Fetus papyraceus

Abstract

Fetal papyraceus is a condition where one of the fetus is compressed in-utero and eventually either gets completely resorbed or becomes paper thin, without major effect on mother or the other surviving fetus. It was rare condition, not encountered very often in the regular practice. Its incidence has increased over the past few years due to use of assisted reproductive techniques (ART). As ART has been the major cause of multiple pregnancies, in recent times, it has also increased the complications associated with it. ART has also made the rare complication a near common condition. Though the condition is managed conservatively, but may be associated with high morbidity and mortality of both mother and fetus. In this article we emphasize on the need for diagnosis of the condition to limit complications for both mother and fetus and plan the delivery accordingly. We present you the case of an elderly female with multiple pregnancy conceived by Artificial reproductive technique, with severe oligohydramnios and severe anemia with no prior evidence of twin pregnancy on routine investigations. She was evaluated and emergency caesarean of babies was done with Intraoperative surprise of total of 5 fetuses with 2 live births and 3 fetus papyraceus.

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Indian Journal of Obstetrics and Gynecology Research 2020;7(2):285–287
Content available at: iponlinejournal.com
Indian Journal of Obstetrics and Gynecology Research
Journal homepage: www.innovativepublication.com
Case Report
Fetus papyraceus
Vidhyulatha Sanata1, Konduru Laxmi2, Sana Firdouse3,*
1Dept. of Radiology, Gurunanak Care Hospitals, Hyderabad, Telangana, India
2Dept. of Obstetrics and Gynecology, Gurunanak Care Hospital, Hyderabad, Telangana, India
3Dept. of General Surgery, Gurunanak Care Hospital, Hyderabad, Telangana, India
ARTICLE INFO
Article history:
Received 06-03-2019
Accepted 26-02-2020
Available online 15-06-2020
Keywords:
Fetus payraceus
Assisted reproductive techniques
Multiple fetuses
ABSTRACT
Fetal papyraceus is a condition where one of the fetus is compressed in-utero and eventually either gets
completely resorbed or becomes paper thin, without major effect on mother or the other surviving fetus.
It was rare condition, not encountered very often in the regular practice. Its incidence has increased over
the past few years due to use of assisted reproductive techniques (ART). As ART has been the major
cause of multiple pregnancies, in recent times, it has also increased the complications associated with it.
ART has also made the rare complication a near common condition. Though the condition is managed
conservatively, but may be associated with high morbidity and mortality of both mother and fetus. In this
article we emphasize on the need for diagnosis of the condition to limit complications for both mother
and fetus and plan the delivery accordingly. We present you the case of an elderly female with multiple
pregnancy conceived by Artificial reproductive technique, with severe oligohydramnios and severe anemia
with no prior evidence of twin pregnancy on routine investigations. She was evaluated and emergency
caesarean of babies was done with Intraoperative surprise of total of 5 fetuses with 2 live births and 3 fetus
papyraceus.
© 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
(https://creativecommons.org/licenses/by-nc/4.0/)
1. Introduction
In recent times, with the increase in Assisted Reproductive
Techniques the incidence of multiple pregnancies is
rising, which in turn also increased incidence of fetal
papyraceus. The reported incidence of fetus papyraceus
is one in 12,000 pregnancies1compared to 1:190 in
twin pregnancies. Fetal papyraceus is a rare condition
which is also called fetal compressus or vanishing
twin syndrome where one of the fetuses is compressed
mummified, parchment-like-state attached to placenta. It
can be seen in Monozygotic or Dizygotic Twins, Ovulation
induction or In vitro fertilization. It is associated with high
morbidity and mortality to mother and fetus. Conditions
associated with this which complicate the pregnancy
are: Pre-eclampsia, Disseminated intravascular coagulation,
Thrombotic thrombocytopenic purpura. The fetal life may
* Corresponding author.
E-mail address: sana.firdouse111@gmail.com (S. Firdouse).
be compromised due to prolonged second stage of labour,
arrest of descent, hypoxia of second twin if not managed
actively. Intrauterine complications effecting outcome of the
pregnancy are premature babies, Low birth weight babies,
Hypoxic ischemic encephalopathy.
2. Case
A 43-year-old Primigravida presented to our hospital at
29 weeks of gestation. She conceived through Artificial
reproductive technique (In-vitro fertilization), done in other
