Case reportA 32 year old nulliparous woman was referred at 28 weeks of gestation because of severe pre-eclampsia in a dichorionic twin pregnancy conceived naturally. Her pregnancy was uneventful until 22 weeks of gestation, when a routine ultrasound scan revealed severe intrauterine growth restriction and reversed umbilical blood flow in one twin, while the other had normal development. At 28 weeks of gestation, the woman developed pre-eclampsia, with a blood pressure greater than 160/100 mmHg, proteinuria, headache and oedema.In our centre, ultrasound examination confirmed growth restriction (weight estimation: 570 g) and reversed umbilical flow with cerebral redistribution in one twin, with a normal co-twin (estimated weight: 1270 g). The woman's clinical state was stable using a calcium channel blocker (nicardipine 100 mg given intravenously per day) to control her blood pressure. The degree of proteinuria was 2.16 g per day. After discussion with the parents and because of the poor prognosis for the growth-restricted twin, expectant management was decided, in order to avoid prematurity in the co-twin. Her proteinuria increased ( Fig. 1) and control of her blood pressure required the addition of labetalol (600 mg intravenously per day). At 32 weeks of gestation, her proteinuria was 6.5 g per day. Ultrasound examination did not show evidence of any growth of the restricted twin and confirmed severe Doppler abnormalities, while the co-twin's assessment was reassuring. After discussion with the parents and in accordance with French law, selective termination of the compromised twin was performed by the administration of an intracardiac injection of potassium chloride.From this point, her symptoms of pre-eclampsia disappeared, the proteinuria started a dramatic decrease (Fig. 1) and her blood pressure remained normal with a low dose of oral nicardipine (60 mg per day). Close follow up was maintained and her pregnancy remained uneventful. The woman was discharged home at 34 weeks of gestation. At 38 weeks, a healthy baby girl weighing 2560 g was born by vaginal delivery and a stillborn boy weighing 330 g was delivered immediately after. Her postpartum course was uneventful. Macroscopic and histologic examination confirmed a dichorionic pregnancy, with two placentas separated by two amnions and chorions. DiscussionPre-eclampsia is a disorder specific to pregnancy characterised by increased blood pressure and proteinuria. It affects 3 -5% of pregnancies and is a major cause of maternal and perinatal mortality 1 . The cause of pre-eclampsia remains elusive in spite of many attempts to understand the mechanisms responsible for its pathogenesis. Studies over the past decades suggest several possible origins of pre-eclampsia 2 . The initiating event could be reduced uteroplacental perfusion due to abnormal trophoblastic invasion of the spiral arterioles 3 . However, recent findings are more suggestive of an inappropriate maternal inflammatory response 4 that could involve a superantigen-like effect 5 . Some authors spec...

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Fig. 1. Degree of proteinuria before and after selective termination. CASE REPORT 69 D RCOG 2003 Br J Obstet Gynaecol 110, pp. 68 -69