endothelial dysfunction and the systemic sequalae seen in mirror syndrome [5]. These mechanisms are similar to the pathways resulting in preeclampsia [4,6]. Mirror syndrome is estimated to complicate 5–30 % of fetal hydrops cases. The maternal presentation has several overlapping clinical features with preeclampsia – such as oedema and hypertension; however, mirror syndrome typically shows haemodilution rather than haemoconcentration [3,4,7]. Mirror syndrome can involve a varied clinical picture, which may include hypertension, pulmonary oedema, acute kidney injury and, rarely, cardiac failure [2,8]. Fetal outcomes are poor, with a live birth rate of less than 10 % reported in several studies [2,9]. Hypereactio luteinalis (HL) is a benign, rare ovarian condition characterized by bilateral multicystic ovarian enlargement, likely linked to elevated β-hCG [10]. Its association with mirror syndrome is very rare, hence this case has several important learning points for clinicians. 2. Case Presentation A 35-year-old woman (G4P3) with a BMI of 33 m/kg2 presented with a spontaneous, planned pregnancy. Her relevant medical history included polycystic ovarian syndrome. Early first-trimester screening revealed an increased nuchal translucency (4.2 mm) with high-risk combined screening for trisomy 21 (1:13). However, non-invasive prenatal testing returned a low-risk result, and further testing with amniocentesis was declined. A fetal echocardiograph at 18 weeks found a normal cardiac structure and function. At 21 + 1 weeks, ultrasound demonstrated fetal hydrops with ascites, pleural effusion, scalp oedema, and placentomegaly. The fetus was noted to have a sustained tachycardia of 260 beats per minute. Fetal cardiology confirmed 1:1

FAQs

What is mirror syndrome and what key features define it?

Mirror syndrome is a rare obstetric disorder characterized by maternal edema with fetal hydrops and placental edema. The paper notes variable diagnostic criteria across studies and highlights a triad-based description.

How did the case lead to mirror syndrome in the patient?

The patient developed mirror syndrome following fetal supraventricular tachycardia complicated by hydrops, along with intrauterine fetal demise. Maternal management included transplacental antiarrhythmic therapy.

What role did hypereactio luteinalis and ovarian torsion play?

Hypereactio luteinalis with massively enlarged bilateral ovaries and theca lutein cysts was identified when the fetus remained hydropic. Ovarian torsion required surgical detorsion, illustrating a rare clinical association.

Sep 29, 2026

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