Abstract

Background. An otherwise healthy 31-year-old gravida 2 para 1 woman with a spontaneous dichorionic, diamniotic twin pregnancy presented with hypertension, nephrotic syndrome and renal insufficiency at 19 weeks' gestation. Fetal ultrasound revealed severe intrauterine growth restriction of one fetus and measurement of serum anti-angiogenic and angiogenic factors were consistent with a profound anti-angiogenic state. After one fetus died and the placenta became increasingly echogenic, the patient improved clinically, and weekly ultrasound assessments of the intact co-twin from 22 weeks onwards demonstrated symmetrical fetal growth along the 10th centile. Repeat serum angiogenic factors at 24 weeks' gestation revealed considerable improvement of the anti-angiogenic state and paralleled resolution of the clinical syndrome.

Investigations. Physical examination, laboratory evaluations including full blood count, liver function tests, electrolytes, renal function tests, screening for glomerular-based disease, 24-h urine collection for total protein, analysis of serum anti-angiogenic and angiogenic factors, fetal ultrasonography and placental Doppler examination.

Diagnosis. Spontaneous resolution of early-onset pre-eclampsia after single fetal demise in a twin pregnancy.

Management. Labetalol was given to treat hypertension and furosemide was given as needed for edema. The patient was closely followed up throughout pregnancy in a combined nephrology/obstetrics outpatient clinic.

Author affiliations

Division of Nephrology, Department of Medicine, Mount Sinai Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. (M A Hladunewich). Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Cambridge, MA, USA. (G Steinberg). (S Ananth Karumanchi). Division of Epidemiology, Statistics and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA. (R J Levine). Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada. (S Keating). Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada. (J Kingdom). (J Keunen).

Correspondence to: M A Hladunewich Email: michelle.hladunewich@sunnybrook.ca