I have been asked by Alice to do a piece about ‘placenta papyrae’, I think she is referring to something variously called the vanishing twin, fetus papyraceous, or fetus compressus, my Mother had an example of this in a kitchen cupboard at home! Firstly, my Mother was a midwife, an early incarnation of a community midwife, bike and all. Secondly, our home was not cluttered with jars containing interesting specimens, just wonderful midwifery and obstetric textbooks with images guaranteed to stimulate a developing mind, this was the only pathological example I can remember. Her story goes that she attended a twin birth, at home, and when examining the placenta found this little ‘mummified’ fetus which she then kept in the bottle with some preserving fluid at home. As you can imagine I found this hugely interesting, I can remember from quite a young age climbing on to the kitchen work-surface to open the wall cupboard so I could sit and marvel at this strange little ‘alien’. It must have been about 3 inches long, it was a creamy colour, my recollection is that it looked like bone and was almost completely flat, with a large bluish dot where the eye should have been. I have no idea where it is now, I just hope it wasn’t left in the cupboard when she moved!What is it then? Well the first name I wrote gives a clue, a vanishing twin. As people are aware a great many more pregnancies begin as a twin one than end as one. S. Levi, who studied over 6,000 early pregnancies sonographically, found that of the 188 sets of twins identified, only 86 sets were delivered as twins. From this it was inferred that the others had “vanished.” also “Review of the sonographic findings of 1000 pregnancies with viable gestations in the first trimester revealed a minimum incidence of twinning of 3.29%. Of these, 21.9% demonstrated the “vanishing twin” phenomenon,” (Am J Obset Gynecol 1986;155:14-9.) Not all vanishing twins will become a fetus papyraceous as this ‘mummifying’ of a dead fetus is most likely to occur if the pregnancy has reached between 15 – 20 weeks.
How does it happen? Basically one, or more, of the feti in a multiple pregnancy dies and the fluid component of their body is absorbed, resulting in the mummification, but due to the bones being reasonably well developed by this gestation the fetus continues to maintain a recognisable shape, it is then compressed by the growing twin leading to the flattening. Hereis an interesting case, with picture, where one live baby was born and two fetus papyraceous were found, originally a triplet pregnancy.
Does this cause any problems for the surviving twin? There is evidence that it may, in some cases. The problems are not generally caused by the development of a fetus papraceous but by the death of the other baby. It may be that there were placental issues and in the case of identical, or uniovular, twins these would then have repercussions for the surviving twin. The change in the blood flow dynamics may also affect the twin that remains, studies have indicated that there is an increase in the incidence of cerebral palsy in the surviving twin, generally though this seems to be more prevalent if the death had occurred after 20 weeks of pregnancy(http://findarticles.com/p/articles/mi_m0CYD/is_17_35/ai_65538238). I have also found reports of a case where the mummified twin is blocking the cervix and so obstructs labour, my comment on this would be that the placenta must have been quite low-lying in the first place so this was a fortuitous event! There are other problems which may affect a surviving twin, the link to Early Path Medical Consultations (below)is quite informative about these.
I have only ever found one fetus papyraceous when examining a placenta, and it looked nothing like a fetus, it was almost discoid and at first I thought it was an area of calcification, the surviving twin was healthy, the parents were told about it and since the woman had experienced a bleed at 14 weeks they felt that this gave them an explanation.
Scanned from an old copy of ‘Obstetrics and the Newborn’. Beischer and McKay. This is a far larger fetus than generally seen and less mummified.
This is far more representative but is as the result of ‘feticide’ in a multiple pregnancy so in fact is not a ‘vanishing twin’. The text accompanying this can be found here, Early Path Medical Consultations.
Alice asked two specific questions:-
Is it current practice to inform parents? Yes. Parents should be informed as there may be implications for the surviving twin. Also, the discovery of the vanished twin would be recorded in the clinical notes which the Mother would have access to, so it would be better that had been previously discussed with her and her partner.