hospital. Her medical records suggest that fetal reduction
was done at 13wks of gestation. Her first and second
trimesters were uneventful. Her serial Ultrasounds showed
diaminiotic and dichorionic twin pregnancies (Figure 1).
In present ultrasound severe oligohydraminious (Amniotic
fluid index was 2-3 for both fetuses) was noticed. On
doppler there was early diastolic reversal in bilateral uterine
arteries, with Utero-placental insufficiency (Figures 2 and 3)
https://doi.org/10.18231/j.ijogr.2020.062
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286 Sanata, Laxmi and Firdouse / Indian Journal of Obstetrics and Gynecology Research 2020;7(2):285–287
Due to uncertainty of the presenting part with arrested
descent and oligohydraminious a decision was reached
to deliver the fetus by Caesarean section. An emergency
Caesarean section was done and a twin gestation with
scanty liquor was noticed. Two male babies were delivered
in cephalic and transverse presentation respectively with
Apgar of 6 in first minute and 8 in fifth minute with
separate placenta and membranes weighing 1.2kgs and
1kgs. Intraoperatively, there were three more fetuses
attached to placenta were noted, two of which were without
a cord approximately of 12 weeks and 9 weeks of gestation
with atrophied placenta and calcifications, mummified fetal
bones on the anterior to the lower segment of the uterus.
A total of 5 fetuses were seen at different gestational ages
(Figure 4). One unit of blood was transfused intraoperatively
due to severe anemia prior to surgery. The mother was
discharged home in stable condition on 5th post-operative
day. In view of prematurity and very low birth weight,
babies were shifted to Neonatal Intensive care unit for
further management.
Fig. 1: Sonological finding showing twin pregnancy with two
separate membranes-Dichorionic twins.
Fig. 2: Ultrasonography view of Umblical cord with two arteries
and one vein.
3. Discussion
Fetal papyraceus is initially diagnosed sonographically
by reduction in the number of gestational sacs in first
trimester. The fetus can be like cyst, calcification, parchment
Fig. 3: Colour Doppler studies showing Diastolic flow reversal of
uterine artery.
Fig. 4: The picture shows the placenta with two healthy umbilical
cord attachments. Three paper like compressed foetuses can be
seen attached to the placenta with necrosed cords. The Black
arrows shows the two fetusses of apprximately 13 wks of
gestational age. The white arrows the foetus at 9 weeks of
gestational age wrapped in the membranes. The red arrows shows
the umblical cords of the live babies. The red arrow heads shows
the necrosed attachments of the compressed fetusses.
like, underdeveloped fetus between membranes of placenta,
partially developed fetus with absent cardiac activity and
mummified bones.2Depending on the gestational period
at which fetal death occurs, there are three forms of this
complication; vanishing twin syndrome in the first trimester,
fetus papyraceus in the second trimester and the macerated
twin in the third trimester.1Different causes for the intra
uterine death of one fetus include twin-twin transfusion
syndrome, membranous or velamentous cord insertion,
true cord knot, cord stricture, placental insufficiency, and
congenital anomalies.3Twin twin transfusion syndrome,
in which thromboplastic substances from the dead twin
are transferred to the survivor through communicating
vascular channels within the placenta.4The surviving
co-twin is at risk of development of growth restriction,
cerebral encephalomalacia and microcephaly. Diagnosis
of Fetus papyraceus is very important to prevent further

Sanata, Laxmi and Firdouse / Indian Journal of Obstetrics and Gynecology Research 2020;7(2):285–287 287
complications, plan the delivery of fetus and have
successful surviving fetus outcome. Maternal consumptive
coagulopathy due to fetal demise of one twin is a rarest
reported complication.5,6
4. Conclusions
The major concern for fetus papyraceus is its effect on the
surviving fetus and on the mother. To prevent complications,
the intrauterine diagnosis of fetus papyraceus by serial sono-
graphic examinations and routine placental examination is
mandatory. In most of the cases, no complications to the
mother or surviving twin are observed and fetus papyraceus
is mostly an incidental finding.
5. Source of Funding
None.
6. Conflict of Interest
None.
References
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Coagulopathy After Umbilical Cord Occlusion for Twin Reversed
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Author biography
Vidhyulatha Sanata Consultant Radiologist
Konduru Laxmi Consultant
Sana Firdouse Junior Resident
Cite this article: Sanata V, Laxmi K, Firdouse S. Fetus papyraceus.
Indian J Obstet Gynecol Res 2020;7(2):285-287.