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Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 242-244

Twin pregnancy with fetus papyraceus – vanishing twin

Department of Neonatal Paediatrics, The Indus Hospital, Karachi, Pakistan

Date of Submission10-Jan-2021
Date of Decision20-Jul-2021
Date of Acceptance22-Jul-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Syed Rehan Ali
Department of Neonatal Paediatrics, The Indus Hospital, Karachi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_7_21

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Fetus papyraceus is a mummified fetus, which is related to multiple gestations.[1] In this rare condition, one fetus expires and becomes compressed between the uterine wall and membrane of the other fetus. Surviving infant is at high risk of developing complications secondary to the release of thrombi and other factors from the dead fetus; including prematurity, intrauterine growth retardation, gastroschisis, intestinal atresia, aplasia cutis, congenital heart abnormalities, and even death. We have reported consecutive case series in dichorionic diamniotic twins and monochorionic diamniotic twins successively. In our case reports, both pregnancies resulted in preterm deliveries and were managed successfully without any complications.

Keywords: Fetus papyraceus, multiple gestation, twin pregnancy

How to cite this article:
Quratulain B, Khalid H, Kumar V, Khan A, Ali SR. Twin pregnancy with fetus papyraceus – vanishing twin. J Clin Neonatol 2021;10:242-4

How to cite this URL:
Quratulain B, Khalid H, Kumar V, Khan A, Ali SR. Twin pregnancy with fetus papyraceus – vanishing twin. J Clin Neonatol [serial online] 2021 [cited 2022 Dec 4];10:242-4. Available from: https://www.jcnonweb.com/text.asp?2021/10/4/242/326614

  Introduction Top

Neonatologist in the modern era comes across with new modalities such as fertilizing medicine, multiple pregnancies, and premature deliveries. The incidence of papyraceus fetuses was reported in 1:1200 pregnancies.[2] When one fetus demise occurs early in a twin pregnancy and if it is retained for more than 10 weeks, causing mechanical compression of the dead fetus resulting in an appearance like parchment paper.[3] Fetus papyraceus is associated with twin-twin transfusion, improper cord implantation like velamentous cord attachment, and chromosomal anomalies.[4] We have reported two consecutive case series of fetuses papyraceous managed conservatively with no complications.

  Case Reports Top

Case 1

A G3P2 + 0, 20 years old, an un-booked patient came to ER at 32 weeks of gestation with a vaginal bleed. Initial blood results showed blood Group O Rh-positive and a hemoglobin of 6.4 grams/dl. Her ultrasound showed dichorionic diamniotic twin pregnancy with a larger twin in breech position. Emergency lower segment cesarean section was conducted due to breech presentation in twin 1 and failure to detect heartbeat on twin 2. The first twin was a female baby weighing 1000 g born with Apgar of 8 and 9 at 1 and 5 min, respectively. The other twin was intrauterine death (IUD) weighing 380 g. The female IUD twin had a separate placenta and was found between layers of the placenta [Figure 1]. The live female was managed in newborn intensive care unit and discharged home with no complications.
Figure 1: Fetus papyraceous in dichorionic diamniotic twins

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Case 2

A 31-year-old G4P3 + 0 previously booked female, married for 15 years came to the emergency room in active labor at 35 + 3 weeks' gestation. Her last born was 7-year-old. She had gestational DM and was on oral hypoglycemic medication (metformin). Her last HbA1C was 5.3%. Her hemoglobin was 6.4 g/dl. Her last performed ultrasound showed alive monochorionic diamniotic twin gestation with twin 1 in a transverse lie and twin 2 in a cephalic lie, corresponding to 29 weeks 5 days ± 1 week and 25 weeks 3 days ± 1-week gestation, respectively. The mother's blood group was O Rh-positive. On arrival, she was fully dilated so shifted to the operation room for Emergency lower segment caesarean section due to a transverse lie (again confirmed on ultrasound) after taking informed, written consent. Twin 1 delivered was a live female baby of 2100 g born with good Apgar. The other twin was found as mummified fetus papyraceous in layers of the extracted placenta [Figure 2]. Twin 1 was sent with the mother to the postnatal unit and successfully discharged with no complications.
Figure 2: Fetus papyraceous in monochorionic diamniotic twins