What is the incidence? Rates quoted appear to be worldwide where articles I’ve read suggest that it ranges from 1:17,000 – 1:20,000 live births. With regad to the UK, the only reference I could find within UK statistics was 1 occurance in the CESDI 2001 report.
If anyone wants to know more I would recommend this page on the FetusNet website.
Hope this has been of interest. If anyone would like me to ramble on about anything else midwifery related I would love to hear from you, especially over the next few weeks when I shall be kicking my heels until I am fit for work!
My main experience of this comes with the very sad death of a twin at 25/27 weeks. The pregnancy went on for another 10 weeks or so and the second baby was born fit and well.
My view would be that in the situation of Fetus Papyraceous, we must remember that this is/was a baby/life and treat it accordingly.
Have fun during your recuperation!!
Sarah – Very true. Acknowledging this I found that one fetus papyraceous had been registered in the CESDI report.
Actually, this is one of the very few complications I haven’t seen during my career, but it might interest you to know that it was mentioned nearly 1800 years ago in the Talmud.
There is a whole body of material that was never actually put into the Talmud–which really is a kind of shorthand rendering of rabbinical discussions from the period about 200 to 500 AD, a sort of “Hansard”–but which is studied even today, and one of these statements deals with what sort of women are permitted to use a “device” to avoid pregnancy. Leaving aside for the moment what is meant by “device”, the three categories of women who are mentioned are (1) the child bride, (2) the nursing mother, and (3) the pregnant woman. Since sexual intercourse in pregnancy was thought to “strengthen” the fetus, the reasoning seems to be that the ancient rabbis thought twin pregnancy resulted from two separate acts of conception, and that fetus papyraceous resulted from one twin “killing” the second, therefore it was advisable to use contraception to avoid twin pregnancy altogether.
Just a factoid I thought you might find useful…
Antigonas – I’m really interested in the fact that the use of a device was permitted for child brides. It would appear from this that there was a realisation that pubescent pregnancy/childbirth was not advisable. I suppose it was easier to see the complications labour and an immature pelvis caused than to understand a twin pregnancy.
Is vasa praevia suitably midwifery-related? Just had a reader story in on the subject – the mum wants to raise awarenss of the condition. She says she was lucky to have an on-the-ball consultant who insisted on an internal Doppler scan even though the normal scan suggsted her placenta was no longer praevia. Have you ever had a mum with this condition?
Mother of the Bride – Wonderful subject. Thank you. I shall start my trawling now!
I too have found a fetus papyraceous, I blogged about it last year – http://cremede.blogspot.com/search?q=histology
I have a photograph if you are interested in seeing it, but it’s not something I would post on-line.
Agatha – Lovely post. I hadn’t come across the issuing of a ‘certificate’, I’m really not quite sure about that. Don’t you think it has all sorts of implications, like following a miscarriage, TOP, should they also receive a certificate?
YES! I think the certificate thingy has a lot of implications – there has to come a point where we say to women, ‘i’m sorry this baby died, i’m sorry he didn’t make it, but this is normal, this is totally normal’
It is not necessarily healthy to mourn the loss of a twin you never knew existed. It is different if you knew of the twin, but otherwise, I think it’s totally ‘normal’ for parents, when told to say ‘wow, that’s really interesting, thanks for telling us’ & leaving it at that.
As for miscarriage & TOP, I think it depends on the gestation. Later gestations do sometimes call for a little certificate, hand & footprints, pictures etc. But many don’t. Many babies/fetuses don’t make it & that is normal, that’s life, it’s the natural order of things, & we need to accept that.
Hi.
I stumbled across your blog while actually searching Fetus Papyraceous on google. I thought I might leave a comment because I am a surviving twin, my twin unfortunately died around 4 months, and my parents and doctors had no idea there was even a twin in there. It wasnt until my mother went into labor and had to have an emergency C-Section because the other baby was blocking the way. Im told that it was the first of its kind in the hospital where I was born. I believed my parents but at the same time it seemed so unreal, until they finally showed me the photo when I turned 18, that made it very real. I am kinda rambling now and not sure what else I can say about it….
