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Angiogenic factor abnormalities and fetal demise in a twin pregnancy

Nature Reviews Nephrology volume 5, pages 658–662 (2009)Cite this article

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.

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Figure 1: Fetal ultrasounds.

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Acknowledgements

M. A. Hladunewich's salary is supported by the Bayer/Canadian Hypertension Society, Canadian Institutes of Health Research, Clinical Scholarship Research Award and her research is supported by the Physicians' Services Incorporated Foundation. S. A. Karumanchi is an investigator at the Howard Hughes Medical Institute. R. J. Levine receives salary support from the intramural research program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).

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Authors and Affiliations

  1. Division of Nephrology, Department of Medicine, Mount Sinai Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

    Michelle A. Hladunewich

  2. Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard University, Cambridge, MA, USA

    Guy Steinberg & S. Ananth Karumanchi

  3. Division of Epidemiology, Statistics and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA

    Richard J. Levine

  4. Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    Sarah Keating

  5. Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada

    John Kingdom & Johannes Keunen

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  1. Michelle A. Hladunewich
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Corresponding author

Correspondence to Michelle A. Hladunewich.

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Competing interests

S. A. Karumanchi declares associations with the following organizations: Abbott Diagnostics, Beckman Coulter, Roche, Johnson & Johnson and the Beth Israel Deaconess Medical Center. See the article online for full details of the relationships. The other authors declare no competing interests. Dr. Karumanchi is a co-inventor on patents for the diagnosis/therapy of pre-eclampsia at Beth Israel Deaconess Medical Center, and a consultant to Abbott Diagnostics, Beckman Coulter, Roche and Johnson & Johnson.

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Hladunewich, M., Steinberg, G., Ananth Karumanchi, S. et al. Angiogenic factor abnormalities and fetal demise in a twin pregnancy. Nat Rev Nephrol 5, 658–662 (2009). https://doi.org/10.1038/nrneph.2009.154

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