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  Discussion Top

Diamniotic and dichorionic pregnancy is associated with high maternal complications and preterm deliveries. Some complications include intrauterine growth restriction (IUGR). Placental-related problems are increased risk of velamentous cord insertion, marginal cord insertion, increased incidence of placenta previa spectrum.[4]

10.7/1000 live birth is the multiple gestation rate in Pakistan.[1] The prevalence of preterm births in Pakistan is 18.89%.[2] The incidence of papyraceus fetus is reported in 1 in 1200 pregnancies.[3] Fetus papyraceus is a term used to describe the IUD of one twin fetus that occurs during early gestation, which results in retention of the dead fetus for approximately 10 weeks' duration. This results in mechanical compression of the dead fetus, which gives an impression of parchment paper. Fetus papyraceus is an infrequent complication with no known cause. It is associated with twin-twin transfusion, improper cord implantation, such as velamentous cord attachment, and chromosomal anomalies.[4],[5],[6]

Fetus papyraceus arise in either monochorionic or dichorionic multiple pregnancies. Although the causative factors in many cases of fetus papyraceus are typically unknown, some hypotheses have been made, including velamentous cord insertion has been thought to influence the development of fetus papyraceus. In addition, it was also reported to occur due to the lethal nuchal cord, a condition associated more strongly with monozygotic twin pregnancies than dizygotic twins. Maternal age, parity, and gravidity were not proved to have any correlation with fetus papyraceus. It is also important to note that in cases reported in the literature, there is a spectrum of presentation in the surviving twin that ranges from no complications[7] to prematurity, IUGR, and even death. Moreover, thrombi and clotting factors released from the deceased fetus can result in different congenital anomalies, which can then cause vascular occlusive lesions in live twins. Examples of congenital anomalies identified so far are gastroschisis, intestinal atresia, absent ear, central nervous system damage, aplasia cutis, and cardiac abnormalities.[7],[8] Dahiya and Bains[5] have reported two cases of fetus papyraceous delivered at term with no complications to the surviving fetus. A case report is available describing fetus papyraceous by Landy and Keith.[6] A dichorionic diamniotic twin pregnancy with the demise of one twin at 27 weeks is reported.[7]

  Conclusion Top

According to literature, there are no known adverse effects of fetus papyraceous on mother or surviving twins. The reason for the fetus papyraceous is not ascertained. It is missed mostly during ultrasound scans so it is recommended to use serial ultrasound examinations with good resolution. Expertise who practices obstetric ultrasound should obtain a high degree of proficiency by better training and maintaining a high index of suspicion. A detailed histopathological examination of the placenta and vanishing twin is essential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Marete I, Tenge C, Pasha O, Goudar S, Chomba E, Patel A, et al. Perinatal outcomes of multiple-gestation pregnancies in Kenya, Zambia, Pakistan, India, Guatemala, and Argentina: A global network study. Am J Perinatol 2014;31:125-32.  Back to cited text no. 1
Hanif A, Ashraf T, Waheed K, Sajid MR, Guler N, Pervaiz MK. Prevalence of preterm birth in Pakistan: A systematic review and meta-analysis. Ann King Edward Med Univ 2017;23:2. [doi: 10.21649/akemu.v23i2.1615].  Back to cited text no. 2
Rathi BA, Rathi S. Fetus papyraceus – A case report. J Obstet Gynaecol India 2003;53:188.  Back to cited text no. 3
Woo HH, Sin SS, Tang LC. Single fetal death in twin pregnancies: Review of the maternal and neonatal outcomes and management. Hon Kong Med J 2000;6:293-300.  Back to cited text no. 4
Dahiya P, Bains R. Conservative management of fetus papyraceus: A report of two cases. Oman Med J 2014;29:132-4.  Back to cited text no. 5
Landy HJ, Keith LG. The vanishing twin: A review. Hum Reprod Update 1998;4:177-83.  Back to cited text no. 6
Kurtz AB, Wapner RJ, Mata J, Johnson A, Morgan P. Twin pregnancies: Accuracy of first-trimester abdominal US in predicting chorionicity and amnionicity. Radiology. 1992;185:759-62.  Back to cited text no. 7
Daw E. Fetus papyraceus-11 cases. Postgrad Med J 1983;59:598-600.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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