Hi… I was born in 1977… 8 weeks prem. There was later found another fetus at around 3 months developed. There was one placenta which means identical. I am only just now exploring this idea and finding myself grieving. Have you experienced this also? Feeling quite bewildered
Samantha – Thank you so much for leaving your comment, it gave me a nudge to remember that there is a baby/person who is the other side of the ‘vanishing twin’ phenomenon. I hope that my very ‘down to earth’ way of writing about fetus papyraceous did not upset you, perhaps I should be more sensitive in future.
Oh no, you didnt upset me in the least. Although I suppose it would be good to rememeber the other living person on the other side. :] The way you wrote was fine with me, in fact I learned a little about what it is exactly. I see it is just something thats different about me than others, and being that I never knew my twin, it isnt very upsetting to think or talk about it. Viewing the photo for the first time was the only time I think that it ever really upset me. Of course there are times that I wish my twin would have lived [like going to school with 8 other sets of twins!] because really how neat would that be?
Hi My name is Danielle and 2 years ago i had my lil boy alfy he was a twin and we lost our other baby @ 5 months but had to carry alfy and tommy all the way though , when having alfy i look at tommy and he was a lil baby but mummfide as well im was only 22 and was very shocked as i was told the oher baby whould have gone .
Very interesting post, thanks!
[…] placenta shock I think if I were the midwife I'd tell her. I was reading another blog here: https://midwifemuse.wordpress.com/200…s-papyraceous/ where the midwife blogger reckons there is evidence that being a twin can sometimes have health […]
I’m not sure how this works but I had a fetus papyraceous delivered with my son back in 1986. The photos that were taken were sent to a Dr Atherton of GOS. Dr Atherton saw my son on several occassions and did try to locate the photo for me but he said that it wasn’t filed away in the place where it should be. How can I find out if the photographs I have seen on the internet are actually of the fetus papyraceous that was delivered with my son? Can anyone help?
Tonight I decided to search the web for some information on “the extra sac” that was attached to the placenta of my now 19 year old son. The doctors never mentioned that it was a “vanishing twin”. They just said it was unusual and asked if they could keep it for educational purposes. I agreed and as far as I know, it is still at the hospital. I’ve often told my son about it but tonight was the first time I told him that he was a twin! Thank you for the enlightenment.
Is there research to indicate how the vanishing twin syndrome might affect the size and/or intelligence of the living twin ? I know of two such young men and both are unusually tall and extremely intelligent.
Came across this site looking for answers to the loss of my baby. I am thinking more of the vanishing twin syndrome. I am doing research since my doctor has not even tried to help me have closure. With the first ultrasound there were two embroys but one of them was not developing and eventually was absorbed by 10 weeks.. I lost the second one at 15 weeks. If this sounds possible that this could be the cause would someone let me know? This took place 1 week ago and of course I am looking for some sort of reason why, if there is any at all. Any feedback would be greatly appreciated.
I too was carrying twins until one of them stopped developing between 17 and 18 weeks. This one is sitting right on the cervix and the other one remains in either a breech or transverse position. I am at 36 weeks and there is discussion about the need for a c-section. Any thoughts on whether attempting to rotate and have a vaginal birth should be pursued would be appreciated.from ultrasound it appears that this is not a case of fetus papayraceous rather it sounds more like a mummified fetus.
While I never saw them, in my second and only successful pregnancy I gave birth to one live baby and two fetus papyri. We knew going into delivery about all three babies, having intended to carry all three babies, but two were not compatible with life, and we had to make the difficult decision to reduce the pregnancy at 14 weeks to save the third baby. I think that there is an important consideration for mothers who know ahead of time about the presence of a vanished twin – the twin is not immediately rendered into the placenta. Compression takes many weeks, and if the mother has ultrasounds during that time, she will see her healthy baby – and she will see her other baby/babies, floating silent and still. That has an emotional impact on the mother (and father) that should be kept in mind. Even among women who lost a twin before the first ultrasound, knowing that there is even just an empty sac can be hard – due to the frequency of vanishing twins, I have had several friends experience this, and they grieved for the child they never knew while alive. Even if the discovery of the vanished twin comes only at birth, families have a right to know of that baby’s existence and have the right to grieve if that is what comes naturally.
[…] PapyraceusUH HUFinal Diagnosis — Fetus PapyraceusUH HUA Midwife’s […]
I had a home birth….I was expecting twins….but four months into the pregnancy…my little girl twin died. They could give me no reason…i had known something was wrong …just didn’t feel right–I was scared too….and having had two prior home births that had gone beautifully….such was very unlike me. I had insisted on an ultrasound and managed to get in to a doctor friend of my midwife the next day after a night of no sleep and worry. I get in there…and i am sent to the hospital…another ultrasound is done (they refused to say anything about the one i had in the doctors office…just telling me they needed to get a ‘better picture’)
Long, and very sad story short…I got to hear the last few beats of my daughter’s heart. I am told how sorry they all are and sent home with the ‘reassurance’ that I shouldn’t worry, the baby will ‘reabsorb’ into my system. I was lucky they said because my twins had each had their own amniotic sac etc….and the remaining twin would most likely be perfectly fine.
Fast forward to my day of labor….a week overdue….and I call the midwife. It takes her nearly an hour to get there as I lived rather rural at the time. She arrives and I’m crying over what I think is the body of my remaining twin…this …it is hard to describe how…..delicate the baby was…. about the size of my palm…curled up…so fragile-so very white in color ..and her little arm was curled at her side…fingers more like the tips of wings in appearance. I thought this was my remaining twin….(I had felt a trickle of water run down my leg…had gone to the bathroom….thinking it was pregnancy related incontinence ….I was rather large at the time….a lot of pressure I imagined on my bladder. As I went about cleaning up…i had the strangest feeling…almost like….right before you hiccup….and out slipped the little baby..)
I was devastated and admittedly not thinking all that clearly…
My midwife arrived a bit later….and not long after she started checking me over…i felt my first labor pains….i gave birth to my son fairly quickly….. He was healthy at 7pounds 8oz. …..
Afterwards….the midwives showed me what i was then told they believed was my papyraceous twin. My daughter (I had known i was having a boy and a girl fraternal twins) …tiny little thing…the midwives wrapped in a lovely bit of cloth and had placed in a small box….i got to touch her–for which I will be ever grateful….I had been mourning her loss nearly my whole pregnancy…..we had a ceremony for her at my midwife’s house later that week…..I think it is absolutely vital that a parent should get to see their child…to touch them, and to be able to have that memory in their grief….I will never forget the kindness of my midwife and her assistant for knowing how much i needed to do so…and how important it was to our family. I will never forget my daughters lovely little wings….and now when i think of Shaelynn….i see her tiny memory in my mind.
Thanks to the women who commented. And sorry, mums, for your losses. I’ll just report on my friend who at age 26 or so noticed a persistent lump in her flank- not small. She was very tall and thin but realized she could she a bulge just inside one hip bone. She made a gyn appointment and in exam the doctor said – what are you then, six months? She was shocked – not pregnant to her knowledge. And on testing she was not. After surgery she was told she had a dermoid cyst, size of an orange (she saw it). And that it was likely from a vanished twin. Lots of twins in her family. Dermoid cysts because they are developed from early fetal cells can have any organ characteristics – fortunately this one did not have hair or teeth. Slow growing, and benign. She mused on the feeling she’d had all her life that she was a twin…indeed she had been, once, and carried the living non-person with her for a quarter century.